Master Techniques in Rhinoplasty

38
Andrew S. Frankel • Umang Mehta
Figure 3-14  Inverted-V deformity. Note the washout of the brow-tip
aesthetic line in the middle third of the nose.
Figure 3-15  Collapse of the external valve. Note the patency on expiration (A) but collapse on inspiration (B).
A
B
Figure 3-13  The tension nose.
points with the turbinates are documented. The size of the
inferior turbinates and quality of the nasal mucosa can
provide insight into the cause of the patient’s nasal
obstruction. A fiberoptic examination of the nasal cavity
should be undertaken when the patient notes a history of
nasal obstruction.
Collapse of the internal nasal valve due to infero­
medial displacement of the caudal edge of the upper
lateral cartilage is easily identified intranasally. The upper
lateral cartilage can be manually displaced with a Q-tip
while asking the patient to inhale and exhale through the
nose. Improvement in nasal breathing via this maneuver
or the modified Cottle maneuver is indicative of internal
valve-related nasal obstruction. Externally, upper lateral
cartilage collapse can give the middle vault a pinched
appearance or inverted-V deformity8 (Figure 3-14).
Examination of the lateral crura will yield causes of exter­
nal valve stenosis, resulting from profound curvature,
subluxation, overresection or excessive thickness. Dynamic
collapse of the external nasal valve should be evaluated
in inspiration and expiration (Figure 3-15).
Analysis of the nasal tip should begin with an assess­
ment of the general shape. While examining and palpating
the nose, the surgeon should perform the mental exercise
of visualizing the underlying cartilages to determine their
shape and contribution to the nasal tip. It is critical to

CHAPTER THREE  Nasal Analysis
39
Palpation of the nasal tip allows the surgeon to assess
the stiffness of the lower lateral cartilages and the other
major and minor mechanisms of tip support. With aging,
fibrous attachments of the scroll weaken, resulting in
separation of the lower lateral cartilages from the upper
lateral cartilages. In addition, the interdomal ligament
weakens, causing splaying of the domes and additional
loss of support. The overall effects of aging include ptosis
of the tip, the appearance of lengthening of the nose, and
valve collapse (Figure 3-16). The tip should be observed
in animation, as this can further accentuate tip ptosis, due
to the action of the depressor septi nasi muscle (Figure
3-17). Bossae at the tip can result from prominent knuck­
les at the dome and are almost always due to loss of
integrity of the alar cartilages from overresection or
division.
On lateral view, important considerations include
nasal tip projection, the degree of columellar show,
supratip break, nasolabial angle, and double break in
the infratip region. There is frequently an asymmetry of
the lower lateral cartilages that causes the profile view
of the tip to differ dramatically from one side to the other.
The thickness of the lateral alar skin and soft tissue is
another common complaint of patients, particularly in
certain ethnic groups. Patients must be counseled regard­
ing the anatomy of these areas and the limitations
in changing their shape. One should also document
the depth of the alar grooves and projection of the
premaxilla.
On base view, some important considerations include
alar base symmetry, ratio of the infratip to the columella,
projection of the caudal septum or medial crura into the
airway, and presence of a previous transcolumellar scar.
Figure 3-16  The aging nose.
consider the multitude of factors at play in creating the
appearance of the tip. Consider, for example, the boxy,
poorly defined, and wide nasal tip. This particular shape
can occur as a result of a number of factors: (1) fullness
in the region of the scroll, (2) prominent cephalic margins
of the lower lateral cartilages, (3) cephalically malposi­
tioned lateral crura, (4) convexity of the lower lateral
cartilages, and (5) obtuse angles of divergence at the inter­
mediate crura. There exist a multitude of tip forms that
can impart an undesirable appearance to the nose, the
discussion of which lies outside the scope of this chapter.
B
A
Figure 3-17  Tip ptosis (A). The degree of ptosis is often accentuated with smiling (B).

40
Andrew S. Frankel • Umang Mehta
The availability of photographs preoperatively allows
the surgeon to generate a plan of expected surgical maneu­
vers. Intraoperatively, the photographs are very useful
in reminding the surgeon of the patient’s baseline nose
as the infiltration of local anesthesia, elevating the skin-
soft tissue envelope, and edema can distort the nasal
appearance. From a self-assessment standpoint, the
careful and honest comparison of preoperative photo­
graphs to those taken postoperatively is an invaluable yet
humbling process. In our practice, we have found that
even when patients are ecstatic with their surgical result,
there are aspects of the nose that we wish could be slightly
different. The rhinoplasty surgeon should be his or her
own toughest critic, as this process promotes tremendous
self-improvement over the course of one’s career.
The equipment required for photography begins with
the digital camera. The surgeon should carefully shop for
a single-lens reflex camera that allows for the use of vari­
able lenses. We find a 105-mm macro lens to be optimal
for our purposes. Standardized distance and lighting are
vital for elucidating subtle irregularities and asymmetries.
Although there may be limitations based on your particu­
lar office space, care should be taken in aligning your
flashes to minimize shadows yet maximize the details.
Depth of field and other settings should be determined by
trial and error until you are satisfied with the images. We
currently use an aperture priority setting of F-16, an ISO
of 200, and shutter speed of 1/60. A stool should be pro­
vided that allows the patient to rotate freely. It is helpful
to place fixed markers to which the patient can face for
the profile and three-quarter views. A flat blue or green
background is most useful, as it is pleasing to the eye and
provides more depth of field. Storing the digital photo­
graphs within a secure network is mandatory.
The standard views taken in rhinoplasty should
include the anterioposterior (AP) view, right and left pro­
files, right and left three-quarter views, and base view. In
many patients, we photograph a bird’s-eye overhead view,
to illustrate twisting of the nose. Additionally, we often
shoot profile views with the patient smiling, to accentuate
tip ptosis. Photographs should be taken precisely in the
Frankfort horizontal plane. Care should also be taken on
profile views to ensure that patients are not rotated more
or less than 90 degrees from the camera, as this may
distort the appearance of the nose significantly. Surgeons
disagree over the precise definition of the three-quarter
view, with some favoring lining up the dorsum with the
medial canthus and others the nasal tip with the contra­
lateral cheek. We advocate the latter.
IMAGING
The use of computer imaging to alter preoperative
images (“morphing”) has become an integral part of our
The shape and location of the prior transcolumellar inci­
sion must be noted. A poorly healed incision should be
palpated to check for a step-off immediately underneath
the incision so it can be addressed intraoperatively. Causes
of this step-off include the edge of a shield graft or the
division of the medial crura.
Revision rhinoplasty consultations necessitate a few
additional points to consider. First, the overall quality of
the skin and soft tissue envelope changes with each revi­
sion. Typically, the skin becomes increasingly translucent
and its vascularity increases, which may lead to reddish
and purple discolorations. Second, a paucity of internal
lining and membranous septum resulting from previous
surgery may be limiting factors in attempting to lengthen
a nose, so it is important to evaluate these factors when
considering such a plan. Third, the patient’s ears should
be closely examined and palpated to determine the pres­
ence and quality of the cartilage in the conchal bowls.
Patients who have undergone prior otoplasty or cartilage
harvest may not be candidates for additional harvest,
necessitating a discussion regarding rib cartilage.
PHOTOGRAPHY
The importance of proper photographic documentation
in plastic and reconstructive nasal surgery cannot be
overstated. The benefits of photography include patient
counseling, surgical planning, self-assessment, and docu­
mentation for insurance and medicolegal reasons.
Digital photography now allows for immediate
viewing of patient photographs, and this is extremely
helpful during an initial consultation. By viewing the pho­
tographs together, the surgeon and patient are able to
identify desirable and undesirable features of the nose in
an organized and detailed fashion. Any preexisting asym­
metry should be pointed out to patients preoperatively as
they will certainly notice such details as they scrutinize
their nose after surgery. Patients often ask for hard or
electronic copies of these photographs to share with family
members after the consultation so as to aid with the deci­
sion of whether to proceed with the rhinoplasty. Also,
patients may request to view photographs of other patients
who have undergone surgery to determine if they like that
particular surgeon’s aesthetic. While viewing a photo­
graph album may seem like a marketing issue, it is actu­
ally quite helpful in identifying patients who may want a
result that is not typical of that surgeon. In the postopera­
tive period, the preoperative photographs can be helpful
in pacifying a patient who is unhappy with the result or
is fixated on a small imperfection or asymmetry, by
reminding the patient of the preoperative appearance. The
use of computer imaging, which will be covered in the
next section, obviously necessitates the taking of stand­
ardized, reproducible photographs.

CHAPTER THREE  Nasal Analysis
41
to suit the patient’s individual taste. This is a crucial
component of the consultation because it allows the
surgeon insight into what the patient desires. Together
the surgeon and patient then reach a consensus about
the optimal end result, and these images are saved and
brought into the operating room for reference during
surgery. It should also be noted that imaging is typically
most useful in the profile views. In the AP view, it is chal­
lenging to accurately morph the lights and shadows to
illustrate expected changes in the nose. We find it quite
helpful to compare our morphed photos to the actual
postoperative photographs 12 months after surgery; this
is an extremely educational, yet often humbling exercise
(Figure 3-18).
For the process to realize its potential, the surgeon
must use the morphing tools in a responsible manner and
be realistic about the limitations of his or her skills. For
example, a patient with an extremely thick soft-tissue
rhinoplasty practice. The improvements in technology
over the past decade and the ability to create and store
multiple high-resolution images of patients have facili­
tated this exercise. There are a number of available
imaging software programs, each with a variety of fea­
tures, the discussion of which lies outside the scope of
this chapter.
At the initial consultation, photographs are taken of
the patient, and the photographs are uploaded into our
database. The images are reviewed as is, often comparing
the two profiles to one another to note asymmetries and
other differences. Next, the surgeon uses the morphing
software in the patient’s presence to illustrate the changes
that the surgeon believes would be warranted. The con­
cepts of what would be done in surgery are discussed
during this process and limitations are brought to the
forefront. Once the surgeon is satisfied with the result, he
or she offers the patient an opportunity to make changes
Figure 3-18  Preoperative (A), “morphed” (B), and postrhinoplasty
(C) photographs.
B
A
C

42
Andrew S. Frankel • Umang Mehta
accurate assessment of the patient’s particular anatomy
and aesthetic, and to execute this plan with average surgi­
cal technique than it is to have a mediocre plan, with little
or no consideration of the patient’s wishes, and to carry
it out exquisitely. The process of nasal analysis is funda­
mentally important in generating this plan and achieving
the goal of satisfying the patient.
REFERENCES
1. Powell N, Humphreys B. Proportions of the aesthetic face. New
York: Thieme-Stratton; 1984.
2. Crumley RL, Lanser M. Quantitative analysis of nasal tip
projection. Laryngoscope. 1988;98(2):202–208.
3. Tardy EM. Rhinoplasty, The art and the science. Philadelphia:
WB Saunders; 1997.
4. Friedman O. Changes associated with the aging face. Fac Plast
Surg Clin N Am. 2005;13:371–380.
5. Johnson CM, To WC. A case approach to open structure
rhinoplasty. Philadelphia: Elsevier Saunders; 2005.
6. Adamson PA, Litner JA, Dahiya R. The M-Arch model: a new
concept of nasal tip dynamics. Arch Fac Plast Surg. 2006;8(1):
16–25.
7. Burget GC. Aesthetic restoration of the nose. Clin Plast Surg.
1985;12:463.
envelope should not be shown an unrealistically delicate
tip with clearly visible underlying anatomy. As a general
rule, imaging should be used as a communication tool
rather than as a marketing tool. A conscientious surgeon
must explain the limitations of preoperative imaging with
the patient and explain that the images reflect the surgical
goal, rather than a guarantee of results. There certainly
are medicolegal implications in imaging, which necessi­
tate honest and clear communication between surgeon
and patient regarding the role of imaging in the
consultation.
For the patient, the chance to provide input into the
generation of these images gives a sense of control and
builds trust in the surgeon. Imaging also promotes an
understanding of the interrelation of various aspects of
the nose. For example, the surgeon can demonstrate that
by increasing projection of the tip, one can reduce the
degree to which the dorsum needs to be taken down in
profile reduction. Patients frequently arrive at the rhino­
plasty consultation with magazine clippings, asking for a
specific celebrity’s nose. We find it very useful to redirect
patients to their own images created during the imaging
exercise.
CONCLUSION
There is an oft-repeated tenet in rhinoplasty: It is far
better to have a well-conceived surgical plan, based on an

43
C H A P T E R F O U R 
The Psychology of Rhinoplasty
Lessons Learned from Fellowship
Peter A. Adamson • Jason A. Litner
This above all: to thine own self be true,
And it must follow, as the night the day,
Thou canst not then be false to any man.
Polonius’ advice to his son, Laertes, Shakespeare’s Hamlet, 1603
surgeons for them. Likewise, many young surgeons believe
they must “sell” their abilities. Instead, the surgeon should
concentrate on determining patients’ suitability to his or
her practice based on his or her skills, personality, and
comfort level while interacting with the patient. That criti­
cal assessment is the focus of this chapter.
A great deal has been written about the psychology
of patients seeking aesthetic surgery, but this subject has
never been more topical than in the past few years. Now
that aesthetic surgery has entered the mainstream, pro­
spective patients are treating it much like any other
luxury purchase. The “retail-ification” of cosmetic surgery
has advantages and disadvantages for both patients and
surgeons. On the positive end, aesthetic improvements
have become more accessible to a host of people who
would not otherwise have had the chance to benefit from
these procedures. On the negative end, the decision to
undergo aesthetic surgery may be less deliberate than it
had been in years past. The selection of a surgeon may
be more impulsive and the preoperative rapport devel­
oped between patient and surgeon may be less than ideal.
In addition, the number and types of practitioners who
are providing these services have expanded immeasur­
ably, and not all share the same level of training and
proficiency. Market conditions have led to the commodi­
tization of even invasive procedures such as rhytidectomy,
where franchises are owned and operated by business
people and surgeons are being used as technicians. Inten­
sive marketing, competition, and mass media coverage of
cosmetic surgery have trivialized operations and overide­
alized outcomes. Patients are also now led to believe that
they can obtain a surgical rhinoplasty result with the use
of injectable fillers alone. These factors increase the pos­
sibility that a rhinoplasty patient may encounter a poor
outcome and, what may be worse, be ill-equipped to
assimilate it.
Starting a practice in cosmetic facial surgery is daunting.
Every new facial plastic surgeon is eager to make his or
her mark and to put into practice his or her numerous
years of training, although, in truth, the real education is
only just beginning. The true value in having completed
a fellowship is in acquiring a lifetime of lessons in what
really matters to a cosmetic practice. Of course, what
interests the young surgeon is to be technically excellent
and to master the latest in techniques. Few surgeons,
especially neophytes, jump to the topic of this chapter
with enthusiasm, yet psychology is as germane to a suc­
cessful rhinoplasty practice as is any other topic in this
book, if not more so. Aesthetic surgery, more than almost
any other branch of medicine short of psychiatry, is really
a study of human relations. A patient’s happiness has to
do with so much more than just the technical proficiency
and the surgical result. Recognition of this fact is a critical
component underpinning all that we do. This chapter will
attempt to encapsulate some of the most useful aphorisms
a cosmetic facial plastic surgeon would do well to keep in
his or her breast pocket at all times. It will also elucidate
the warning signs that herald the potential for a maladap­
tive response to surgery and an unsatisfying situation for
both the patient and surgeon.
Patients choose our services based on so many real and
intangible factors. They do not really “need” us but they
simultaneously hope we have something to offer them that
will satisfy one of their most basic desires—to feel valued
by themselves and by others. Most rational, healthy people
do not actually want to have surgery. They understand,
though, that surgery is the step that must be taken to reach
their desired level of self-fulfillment. While they may not
have decided on the surgeon or on an exact procedure,
most patients have already taken the leap and decided to
have surgery before they visit us. The objective of the con­
sultation in their eyes is to determine if we are the right

