Master Techniques in Rhinoplasty

90
Amit Patel • Stephen W. Perkins
CONCLUSION
Variation in patient anatomy, aesthetic expectations, and
tolerance for postoperative recovery time precludes the
existence of a single technique. Additionally, differences
in surgical training, philosophy, and comfort among rhi­
noplasty surgeons support the need for a variety of
approaches. We, therefore, emphasize the importance of
transcending beyond a “cookbook” philosophy toward tip
rhinoplasty.
REFERENCES
1. Tebbets JB. Rethinking the logic and techniques of primary tip
rhinoplasty: A perspective of the evolution of surgery of the
nasal tip. Clin Plast Surg. 1996;23:245–253.
2. McCollough EG, English JL: A new twist in nasal tip surgery:
An alternative to the Goldman tip for the wide or bulbous
lobule. Arch Otolaryngol. 1985;111:524–529.
3. Perkins SW, Hamilton MM, MacDonald K. A successful 15 year
experience in double-dome tip surgery via endonasal approach:
Nuances and pitfalls. Arch Fac Plast Surg. 2001;3:157–164.
4. Tardy ME. Sculpturing the nasal tip. In: Tardy ME, ed.
Rhinoplasty. The art and science. Philadelphia: WB Saunders;
1997:374–571.
5. Daniel RK. Rhinoplasty: creating an aesthetic tip: A
preliminary report. Plast Reconstr Surg. 1987;80:775–783.
6. Lipsett EM. A new approach to surgery of the lower
cartilaginous vault. Arch Otolaryngol. 1959;70:42.
7. Tardy ME Jr, Toriumi DM. Alar retraction: A composite
correction. Fac Plast Surg. 1989;6(2):101–107.
continual intraoperative assessment will help to avoid
either overprojection or underprojection.
SUMMARY
The advantages that open rhinoplasty offers with increased
exposure come with many downsides. The external inci­
sion itself can be a source of noticeable scarring, alar
notching, or even trap door deformity. Patients are
required to make a special visit for removal of the colu­
mellar sutures at postoperative day 5. This is both an
inconvenience and a somewhat painful experience. Finally,
resolution of tip edema is significantly prolonged with the
external approach. For all of these reasons, our first choice
is to use endonasal dome-delivery technique whenever
possible.
Endonasal double-dome techniques, in particular, are
based on the philosophy of utilization of the normal ana­
tomic structures of the nasal tip (lobule). The merits of
these techniques are many. Results of individual steps can
continuously be reevaluated. Most of these incremental
steps are reversible. Often, use of grafts can be avoided as
well as the possibility of secondary deformities that come
with them. The disadvantages of these techniques include
the need for greater surgical finesse in delivering and
suturing the alar cartilages. Also, techniques for the cor­
rection of certain deformities may be better addressed
through the external approach. Nevertheless, for most
primary cosmetic tip rhinoplasties, the beauty and expedi­
ent nature of the endonasal delivery flap approach with
double-dome techniques provide consistent long-term
results and few complications.
Figure 6-17  Asymmetric tip.
A
B

91
C H A P T E R S E V E N 
Secondary Rhinoplasty via
the External Approach
C. Spencer Cochran • Jack P. Gunter
The incidence of postoperative nasal deformities requiring
secondary rhinoplasty varies from 5% to 12%.1 The eti­
ologies of postoperative nasal deformities (Table 7-1) are
usually related to one or any combination of the following
three problems: (1) displacement or distortion of ana­
tomic structures, (2) underresection due to incomplete
surgery, and (3) overresection due to overzealous surgery.
Diagnosing these deformities and reconstructing the nasal
osseocartilagenous framework form the foundation for
obtaining consistent functional and aesthetic results in
secondary rhinoplasty.
While adequate results may be attained with the
endonasal technique in certain circumstances, the limited
dissection and exposure offered by the endonasal approach
often do not permit accurate assessment, intraoperative
diagnosis, and appropriate treatment of complex ana­
tomic problems. Open rhinoplasty techniques eliminate
these restrictions imposed by the endonasal approach. We
present a systematic approach to secondary rhinoplasty
via the external approach that helps ensure consistent
aesthetic and functional results in patients with both
major and minor postoperative nasal deformities.
PREOPERATIVE ASSESSMENT
AND PLANNING
A precise anatomic diagnosis is a key step to achieving
optimal results in secondary rhinoplasty. The preoperative
evaluation begins by defining the deformity, which is
accomplished by a detailed history, physical examination,
and complete aesthetic facial and nasal analysis. Starting
superiorly, the nasofrontal angle height and depth are
noted. The bony pyramid, upper lateral cartilages, and
supratip are evaluated for their length, height, width, and
symmetry. The nasal tip is evaluated in terms of its projec­
tion, rotation, symmetry, and position of the tip-defining
points. The alae are inspected for increased width, col­
lapse, or retraction. The columella is examined for
increased or decreased show. The columellar-lobular and
columellar-labial angles are evaluated to ascertain the
desired angulation. The internal nasal examination
evaluates patency of the nasal valves, position and integ­
rity of the septum, and state of the turbinates.
After the diagnosis is determined and the deformities
are defined, the goals of the surgery are established, and
a treatment plan is formulated. The operative goals are
individualized for each patient according to the deformity.
The goals may be to augment the nasofrontal angle,
straighten the nasal dorsum, lower the supratip area,
correct tip asymmetry and alar collapse, decrease colu­
mellar show, etc. If the existing osseocartilagenous frame­
work is underresected, the amount and location of further
reduction are determined. If the nasal framework has
been overresected, it is determined what tissues are
missing and where augmentation is needed. Secondary
surgery is usually deferred until 12 months after the previ­
ous rhinoplasty.
GRAFTING ALTERNATIVES
A key component of the operative planning includes
assessment of the grafting requirements and the potential
source of grafting materials that will be required. While
septal cartilage is generally the preferred grafting material
in both primary and secondary rhinoplasty, severe deform­
ities or a paucity of available septal cartilage requires an
alternative source of grafting material. This is particularly
true in secondary rhinoplasty when structural deformities
resulting from previous procedures necessitate significant
numbers of grafts.2 Autogenous cartilage is preferred for
any nasal framework replacement.
SEPTAL CARTILAGE
There are several advantages to using septal cartilage. A
large amount of septal cartilage and septal bone can be
harvested from the same operative field without the mor­
bidity of an additional donor site. Compared to auricular
cartilage, septal cartilage is more rigid, provides better
support, and does not have convolutions. It is preferably
used as a columellar strut, spreader grafts between the
upper lateral cartilages and the septum, and lateral crural

92
C. Spencer Cochran • Jack P. Gunter
for small onlay grafts, or for placement in the columella
to provide tip support. However, it is a second choice to
septal cartilage because of the inherent difficulty in obtain­
ing and maintaining the desired shape and contour. While
initial results of dorsal augmentation with auricular car­
tilage are often satisfactory, surface irregularities can
become apparent with the passage of time. Furthermore,
the irregular contour and limited supply of auricular car­
tilage often preclude its use.
COSTAL CARTILAGE
Because autogenous rib cartilage provides the most abun­
dant source of cartilage for graft fabrication and is the
most reliable when structural support or augmentation is
needed, rib cartilage has been our graft material of choice
for secondary rhinoplasty when sufficient septal cartilage
is not available.4,5
The choice of which rib to harvest depends on the
planned uses and grafting requirements because the
amount of cartilage required dictates whether the carti­
laginous segment is needed from one rib, one rib and a
portion of another, or two ribs. In general, the surgeon
should choose the cartilaginous portion of a rib that pro­
vides a straight segment as it is often possible to construct
all required grafts from a single rib. For dorsal augmenta­
tion with a dorsal onlay graft, we prefer to harvest carti­
lage from the fifth, sixth, or seventh rib, depending on
which rib feels the longest and straightest. If additional
grafts are needed, a part or the entire cartilaginous portion
of an adjacent rib may be harvested.
Rib cartilage may be harvest from either the patient’s
left or right side; however, harvesting from the patient’s
left side facilitates a two-team approach. In female
patients, the incision is marked several millimeters supe­
rior to the inframammary fold and measures 5 cm in
length (Figure 7-2). In males, the incision is usually
placed directly over the chosen rib to facilitate the
dissection.
The skin is incised with a scalpel, and the subcutane­
ous tissue is divided with the use of electrocautery. Once
the muscle fascia has been reached, the surgeon palpates
the underlying ribs and divides the muscle and fascia with
electrocautery directly over the chosen rib. The dissection
should be carried medially until the junction of the rib
cartilage and sternum can be palpated. The most lateral
extent of the dissection is demarcated by the costochon­
dral junction. Identification of the junction is facilitated
by the subtle change in color at the interface; the carti­
laginous portion is generally off-white, whereas the bone
demonstrates a distinct reddish-gray hue.
After exposure of the selected rib, the perichondrium
is incised along the long axis of the rib. Perpendicular cuts
are also made at the most medial and lateral aspects
of the cartilaginous rib to facilitate reflection of the
perichondrium.
Table 7-1  Etiologies of Postoperative Nasal Deformities
• Displacement or distortion of anatomic structures
• Underresection due to incomplete surgery
• Overresection due to overzealous surgery
Figure 7-1  Intraoperative view of auricular cartilage graft harvested via
a postauricular incision.
strut grafts to support or replace parts of the lower lateral
cartilage complexes. When a sufficient quantity is avail­
able, it may also be used as a dorsal onlay graft for
minimal amounts of dorsal augmentation.
AURICULAR CARTILAGE
The auricle can provide a modest amount of cartilage for
nasal reconstruction.3 Using a postauricular approach, the
amount of harvested conchal cartilage can be maximized
without compromising ear protrusion by preserving suf­
ficient cartilage in three key areas: (1) the inferior crus of
the antihelix, (2) the root of the helix, and (3) the area
where the concha cavum transitions into the posterior-
inferior margin of the external auditory canal. An incision
is created longitudinally along the posterior aspect of the
auricle, and dissection is carried down through the peri­
chondrium. A 27-gauge needle dipped in methylene blue
is percutaneously placed every 1 to 2 cm along the inner
aspect of the antihelical fold to tattoo the cartilage along
the planned excision path to ensure that sufficient anti­
helical contour is maintained. Dissection proceeds along
both the anterior and posterior surface of the conchal
bowl, and a kidney bean–shaped piece of conchal carti­
lage (Figure 7-1) is harvested while leaving sufficient
cartilage at the aforementioned key areas for support.
Because of its flaccidity and convolutions, it is best
used when these characteristics are desired. It is usually
used for reconstructing the lower lateral cartilage complex,