44
Peter A. Adamson • Jason A. Litner
may have unwittingly misled the patient as to what you
could accomplish with the proposed procedure. You may
not have given the patient the time and attention he or
she deserved. You may have talked the patient into having
a chin implant because you thought it would improve her
rhinoplasty result, even though she expressed no interest
in this procedure. You may have been insensitive when
she was airing her postoperative concerns. You may have
accepted a patient who was a decidedly poor candidate
for rhinoplasty. Most of these factors are avoidable. A
patient’s happiness with the procedure is arguably as
much dependent on your attitude and conduct toward the
patient as it is on the technical result itself and on the
patient’s personality features.
To be sure, many patient factors play a role in this
interaction, and these will be examined. Yet, a survey by
the American Academy of Facial Plastic and Reconstruc­
tive Surgery showed that the most common reason for
patient unhappiness, more than all others combined, was
a breakdown of rapport (51% of cases). The rapport
developed preoperatively is most indicative of the direc­
tion of the postoperative dynamic. A strong preoperative
bond will usually be reinforced under difficult circum­
stances when both the surgeon and patient are working
toward a common goal of improvement. Likewise, a defi­
cient relationship will usually decay under duress, some­
times beyond recovery. To fully understand and prevent
problems pertaining to the surgeon–patient relationship,
the microscope must be turned inward.
AVOIDING AND PREVENTING
UNHAPPY PATIENTS
There is a kernel of truth in the old adage that the secret
to a successful practice is first Affability, followed by Avail­
ability and, finally, by Ability. Yet, there is no getting
around an undeniably flawed technical result. No amount
of kindness on the part of the surgeon can fully compen­
sate for this failure. Jack Anderson, M.D., was known to
teach that it is not essential that you operate brilliantly;
rather, you should strive to never operate badly. The best
defense against unhappiness, then, is to consistently do
good work. But, what of the majority of patients who
encounter an “adequate” result, one that most people
would describe as at least good, if not perfect? This result
has the potential to produce an overjoyed patient, a mostly
satisfied albeit mildly disappointed patient, or a hopelessly
discontent one. This difference has mostly to do with per­
ception. A patient who was given realistic expectations and
who is treated with true caring will be inclined to overlook
the minor imperfections associated with this outcome. A
similar patient with the identical result will be given to
chronic unhappiness if she was led to anticipate a far
superior outcome or if she or he was treated unjustly. The
following section takes a practical, rather than theoretical,
Against this backdrop, it is ever more important that
surgeons understand and embrace a rhinoplasty patient’s
psychology. Psychology is arguably more relevant to rhi­
noplasty than it is to other facial plastic surgical proce­
dures, because patients seeking aging face procedures are
not in search of a change so much as they are in pursuit
of a return to a previously favorable self-image. Rhino­
plasty patients, on the other hand, have often been living
since puberty with the insecurity attached to their nose.
This uneasiness has usually been a formative part of their
body image. They are more apprehensive about the
changes proposed since they often possess a clear vision
of their preferred self-image, although they may have a
hard time articulating that ideal. The failure of a rhino­
plasty procedure to harmonize with this desired self-image
can meet with profound anxiety. This is especially true
for revision rhinoplasty patients who carry the added
burden of already having experienced an overwhelming
disappointment.
The gravity of this reality should not be underesti­
mated. Physical violence against surgeons is rare but real.
In the decade from 1995 to 2005, five plastic surgeons in
the United States were killed by former patients. We all
possess a dominant personality type and we tend to use it
as a filter in response to our surroundings. In times of
stress, this response mechanism becomes exaggerated.1
Some of us weather the storms of our lives with little
fanfare. Some withdraw and retreat into ourselves. Others
strike out with aggression. A patient’s personality type can
be of prime importance in determining how he or she will
interact when faced with an unexpected surgical result.
WHAT MAKES PATIENTS UNHAPPY
Treatises on the subject of patient unhappiness usually
focus on patient factors that may contribute to this unfor­
tunate situation and tend to deemphasize the discussion
on surgeon-related factors as a possible cause. Since
surgeon factors are the only ones we can really influence,
it makes sense to explore these more in depth. You may
find it hard to admit that, more often than not, patients
are justifiably unhappy because you failed to meet their
expectations. With any luck, this happens very infre­
quently but, as the saying goes, if you do not have any
surgical problems, you are probably not operating enough.
Even the most meticulous and accomplished among us
has a measurable revision rate. Having a very low revision
rate, however, does not by itself declare you a great
surgeon. Your unhappy patients may simply be taking
your revisions elsewhere.
Patient expectations may have been unfulfilled for
several reasons that may or may not fall within your
control. The surgical outcome may have been truly subpar.
The patient may be the inauspicious recipient of a com­
plication despite your best efforts at avoiding one. You

CHAPTER FOUR  The Psychology of Rhinoplasty
45
is undertaking the procedure for some reason other than
his or her personal satisfaction, you should consider not
doing the surgery. A patient responding to external
motivators is far more likely to be discontent even with
an outstanding result. Unhealthy motivation and poor
self-image often combine to increase the chances of psy­
chological instability and dissatisfaction after surgery. By
the time you agree to schedule surgery, you should be
absolutely sure of the patient’s sincere motives for self-
betterment. Occasionally, surgery is not the answer and
patients deserve to know that at the outset. Otherwise,
you will discover a patient who continues to be dissatisfied
despite obtaining a good technical result.
Listen more. It can be tempting during your consulta­
tion to launch into a discourse on what patients need and
how fortunate they will be to benefit from your formidable
talents. Spend more time listening than speaking during
the consultation. A patient’s questions can be as revealing
as can their omissions. If the consultation becomes more
about you than about the patient, you will have missed
your chance to truly evaluate his or her suitability.
Be honest about your own motivations. External
motivators play a complicating role when deciding on
whether to operate on a potentially problematic patient.
Experienced surgeons have the benefit of a more finely
tuned “sixth sense” coupled with a motivation to avoid
accepting patients who are at higher risk for being dis­
satisfied. A younger surgeon is more driven to accept every
patient early in his career because he or she can ill-afford
to lose a case. He or she wants every potential patient to
choose him or her and will often ignore the little voice of
unease that says this patient may not be right for him or
her. Good judgment can easily be obscured by needs per­
taining to the ego or to the pocketbook. An unselfish
commitment to the patient’s best interests in every situa­
tion may necessitate some short-term sacrifice, in the form
of refusing surgery where appropriate, but will undoubt­
edly have the long-term rewarding effect of growing
your practice.
Recognize and respect your limitations. It is more
important to tell the patient what you cannot do rather
than what you can. Check your ego at the door. You
cannot be an expert at everything. The most respected
giants in our field often do no more than four or five
operations most of the time. They accumulate mastery of
a technique. That is not to say that all learning should
cease after training; quite the opposite is true. But, be
cognizant of your place on the learning curve. If you are
incorporating an emerging technology that you just dis­
covered at a recent meeting, tell the patient that the poten­
tial benefits are not entirely clear. Ask yourself if this new
technology is really likely to make your patient happier
with the result. If a patient would most benefit from a rib
graft, which you perform once a year, consider referring
him or her to a trusted colleague who has more experience
if you believe that to be the best procedure for that
approach to the discussion of what a surgeon may do to
increase the chances for having patients fall into the former
category. These truisms are not meant to be patronizing
but, rather, to act as a gentle reminder that the surgeon
very often controls the direction of the physician–patient
dynamic. The fact that they are generally simplistic and
even patently obvious does not diminish their value as
good principles of patient management.
If you do not like the patient, do not operate. This
seems self-evident, but you should follow the principle of
performing surgery on happy patients that you like. This
is probably the single most important tenet of patient
selection. A small percentage of people have a negative
outlook on virtually every aspect of their lives and there
is no reason to expect that your surgery will be any dif­
ferent. These are pessimists who exaggerate the negative
impact of a majority of their life circumstances. Many
harbor a general mistrust of physicians. As a result, they
are unlikely to be fully satisfied with even an excellent
outcome. Thankfully, these patients are relatively easy to
identify during the preoperative consultation. Happy
people, in general, are more likely to remain happy with
their results, to accept imperfection, and to refer their
like-minded friends and colleagues. This way, you will
continue to attract happy people to your practice.
Take yourself out of the equation. Understand, first
and foremost, that you do not matter as much as you
might think. We call what we do preoperatively “patient
selection” when, in fact, the truth is that you do not
choose the patient; the patient chooses you. You are the
gatekeeper of your practice. At best, you can refuse a
patient. It matters not what you think of your surgical
results. It matters only what your patients think; theirs is
the measure of your success.
Work at keeping your patients happy. When patients
agree to have you perform surgery, they are excited and
optimistic. They want to enjoy a fulfilling and productive
relationship with you. Contrary to popular belief, most
cosmetic surgery patients are usually happy, well-adjusted,
and committed people who are interested in self-
improvement. Testing has repeatedly shown that cosmetic
surgery patients are in the normal range for self-esteem,
although most have a low self-image for the particular
feature of concern.2 They are not typically unreasonable,
discontent, disordered, experiencing chronic health con­
cerns, or seeking secondary gain. Furthermore, most do
not expect perfection. When they cease to be happy, it is
usually because we have contributed to their displeasure
by the way in which we have responded to them. A cos­
metic practice is a little like a marriage in that happiness
does not appear out of thin air. With that in mind, you
should undertake every interaction with the philosophy
that your foremost purpose is in helping your patients to
achieve happiness.
Explore patients’ motivations. If you have concerns
that a patient may have a generalized low self-image or

46
Peter A. Adamson • Jason A. Litner
their fitness for our practice but also to convey informa­
tion at a time when they are more relaxed and more likely
to be receptive. The authors ask patients to sign a docu­
ment stating that they have received, read, understood,
and agreed to abide by all of the preoperative and post­
operative instructions. By doing so, patients grasp that
they are partners in this endeavor.
Tell a patient about the possibility of a revision. It is
easy to gloss over possible complications because this
discussion is uncomfortable and many patients do not
even wish to have it. This temptation should be avoided.
Patients should be given information along with an expla­
nation of the surgical consent both verbally and in writing.
The authors send patients home with a sheaf of literature
that is more inclusive rather than exclusive of instructions
on preoperative and postoperative care in addition to
potential risks of the proposed procedures. Patients should
be given time to review this information so they have a
chance to digest it quietly at home within their comfort
zone. That way, you are not springing something new on
them in the follow-up period at a time when they will view
new information with suspicion.
Respect your patients. Be likable and courteous. Do
not keep patients waiting and apologize when you do.
Schedule enough time to answer their questions. Patients
are more inclined to be happy with you if you show them
you actually care about them personally. Although you
cannot forge a successful practice just by being nice, a
cordial nature can produce inestimable dividends. If you
come off as distant, dismissive, or arrogant, your patient
is likely to form the impression that you treat every aspect
of his care or her with the same lack of concern, inclusive
of the surgery. You are more likely to end up with a prac­
tice full of patients who point out your minor failings
rather than be accepting of the minor imperfections they
encounter.
Save your patients added expense, time commitment,
and inconvenience. Do not put them through unnecessary
tests. If there will be added expense in the event of a
revision, spell these out for them ahead of time. Some­
times a patient is justified in being unhappy with the
result. Consider what you are willing to do for them in
that event.
WARNING SIGNS OF POTENTIAL
PATIENT DISSATISFACTION
The patients described earlier in this chapter are those we
seek for our practices. These are patients who have clear
and sensible motivations and reasonable expectations.
They understand the risks entailed by surgery and accept
that there is no guarantee of a perfect result or of absolute
satisfaction. They have divergent features of real concern
but they are not excessively preoccupied with them. Their
goals are reachable in our hands. They are courteous,
particular patient. A fourth time revision is perhaps not
one you wish to include among your first 50 rhinoplasties.
In general, a spirit of conservatism and prudence should
prevail if you wish to minimize the number of unhappy
patients you inherit. This is especially true early in your
career where a single unhappy patient can wreak havoc
on your budding practice.
Undersell the benefits. When you give your patients
an expectation of the result preoperatively, whether by
computer imaging or by other means, underpromise so
that you can overdeliver, exceeding patient expectations.
The authors make a habit of imaging a less than ideal
result. We tell our patients that surgery is imperfect but
we know that if they can be happy with the imaged
“average” result, then we can almost assuredly do better
for them. Be cautious of the rhinoplasty patient who also
needs a chin implant. Do not push the patient to have a
procedure that you think would be more beneficial. The
level of unhappiness with a less than perfect result is far
greater when the procedure was suggested by you rather
than by the patient. Instead, be honest in your appraisal
and dissuade patients from pursuing a procedure if they
would not benefit optimally. Your integrity will be most
welcome and will often result in a successful relationship
in the future.
Do not let your head overrule your gut. Your gut
instincts are not always right, but they often are. Your
impression of the patient in the first 5 minutes of your
interaction is usually an accurate preview of how this
interaction will play out postoperatively. In the book
Blink, the author Malcolm Gladwell describes that sub­
cognitive perception enables us to make rapid assessments
that have greater precision than those judgments that
result from extensive analysis. The patient you initially
think might present a problem after surgery often does
live up to those expectations. Most physicians are often
influenced by their urge to “do good.” The hope that your
technically good procedure will engender a joyful disposi­
tion in a patient who is psychologically unsuitable for
surgery is rarely realized. If you are unsure about a
patient’s suitability, spend more time with him or her. If
your doubts are reinforced, you will have made better use
of your time in deciding not to proceed with surgery than
in spending countless hours with an unsatisfied patient
after surgery. Remember, though, that the more time spent
with some personality types, the more psychologically
healthy they may appear.
Inform your patients properly. There is a saying
among experienced surgeons, “What you tell patients
before surgery is an explanation … what you tell them
afterwards is an excuse.” It is true that patients hear only
a small fraction of what you tell them during the consulta­
tion. So, make a habit of eliciting questions, speaking
slowly, repeating often, and imparting information in
more than one format. The authors routinely see patients
for a second visit prior to surgery, partly to further gauge