CHAPTER SEVEN  Secondary Rhinoplasty via the External Approach
93
and fascia layers tightly to prevent a palpable or visible
chest wall deformity. A tight closure also helps “splint”
the wound and reduce postoperative pain. Skin closure is
carried out using deep dermal and subcuticular 4-0
Monocryl sutures.
If a pneumothorax has been diagnosed, this usually
represents an injury only to the parietal pleura and not to
the lung parenchyma itself. As such, this does not mandate
chest tube placement. Rather, a red rubber catheter can
be inserted through the parietal pleural tear into the tho­
racic cavity. The incision should then be closed, as previ­
ously described, in layers around the catheter. Positive
pressure is then applied and the catheter is clamped with
a hemostat until the surgeon is prepared for removal. At
the end of the operation, the anesthesiologist applies
maximal positive pressure into the lungs and holds this as
the catheter is placed on suction and removed. A postop­
erative chest radiograph should be taken if there is any
concern about the effectiveness of reestablishing negative
pressure within the pleural space.
In older patients, ossification of the cartilaginous rib
is a significant concern, and a limited computed tomog­
raphy scan of the sternum and ribs with coronal recon­
structions is recommended in those patients in whom
there is a high index of suspicion. Despite appropriate
preoperative screening, occasionally patients will present
with premature calcification of the cartilaginous rib. Fre­
quently, this is limited and occurs commonly at the junc­
tion of the osseous and cartilaginous portions of the rib.
Small foci of calcification may also be found within the
body of the rib cartilage itself. This can impair the prepa­
ration of individual grafts as well as act as a site of weak­
ness often having a tendency to fracture during graft
harvest. We have found that the use of a smooth diamond
burr can also prove useful in contouring areas of calcifica­
tion to salvage these uncommon circumstances. If the
Figure 7-2  The skin incision (thin line) for harvesting rib cartilage grafts
in a female patient is placed several millimeters superior to the inframam­
mary fold (thick line). The ribs are numbered according to their position.
Figure 7-3  Right fifth and sixth rib cartilage segments.
A Dingman elevator is used to elevate the perichon­
drium superiorly and inferiorly from the cartilaginous rib.
The subperichondrial dissection continues circumferen­
tially as far posteriorly as possible until a curved rib
stripper can be used to complete the posterior dissection.
The curved rib stripper is slid back and forth along the
rib, with care taken to remain between the cartilage and
perichondrium until the undermining is complete.
The cartilaginous rib is cut near its attachment to the
sternum and laterally where it meets the bony rib by
making a partial-thickness incision perpendicular to the
long axis of the rib using a No. 15 blade at the aforemen­
tioned junctions. The cartilaginous incision can then be
completed with a Freer elevator using a gentle side-to-side
movement. Once the cartilage segment is released both
medially and laterally, the graft is easily removed from
the wound and placed in sterile saline until the surgeon
is ready to fabricate the grafts. If more grafting material
is required, a portion of cartilage or the entire cartilagi­
nous part of another rib is then harvested in a similar
fashion (Figure 7-3).
The donor site is checked to ensure that no pneumo­
thorax has occurred by filling the wound with saline solu­
tion and the anesthesiologist applies positive pressure into
the lungs. If no air leak is detected, a pneumothorax can
be excluded. A 16-gauge angiocath catheter is inserted
through the skin and placed in the bed of the wound to
allow instillation of a long-acting local anesthetic at the
conclusion of the procedure. The wound may then be
closed in layers using 2-0 Vicryl sutures. Particular atten­
tion should be directed at reapproximating the perichon­
drium. It is important to close the perichondrium, muscle,