CHAPTER FOUR  The Psychology of Rhinoplasty
47
undergo surgery, rather than by expectations relating to
external factors, are more likely to view their surgical
results as successes. So, while cosmetic surgery may some­
times bring about secondary gains in the way of positive
life changes, these desired gains should not be the sole
motivation for surgery.
Patients with Culturally Rooted Concerns
Some patients face possible disapproval from family
members for their desire to alter the “family nose.” For
patients of specific ethnic backgrounds, their desire to
even consider undergoing rhinoplasty may be met with
condemnation by others sharing their ethnicity. Those
close to them may perceive patients as rejecting their
racial heritage. However, in our experience most ethnic
rhinoplasty patients wish to achieve a more balanced
nasal aesthetic while maintaining a strong ethnic identity.
If possible, the family should be made aware of this moti­
vation, as they will be more likely to be supportive of the
patient’s decision. Nevertheless, the negative influences of
family members and friends may unduly taint a patient’s
postoperative perspective. Therefore, it is important to
counsel patients with delicacy when they face such a situ­
ation if you wish to avoid having the patient’s frustration
with this scenario transferred to you. In addition, patients
who have some ethnic-specific features must accept the
inherent limitations presented, in that they may achieve
a result that is shy of what they wish. Thicker skin may
restrict the amount of definition and refinement achieved.
Very low nasal height may permit less than desired aug­
mentation. Darker skin may likewise render scars that are
more visible. On the positive side, patients should also be
apprised of the advantages inherent to some ethnic char­
acteristics, such as superior graft concealment.
INTRINSIC FACTORS
The following descriptions relate general psychological
states and behavior patterns that put patients at risk
for postoperative dissatisfaction. These are not meant to
be unkind to patients nor should they substitute for a
referral for definitive diagnosis and treatment of a
categorical mood, anxiety, or personality disorder. While
a surgeon cannot take the place of a psychiatrist, he
or she should be attuned to detection of these traits,
regardless of whether they meet criteria sufficient for
diagnosis, as they can impact the patient’s postoperative
temperament.
Mood Disorders
Depression. In any given year, 9.5% of the U.S. popula­
tion, suffer from a depressive illness, with women being
affected twice as often as men.6 Preoperative depressive
symptoms are the best predictors of postoperative depres­
sion, more so than other psychological aspects of surgery.2
Rarely, this postoperative decompensation can be severe,
pleasant, earnest, and dependable. They accept their
share of the responsibility for their actions and decisions.
They are not looking for nor expecting a radical, life-
altering change. They desire an outstanding result but
would be pleased with a good one. In short, these are
generous, happy, and well-balanced people who constitute
the majority of cosmetic surgery candidates.
We would all like to believe that every patient fits this
description, but not all prospective patients do. These are
not terrible people but they possess personality and psy­
chodynamic traits and coping mechanisms that place
them at an unhealthy risk for dysfunction following aes­
thetic surgery. They are more likely to be unhappy with
any result. We owe it to our patients to remember our
oaths and to make recommendations that will most benefit
them. For some of these patients, surgery is not the appro­
priate recommendation and we should make every effort
to save them and us the hardship of dealing with an
unhappy outcome. Unfortunately, poor candidates for
cosmetic surgery do not wear warning signs on their
chests. Some of these maladaptive traits take time to
become apparent and still others masquerade as wolves
in sheep’s clothing, only to surface after the procedure.
What follows is an accounting of the common warning
signs to which surgeons should be attuned in the preop­
erative period that will allow them to appropriately
counsel patients not to proceed with surgery. These have
been previously published in detail by the senior author
(P.A.A.) under the moniker “The Dangerous Dozen” and
can be further subcategorized as extrinsic or intrinsic
factors.3–5
EXTRINSIC FACTORS
Patients Experiencing A Life Crisis
Sometimes patients request cosmetic surgery after a
divorce, job loss, bereavement, accident, or illness. Alter­
natively, some patients wish to have surgery before a
wedding or graduation. Be careful of operating on patients
in the midst of a major life event, whether positive or
negative, as these may be significant stressors. It is ever
more important in these situations to analyze a candi­
date’s rationale. It is true that someone who possesses
improved self-esteem and confidence, as can be achieved
through cosmetic surgery, may in turn have greater success
finding a new mate or a new job. However, a decision
made under pressured circumstances or situational stress
may have unwanted consequences. Patients who thought
surgery was the answer to their problems may perceive
otherwise after these life stressors have settled. Patients
should ideally possess a state of mind that will permit
them to focus their energies on recovery. A more consid­
ered decision could often be made when life conditions
have been stable for some time. Evidence points to the
likelihood that patients who are motivated intrinsically to

48
Peter A. Adamson • Jason A. Litner
undergoing surgery since it is destined to failure in that it
will not diminish appearance-related concerns. The dis­
order is likely to persist or worsen despite surgical altera­
tion. Thankfully, effective treatment is usually possible in
the form of selective serotonin reuptake inhibitors and
cognitive-behavioral therapy.
Personality Disorders
Personality disorders are the psychological disturbance
most commonly encountered in patients seeking cosmetic
surgery.11 The following descriptions summarize those
specific personality types who are best deterred from
considering cosmetic surgery.
Psychologically estranged personalities. If you
encounter a patient who displays slightly odd thought or
behavior patterns and with whom you have difficulty
establishing a meaningful connection, you should consider
this personality type. In the initial consultation, it is not
uncommon to feel like “there is something missing” in the
interaction. It just “does not feel right.” Pay attention to
these instinctive reactions, as persons having this person­
ality type may appear more “normal” as you spend more
time with them. These are patients who may exhibit some
paranoid, schizoid, or schizotypical traits. They tend to
have suspicious thoughts and are guarded about their
histories and motivations. They may be eccentric in their
mannerisms. They may also appear to be emotionally
withdrawn and excessively serious and may react inap­
propriately to conversation. Patients who fit this category
have trouble giving you their trust and fall into the gener­
ally unhappy group of patients. Plastic surgeons should
avoid operating electively on patients with this personality
type. In the postoperative period, psychologically estranged
patients are more likely to be unforgiving and prone to
anger and even aggression. Since surgeons can never truly
be able to develop a rapport with patients of this personal­
ity type, it will be nearly impossible to deal with them
effectively after surgery. Thankfully, these high-risk
patients are rare.
Borderline personalities: The Goldilocks syndrome.
Borderline personalities are unstable in many areas of
their lives, including interpersonal relationships, thoughts,
mood, behavior, and self-image. More often female, they
are often very bright, manipulative, and beguiling and,
for that reason, may escape detection in the initial con­
sultation. Be wary of patients who appeal to your vanity
with premature and excessive familiarity or praise. Fre­
quently heard expressions include, “I just knew a surgeon
with your talents could help me” and “You’re the first one
to understand me perfectly.” This personality type’s ten­
dency to impulsive extremes and absolutes results in the
phenomenon known as “splitting.” While you may be
idealized preoperatively, you may be vilified postopera­
tively with comparable ease.
The Goldilocks syndrome is a manifestation of the
borderline personality with histrionic characteristics.
even manifesting with psychotic symptoms. Postoperative
depressive illness appears to occur more frequently after
rhinoplasty. So, it is incumbent upon the surgeon to
address this issue in the preoperative period. Patients with
a history of depression should be informed of the increased
risk for impaired coping in the postoperative period. The
patient’s counselor should be involved during the preop­
erative assessment to ensure that management of this
illness is optimized prior to undertaking surgery. Extra
care should be taken to ensure that these patients have
the support they need to endure the stresses associated
with postoperative healing.
Anxiety Disorders
Generalized anxiety disorder. Anxiety affects up to 18%
of the U.S. population and often occurs coincidentally
with depression.7 People suffering from generalized
anxiety have chronic, nonspecific worry that is difficult to
control. Although they may be good surgical candidates,
these patients usually need extra attention and care. They
are pessimistic by nature and may tend to fret over even
normal postoperative healing. Stressful events such as
surgery may cause an exacerbation of symptoms. Never­
theless, reassurance and care will often allow these patients
to appropriately frame their results and to obtain postop­
erative satisfaction.
Body Dysmorphic Disorder
Body dysmorphic disorder (BDD) is an uncommon but
severe psychiatric disorder in which the affected person is
excessively preoccupied with a minor or even imagined
physical defect. People suffering from BDD are generally
of normal or even highly attractive appearance, yet believe
themselves to be so hideous as to inhibit normal social
interaction. It is estimated that between 1% and 2% of
the general population is affected, although the incidence
of a milder phenotype may be as high as 5% to 15%
among cosmetic surgery patients.8,9 The nose is the third
most frequently associated body area after the skin and
hair.10 Thus, facial plastic surgeons must maintain a high
index of suspicion for this disorder with all patients
seeking rhinoplasty.
BDD is linked to the obsessive-compulsive spectrum of
disorders and affects men and women equally. Personality
types that are more susceptible to this disorder include
introverted, perfectionist, dependent, and avoidant per­
sonalities who are highly sensitive to criticism. They tend
to be secretive, even reclusive, and reluctant to admit to
the severity of the disorder or to seek help for fear of
rejection. Psychological comorbidity is prevalent, includ­
ing social anxiety, obsessive-compulsive disorder, and
depression. Suicidal ideation is present in about 80% of
sufferers, and the completed suicide rate is more
than double that of those with clinical depression and 45
times the rate of the general population.10 These patients
should be identified preoperatively and dissuaded from

CHAPTER FOUR  The Psychology of Rhinoplasty
49
your postoperative directions. Since he is unwilling to
accept a share of the responsibility for his decision, he is
also unlikely to be forgiving of an imperfect result. You
should try to identify and avoid this personality type early
in the consultative process.
Antisocial personalities: The “my theory” syndrome.
While the extreme antisocial personality can be character­
ized as a true psychopath, a milder phenotype is occasion­
ally seen among aesthetic surgery candidates. These are
patients having a superficial charm that masks an inflated
self-appraisal and lack of empathy. They may be deceit­
ful, withhold information, and fail to conform to office
standards. They may have a history of drug seeking and
substance abuse. There may also be a component of
antagonistic behavior, including a disregard for financial
obligations and a history of lawsuits against previous sur­
geons. Conduct is characterized by agitation, bouts of
aggression, and impulsivity. The “My theory” syndrome
patients display a variant of this personality type that
blends obsessive and antisocial traits. These patients have
little respect for the surgeon’s viewpoint and have little
interest in listening to what the surgeon has to say. Instead,
they are only interested in advancing their own theories
of what is wrong with their noses and what must be done
to fix them. They are usually extensively well read and
often present with scientific articles and detailed drawings
or alterations of their own images. They believe they know
exactly what surgical maneuvers are needed to achieve the
improvements they seek. “My theory” patients frequently
interrupt the consultative process, dominate the interac­
tion, solicit information already provided, and react with
veiled hostility when presented with an explanation or
recommendation that does not support their own conclu­
sions. Extra care must be taken to ensure that these
patients are adequately informed of the risks and realities
of surgery. If it appears that a “my theory” patient is
unwilling to surrender his beliefs and to entrust his care
to his surgeon, it would be wise to advise against surgery.
Any patient who demonstrates hostility in the preopera­
tive period or who breaks the “sacred trust” should be
avoided altogether.
A more radical version of this personality is the well-
described SIMON syndrome (single, immature, male,
obsessive, and narcissistic).12–14 This syndrome has
received singular attention in the literature because of the
dangers involved. Patients falling into this category
possess a multiplicity of maladaptive traits that dispose
them to both dissatisfaction and potentially threatening
behavior. As a result, surgeons should proceed with
extreme caution when considering rhinoplasty in such
patients.
Obsessive-compulsive personalities: The “package of
pictures” syndrome. Compulsive personalities are high-
achievers but they are rarely fully satisfied with their
achievements and may have a deflated self-image. They
are often orderly, punctual, and dependable. You can rely
These patients function at a high level but tend to use
their ample social skills in the service of manipulating
others in their quest to become the center of attention.
Like the protagonist of the children’s story after which
this patient is named, they will never be fully satisfied
unless everything is “just right.” She often fails to see her
personal situation realistically and tends to overly drama­
tize her problems while shifting the blame for her disap­
pointments to you. All of these factors, along with
instability of self-image, predispose this patient to greater
risk for development of dissociative tendencies, crisis
involving loss of identity, and depressive states after
rhinoplasty.
Patients with loss of identity will complain that their
rhinoplasty changes, no matter how subtle, have caused
them to no longer “look like themselves.” When probed
for details, they are vague, evasive, unfocused, and unable
to give any more specific descriptions. This frustrates both
patient and surgeon and may lead to inappropriate out­
bursts of anger by the patient. Somatic complaints are
frequently associated with the nose, including airway
obstruction, pain, and tenderness, especially at the rhinion.
Borderline personalities typically become more apparent
as the extent of the interaction increases, so ample time
should be invested during the preoperative period. If in
doubt, one should not operate on patients showing this
personality type. Their unstable behavior and fluctuating
self-image make these patients prone to isolation, unhap­
piness, and unpredictable and self-destructive behavior.
Narcissistic personalities: The exceptionalism syn­
drome. This personality type is excessively preoccupied
with issues of personal adequacy, power, and prestige.
Often, these patients are successful in their chosen indus­
try and exhibit a pervasive pattern of grandiosity com­
bined with a lack of empathy. These patients are easy to
recognize and often will frustrate your front office staff by
their blatant egocentrism starting as early as through the
first telephone contact. The overriding message projected
by this personality type is that his time is valuable while
yours is expendable. He is often late, cancels appoint­
ments frequently, takes telephone calls in the office, and
demands to see the physician immediately upon arrival
because he has an important meeting afterward. These
patients’ overinflated sense of self-importance extends to
their interactions as well. They hold the belief that no one
but persons of high status are deserving of their attention
and, very often, they will attempt to bypass any dealings
with nurses, associates, or other staff members. While a
patient with exceptionalism syndrome may treat the
surgeon with deference, at least initially, difficulties often
arise later. He is usually inconsiderate of the viewpoint of
others and does not listen during the preoperative consul­
tation. If the patient will not make time for the consulta­
tion or cancels for trivial reasons without the courtesy of
notice or apology, you can be sure he will not have much
patience for you after surgery nor is he likely to follow