94
C. Spencer Cochran • Jack P. Gunter
with gauze soaked with a vasoconstricting medication,
such as oxymetazoline HCl. Bilateral marginal incisions
along the caudal edge of the lower lateral cartilages are
terminated medially at the narrowest part of the columella
and connected with a transcolumellar incision. A straight-
line incision is avoided by placing a broken-line incision
across the columella, which allows precise wound closure.
Elevation of the soft tissue envelope is begun by dis­
secting the thin columellar skin off the caudal edges of
the medial crura. The dissection continues over the lateral
crura in either a medial-to-lateral or lateral-to-medial
direction. Care should be taken to avoid unnecessary
retraction or injury to the soft tissue envelope, and in
particular, the columellar skin, as the blood supply may
be tenuous due to previous disruption in prior surgeries.
The normal tissue planes are frequently nonexistent,
having been replaced with varying amounts of scar tissue,
and the surgeon should be cautious not to perforate the
skin overlying the lower lateral cartilage complexes.
As dissection continues over the tip, it is important to
preserve the integrity of the domal segments when they
are present as this will facilitate reconstruction of the tip
complex. Once the tip is exposed, dissection continues
over the dorsal septum and upper lateral cartilages. Once
the nasal bones have been reached, a Joseph elevator is
used to lift the periosteum off the nasal bones superiorly
to the level of the nasofrontal angle. Retraction of the
undermined area allows exposure of the entire osseocar­
tilagenous framework.
INTRAOPERATIVE DIAGNOSIS AND
ASSESSMENT OF GRAFTING REQUIREMENTS
After the soft tissue envelope is elevated from the underly­
ing nasal framework, the nasal cartilages are evaluated
and correlated with the preoperative diagnosis. The extent
of the upper lateral cartilages and nasal tip deformity is
determined, and any cartilages displaced or distorted by
scar tissue are dissected free, but resection or final correc­
tion is delayed. Next, it is determined whether the tip
projection needs to be altered since this will determine the
height at which the dorsal profile line should be set. Any
alteration of the dorsum should be performed with the
final tip projection in mind.
Silicone sizers can be used to estimate the shape and
size of the columellar strut and dorsal onlay graft when
indicated. The silicone sizers are prefabricated by the
surgeon from molds of anatomically shaped dorsal onlay
grafts and columellar struts carved in a paraffin wax block
in an assortment of shapes and sizes (Figure 7-4). RTV
(room temperature vulcanizing) silicone is mixed, poured
into the molds, and left for 24 hours to polymerize before
trimming to their final form. The sizers are then sterilized
before being placed in the operative field. With a columel­
lar sizer in place, various dorsal sizers are then placed on
cartilage is unexpectedly found to be so extensively calci­
fied at the time of the operation that it is unusable, we
would then consider the use of irradiated donor cartilage,
accepting the increased risks of progressive resorption
over time. Irradiated homologous rib cartilage has been
used successfully,6 but problems with infection, absorp­
tion, and warping limit its routine use in dorsal augmenta­
tion (R. O. Dingman, personal communication, 1980).
OPERATIVE TECHNIQUE FOR
SECONDARY RHINOPLASTY
A systematic approach to the open rhinoplasty technique
is helpful for obtaining consistent results. While an indi­
vidualized approach is applied to each case and variations
in operative steps and sequence occur, the general steps
of open secondary rhinoplasty (Table 7-2) proceed in the
following sequence: incisions, skin elevation, intraopera­
tive diagnosis and assessment of grafting requirements,
septoplasty/septal cartilage harvest, dorsal modification,
establishment of desired tip projection and reconstruction
of the nasal tip complex, osteotomies, final tip cartilage
positioning and shaping, wound closure, and application
of splints and dressings.
INCISIONS AND ELEVATION OF
THE SOFT TISSUE ENVELOPE
With the patient under general anesthesia, the external
nose and septum are injected with 1.0% lidocaine with
1 : 100,000 epinephrine, and the internal nose is packed
Table 7-2  Operative Sequence in Open
Secondary Rhinoplasty
Incisions and elevation of the soft tissue envelope
• Dissection of displaced tip cartilages
Intraoperative diagnosis and assessment of grafting
requirements
• Estimation of desired tip projection
Septal cartilage harvest/septoplasty
Dorsal modification
• Dorsal reduction (if indicated)
• Spreader graft placement
• Dorsal augmentation (if indicated)
Osteotomies
Tip reconstruction using the tripod concept
• Establishment of final tip projection
• Lateral crural reconstruction
Final inspection
Wound closure
Application of splints and dressings

CHAPTER SEVEN  Secondary Rhinoplasty via the External Approach
95
to the desired height with a scalpel or sharp-angled scis­
sors (Figure 7-5).
Frequently, secondary rhinoplasty patients require
placement of dorsal spreader grafts. Spreader grafts
are usually paired, longitudinal grafts placed between
the dorsal septum and the upper lateral cartilages
(Figure 7-6). They are used to straighten a deviated dorsal
septum, improve the dorsal aesthetic lines, correct upper
lateral cartilage collapse, and reconstruct an open roof
deformity.7 If the dorsal aspect of the septal “L-strut” has
been weakened or overresected during previous surgery,
dorsal spreader grafts placed along either side of the
septum allow for stabilization and also provide a stable
platform for dorsal augmentation.
The length and shape may vary depending on the
indication. The grafts may extend above the level of the
dorsal septum to slightly augment the dorsum or extend
caudally beyond the septal angle as extended spreader
grafts to lengthen the nose. The grafts should be suture-
fixated to the septum prior to reapproximation of the
upper lateral cartilages to the septum–spreader graft
complex.
With the midvault reconstructed, the dorsum may
then be augmented as necessary. Autogenous rib cartilage
has been our graft material of choice for dorsal augmenta­
tion when sufficient septal cartilage is not available. Prior
to graft preparation, the dorsum of the nose must be
prepared to receive the dorsal graft. The recipient bed on
the dorsum must be made as flat and smooth as possible
to give the greatest surface area for the dorsal onlay graft
to contact. A uniform surface of the dorsal recipient bed
aids in the graft adhering solidly to the osseocartilagenous
framework. This prevents postoperative movement of the
graft after healing is complete, as is often seen in grafts
placed in soft tissue envelopes.
The major disadvantage in using rib cartilage is its
tendency to warp (Figure 7-7). In response to this, the
senior author (J.P.G.) devised a technique in which the
larger costal cartilage grafts, the dorsal onlay graft,
and often the columellar strut are reinforced with a
centrally placed Kirschner wire (K-wire) to decrease
warping and provide a more stable and predictable
result.8 To avoid warping of smaller grafts, we follow the
principle of carving balanced cross sections originally
described by Gibson and Davis9 and later substantiated
by Kim et al.10
The harvested rib segment that is selected for the
dorsal onlay graft is manually stabilized in a specifically
designed K-wire guide jig, and a smooth 0.028-inch
K-wire is drilled longitudinally through the center of the
graft. The 0.028-inch K-wire is removed and replaced
with a threaded 0.035-inch K-wire to better stabilize the
graft and avoid migration of the K-wire. The same routine
is used for placing an internal K-wire in the columellar
strut if rib cartilage is used.
Figure 7-4  Silicone dorsal onlay graft sizers prefabricated by surgeon
are helpful in estimating the desired graft size.
the dorsum and the skin is redraped until the desired
combination is determined.
SEPTAL CARTILAGE HARVEST/SEPTOPLASTY
If septal work is required, the septum may be approached
from above after the upper lateral cartilages have been
divided from the septum. The upper lateral cartilages can
be freed from the dorsal septum after submucopericon­
drial tunnels are created bilaterally using an elevator
beginning at the septal angle. Alternatively, the septum
may be approached via a separate transfixion incision.
The mucoperichondrium is elevated on one side, and
the appropriate septal modification or septal cartilage
harvest is performed. If septal cartilage is to be harvested,
care should be taken to preserve an “L-shaped” septal
strut measuring at least 1 cm in width. If the caudal
septum is deviated or dislocated from the maxillary crest
or nasal spine area, it should be reduced to the midline
and fixated with a figure-of-eight suture. It may be neces­
sary to separate the medial crura to gain better exposure,
but their attachment to each other, which aids in support
of the tip, must be reestablished before the end of the
operation.
DORSAL MODIFICATION
After the desired tip projection is estimated and septal
work has been completed, the cartilaginous-bony dorsum
is evaluated and any needed augmentation or reduction
of the dorsum is performed. Reduction of the bony dorsum
is usually performed with a rasp, and any remaining
contour irregularities of the bony dorsum can be smoothed
using a drill with a coarse diamond burr. The dorsal
septum and upper lateral cartilages can then be trimmed