50
Peter A. Adamson • Jason A. Litner
identifying a specific complaint about their noses. Instead,
they may shift the burden of decision and action to you.
This indecision may be expressed by such phrases as, “I’ve
never liked my nose but I cannot say why.” Surgical plan­
ning is compromised in that surgeons bear the sole re­
sponsibility for an undesirable outcome. Patients in this
situation are at risk for postoperative dissatisfaction.
These will usually manifest as vague complaints, such as,
“I do not know what it is, but I just do not like how the
surgery turned out.” Preoperative counseling should focus
on gaining the patient’s trust, encouraging him or her to
identify specific concerns and to challenge his or her exag­
gerated negative beliefs. If that is successfully accom­
plished, then a satisfying operative experience is made
possible.
Dependent personalities: The “exhausted surgeon”
syndrome. As the name suggests, patients exhibiting this
personality characteristic have exhausted themselves and
every surgeon they have seen. They are the quintessential
“doctor shoppers,” spending inordinate amounts of time
researching and visiting surgeons. This behavior pattern
has arisen from a general lack of confidence in their own
judgment, abilities, and capacity to make good decisions.
Dependent personalities often require disproportionate
amounts of advice and reassurance from spouses, friends,
relatives, and even strangers, such as visitors to online
rhinoplasty forums.
Like the avoidant personality, dependent patients
would prefer for you to direct the consultation. When
asked about her nose, this patient may demonstrate her
need for you to assume responsibility with statements
such as, “You’re the expert. What do you think I should
do to my nose?” They may have difficulty expressing open
disagreement with your suggestions. When they are finally
able to commit to surgery, these characteristics continue
to guide the postoperative dynamic. This patient may go
to excessive lengths to ensure your unwavering support
and nurturance such as through elaborate gift-giving and
excessive praise. Yet, they will probably not voice their
disappointments and instead will eventually seek another
surgeon when events do not go exactly as planned. Fre­
quently, this syndrome is accompanied by anxiety, insom­
nia, and depression, as a result of the stress associated
with perceived powerlessness and indecision. Not infre­
quently, it may affect aesthetic surgery patients who work
in the medical or paramedical field. These patients meet
the description of “maximizers” put forth by Barry
Schwartz, author of The Paradox of Choice. Unlike “sat­
isficers,” who make quick and confident purchasing deci­
sions and are satisfied by “good enough,” “maximizers”
are preoccupied by hypothetical “what if’s.” They are
unable to commit to a decision without first exploring
every avenue and making comparisons. They suffer from
“paralysis of analysis,” holding out for the absolute best
conditions and surgeon, taking years to reach a decision.
Because of the expectations heaped on this choice, patients
on these patients to follow instructions to the letter. Yet,
while they can be reliable patients, they also tend to be
excessively cautious and detail-oriented, making it diffi­
cult for them to make a decision. They may need to see
you numerous times to review the imaging or surgical plan
before agreeing to surgery. The “package of pictures”
syndrome may be a specific manifestation of the obsessive
personality type. Patients presenting with a package of
pictures often have unrealistic expectations. They may
present preinjury or presurgical photographs of them­
selves or photographs of models demonstrating the very
clear and specific improvements they desire. Very often,
these desired changes are unattainable for that patient.
This does not mean that every patient in this category is
at high risk for postoperative disappointment.
To stratify patients’ risk in this scenario, it is neces­
sary to ascertain to what degree they cling to their expec­
tations. The trouble with obsessive patients lies in their
inflexibility. You will be able to differentiate the obsessive
personalities by their inability to “let go” of their exces­
sively optimistic demands. If a patient is simply unin­
formed, he or she will be able to alter his or her expectations
after careful explanation of the limitations and realities of
cosmetic surgery. These are favorable surgical candidates
who understand that the goal of surgery is improvement.
If, however, a patient is unable or unwilling to reframe his
or her too-lofty expectations and continues to demand
unrealistic assurances of any kind, the surgeon should
decline to operate. These patients manifest attributes of
BDD and obsessive-compulsive personalities and are at
very high risk for postoperative unhappiness. They are not
dangerous per se, but they will often be troubled with the
operative result. Postoperatively, they will perseverate
over minor or barely perceptible defects and will find
themselves unable to acknowledge the overall improve­
ment or to derive enjoyment from their good surgical
result.
Avoidant personalities: The unfocused syndrome.
Avoidant personalities are socially inhibited and are pre­
occupied by feelings of inadequacy. They consider them­
selves to be personally unappealing and, rather than
facing possible rejection, they choose to preempt this risk
by consigning themselves to self-imposed isolation. This
personality is associated with perceived or actual rejection
by parents or close peers during the formative years and,
thus, they have an intense desire for intimacy in relation­
ships. This intense need can often be inappropriately dis­
placed onto unrealistic hopes for the surgical outcome.
The avoidant personality’s interactions are distinguished
by intense monitoring of their own internal reactions
along with those of others. This constant monitoring pro­
duces in them extreme tension that manifests as hesitant
speech and taciturn behavior. Surgeons should look for
symptoms of self-loathing, extreme shyness, mistrust,
emotional distancing, and loss of identity. They are often
unfocused and may show a reluctance or incapacity for

CHAPTER FOUR  The Psychology of Rhinoplasty
51
defensive posture. Sure, it may help to bring out the
preoperative photographs to demonstrate how much
better the result is now. But, do not argue with unhappy
patients. You would not make them happier. Be empathic
and compassionate. Acknowledge their disappointment.
Then, ask the patient what they are looking for to be
happier with the result. Sometimes all they want is your
empathy. If you think the result is good and you have done
your best, tell them you do not think you can do any better
for them. Try to understand the reasons for their disap­
pointment even in the face of a good result. If the result
is less than your best, admit to the fact that you see the
problem. If there is something you think you can and
should fix, then offer to do so at the appropriate time.
Say you are sorry. When something does not go as
planned, say you are sorry. The prevailing culture among
physicians is one of fear of apology for unexpected out­
comes as this may be misconstrued as an admission of
wrongdoing. Nondisclosure of medical errors is, in actual­
ity, associated with a more negative emotional response,
reduced patient satisfaction and trust, and increased like­
lihood of changing physicians or of seeking legal advice.15,16
To encourage a policy of disclosure when there is a medical
error involved, some states have now passed “apology
laws” that allow providers to exclude statements of sym­
pathy from evidence in a liability lawsuit. Although
patient unhappiness does not constitute an error as such,
patients facing a disappointment following cosmetic
surgery are experiencing emotions similar to those facing
a medical error claim. An expression of your empathy can
go a long way toward attenuating a patient’s sense of
resentment without constituting an admission of wrong­
doing. Often, this position can strengthen your rapport
with your patient and permit you both to endure the
outcome together. Of interest, the act of apology appears
more important even than monetary restitution, as in one
study an offer to waive costs was not associated with a
statistically significant impact on patient responses.15
Do not lecture to or blame your patient. Labeling
patients as “problems” or as “difficult” is self-defeating
and sometimes unfair. This is pejorative defensive postur­
ing that does not improve the situation and sets an antag­
onistic stance that risks alienating both the patient and
the surgeon. It is easy to castigate a patient for not fol­
lowing instructions. But, it is the rare case where a poor
outcome can be attributed solely and completely to a
patient’s noncompliance. Dealing with unwanted results
really boils down to how people relate to one another. A
patient that you see as a “problem” might have a com­
pletely different experience with another surgeon, and the
opposite is true. We cannot relate perfectly to everyone.
The objective of patient selection is to find the right fit. If
the fit was not quite right, acknowledge that privately and
try to make the best of the situation. By providing yourself
this constant reminder, you will avoid having the interac­
tion evolve into a far less constructive one.
with “exhausted surgeon” syndrome often suffer from
buyer’s remorse. They cannot help but compare their
results to those of others, think of the alternatives, and
wonder whether that other surgeon would have done any
better. According to The Paradox of Choice, these patients
could be happier if they gained insight into their struggles,
enacted voluntary constraints on their freedom of choice,
lowered their expectations, accepted good enough rather
than perfect, and they stopped comparing their experi­
ences to others. This advice is reminiscent of the surgeon’s
adage, “Perfect is the enemy of good.” Comparably to the
“maximize,” we need to bear in mind that although per­
fection is our relentless pursuit, it is unattainable.
DEALING WITH UNHAPPY PATIENTS
Thankfully, patient dissatisfaction is uncommon in plastic
surgery. Nevertheless, it can be a source of great stress to
a practice, not to mention the distress experienced by the
patient. It can be easy to characterize an unhappy patient
as “difficult.” Even when it may be justified, this attitude
will not put you in the right mindset to deal with the situ­
ation most effectively. Rather, the overriding question
should be how you can best help your patient beyond his
or her current level of distress. To do this, you must learn
to always gain control of your emotions and to overcome
your instinct toward self-protectionism. That way, you
can approach every interaction with the patient’s best
interests at heart and operate with the knowledge that you
are “doing right” by the patient.
Embrace your complications. A most memorable
lesson offered by Joseph V. Arigo, M.D., to his residents
during their training was the turn of phrase, “Embrace
your complications.” This surgeon, who had never been
sued in over 40 years of practice, was convinced that the
secret to his success was not his technical prowess but his
extraordinary care of occasional patients who had suffered
setbacks during their course of healing. According to his
philosophy, unhappy patients or those suffering complica­
tions should be contacted and seen in the office twice as
often as was necessary or routine for an uncomplicated
course. Where many surgeons go wrong is in following the
impulse to retreat from “problem” patients. We all wish
to avoid contentious situations. Yet, by rushing unhappy
patients out of the office, refusing to listen or to let them
vent their frustrations, and, in essence, disengaging from
their care, we are only underscoring their misgivings that
we perhaps did not do our best for them. You should take
every opportunity to do the opposite. By showing the
patient that his or her concerns are worthy of your time
and caring, you are giving your patient much needed
legitimacy. This simple act, by itself, can reduce the inten­
sity of any negative feelings toward you.
Do not be overly defensive. One of the major pitfalls
to avoid in dealing with unhappy patients is to take a

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Peter A. Adamson • Jason A. Litner
of a discourse. This person may help to articulate the
patient’s concerns in a more constructive way. By intro­
ducing at least some measure of objectivity, this person
may also ease the patient’s agitation about the outcome.
When the surgeon tells a patient she has had a good result,
the surgeon will appear self-serving. When the patient’s
friend tells her that she has had a good result, the patient
is more likely to be responsive.
An important aspect of this interaction is the family’s
attitude toward the patient. Some family members reject
patients experiencing a difficult postoperative course, cen­
suring them for failing to heed initial warnings not to
undergo surgery. This lack of support can deepen the
patient’s sense of guilt and isolation. In this case, efforts
to reach out to the family may help to bolster support for
the patient and to facilitate her recovery.
Involve your staff. Experienced staff members are an
invaluable part of a plastic surgeon’s practice. Respect
your staff’s intuition. A well-attuned staff can alert you to
potential problems with prospective patients and even
save you from yourself at times. Staff can sometimes elicit
greater information about a patient’s history, motivations,
expectations, coping strategies, and postoperative com­
plaints than the patient is willing to express directly. This
should inform your decision of whether to welcome the
patient into your practice. Think twice about whether to
operate on a patient who treats your staff far differently
than he or she treats you.
Your staff should be trained to present themselves as
a cohesive unit. You can hire the most wonderful indivi­
duals, but they must learn to work together effectively.
Model the behavior that you wish them to exhibit. Since
the patient experiences the practice in its entirety, one
unpleasant note can sour the whole impression of your
office. Your staff can be particularly helpful in dealing
with unhappy patients. While dispensing medical advice
is your prerogative, your staff can provide an air of avail­
ability, a listening ear, and an empathic voice. This does
not mean they should jointly descend on an unhappy
patient to convince him or her of his or her good result.
This type of behavior will only raise a patient’s suspicions.
Rather, patients coping with postoperative difficulties will
welcome a sense of staff receptiveness and responsiveness
to help assuage their anxieties.
Involve your colleagues. Develop referral patterns
with supportive colleagues early on in your practice.
Having trustworthy colleagues with whom you can “float”
your concerns and anxieties around unhappy patients can
have a tremendously positive effect on your ability to
manage these stressful situations. Sometimes, referring
your dissatisfied patient to a colleague for an objective
opinion can help to settle the patient’s worries about the
result. Give your patient several names of reputable physi­
cians to whom you would entrust his or her care. You
should understand that a distrusting patient will look
upon your referral with wariness, suspecting that you and
Do not try to solve the problem. Surgeons are problem-
solvers by nature. We tend to be overly analytical. When
faced with an unhappy patient, resist the urge to solve the
problem. The majority of patients experiencing postop­
erative concerns with healing are looking for understand­
ing and acceptance of their worries, and for support and
reassurance. This applies to every scenario. If the patient
is experiencing distress around a normal course of healing,
she or he wishes reassurance that all will be satisfactory.
If a patient, on the other hand, has experienced a compli­
cation or a flawed result, she or he wishes honest disclo­
sure and reassurance that you will do your best to support
her or him through the problem. Depending on the cir­
cumstance, this may mean doing nothing but listening
and providing support, returning her or his investment if
you believe in that practice, revising the procedure if you
can and if you feel it warranted, or referring the patient
to a colleague if so desired. If you take a stance of partner­
ship in the early period of distress, you are likely to cul­
tivate a sense of collaboration rather than opposition.
Patients’ reactions rarely become litigious unless and until
you have also escalated your oppositional behavior in
response.
Resist the urge to rush to intervention. This caution
is similar to that just given. Sometimes, you may have an
inkling that a revision will be necessary in the future.
However, time heals many concerns, so make a policy of
watchful waiting. Waiting at least 6 months before offer­
ing a revision is a good strategy. This has several favorable
effects. The early inflammatory response will have had
time to settle, rendering the revision easier to accomplish.
The patient’s initial anxiety response associated with the
outcome will also likely have diminished somewhat.
Finally, the problem may resolve to the extent that neither
the patient nor the surgeon believes a revision is necessary.
An exception to this rule would be a case in which you
expect that the problem will worsen or will not improve
sufficiently over time.
Do not let the patient talk you into an unnecessary
revision. If the result is not completely satisfactory, then
you and the patient can agree that a revision may be
advisable. Obviously, you will do your best to correct any
problems. However, if the patient is overly concerned by
a barely perceptible problem, you will not be doing the
patient a service by trying to improve upon your good
result. Remember the law of diminishing returns. The
closer you get to an ideal result, the harder each incre­
mental improvement is to achieve. If you agree to a revi­
sion, do not alter your surgical plan or add procedures at
the final moment. This applies to the primary procedure
as well.
Involve the patient’s family or friends. If a patient is
open to involvement of her or his family members or
friends, this can sometimes help greatly in easing tensions.
Rather than limiting the contact to the patient and
surgeon, this scenario returns the communication to more

CHAPTER FOUR  The Psychology of Rhinoplasty
53
To make this change effectively, a surgeon must look
outward to identify and steer clear of potential at-risk
personalities but also look inward to identify his or her
distinct style of behavior in reaction to various personal­
ity types. By combining these factors with experience, a
surgeon can best resolve to determine which rhinoplasty
candidates should or should not meet the threshold for
admission to his practice. While patient dissatisfaction is
an unpleasant reality imposed by the imperfect art of
aesthetic surgery, as surgeons we should learn to mini­
mize the impact of these uncertainties on our practice to
create a legacy of contentment among patients and in our
professional life.
REFERENCES
1. Littauer F. Personality Plus. Grand Rapids, MI: Fleming H.
Revell Co; 1994.
2. Goin JM, Goin MK. Changing the body: Psychological effects
of physical surgery. Baltimore: Williams and Wilkins; 1981.
3. Adamson PA, Chen T. The dangerous dozen: Avoiding
potential problem patients in cosmetic surgery. Fac Plast Surg
Clin North Am. 2008;16(2):195–202.
4. Adamson PA, Litner JA. Psychologic aspects of revision
rhinoplasty. Fac Plast Surg Clin North Am.
2006;14(4):269–277.
5. Adamson PA, Strecker HD. Patient selection. Aesthet Plast
Surg. 2002;26(suppl 1):S11.
6. Robins LN, Regier DA, editors. Psychiatric disorders in
America, the epidemiologic catchment area study. New York:
The Free Press; 1990.
7. Kessler RC, Chiu WT, Demler O, et al. Prevalence, severity,
and comorbidity of 12-month DSM-IV disorders in the
National Comorbidity Survey Replication. Arch Gen
Psychiatry. 2005;62(6):617.
8. Wilson JB, Arpey CJ. Body dysmorphic disorder: Suggestions
for detection and treatment in a surgical dermatology
practice. Dermatol Surg. 2004;30:1391–1399.
9. Veale D. Body dysmorphic disorder. Postgrad Med J.
2004;80:67–71.
10. Phillips KA. The broken mirror: understanding and treating
body dysmorphic disorder. New York: Oxford University
Press; 2005.
11. Wright MR. Management of patient dissatisfaction with results
of cosmetic procedures. Arch Otolaryngol. 1980;106:466–471.
12. Ely JF. Less is more: A conservative approach to male
rhinoplasty. Aesthet Plast Surg. 1996:20:23–28.
13. Gorney M. Cosmetic surgery in males. Plast Reconstr Surg.
2002;110:719.
14. Rohrich RJ, Janis JE, Kenkel JM. Male rhinoplasty. Plast
Reconstr Surg. 2003;112:1071–1085.
15. Mazor KM, Reed GW, Yood RA, et al. Disclosure of medical
errors: what factors influence how patients respond? J Gen
Intern Med. 2006;21(7):704–710.
16. Wei M. Doctors, apologies, and the law: An analysis and
critique of apology laws. J Health Law. 2007;40(1):107–159.
your colleague are in cahoots. This pattern of thinking
will be discouraged if your overriding attitude is one of
concern for your patient’s well-being. Your patient will be
more likely to be accepting of the fact that you are doing
your best to satisfy her or his expectations.
Involve your medical liability insurance carrier. If it
appears that a patient remains very angry and upset with
the result despite the passage of time and your best efforts
at resolution, you should consider involving your mal­
practice carrier or your institution’s risk management unit
once it appears the relationship is deteriorating. Your
carrier may choose to intervene to help defuse the situa­
tion before it escalates beyond control. The company may
also provide useful advice on how to conduct yourself in
this situation. Finally, if you are considering a touch-up
revision or a return of the patient’s fees, you should look
into obtaining a waiver of liability from the patient.
SUMMARY
Cosmetic surgery, and especially rhinoplasty, is different
from other types of surgery by virtue of the whirlwind
of emotions and expectations concerned and by the
extraordinary weight attached to them. Attempting to
displace the role of the psychiatrist in the assessment of
rhinoplasty candidates is not only misguided but danger­
ous. That is by no means the purpose of this chapter.
However, those surgeons who naively dismiss the impact
of psychology on the rhinoplasty candidate’s belief system
do so at their own peril. The material offered here is
designed to help the surgeon to understand both patient
and surgeon factors that increase the chances for patient
unhappiness.
In the current litigious climate in which we practice
surgery, it can be easy to approach this topic from the
perspective of self-preservation. Yet a surgeon is able to
better develop a solid rapport and ultimately to satisfy
his or her patients’ desires if the surgeon approaches his
or her practice with a spirit of beneficence. Emphasis
should be placed on a caring and comprehensive approach
to patient education that stresses the realistic goals, risks,
results, and limitations of rhinoplasty. To ensure optimal
outcomes and to minimize the number of unhappy
patients under his or her care, a proactive approach
needs be taken to refine the patient selection process. The
question facing surgeons during the consultative process
should be shifted from, “Can I achieve a good result for
this patient?” to “Will I be able to satisfy this patient?”
This nuanced shift in thinking not only takes into account
the technical probabilities at hand but also marries these
to the patient’s characteristics and expectations within
the context of the overall patient–physician relationship.