96
C. Spencer Cochran • Jack P. Gunter
Figure 7-7  Rib cartilage graft (without K-wire stabilization) removed from a secondary rhinoplasty patient that exhibits significant warping.
Figure 7-6  Spreader grafts are sutured along the dorsal septum.
Figure 7-5  Preoperative (left) versus postoperative (right) photographs of a secondary rhinoplasty patient with a dorsal deformity resulting from inad­
equate resection of her dorsal septum during a previous rhinoplasty.

CHAPTER SEVEN  Secondary Rhinoplasty via the External Approach
97
completed as well as indicated osteotomies, if not previ­
ously performed.
TIP RECONSTRUCTION USING
THE TRIPOD CONCEPT
Once the nasal dorsum has been addressed, attention is
redirected to the tip, where the estimated tip projection is
confirmed, final tip projection is established, and recon­
struction of the tip cartilages is performed. The Tripod
Concept, which relates nasal tip support and shape to the
paired lower lateral cartilage complexes, is a useful
premise for nasal tip reconstruction and for correcting
deformed lower lateral cartilages. Each lower lateral car­
tilage complex consists of a medial crus (including the
intermediate crus) and a lateral crus. These paired com­
plexes can be visualized as a tripod (Figure 7-10), with
each lateral crus forming a separate lateral (cephalic) leg
and the adjoining medial crura forming the caudal third
leg.11 Using this concept to anatomically simulate the
paired lower lateral cartilage complexes allows reestab­
lishment of this tripod and is the goal for any nasal-tip
reconstruction.
To be successful, the reconstructed tripod structure
must have the strength to support the tip and prevent the
alar sidewalls from collapsing and the shape to provide
the nasal tip with an aesthetically pleasing, natural
Figure 7-8  A columellar strut graft fashioned out of rib cartilage with
internal K-wire stabilization is placed in a maxillary drill hole, which allows
precise control of projection and rotation.
Figure 7-9  Rib cartilage dorsal onlay graft.
Nasion
Anterior
septal
angle
Dorsal
onlay
implant
The cartilage grafts with the internal K-wires are then
carved into similar but slightly larger shapes of the selected
sizers. The K-wire in the dorsal onlay graft should be
placed to within 2 to 3 mm of the cephalic end of the graft
and cut flush with the caudal end. The K-wire in the colu­
mellar strut should extend three-fourths of the length of
the graft with 8 to 10 mm of the K-wire left exposed at
the graft base, which will be seated into a drill hole
created in the maxilla (Figure 7-8).
The grafts are then placed in their anatomic position
to determine what further shaping is required. Carving
proceeds carefully from this point usually by scraping the
grafts with the sharp edge of a No. 10 blade perpendicular
to the graft surface until the exact desired size, shape, and
contour are obtained. After the carving is completed, the
K-wire placement can be adjusted if indicated.
Next, the dorsal onlay graft is placed and secured
(Figure 7-9). Fixation of the cephalic end of the dorsal
graft is achieved by placing a temporary 0.028-inch
smooth K-wire percutaneously through the graft into the
nasal root. This percutaneous K-wire is removed in the
office with a wire twister 1 week postoperatively when
the external splint is removed. Caudally, the graft is
secured to the nasal dorsum by a suture that passes around
or through the graft and through the upper lateral carti­
lages and nasal septum–spreader graft complex in the
area of the septal angle. Any remaining tip work is then

98
C. Spencer Cochran • Jack P. Gunter
Figure 7-10  The Tripod Concept. Each lateral crus makes up
one of the lateral legs of the tripod and the paired medial crura make
up the caudal leg.
Central limb
of tripod
Combined
medial crura
form one limb
appearance. Septal, auricular, and rib cartilage can all be
used with each having its own inherent advantages and
disadvantages.
The method used for rebuilding the tripod depends
on several factors. The most important factors are (1) how
much usable cartilage is present in the tip and (2) what
cartilage (septal, auricular, or rib) is available for grafting.
In minor tip deformities (Figure 7-11), when the lateral
crura are present but collapsed or mildly deformed, lateral
crural strut grafts fashioned from septal or auricular car­
tilage are the treatment of choice to reestablish the shape
and stability of the lateral legs of the tripod.12 Lateral
crural strut grafts are grafts placed in an undermined
pocket between the undersurface of the lateral crus and
the vestibular skin and stabilized by suturing it to the crus
(Figure 7-12). They are used to correct alar retraction,
alar rim collapse, and concave, convex, or malpositioned
lateral crura (Figure 7-13). The lateral crural strut grafts
extend laterally to overlap the piriform aperture and end
in an undermined pocket inferior to the alar groove. If the
pocket is created superior to the alar groove, it will some­
times produce a visible bulge above the ala. We use a
columellar strut in almost all cases of nasal-tip recon­
struction to stabilize the caudal leg and thereby resist
displacement by scar tissue contraction or swelling.
When the lateral crura are absent or so deformed that
they cannot be used, correction is more challenging, and
autogenous rib cartilage has proved to be the cartilage of
choice. If the lateral crura are not usable but the medial
crura and domes are intact, a columellar strut is sutured
between the medial crura to strengthen the caudal leg of
the tripod. Next, the vestibular skin is undermined off the
undersurfaces of the domes. The lateral crural strut grafts
are sutured to the undersurface of each dome to replace
the missing lateral crura (Figure 7-14).
If both the medial and lateral crura are absent or
unusable, autogenous rib cartilage is carved as a “shaped”
columellar strut to act as the caudal leg of the tripod
(Figure 7-15). It is carved to simulate the contour of the
caudal margins of the medial crura and medial portion of
the domes along the columella-infratip lobule. The graft
is stabilized with an internal 0.035-inch threaded K-wire
that extends to within 4 or 5 mm of the tip.13 Approxi­
mately 10 mm of the K-wire protrudes from the base of
the graft and is placed in a 12-mm drill hole in the maxilla
just off the midline in the nasal spine area after the spine
is removed with a rongeur. The strut replaces the support
of the missing medial crura. The drill hole should travel
just below and parallel to the nasal floor so that it will not
extrude through the nasal or palatal bony surfaces.
The lateral legs of the tripod are reconstructed in a
fashion similar to that used when the domes are present.
The only difference is that instead of suturing the medial
ends of the lateral crural strut grafts to the undersurface
of the domes, the surgeon sutures the grafts to the tip of
the “shaped” columellar strut to replace the missing
lateral crura (Figure 7-16). It is preferable and easier to
suture the lateral crural strut grafts to the undersurface
of the domes, assuming they are present, than to the tip
of the columellar strut. In the event that the domes are
absent, the “shaped” strut and the lateral crural strut
grafts should be tapered. A soft tissue onlay graft of fascia
or perichondrium is also an effective means of camouflag­
ing irregularities of the tip cartilages and grafts edges.
WOUND CLOSURE AND SPLINTS
The skin is redraped after a final inspection of the nasal
framework. The external appearance and nasal interior
are evaluated, and the incisions are closed. After closure
of the marginal incisions with interrupted 5-0 chromic
sutures, the transcolumellar incision is meticulously closed
with interrupted 6-0 nylon sutures. No subcutaneous
sutures are necessary. If septal work has been performed,
bilateral septal splints are placed and sutured in place
with through-and-through 3-0 nylon sutures. Nasal

CHAPTER SEVEN  Secondary Rhinoplasty via the External Approach
99
A
B
Figure 7-11  Preoperative (left) and postoperative (right) views of a patient with an asymmetric and distorted tip resulting from a previous surgery, which
was corrected using septal and auricular cartilage to reconstruct her tip.

100
C. Spencer Cochran • Jack P. Gunter
Figure 7-11, cont’d 
C
D
E
F

CHAPTER SEVEN  Secondary Rhinoplasty via the External Approach
101
Previously
resected
Figure 7-11, cont’d 
Figure 7-12  Lateral crural strut grafts are placed under the existing
lateral crura when they are only minimally deformed.
packing is avoided if hemostasis is adequate. Steri-Strips
and an aluminum cast are placed on the nose and remain
for 1 week.
DISCUSSION
The major advantage of the open approach in the man­
agement of secondary nasal deformities lies in the com­
plete, undistorted anatomic exposure of the nasal
framework. This allows for a precise anatomic diagnosis
and correction of the deformity with original tissues and
supplemental cartilage grafts. The bony and cartilaginous
structures can be continuously assessed intraoperatively.
The final anatomic alignment and symmetry of the nasal
framework become more predictable. Despite all the
advantages of the open approach, it is not indicated for
every secondary nasal deformity. Minor asymmetries or
underresection can sometimes be corrected endonasally,
but for major deformities, the open approach is
preferred.
The major potential disadvantage of the open rhino­
plasty technique is the transcolumellar scar. However,

102
C. Spencer Cochran • Jack P. Gunter
Figure 7-13  Preoperative (left) versus postoperative (right)
views of a secondary rhinoplasty patient whose deformities were
corrected with a dorsal onlay and columellar strut fashioned out of
rib cartilage and reinforced with internal K-wires.
A
B
C
D

CHAPTER SEVEN  Secondary Rhinoplasty via the External Approach
103
Figure 7-13, cont’d 
Previously
resected