55
C H A P T E R F I V E 
Primary Open Structure Rhinoplasty
William Numa • Calvin M. Johnson, Jr. • Wyatt C. To
There are no shortcuts to quality.
Ernest and Mary Hansen
Founders of Hansen’s Sno-Bliz, New Orleans, LA
that approximates zero but should be able to tolerate one
approximating 5%.
PREOPERATIVE EVALUATION
AND DIAGNOSIS
A separate chapter is specifically dedicated to this criti­
cally important topic. Throughout the initial consulta­
tion, a complete medical history and head and neck
physical examination is carried out, with particular atten­
tion being directed to the nasal anatomy and function.
The patient’s stated functional and aesthetic concerns
are documented in the medical record and standardized
digital photodocumentation takes place. An open conver­
sation clarifying realistic expectations of what can be
accomplished with rhinoplasty is carried out in light of
the functional and aesthetic priorities discussed by both
patient and surgeon.
The columellar scar is next to imperceptible if meticu­
lous suturing techniques are used, and by itself it should
not be a critical factor in deciding whether an endonasal
or an external approach is carried out.
ANESTHESIA
The meticulous and detail-oriented nature of open struc­
ture rhinoplasty requires the use of general endotracheal
anesthesia or deep intravenous sedation. Appropriate
anesthesia will aid in hemostasis, amnesia, and analgesia
during and after the case.
Prior to arrival at the surgical facility, the patient is
instructed to take an antiemetic (aprepitant 40 mg) for
postoperative nausea, along with an anxiolytic (lorazepam
1 mg) as needed for anxiety. An intravenous line is initi­
ated, and the patient is administered a dose of anxiolytic
PRIMUM NON NOCERE
The first goal during rhinoplasty, as with all other aspects
of medicine and surgery, is to do no harm, and it pertains
to both nasal function and aesthetics. Moreover, every
rhinoplasty patient will present with a set of positive nasal
functional or aesthetic features that need be preserved.
Capitalizing on years of training and cumulative experi­
ence while paying close attention to the patient’s stated
concerns, surgeons should prioritize the nasal features to
be surgically addressed and, in some ways even more
important, those that need to be preserved both function­
ally and aesthetically.
Paradigms of beauty are somewhat subjective and
variable, and may shift gradually with time. Some models
considered beautiful today may have not been considered
as such in different time periods throughout history.
However, timeless concepts such as balance, symmetry,
and general guidelines of facial and nasal proportions can
help lead us with the certainty and conviction of knowing
the surgical goal will be aesthetically pleasing and natural-
appearing decades after accomplished.
An ideal surgical result is based on excellent nasal
function as well as a proportioned, balanced, natural-
appearing, aesthetically pleasing nose. Conceptually, a
great rhinoplasty result deemphasizes the nose to allow
the casual observer to look past it, focusing on the sub­
ject’s eyes, appreciating the entire face in context, without
specific distractions. Each rhinoplasty is different, in as
much as a person’s nose should befit their gender, ethnic­
ity, and surrounding facial features as well as their under­
lying facial skeletal structure.
The rhinoplasty surgeon’s mindset should be to carry
out every measure possible to ensure that the current
rhinoplasty procedure is the patient’s last one. Having said
that, some patients seek and subsequently undergo revi­
sion rhinoplasty. Surgeons should strive for a revision rate

56
William Numa • Calvin M. Johnson • Wyatt C. To
deviates the nasal pyramid to the right. The caudal septum
pulls the lip forward, blunting the nasolabial angle. The
thickness of the SSTE can be described as thin to medium
thickness.
PREOPERATIVE CONSIDERATIONS
1. The size and shape of the tripod must be
optimized—notably, the bulbosity of the lateral
crura and the bifidity of the medial crura.
2. As the anterior septal angle is reduced and the tip
deprojected, the height of the dorsum will seem
even higher. Thus, the bony–cartilaginous hump
will require reduction.
OPERATIVE PROCEDURE
1. Marks are made in the midline of the glabella, the
midline of the tip, and the midline of the upper lip
to serve as reference points. Note that the nose is
deviated to the right.
2. The nasal cavity is packed loosely with Nu-Gauze/
cottonoid pledgets moistened with a solution
containing 4% cocaine. This is left in place for
several minutes and removed prior to injecting the
local anesthetic.
3. An equal mixture of 1% lidocaine with
1 : 100,000 epinephrine and 0.5% bupivacaine
with 1 : 200,000 epinephrine is used for injection.
The bupivacaine is included for its longer duration
of action, which helps to reduce the amount of
inhalational and parenteral anesthetic agents
needed to maintain an adequate level of anesthesia
during the procedure. The septum is injected
using a 27-gauge needle on a 12-mL offset port
syringe. The offset port allows easier visualization
of the nasal cavity during injection. The septum is
injected in a subperichondrial/subperiosteal plane
with the bevel facing the septal cartilage, elevating,
hydrodissecting, and causing blanching of the
mucosa. The local anesthetic provides
hydrodissection, vasoconstriction, and hemostasis.
Both sides of the septum are injected with multiple
needle sticks in a posterior-to-anterior fashion.
4. The membranous septum is not injected directly to
prevent distortion of the columella and tip. Instead,
the caudal edge of the septum is injected and the
local anesthetic is allowed to diffuse into the area
of the membranous septum on its own.
5. The pyriform aperture and anterior nasal floor are
injected at multiple sites.
6. The lateral walls of the nose are injected via an
intercartilaginous approach just superficial to the
nasal bone periosteum. Injection is done as the
and narcotic for sedation (typically midazolam 1 mg)
(Sublimaze [fentanyl] 50 micrograms). Additional doses
of midazolam and fentanyl may be administered through­
out the duration of the surgery, titrating to appropriate
levels of analgesia, amnesia, and sedation. Preoperative
antibiotics with broad-spectrum gram-positive coverage
are dosed intravenously.
Monitoring includes continuous pulsoximetry, electro­
cardiography, blood pressure, and end-tidal CO2. General
anesthesia can be induced with a propofol bolus in con­
junction with a short- or intermediate-acting, nondepolar­
izing muscle relaxant such as atracurium. After intubation,
general anesthesia is typically maintained with sevoflu­
rane, which is favored for its fast onset and offset, its
favorable cardiovascular profile, and its lower incidence
of nausea, vomiting, and airway reactivity.
Use of a preformed endotracheal oral RAE tube allows
the anesthesia tubing to run toward the patient’s feet,
away from the surgical field. Care is taken to avoid undue
traction of the mouth and nose with the endotracheal tube
to minimize traction and asymmetries, which can mislead
the surgeon.
PATIENT POSITION AND SURGICAL PREP
The patient is placed in the supine position on the surgical
bed, the head of which is tapered to allow the surgeon
access to the head and neck region. Sufficient padding is
layered underneath the patient, preventing pressure points
and positioning-related injuries. After the induction of
general anesthesia, the hair is taped or otherwise secured
away from the face, and the face and nose are prepped
and draped using standard sterile technique. Cotton-
tipped applicators are used to clean the nasal vestibules.
Eye lubrication is important to prevent corneal injuries.
OPEN STRUCTURE RHINOPLASTY:
THE BASIC TECHNIQUE
A detailed description of the basic technique of open
structure rhinoplasty is described in this chapter. This
includes operative steps that are performed in most
of our rhinoplasty procedures, such as the injection of
local anesthetic, septal cartilage harvesting, skin and
mucosal incisions, and dissection of the skin–soft tissue
envelope (SSTE) from the underlying bony–cartilaginous
framework.
We begin with analysis of the preoperative photo­
graphs (Figure 5-1). A high dorsum can be seen with a
mild to moderate bony–cartilaginous dorsal hump. The
tip is ptotic, blunt, and underrotated. The tripod is larger
than ideal. The medial crura are prominent, while the
lateral crura are bulbous and convex. A larger than ideal
pedestal overprojects the tripod. A caudal septal deflection

CHAPTER FIVE  Primary Open Structure Rhinoplasty
57
9. The interdomal region is injected with a very small
amount of local anesthetic.
10. The cocaine-soaked nasal packing is left inside the
nose while the patient is prepped and draped.
11. A limited amount of local anesthesia is injected,
perhaps 7 to 8 mL in the septum and 1 to 2 mL
in the tripod/lateral nasal walls. More injected
anesthetic may distort the nasal structure, making
the true appearance more difficult to judge. No
local anesthesia is injected into the nasal dorsum
to avoid distortion.
12. Tip projection can be measured with the
projectimeter, which uses the bony points of the
needle is withdrawn, thereby avoiding injecting
intravascularly.
7. The planned marginal incision is then injected at
the caudal margin of the lower lateral cartilage
(LLC). Multiple small injections are performed using
a 12 -inch 30-gauge needle. The nasal tip is
manipulated between the thumb and index finger
to evert the nostril and expose the caudal edge of
the LLC.
8. The columella is then injected, with the needle just
off the caudal edge of the medial crus. Only a very
small amount (0.2 to 0.3 mL) is infiltrated to
prevent tip distortion.
Figure 5-1  Photographs providing preoperative analysis.
A
B
C
D

58
William Numa • Calvin M. Johnson • Wyatt C. To
patient’s forehead and maxilla as fixed landmarks
to provide a reproducible assessment of tip
projection. Projection can be measured at various
points during the surgery.
13. The open approach to the nose involves a mid-
columellar inverted-V transverse incision with
bilateral marginal incisions (see Figure 5-2). The
mid-columellar incision is designed to break up the
scar line avoiding cicatricial contracture. It is placed
at an area where the underlying cartilage is closest
to the skin, thus minimizing the risk of creating a
depressed scar. If the incision is placed too low in
the columella, where the skin is not as closely
supported by the underlying medial crus,
indentation of the scar can occur. Placement of
the incision too high near the apex risks scar
contracture, which can deform the nostrils.
14. The septum can be addressed first to correct
deformities in this area and to obtain appropriate
grafting material. A full transfixion incision is usually
used to allow access to the caudal septum and
nasal spine. This incision is made as close as
possible to the caudal edge of the septum so as to
maintain the integrity of the membranous septum,
which will serve as part of the pocket for the
columellar strut. The incision may be extended to
the nasal spine if necessary. If caudal septal work is
not required, a Killian incision may be used.
15. The perichondrium is incised, and the
subperichondrial plane identified. The cartilage may
be lightly cross-hatched with the No. 15 blade,
then abraded with a dental amalgam packer, a
Woodson elevator, or a cotton-tipped applicator
to raise the perichondrium.
16. The mucoperichondrial flaps are raised bilaterally
with the elevator, taking care to elevate past
the borders of the septal cartilage and the
perpendicular plate of the ethmoid, vomer, and
maxillary crest (Figure 5-3).
Figure 5-2  The midcolumellar incision is placed at an area where the
underlying cartilage is closest to the skin.
Figure 5-3  A, B, The perichondrium is incised and the flap is raised in
the subperichondrial plane.
Elevation of
mucoperichondrium
Sharp incision
at “transition point”
Perichondrium
Periosteum
A
B
17. The cuts in the septal cartilage are made with a
No. 15 blade leaving at least 15 mm at the caudal
and dorsal struts for support (Figure 5-4). The
cartilage graft is then freed from its attachments to
the bony septum using the dissector to
atraumatically remove the cartilage from between
the maxillary crest and vomer. Care must be taken
to ensure the graft remains intact during the
harvesting process. The harvested cartilage is
stored in sterile saline or antibiotic solution.
18. The thickness of the cartilage graft varies
depending on the location, and we use this to our
advantage. The columellar strut is usually designed
from the maxillary or dorsal portion of the graft,
areas that are of relatively uniform thickness. When
a shield graft is used, the thickened portion of the
septum near the bony–cartilaginous junction is
used for the distal end of the tapered tip graft
(Figure 5-5). Other grafts (alar, apex, spreader,
etc.) can be made from the remaining cartilage.
19. Loss of projection may be seen after septoplasty,
due to the transfixion incision, as this can divide
one of the major tip support mechanisms.