104
C. Spencer Cochran • Jack P. Gunter
Figure 7-14  For lateral crura that have been completely resected or
that are unusable, the lateral crural strut grafts are sutured to the undersur­
face of the domes.
using a broken line incision across the columella with
strict attention to operative technique during closure
results in a scar that is usually indistinguishable at con­
versational distances. Wound separation and delayed sec­
ondary healing are rare occurrences. The open approach
also increases the operative time and may prolong tip
edema. The increased operating time is necessary for the
suture stabilization required for any grafting and reposi­
tioning of the anatomic structures and accurate closure of
the transcolumellar incision.
Major postoperative nasal deformities having a dis­
torted nasal framework with aesthetic and functional
compromise are a difficult problem. The complexity of
secondary nasal deformities requires strict adherence to
the basic principles as outlined, an understanding of the
individual’s aesthetic nasal analysis, and a systematic
treatment plan. Use of the open approach for major post­
operative nasal deformities has produced more consistent
aesthetic and functional results in the management of
these multifaceted problems.
REFERENCES
1. Rees TD, Krupp S, Wood-Smith D. Secondary rhinoplasty.
Plast Reconstr Surg. 1970;46:332.
2. Gunter JP, Rohrich RJ. Augmentation rhinoplasty: Onlay
grafting using shaped autogenous septal cartilage. Plast
Reconstr Surg. 1990;86:39.
3. Murrell GL. Auricular cartilage grafts and nasal surgery.
Laryngoscope. 2004;114(12):2092–2102.
4. Gunter JP, Rohrich RJ. External approach for secondary
rhinoplasty. Plast Reconstr Surg. 1987;80:161.
5. Gunter JP, Rohrich RJ. Augmentation rhinoplasty: Dorsal
onlay grafting using shaped autogenous septal cartilage.
Plast Reconstr Surg. 1990;86:39.
6. Clark JM, Cook TA. Immediate reconstruction of extruded
alloplastic nasal implants with irradiated homograft costal
cartilage. Laryngoscope. 2002;112(6):968–974.
Figure 7-15  When both the medial and lateral crura have been resected
or are unusable, the nasal tip tripod is reconstructed with lateral crural strut
grafts that are sutured directly to a “shaped” columellar strut.
Figure 7-16  Intraoperative photograph showing lateral crural strut
grafts sutured directly to the “shaped” columellar strut.

CHAPTER SEVEN  Secondary Rhinoplasty via the External Approach
105
7. Sheen JH. Spreader graft: A method of reconstructing the roof
of the middle nasal vault following rhinoplasty. Plast Reconstr
Surg. 1984;73(2): 230–239.
8. Gunter JP, Clark CP, Friedman RM. Internal stabilization of
autogenous rib cartilage grafts in rhinoplasty: A barrier to
cartilage warping. Plast Reconstr Surg. 1997;100:162.
9. Gibson T, Davis WB. The distortion of autogenous cartilage
grafts: its causes and prevention. Br J Plast Surg. 1958;10:
257.
10. Kim DW, Shah AR, Toriumi DM. Concentric and eccentric
carved costal cartilage: A comparison of warping. Arch Fac
Plast Surg. 2006;8(1):42–46.
11. Anderson JR. A reasoned approach to nasal base surgery.
Arch Otolaryngol. 1984;110:349–358.
12. Gunter JP, Friedman RM. Lateral crural strut graft:
Technique and clinical applications in rhinoplasty. Plast
Reconstr Surg. 1997;99:943–952.
13. Gunter JP, Clark CP, Friedman RM. Internal stabilization of
autogenous rib cartilage grafts in rhinoplasty: A barrier to
cartilage warping. Plast Reconstr Surg. 1997;100(1):
161–169.

107
C H A P T E R E I G H T 
Endonasal Rhinoplasty:
Transcartilaginous Approach
Raj Kanodia • Anil R. Shah
Rhinoplasty is one of the most challenging operations
in plastic surgery. The three-dimensional nature of the
nose, conformed by skin and soft tissue envelope (S-STE),
and the shape and orientation of the nasal cartilages and
bones are variables that, when grouped together, confer a
nearly limitless number of different configurations seen in
nasal appearance. Additionally, each of the constituent
parts of the nose are intricately related to one another so
that even small change in one component can lead to
substantial changes elsewhere, thereby creating a large
impact upon the nose. Another obstacle in rhinoplasty is
the technical demands that the operation imposes.
Nowhere else in plastic surgery is the margin upon which
success hinges so slim, that a millimeter can spell the dif­
ference between a successful result or disappointment.
Finally, manipulation of the form of the nose requires an
artistic vision and sense of proportion and dimension.
While there may be an aesthetic ideal for other operations,
the ideal nose for one face may be completely different
for another face, necessitating a keen aesthetic judgment
by the surgeon.
Wide variations in technique, philosophies, and surgi­
cal results can be seen among rhinoplasty surgeons. Some
surgeons use an “ideal nose strategy” for rhinoplasty.
These surgeons have a vision of a perfect nose and focus
their rhinoplasty efforts toward the creation of this ideal­
ized goal for every face. Unfortunately, the “ideal nose
strategy” carries some inherent flaws. This strategy
assumes that all parts of the nose that do not meet the
criteria of this ideal nose need to be changed. The authors
contend there is a wide range of features that may be
deemed as attractive and must be considered in the
context of the remainder of the facial features and nose.
Surgeons who ascribe to the ideal nose strategy will often
use more extensive radical procedures with extensive
grafting in an effort to impart more dramatic changes to
the nose. While the surgeon may be able to achieve their
goal in changing one aspect of the nose, it often comes at
the expense of unintended changes in the remainder of
the nose. Another downside with the ideal nose mindset
is that it will lead the surgeon to creating an imbalance
between the nose and the corresponding facial features. A
successful rhinoplasty operation is a marriage between the
face and nose so that not only is the appearance of the
nose improved but the remainder of the facial features are
also enhanced.
PHILOSOPHY
Rather than purporting that all noses should appear
similar (the ideal nose strategy), the senior author (R.K.)
ascribes an approach that attempts to maximize the
beauty within each nose. The senior author has developed
a philosophy emphasizing a collection of subtle changes
to the nose as a means to maximize both its function and
natural appearance. A central tenet to this philosophy is
to respect the complexities of the nasal anatomy. Each
constituent part of the nose is interrelated, whereby seem­
ingly small changes in one part of the nose may create
untoward subsequent changes in other parts of the nose.
The time factor can add another dimension of complexity
where additional changes may manifest within the nose
when long-term follow-up is undertaken.
This philosophy is based on 28 years of experience
and more than 5000 rhinoplasty patients. The aesthetic
goals of the operation are to create subtle, artistic refine­
ments that will continue to improve during the healing
continuum. While some surgeons may try to forcibly
manipulate each nose to look like an “ideal nose,” the
authors contend that soft, subtle changes to the existing
nose will lead to a more natural looking nose and harmo­
niously achieve facial balance. Many of these small
changes will continue to improve with time, resulting in
further refinement of the nose.
The senior author’s approach to nasal tip definition
is classified under the broad category of transcartilagi­
nous techniques, where the lower lateral cartilages are
shaped through direct excision and removal of excessive
lower lateral cartilage bulk.1 Traditionally, these tech­
niques have been separated into two categories: retro­
grade excision of cartilage and direct excision. The
transcartilaginous approach offers several distinct advan­
tages. First, this technique is the least disruptive tech­
nique available. The only major tip supportive mechanism
affected is the relationship between the lower lateral