CHAPTER FIVE  Primary Open Structure Rhinoplasty
59
septoplasty can be performed through a an
anterior (external) approach.
21. The inverted-V mid-columellar incision is made
with a No. 11 or 15 blade, taking care to
avoid cutting into the medial crus of the LLC
(see Figure 5-2). The incision must be kept
perpendicular to the skin surface to avoid beveling
the flap. If a No. 11 blade is used, a sawing
motion is carried out for this portion of the
procedure.
20. Quilting sutures are placed using 4-0 gut on a
straight Keith needle in a running horizontal
mattress fashion to reapproximate the
mucoperichondrial flaps and obliterate the dead
space. A short (~1 cm) incision is made through
one of the flaps overlying the maxillary crest to
allow drainage of blood and serum from the
septoplasty site. Silicone/silastic septal splints can
be sutured onto each other using a 2-0 silk
suture. If spreader grafts are planned, the
Figure 5-4  A, B, Septal cartilage graft is harvested while preserving a 1.5 cm dorsal and caudal cartilaginous strut.
Perpendicular
plate of
ethmoid
Vomer
Palatine
crest
Caudal
support
Dorsal
support
Quadrangular
cartilage
Cartilage
available
for graft
harvest
Maxillary
crest
Premaxilla
A
1.5 cm dorsal
cartilagenous
strut
1.5 cm
caudal
strut
B

60
William Numa • Calvin M. Johnson • Wyatt C. To
Figure 5-5  The thickened portion of the septum near the bony-
cartilaginous junction is used for the distal end of the tapered tip graft.
Other grafts such as alar, apex, and spreader grafts can be made from the
remaining cartilage.
Figure 5-6  Marginal incisions are made at the caudal edges of the LLCs. The marginal columellar incision is created approximately 2 mm behind the
columellar rim.
Marginal
incision
22. The mid-columellar incision is joined to the
marginal incisions, which are created with the
No. 15 blade at the caudal edges of the LLCs
(Figure 5-6). Medially, the marginal columellar
incision is created approximately 2 mm behind the
columellar rim. Laterally, the back edge of the
blade can be used to palpate the caudal edge of
the cartilage and guide the incision. The nostril is
pinched between the 10-mm Joseph double hook
and the surgeon’s finger and is everted. This
especially helps with exposure of the marginal
incision near the apex of the domes. It is very easy
to inadvertently cut the LLC. The lateral and medial
marginal incisions are connected along the
undersurface of the soft tissue triangle, taking care
to avoid notching the rim, which may lead to
distortion of the nostril apex.
23. The angled Converse scissors are used to elevate
the columellar portion of the flap. Care is taken to
elevate the entire corner (junction between the
mid-columellar and marginal incisions) with
the flap.
24. The plane of dissection while elevating the
columellar flap is just superficial to the medial
crus—we try to keep this portion of the flap
as thick as possible.
25. This is especially important in the patient with a thin
SSTE. The flap should be of uniform thickness
across the columella—the soft tissue between the
medial crura is not elevated with the flap.
26. Dissection is continued along the LLC, elevating
the SSTE using three-point retraction (Figure 5-7).
Two small skin hooks are held by the assistant,
one on the skin flap and the second one along the
undersurface of the medial crus. The surgeon uses

CHAPTER FIVE  Primary Open Structure Rhinoplasty
61
Figure 5-7  Dissection is continued along the LLC, elevating the SSTE using three-point retraction. The skin hooks are repositioned as necessary to
optimize exposure by the principle of traction and countertraction.

62
William Numa • Calvin M. Johnson • Wyatt C. To
Figure 5-8  A, B, A pie-shaped segment of caudal septum can be excised. Varying the nature of the excision can help tailor the intended result (a wider
excision at the posterior septal angle, will aid favoring tip counter rotation and make the nasolabial angle more acute).
the 10-mm double hook to retract the nostril rim.
The skin hooks are repositioned as necessary to
optimize exposure by the principle of traction and
countertraction.
27. Dissection is carried out along the relatively
avascular plane just superficial to the
perichondrium, taking care to avoid injuring the
cartilage. The lateral extent of dissection is to the
region of the sesmoid cartilages bilaterally; the LLC
are not detached from the overlying SSTE laterally.
28. In addition to dissection with the scissors, blunt
dissection of the SSTE off the cartilage is performed
using the cotton-tipped applicators.
29. The adherence of the SSTE to the cartilage varies
between patients. The most adherent SSTE is
found in young patients with very reactive,
sebaceous skin.
30. Dissection between the domes is avoided while
raising the flap.
31. Dissection progresses cephalad, exposing the
upper lateral cartilage (ULC). A No. 15 blade is
used to divide the perichondrium off the ULC, after
which the flap is raised in a subperichondrial plane.
A periosteal elevator is used to raise the flap over
the nasal and frontal bones up to the nasofrontal
angle. Staying in a subperiosteal plane while
elevating the SSTE at the level of the nasal bones
allows easy avoidance of the angular vessels.
32. Once the SSTE flap has been completely raised,
the tip cartilages may be evaluated in situ, in their
undisturbed, anatomic configuration.
33. A pie-shaped segment of caudal septum can be
excised. Varying the nature of the excision can
help tailor the intended result (a wider excision
at the posterior septal angle will aid favoring tip
counter rotation and make the nasolabial angle
more acute) (Figure 5-8).
34. An overly prominent nasal spine can be reduced
to modify the nasolabial angle.
35. A Wright stitch is placed to affix the septal remnant
in the midline. Superiorly, this suture incorporates
the septal mucoperichondrium. Inferiorly, the
suture goes through septal mucoperichondrium
and maxillary crest periosteum (see Figure 5-9).
Care must be taken, as this maneuver can further
decrease tip projection.
36. We prefer to carry out nasal dorsal work prior to
addressing the nasal tip as the latter can readily be
modified to complement the dorsum.
37. The cartilaginous dorsum is reduced sharply
with the No. 15 blade under direct vision,
taking care not to violate the nasal mucosa
(Figure 5-10).
38. When reducing a large bony hump, an osteotome
is used to uncap the bony dorsum prior to rasping
(Figure 5-11). When correcting a concurrent
moderate to severe lateral deviation of the nasal
dorsum, an off-balance osteotomy will help
correct the deformity (Figure 5-12). If the rasp
alone is used to reduce a large hump, a “floating”
central remnant may result. The osteotome is
positioned at the caudal border of the frontal
bones. The osteotome must be directed toward
the nasofrontal angle to prevent overresection of
the lower bony dorsum and a resulting irregular
dorsum.

CHAPTER FIVE  Primary Open Structure Rhinoplasty
63
Figure 5-9  A “swinging door” maneuver with excision of redundant inferior-caudal septal cartilage can be performed to correct any existing caudal
septal deviations.
A
B
C
Lateral
crus
Medial
crus
Middle
(intermediate)
crus
D
Figure 5-10  Cartilaginous dorsum sharply reduced under direct vision.
Cartilaginous
hump
Figure 5-11  When reducing a large bony hump, an osteotome is used
to uncap the bony dorsum prior to rasping.
Bone
convexity

64
William Numa • Calvin M. Johnson • Wyatt C. To
Figure 5-12  When correcting a concurrent moderate to severe lateral
deviation of the nasal dorsum, an off-balance osteotomy will help correct
the deformity.
Medial
osteotomy
pathway
Lateral
osteotomy
pathway
Intermediate
osteotomy
pathway
Figure 5-13  To obtain a straight dorsum, the bony–cartilaginous junc­
tion should be slightly higher than the rest of the dorsal skeleton.
Keystone
area
39. A tungsten carbide rasp is used in a pulling fashion
to reduce the bony dorsum in a graduated
fashion. The bone of the cephalic bony dorsum
near the nasion is significantly thicker than that of
the caudal portion. It is thus easy to overreduce
the caudal bony dorsum with rasping, leaving
excess cephalic bone. To compensate for this,
the rasp can be angled more perpendicularly than
the intended plane of the dorsum by lifting up
the handle, thus putting more pressure on the
cephalic bony dorsum. The rasp must be used in
the correct direction.
40. The rasps are cleaned frequently with a wire
brush. We try to remove all the bony fragments
from the nose, especially from the nasofrontal
angle.
41. The reduced dorsum is visually inspected. This
may be difficult to do due to swelling of the SSTE,
especially during lengthy procedures. Additional
refinement of the cartilaginous or bony dorsum is
done as necessary.
42. The variable thickness of the SSTE must be taken
into consideration while contouring the nasal
dorsum. The skin is thickest over the nasion and
supratip and thinnest over the bony–cartilaginous
junction and tip. Consequently, to obtain a
straight dorsum, the bony–cartilaginous
junction should be slightly higher than the
rest of the dorsal skeleton (Figure 5-13). A
radix graft may also be helpful to fine-tune
and deaccentuate a dorsal hump due to a deep
radix (Figure 5-14).
43. At this point, either the middle vault or the nasal
tip can be addressed.
44. The first step in addressing the lower third of the
nose is the placement of a columellar strut to
provide structure and support to the medial limb
of the tripod (Figure 5-15). The columellar strut
may also help lengthen and project the nose. The
domes may also be narrowed slightly by lifting the
domes up onto the strut. If the medial limb does
not have sufficient strength by the end of the case,
postoperative sagging of the medial crura and a
hanging columella will result. A columellar strut
is used in almost all our cases, except when
additional support requires placement of a caudal
septal extension graft.
45. The dorsal portion of the harvested septal cartilage
used for the strut has a relatively uniform
thickness. The strut is shaped and smoothed
around the edges. Sufficient cartilage is reserved
for other grafts.
46. A pocket is created between the medial crura for
the columellar strut using the Converse scissors as
a dissection instrument. Tissue is left between the
medial crural footplates and the nasal spine to
keep the strut in place. This pocket should not
communicate with the transfixion incision. The
strut is then gently inserted along the axis of the
medial crura (Figure 5-16). It should not extend
much past the medial crura and should not rest on
the nasal spine or anterior septal angle. If the strut

CHAPTER FIVE  Primary Open Structure Rhinoplasty
65
rests on bone, it can tend to shift and “click” from
one side to the other.
47. A horizontal mattress using a 4-0 gut on a Keith
needle is used in a through and through fashion to
secure the columellar strut (Figure 5-16 B and C).
Placing the domes on slight tension with the skin
hook may help. Care must be taken to avoid
creating domal asymmetry while doing this.
48. Excision of a segment of the caudal septum can at
times allow the tripod to settle in a cephalad
fashion. Redundant mucoperichondrium along the
transfixion incision can be excised in conjunction
with the caudal septal excision to support the
elevated tip position. Extreme caution must be
exercised with this maneuver, as this can have a
powerful effect which can be difficult to revert. The
transfixion incision is repaired with 4-0 chromic
gut, bringing the medial limb of the tripod up to
the caudal septum.
49. On the nasal base view, the aim is to restore an
ideal equilateral configuration to the nose (Figure
5-17) from a boxy (or trapezoidal) configuration
or from an isosceles configuration in a tension
nose deformity, where an overly lengthy septum
typically overprojects the nasal tip, creating narrow
nostrils as seen on the base view.
50. Prominent caudal medial crura can be responsible
for the excess columellar show and the bifid
Figure 5-14  A radix graft may also be helpful to fine-tune and deaccentuate a dorsal hump due to a deep radix.
Nasion
Supratip
Limit
resection
at rhinion
B
A
Glabella
Nasion
Radix
implant
C
Figure 5-15  The columellar strut may also help lengthen and project
the nose by strengthening the central limb of the tripod.
Central limb
of tripod
Columellar
strut
Medial
crura

66
William Numa • Calvin M. Johnson • Wyatt C. To
conservative and confined to the medial two thirds
of the LLC, avoiding a full-length injury to the scroll
(recurvature between the ULC and LLC) (Figure
5-19). At least 7 mm of LLC width is left to ensure
adequate support. Carrying out a cephalic trim
without reducing the excess LLC length can result
in an even wider, bulbous tripod due to the
resultant weakening of the lateral limbs of the
tripod.
53. A mucosal apposition stitch is placed caudal to the
anterior septal angle incorporating the mucosa
only, bringing the mucosa near the domes
together and slightly narrowing the tip. This
maneuver provides additional domal support and
decreases supratip dead space.
Figure 5-16  A-C, A horizontal mattress using a 4-0 gut on a Keith needle is used in a through-and-through fashion to secure the columellar strut. Placing
the domes on slight tension with the skin hook may help.
A
B
C
columella. To correct this deformity, the vestibular
skin can be elevated off the cartilage, exposing the
medial crura down to the crural footplates, after
which the caudal septal margin can trimmed.
51. The LLCs can be shaped and reoriented using
suturing (“cartilage-sparing”) techniques including a
series of domal and interdomal sutures as well as
other maneuvers to bring the nasal domes
together into the desired levels of symmetry,
alignment, rotation, and projection. This technique
will be covered in detail in another chapter (Figure
5-18).
52. Overly lengthy and wide lateral crura can be
reduced with a medial cephalic trim extending
between the domes. The cephalic trim is usually

CHAPTER FIVE  Primary Open Structure Rhinoplasty
67
Figure 5-17  An equilateral configuration is ideal on the nasal base view.
Figure 5-18  Various cartilage-sparing suture techniques can be used in an open rhinoplasty.
54. To reduce the length of the lateral crus, a segment
of cartilage can be excised or incised and
subsequently overlapped. The segment excised
may be from the intermediate or lateral crus
depending on the area of excess and the
appearance of the domes. A transverse incision is
made with the No. 15 blade, after which the
lateral edge is elevated in a subperichondrial plane.
The lateral edge is allowed to overlap and the
excess portion is excised, leaving the incised
edges apposing one another without tension or a
gap. Simple 6-0 nylon sutures are used to repair
the edges.
55. Alar onlay grafts provide additional support to the
incised segment. If a shield graft is used, it is
designed first, and the remaining septal cartilage
may be used for any additional grafts. The distal
portion of the tip graft uses the thicker portion of
the cartilage at the posterior bony–cartilaginous
junction. Although templates to cut shield cartilage
grafts have been used in the past, we prefer to
fashion our own, thereby individualizing each nasal
tip based on each patient’s needs.
56. Alar onlay grafts are carved and beveled, then laid
over the lateral crus, supporting the incised edges.
The onlay grafts are sutured in place using 4-0 gut
in a through-and-through manner. The edges are
Figure 5-19  The cephalic trim of the LLC is limited to the anterior two
thirds of the scroll.

68
William Numa • Calvin M. Johnson • Wyatt C. To
The final step of the lateral osteotomy is the
controlled infracture or outfracture, performed by
rotating the osteotome toward or away from the
midline, as necessary.
63. The osteotome is guided through the incision and
seated perpendicularly to the anterior margin of
the pyriform aperture. The osteotome is advanced
several millimeters in this vector until solid bone is
encountered. The osteotome is then redirected
cephalad, almost parallel to the anterior face,
along the base of the bony nasal pyramid,
gradually angling up towards the nasofrontal angle,
until the level of the medial canthus, where the
controlled fracture is performed.
64. A transcutaneous osteotomy using a 2-mm straight
osteotome may be necessary if the infracture is
incomplete to avoid a rocker deformity (Figure
5-23C).
carefully beveled in vivo to ensure that they are
not seen through the SSTE. This is done bilaterally
with careful attention to symmetry.
57. A 2-0 Prolene transfixion suture is placed to
hold the medial crus/columellar strut complex
up to the membranous septum. This suture
allows the medial limb of the tripod to heal in the
rotated position. It is typically left in place for 2
weeks.
58. The shield tip graft is trimmed and carefully
beveled (Figure 5-20). It is thicker and wider at the
tip with a tapering base. The graft is sutured in
place to the underlying domes and medial crura
with 6-0 nylon suture (Figure 5-21). Precise
placement of the tip graft to provide proper
projection and definition is paramount. The graft
must be flexible enough to follow the curvature of
the medial crura. If the tip graft is too rigid it will be
evident under the SSTE as a “gravestone”
deformity. The tip graft extends slightly past the
domes, and can serve to project, narrow, and
define the tip, accentuating a supratip break (Figure
5-22).
59. The skin flap is re-draped and the nasal tip
evaluated. Repositioning of the graft may be
necessary, and patience during this portion of
the case is required.
60. Sharp reduction of the bony dorsum will leave an
open roof deformity requiring lateral osteotomies
to close it. Medial osteotomies may also be
necessary if the structure of the medial bony
dorsum is too intact to allow a controlled infracture
or outfracture depending on the desired effect.
They are performed fading laterally towards the
face (Figure 5-23). The thick bone of the
nasofrontal angle is avoided. If an intermediate
osteotomy is planned, it is best to carry out after
the medial fading osteotomy to retain support of
the attached nasal bone until the lateral osteotomy
is performed last.
61. The pyriform apertures at the planned lateral
osteotomy sites are reinjected with local
anesthesia. A No. 15 blade is used to incise the
mucosa at the pyriform apertures at the origin of
the inferior turbinates. Scissors are used to enlarge
the incision and start dissection in a subperiosteal
plane. Dissection is completed with the periosteal
elevator. In older patients, periosteal elevation is
avoided to enable some residual soft tissue
support.
62. The path of the planned osteotomy is
demonstrated externally following a high–low–
high course as demonstrated in Figure 5-23A.
Note that the path is such that a triangular remnant
of bone will be left at the pyriform aperture to
prevent collapse at the apex of the osteotomy.
Figure 5-20  The tip graft is shaped and beveled to minimize visibility.

Figure 5-21  A, B, Precise placement of the tip graft to provide proper projec­
tion and definition is paramount. The graft is sutured in place to the underlying
domes and medial crura using 6-0 nylon suture.
Figure 5-22  The tip graft extends slightly
past the domes, and can serve to project,
narrow, and define the tip, accentuating a
supratip break.
Increased
tip projection

70
William Numa • Calvin M. Johnson • Wyatt C. To
Figure 5-23  A, Osteotomy details (medial, intermediate, and lateral osteotomy). B, Osteotomy extended too far cephalad. C, Resulting rocker
deformity.
Osteotomy
taken too far
cephalad
Resulting
rocker deformity
B
A
C
Medial
osteotomy
pathway
Lateral
osteotomy
pathway
Intermediate
osteotomy
pathway
65. The middle vault is an area that has appropriately
received increased attention over the past decade,
as it is critically important to restore an optimal
nasal function. When the internal nasal valve (the
angle formed by the septum and the ULC) is more
acute than 15 degrees, or when short nasal bones
exist, patients will often benefit from reconstructing
the internal nasal valve. One of the most effective
reconstructive methods is by the use of spreader
grafts (Figure 5-24). This will be covered in detail
in a separate chapter.
66. Near the end of the case, the SSTE flap is
re-draped and the external nasal appearance is
evaluated.
67. The tip graft is trimmed and beveled in situ, and
the appearance reevaluated.
68. The bony–cartilaginous framework is carefully
inspected and hemostasis is obtained.
69. The transcolumellar incision is closed with
interrupted, simple 6-0 nylon suture, taking
particular care to evert the skin edges. Precise
placement of the corner stitch is particularly
important to prevent notching. Sometimes, a
vertical mattress suture can be used to obtain
maximal eversion.
70. The marginal incisions are sutured using
interrupted 6-0 chromic sutures. No attempt is
made to close the marginal incision at the domes,
as this has potential to distort the tip.
71. Projection can be measured at the end of the
case. The tip is reprojected by the columellar strut
and tip graft to achieve the intended nasal tip
projection. Deprojection of the tip can cause an
unintended widening of the alar base. To address
this issue, and in some patients who intend to
correct a widened alar base, certain alar base
reduction techniques can be used and will be
discussed in a separate chapter in more detail
(Figure 5-25).
72. Alar batten grafts are onlay grafts aimed at stiffening
the lateral nasal sidewall to prevent collapse of the
LLCs with inspiration. They are positioned in a tight
pocket created by dissecting superficial, lateral,
and superior to the LLC and are positioned
superficial to the pyriform aperture. They are
typically fashioned from septal cartilage but can
also be carved from conchal or costal cartilage
(Figure 5-26).
73. Mastisol (Ferndale Labs, Ferndale, MI) is applied
to the skin prior to application of elastic tape. The

CHAPTER FIVE  Primary Open Structure Rhinoplasty
71
elastic tape keeps gentle pressure on the SSTE,
reducing the amount of postoperative edema.
Tape is applied with gentle pressure from the
nasofrontal angle to the supratip. A longer strip is
placed around the infratip lobule as a sling,
squeezing and supporting the tip in its intended
level of rotation.
74. An Aquaplast splint (Aquaplast Corp., Wyckoff, NJ)
is then applied. This material becomes soft and
pliable when exposed to hot water, hardening as it
cools off.
75. Bacitracin ointment is applied to both nares
prior to placement of a moustache
dressing.
Figure 5-24  The middle nasal vault is a critically important area to preserve and restore for optimal nasal function. There are a number of different ways
to reconstruct the internal nasal valve.
Upper
lateral
cartilage
Lower
lateral
cartilage
B. Sagittal
A. Frontal
Dorsal
septum
Upper
lateral
cartilage
C. Axial
Nasal
bone
Dorsal
septum
Sesamoid
cartilage
Spreader graft
Horizontal spreader graft
Autospreader graft
Butterfly graft
Lateral battens
POSTOPERATIVE COMMENTS
1. The dorsum and tip blend in better, improving the
profile.
2. Overall projection has been increased by 1.4 mm.
3. Tip rotation has been increased, which along with a
reduction of the columellar show, improves alar–
columellar harmony.
4. Bifidity of the tip is corrected.
5. Nostrils are better defined and the nasolabial angle
is more appropriate.
6. The strong chin balances the still slightly large nose;
the patient has generally angular features, which go
along well with the strong profile.

72
William Numa • Calvin M. Johnson • Wyatt C. To
Figure 5-25  Alar base reduction.
Figure 5-26  A, B, Alar batten grafts are onlay grafts aimed at stiffening
the lateral nasal sidewall to prevent collapse of the lower lateral cartilages
with inspiration. They are positioned in a tight pocket created by dissecting
superficial, lateral, and superior to the LLC and are positioned superficial to
the pyriform aperture. They are typically fashioned from septal cartilage but
can also be carved from conchal or costal cartilage.
Alar batten
graft
Another representative patient, in this case presenting
with a tension tip deformity and a prominent nasal dorsal
hump deformity (Figures 5-27 and 5-28).
POSTOPERATIVE CARE
Patients are given detailed postoperative instructions. The
marginal and transcolumellar incisions are cleaned with
peroxide and cotton swabs once a day, followed by appli­
cation of topical Bactroban (2% mupirocin topical)
ointment (SmithKline Beecham Pharmaceuticals, Phila­
delphia, PA) to keep the incisions moist and infection free
and to reduce crusting. The head is elevated during sleep,
and the use of a humidifier is encouraged. The patient
is allowed to shower on the second postoperative day,
keeping the cast and tape dry with plastic wrap. Activity
is limited during the first week; patients are asked to
avoid heavy lifting and exertion. The level of activity is
gradually increased, until all limitations are lifted at 4
weeks.
Alcohol and nonsteroidal anti-inflammatory drugs are
avoided for 2 weeks postoperatively. A combination of
500 mg acetaminophen/5 mg oxycodone is used for pain
control, but most patients can obtain adequate pain
control with just acetaminophen after postoperative day
3. Zolpidem 10 mg is prescribed for insomnia. In revision
cases, amoxicillin–clavulanate is prescribed as postopera­
tive antibiotic prophylaxis.
Close follow-up is important to monitor the healing
process and to reassure the patient. The first postoperative
visit is on day 4, when the nasal passages are cleaned
and inspected. The transcolumellar sutures are removed
during this visit. The incision is then glued with Collodion
(Paddock Laboratories, Minneapolis, MN) and taped with
brown paper tape (3M Corp, Minneapolis, MN). On post­
operative day 7, the cast and tape are removed using
Detachol adhesive remover (Ferndale Laboratories Inc,
Ferndale, MI) to loosen the adhesive and carefully lift the
tape off from the skin while using a cerumen curette to
keep down the SSTE. The skin of the nose is then cleaned
with adhesive remover, and elastic tape is reapplied. The
elastic tape is left on for an additional week, after which
the nose is taped with the brown paper tape. Taping the
nose helps decrease nasal swelling, maintain rotation, and
support the tip while healing takes place.
Septal splints may be used in cases where a severe
septal deviation is corrected or a septal perforation
repaired. These are typically left in place for 1 to 2 weeks.
If a Prolene transfixion suture was placed, then it is
removed after a similar duration. Patients are occasionally
instructed to perform nasal “exercises” if they have had
Text continued on p. 77

CHAPTER FIVE  Primary Open Structure Rhinoplasty
73
A
B
C
D
Figure 5-27  A–H, Young Caucasian, thin-skinned female with ptotic, poorly-defined nasal tip with moderately severe right-sided deviation of the nasal
pyramid. Tip graft significantly aids to define her nasal tip.
Continued

74
William Numa • Calvin M. Johnson • Wyatt C. To
E
F
G
H
Figure 5-27, cont’d.

CHAPTER FIVE  Primary Open Structure Rhinoplasty
75
A
B
C
D
Figure 5-28  A–J, Young, thin-skinned female with moderately prominent dorsal hump deformity, tension nose deformity, and obtuse nasolabial angle.
Continued

E
F
G
H
I
J
Figure 5-28, cont’d. Adequately corrected proportions of her nasal contour and features.

CHAPTER FIVE  Primary Open Structure Rhinoplasty
77
osteotomies to narrow the bony vault. Gentle pressure is
applied to the upper third of the nose in a posterior and
medial vector for 10 seconds several times each day. This
maneuver helps the nasal bone fragments heal in the
correct position and encourages the SSTE to settle down
onto the bony–cartilaginous framework.
Swelling of the SSTE may take 1 year or longer to
subside, and thus the final result may not be evident until
that time. In patients with a particularly thick or swollen
SSTE, minute amounts of Kenalog (triamcinolone HCl)
10 mg/mL may be injected using a 30-gauge needle and
tuberculin syringe to decrease SSTE edema. This is
especially useful in the supratip region. The steroid is
injected beneath the dermis; if it is injected too superfi­
cially, skin atrophy may result. Gentle pressure is held for
several minutes over the injected site. Injections may be
repeated as necessary but no more frequently than once
a month.
We never discharge a rhinoplasty patient from our
care, preferring to see them on an annual basis after they
are 1 year post surgery. This allows us to evaluate the
long-term consequences of our surgery and perform
touch-up procedures if necessary. Revisions are not con­
sidered any sooner than after 1 year postoperatively.

79
C H A P T E R S I X 
Primary Endonasal Rhinoplasty
Double-Dome Technique via Intercartilaginous Dome-Delivery
Amit Patel • Stephen W. Perkins
Surgical refinement of the nasal tip is considered by many
to be one of the most challenging components of rhino­
plasty. At the heart of the challenge is the need to not only
adequately access and visualize but also control the
complex three-dimensional architecture of the alar carti­
lages while being cognizant of tip support mechanisms
and postoperative contracture. Although numerous
approaches have been described throughout the literature,
the endonasal delivery flap technique continues to be a
workhorse in the armamentarium of surgical approaches
for tip refinement. This chapter will focus on the beauty,
versatility, and simplicity of endonasal tip surgery.
Tip rhinoplasty techniques have evolved substantially
since Joseph first introduced cosmetic rhinoplasty in the
late 1800s.1 This evolution continues even to this day as
discussions on the “ideal” surgical approach for nasal tip
contouring ensue. The various incisions commonly used
in rhinoplasty and their respective indications are illus­
trated in Figure 6-1. Four essential points must be kept
in mind when choosing an approach for intermediate to
advanced tip maneuvers: (1) the ability to adequately
visualize the entire alar complex including all areas of the
medial, intermediate, and lateral crura; (2) the ability to
modify each alar unit separately and address asymmetries;
(3) the ability to maintain or reconstitute tip support
mechanisms; and (4) the ability to minimize resection of
natural structural elements.
Next, we describe our philosophy, which is based on
the creation of the double-dome unit as described by
McCollough and English.2 In our hands, this particular
tip-sculpting technique has become a workhorse in tip
modification as it nicely fulfills the above criteria. In fact,
a 15-year review of the senior author’s results with use of
the double-dome unit procedure for tip rhinoplasty not
only has proved the technique to be reliable with consist­
ent results but also has shown it to carry a low rate of
revision.3 In this chapter, we will first describe our basic
surgical technique for endonasal intercartilaginous dome-
delivery via the double-dome technique, followed by a
review of specific nasal tip deformities and steps utilized
to correct these.
PREOPERATIVE ANALYSIS AND
PATIENT SELECTION
It is critical to determine the exact tip deformities before
creating a surgical plan. What is the aesthetic problem of
the tip and what is one attempting to achieve? This begins
with a detailed examination during the consultation
period. Standardized forms are helpful for ensuring a
complete examination as well as simplifying documenta­
tion (Figure 6-2). The tip shape should be described, such
as bulbous, twisted, or infantile. Both the degree of rota­
tion and the extent of projection should be evaluated. Skin
thickness is critical to assess, and this issue alone may
dictate the approach to be taken and/or the procedure to
be performed. Palpation is helpful in determining the
nature, volume, strength, and resiliency of the lobular
cartilages as well as in evaluating tip support. Finally, it
is important to note columellar abnormalities and their
relation to the alar cartilages.
The ideal patient for these techniques has been
described by Tardy.4 The ideal patient has a slightly bifid
or broad tip with dual-dome highlights. Thin skin and
sparse subcutaneous tissue allow for more refined results
from these endonasal techniques. The alar cartilages
themselves must be firm and strong. Finally, the alar
sidewalls should be thin and delicate, yet resist collapse
and recurvature. By using the endonasal delivery approach
along with a graduated approach to tip contouring, excel­
lent aesthetic results can be achieved.
There are certain conditions, in our experience, that
favor the use of the external columellar approach. It is
often difficult to deliver, in a safe and adequate manner,
alar cartilages in a patient with scar tissue in the lobule
from previous surgery or trauma. Middle nasal vault
deformities, in our experience, are more easily corrected

80
Amit Patel • Stephen W. Perkins
marked overprojection, overrotation, underprojection,
and underrotation of the lobule.
All patients are initially seen in consultation with
their selected surgeon. The consult room is designed to
put the patient at ease while still maintaining a profes­
sional environment. The nasal analysis begins with the
patient on a comfortable bar stool in front of a three-way
mirror with the physician directly behind him or her.
through the external columellar approach. Patients with
marked asymmetry in the nasal tip, with thin skin and
bossa, may require camouflage tip grafting sutured in
place. Also, marked twisting of the columella with signifi­
cant discrepancies between the two medial crura may
necessitate the use of an external columellar approach.
Other indications for the external approach are extremely
soft alar cartilages with no inherent support as well as
Figure 6-1  A, Marginal incision. B, Intercartilaginous incision. The intercartilaginous incision violates an important tip support mechanism, which must be
considered when the tip is reconstructed. The double-dome suture helps to stabilize the tip complex.
Marginal
incision
A
Intercartilagenous
incision
Transfixion incision
B

CHAPTER SIX  Primary Endonasal Rhinoplasty
81
Meridian Plastic Surgeons
Patient:
__History of trauma to nose:
__Previous surgery:
__Difficulty breathing:
__Patient desires:
__Sinus disease
__Medications tried:
__Deviated nasal bones
__Fractured nasal bones
__C-shaped deformity
__Irregular nasal bones
__Nasal bones holding septum off center
Drawing
% airway obstruction
R___ L___
(60–65–70–75–80–85–90–95–100–105)
Pyramid
R
L
R
L
Septum
__Traumatic dorsal hump
__Dorsal saddling: Cartilage__ Bone__ Both__
__Angulated
Dorsal ridge

Septum deviated
Spurs
Caudal end deflected
blocking vestibule
__Floor obstruction
__Nasal valve collapse
__Internal __Alar
__Middle vault narrowing or collapse
__Loss of tip support
__Collapsed lobule w/ valve collapse
__Avulsed/depressed ULC’s
__Soft lobular cartilages
R__ L__
R__ L__
R__ L__
R__ L__
R__ L__
R__ L__
R__ L__
R__ L__
R__ L__
R__ L__
R__ L__
R__ L__
__Intranasal synechia(e)
__Inferior turbinate hypertrophy
__Middle turbinate hypertrophy
or concha bullosa
__Septal ulcer
__Septal perforation:
Size:__________________
Location:_______________
__Nasal polyposis
__Retraction of columella
__Acute nasolabial angle
__Premaxillary deficiency:
__Cleft lip nasal deformity:
Notes:
Doctor:
Date:
R__ L__
R__ L__
R__ L__
R__ L__
R__ L__
R__ L__
Complete____
R__ L__
Bilateral_____
Functional abnormalities
R
Straighter nose
Improved breathing
L
Bilateral
Snoring
Mouth breathing
Nasal History and Physical
Figure 6-2  Standardized forms used for ensuring a complete examination as well as simplifying documentation.
Together they analyze the nose with the physician gently
guiding the discussion. The three-way mirror not only
allows the patient to get a more accurate view of the three-
dimensional qualities of their nose but also relays specific
concerns to the surgeon.
An in-depth nasal history is taken during the consult.
Inquiries include any previous nasal trauma or surgery,
difficulties breathing through the nose, any history of
sinus disease or allergies, and present nasal medications.
The physician also reviews the more extensive complete
history form, which is completed by the patient prior to
consultation. An intranasal examination is performed at
this time to detect deformities of the septum, enlargement
of the turbinates, or other intranasal pathology. A preop­
erative rhinoplasty form is also completed to document
the consultation findings as well as for later reference.
The procedure should be thoroughly discussed at
this time and goals summarized with the patient. The
Continued

82
Amit Patel • Stephen W. Perkins
desired goals to be achieved. Following this, a full set of
nasal images are taken for preoperative documentation.
The last phase of the consultation is spent with the
scheduling nurse, where questions can be answered in
what often is a more comfortable setting for the patient.
Fees are reviewed with the patient, and signed copies of
the procedures and fees are given to the patient. Any
necessary lab work is arranged at this time.
Prior to surgery, all patients receive folders with
detailed instructions for surgery, prescriptions, and a
physician reviews with the patient what to expect on the
day of surgery, including the length of surgery, anesthesia,
recovery, and discharge. Initial postoperative care and
activity restrictions are also discussed. Finally, the limita­
tions of the surgery, as well as possible complications, are
given as part of the informed consent.
The consultation is then continued in the photogra­
phy suite, where computer imaging is used to illustrate
the planned aesthetic endpoint. This allows for confirma­
tion that both the patient and the surgeon agree on the
Meridian Plastic Surgeons
Patient:
__History of trauma to nose:
__Previous surgery:
__Difficulty breathing:
__Patient desires:
__Deviated nasal bones
__Fractured nasal bones
__C-shaped deformity
__Irregular nasal bones
__Nasal bones holding septum off center
__Too short
__Too long: Whole lobule Infra tip lobule
__Projection: Over Under
__Soft lobular cartilages
__Rotation: Over Under
__Dorsal hump
__Traumatic dorsal hump
__Dorsal saddling
__Angulated
__Dorasl curved septum only
__Dorsal ridge
__Avulsed/depressed ULC’s
__Acute/deep N-F angle
__Obtuse N-F angle
__Poor tip support
R__ L__
R__ L__
R__ L__
R__ L__
R__ L__
R__ L__
R__ L__
R__ L__
R__ L__
R__ L__
R__ L__
R__ L__
R__ L__
R__ L__
R__ L__
R__ L__
__Supratip fullness: Soft tissue Cartilage
__Bulbous tip
__Asymmetric tip
__Broad tip
__Bifid tip
__Amorphous tip
__Infantile tip
__LLC’s asymmetric
__Concave LLC
__Bossa
__Retracted ala
__Nostrils wide: Horizontal
Asymmetrical
__Wide alae
__Alar base flare
__Unusual cartilage bump
Doctor:
Date:
Cosmetic abnormalities
Tip
__Crooked
__Show: Elongated septum
__Hanging
__Retracted
__Short
__Long
__Twisted
__Short infratip lobule
__MC buckle
__Medial crural shift caudally
__Acute nasolabial angle _____%
(60–65–70–75–80–85–90–95–100–105)
__Bifid
Columella
Cartilage____ Bone____
Cartilage____ Bone____
Cartilage____ Bone____
__Dorsal hump
__Dorsal irregularities
__Dorsal saddle
__Dorsum wide
__Open roof deformity Central Right Left
__Thick skin
__Thin skin
__Skin irregularities
__Weak chin
Dorsum
Smaller
Straighter
Improved tip:
Improved dorsum:
More defined
Narrower
Hump removed
Nasal History and Physical
Figure 6-2, cont’d

CHAPTER SIX  Primary Endonasal Rhinoplasty
83
This achieves both volume reduction and improved
supratip definition. It is essential to preserve at least a
7- to 9-mm width of cartilage. In a few select cases, this
may be all that is required and the cartilages may be
replaced in situ. In most cases, however, other techniques
are required to achieve satisfactory tip definition and
symmetry.
The ideal alar configuration has been described as
being when the domal segment is convex, the adjacent
lateral crura is slightly concave, and the overlying soft
tissue is thin.5 Occasionally, careful “pinching” of the
individual dome cartilages can mold the cartilage into the
ideal shape. Most often, however, individual dome treat­
ment with suture is required. Prior to placing the single-
dome suture, the vestibular skin is separated from the
undersurface of the domal cartilage (Figure 6-6). A 5-0
absorbable synthetic polyglycolic acid (Dexon) mattress
suture is placed at the junction of the lateral and medial
Figure 6-3  High septal transfixtion or complete transfixtion incision.
Figure 6-4  Delivery of lower lateral cartilage/Dome (LLC) with single
hook and supported with Metzenbaum scissors.
Figure 6-5  Cephalic trim.
booklet reviewing postoperative healing and expectations.
All patients start an oral antibiotic the day prior to surgery,
most often either oral cephalexin (Keflex) or azithromycin
(Zithromax), and continue this for 5 days.
SURGICAL TECHNIQUE
At 1.5 hours prior to surgery, patients are administered
oral diazepam (Valium), promethazine (Phenergan),
metoclopramide (Reglan), and dexamethasone (Dec­
adron) as well as oxymetazoline nasal (Afrin Nasal Sinus)
spray. In the operating room, deep sedation, typically
using intravenous propofol, is instituted prior to infiltra­
tion of the local anesthesia. First, pledgets soaked in 4%
cocaine are placed intranasally. After adequate time for
decongestion, infiltration is started with 2% lidocaine
(Xylocaine) with 1 : 50,000 epinephrine. No more than 7
to 8 mL is injected to minimize volume distortion.
The delivery approach is begun by making either a
complete transfixion or a high septal transfixion incision
depending on tip projection (Figure 6-3). Curved sharp
scissors are then used to dissect up over the anterior supe­
rior angle and expose the upper lateral cartilages. Next,
intercartilaginous and marginal incisions are made in a
standard fashion (see Figure 6-1). Thin Metzenbaum scis­
sors are then used to separate the overlying skin from the
underlying lower lateral cartilages, nasal domes, and
infratip lobule (intermediate crura). Finally, the alar car­
tilages are delivered with a single hook and supported
with Metzenbaum scissors (Figure 6-4). In this fashion,
each dome is assessed and recontoured individually.
The first step in achieving improved tip definition is
the removal of fibrofatty tissue between the domes. This
allows greater approximation of the two alar domes. An
intact or a complete strip can be performed next by excis­
ing the cephalic portion of the lateral crura (Figure 6-5).

84
Amit Patel • Stephen W. Perkins
narrowing can be seen as one tightens the knot (Figure
6-9). It is important to avoid cinching down the suture
and creating a unitip appearance.
The tip is then reevaluated. At this point, the decision
is made on whether more aggressive steps will be required
to achieve the desired tip aesthetics. This could include
steps such as lateral crural flap, dome division, or the
Lipsett maneuver. Marked disparity in length between the
two medial crura is best corrected with the Lipsett proce­
dure.6 With this technique, the lengthier medial crura is
delivered and dissected free from its attachments. An
appropriate length of crura is resected to achieve equality
in length between the medial crura. The two resected ends
are then reapproximated with 6-0 monocryl (Figure
6-10). Removing or replacing the double-dome mattress
sutures and addressing the anterior-posterior or caudal-
cephalic placement of a suture in relation to the other
dome may address minor asymmetries.
Figure 6-7  Suture is placed such that the knot is tied medial to both
domes.
Figure 6-8  Asymmetries or abnormalities of the tip contour that persist after placement of the dome sutures can be corrected through a slight beveled
trim at the cephalic border of a one-dome unit.
A
B
Figure 6-6  LLC/Dome separated from vestibular skin.
crura. The knot is tightened to the point where the proper
amount of domal definition is achieved (Figure 6-7).
If the individual domes remain asymmetric or
improved supratip definition is desired, individual dome
trimming can be performed. This involves “beveling” the
cephalic portion of the single-dome unit (Figure 6-8).
With achievement of symmetric, aesthetically pleas­
ing individual domes, the entire tip is reevaluated. Utiliza­
tion of the endonasal approach allows this continual
critiquing. A double-dome or transdomal mattress suture
is next used to bring together the individually defined
domes and stabilize these into one unit. Stabilization of
the domes is the key to maintenance of long-term results.
The suture is placed horizontally through the lateral and
medial crura of both domes. We typically use a 5-0 clear
polypropylene (Prolene) suture. The desired amount of
lobular narrowing can be achieved by altering the tension
of the stitch. With the domes replaced, the amount of

CHAPTER SIX  Primary Endonasal Rhinoplasty
85
Figure 6-9  The knot is tied with both dome units replaced to their
natural position. This allows a “real-time” assessment of the degree of nar­
rowing that is achieved. Excessive narrowing should be avoided to prevent
a “unitip” appearance.
Figure 6-10  Lipsette maneuver to correct an overprojected tip or asymmetry in projection between the two dome complexes.
A
B
Finally, correction of tip asymmetries may be more
easily addressed with dome division, which can be per­
formed medial to the dome, lateral to the dome, or at the
mid-point of the dome (Figure 6-11). Dome division is
used for a variety of situations when the described more
conservative techniques have not been successful. Dome
division can allow for more tip narrowing, which is espe­
cially required in those with thick skin. Furthermore, it
can also be used to achieve upward rotation and increase
or decrease tip projection.
Conservative upward rotation of the tip, on the other
hand, is typically achieved by resection of an inverted
triangle of caudal septum with corresponding vestibular
skin and using a columellar strut to assist in “pushing”
the lobule cephalically. If further rotation is required fol­
lowing this, the lateral crural flap technique can be used.
This can involve a full incision of the lateral crura or
simply a cephalic wedge excision (Figure 6-12). The

86
Amit Patel • Stephen W. Perkins
Figure 6-12  Lateral crura flap to increase rotation.
A
B
Figure 6-11  Vertical dome division.
A
B
lateral crura can be overlapped and sutured to shorten
their length and create upward rotation.
Following achievement of a symmetric and well-
defined tip, attention is then turned to the septum, the
dorsum and, last, osteotomies. A columellar strut fash­
ioned from septal cartilage is placed between the medial
crura and anterior to the nasal spine prior to osteotomies.
Intranasal incisions are closed with 5-0 catgut. In closing
the marginal incisions, it is important to avoid the lateral
crura when suturing. Retraction of the lateral crura could
lead to possible alar collapse and nostril asymmetries.
A small rolled piece of absorbable oxidized regener­
ated cellulose (Surgicel) is placed inside the nose within
the vestibule of each newly constructed dome to add sta­
bility and prevent hematoma. Tan surgical tape (Micro­
pore) along with an alloy metal splint is used for the
external dressing that is removed at 1 week.
INDIVIDUAL CASE EXAMPLES
BROAD/WIDE TIP
Tips that demonstrate minimal deformity and minimally
excess width can be addressed in the most conservative
fashion. Single-dome suture treatment is often not required
in these patients if the alar dome cartilages are delicate,
thin, or soft. A conservative cephalic trim followed by a
double-dome suture alone can often achieve the desired
result (Figure 6-13).
BULBOUS/BOXY TIP
The bulbous tip requires individual treatment of the
domes. This is most often addressed with a conservative
cephalic trim and an individual single-dome mattress

CHAPTER SIX  Primary Endonasal Rhinoplasty
87
ASYMMETRIC TIP
A variety of techniques can be used to correct the asym­
metric tip depending on the degree and the exact deform­
ity. Minor deformities may be corrected with double-dome
suture techniques alone. If asymmetry is due primarily to
a disparity in medial crura length, the Lipsett procedure
may be used. For marked asymmetry between the domes,
dome division is used (Figure 6-17). Typically, the over­
projecting dome is truncated and the double-dome unit is
reconstituted. When the entire nose is overprojected, bilat­
eral dome truncation may be performed.
COMPLICATIONS
BOSSA FORMATION
Knuckling of the lower lateral cartilages with healing can
occur. Typically, this is due to weakening of the lateral
crura secondary to either overresection or cartilage-
splitting techniques. Patients with thin skin, strong carti­
lages, and nasal tip bifidity are at the highest risk for this.
Bossae can be treated by resecting the deformed cartilage
through a marginal incision. Further camouflage can be
provided by either morselized cartilage or fascia.
ALAR RETRACTION
Retraction of the ala is usually due to either overresection
of the lateral crura or excess resection of vestibular
mucosa. Improper suture placement during closure of the
suture. Reconstitution of the double-dome unit with a 5-0
clear Prolene suture completes tip refinement (Figure
6-14). In the case of residual excess width, an alar span­
ning suture can be used to achieve further narrowing.
BIFID TIP
The bifid tip often requires both single-dome and double-
dome mattress treatment of the tip complex. Occasionally,
suture approximation of the tip alone will eliminate the
bifidity. Most often, however, placement of either a non­
sutured tip graft or a columellar filler graft is also required
(Figure 6-15).
TRAPEZOID TIP
The trapezoid tip deformity is due to divergent intermedi­
ate crura (Figure 6-16). Cartilage splitting or transcarti­
laginous cephalic margin resection is unwise in these
patients as both can lead to the late development of
bossae. The alar cartilages have to be reoriented more
caudally, or lateral alar batten grafts or possibly even alar
struts must be added. This can be necessary if the lateral
alar sidewalls are weak and tend to collapse or re-curve
inward when the domes are brought together. Reconstitu­
tion of the interdomal ligament—single-dome and double-
dome suture techniques—is required for correction. Tip
grafting of the infratip lobule is also often necessary.
Often, even when the earlier-mentioned aggressive tech­
niques are used, an aesthetic tip cannot be achieved. In
these more difficult cases, dome division is indicated to
narrow the tip and straighten the lateral ala.
Figure 6-13  Broad/wide tip.
B
A

Figure 6-15  Bifid tip.
A
B
Figure 6-14  Bulbous/boxy tip.
A
B
C
D