108
Raj Kanodia • Anil R. Shah
limits potential complications compared to other more
aggressive techniques.
PREOPERATIVE EVALUATION
All patients are evaluated in person by the physician.
While the Internet and email are continuing to revolution­
ize the practice of medicine, electronic photographs cannot
replace a thorough intranasal exam and palpation of the
lower lateral cartilages and nasal tip support. Anterior
rhinoscopy allows for evaluation of the nasal septum and
any deflections which may need to be addressed during
the operation. Palpation of the anterior portion of the
septum can help determine the contribution of the septum
to projection and rotation. During the initial consultation,
an understanding between the surgeon and patient is nec­
essary to ensure the patient and surgeon have a shared
goal of what can be achieved.
OPERATIVE TECHNIQUE
PREOPERATIVE PREPARATION
Preoperative preparation of the patient plays a significant
role in creating the setting of a successful operation. First,
preoperative icing is performed on all patients. Ice acts as
a natural and powerful vasoconstrictor of the nose, which
significantly reduces edema, swelling, and bruising. Low
doses of preoperative diazepam and meperidine can help
patients relax and thereby release less stress hormones,
which can lengthen the recovery process.
INJECTION TECHNIQUE
Cotton pledgets soaked with 2% tetracaine (Pontocaine)
are placed against the intranasal mucosa to locally anes­
thetize the field. Patients are initially injected with a
solution of 0.5% ropivacaine and 1% lidocaine with
epinephrine 1 : 200,000 in a 1 : 1 mixture along the soft
tissues of the nose and septal mucosa. The authors prefer
to mix the epinephrine due to a perceived longer lasting
effect intraoperatively and quicker onset of action than
that seen when using premixed lidocaine and epinephrine.
Care must be taken to ensure avoiding dosing mistakes
when mixing these directly. Another common mistake to
be avoided is using too much volume with local anesthe­
sia, thereby obscuring the nasal form of the nose.
ADDRESSING THE SEPTUM
Initially, a modified hemitransfixion incision is made
5 mm posterior to the membranous septum. The posterior
location of the incision conceals visibility of the scar from
the lateral view. In addition, the farther posterior location
cartilages and the upper lateral cartilages.2 However, the
underlying anatomy of the nose, including the vestibular
mucosa, is left for the most part undisrupted, which
translates visually into results that maintain the natural
features of the nose. While other techniques may leave
behind a footprint of a rhinoplasty such as a columellar
scar, asymmetry of the alar rim, or loss of the highlights
of the soft tissue facets, the transcartilaginous approach
we describe provides visual improvements while minimiz­
ing the usual surgical stigmata. When properly executed,
the integrity of the lower lateral cartilage is preserved,
providing a natural shape to the lower lateral cartilage.
Over time, further nasal tip refinement is seen as the skin
continues to mold.
ADVANTAGES/DISADVANTAGES
When a rhinoplasty surgeon decides to perform a particu­
lar surgical maneuver, consideration must be given to
the serious, aesthetic consequences for the patient. For
example, suture techniques can in some instances exacer­
bate internal recurvature of the lower lateral cartilages,
creating potential airway obstruction. Over time, some
suture techniques can result in bossae and knuckling or,
if improperly executed, can also lead to nostril asymmetry,
alar notching, loss of the soft tissue triangle facets, unnat­
ural nasal contours, and alar depressions. Additionally,
suture techniques can result in a pinched nasal tip, an
obvious surgical stigma.
The transcartilaginous technique has the significant
advantage of minimizing soft tissue edema. While the
open technique and suture methods will require dissection
over the nasal domes, the soft tissue of the nasal tip is left
relatively undisturbed while using the transcartilaginous
operation. The larger extent of supratip swelling associ­
ated with other techniques can lead to an undesired
outcome. Many surgeons have attempted to compensate
for this additional swelling by overprojecting the nose,
making the entire nose larger. Most patients seeking
primary rhinoplasty do not want their nose larger but
instead are seeking a less extreme version of their existing
nose.
One purported disadvantage of the transcartilaginous
technique is the steep learning curve associated with it.
This technique requires the ability to interpret the under­
lying lower lateral cartilage anatomy without direct visu­
alization. A combination of visualization, palpation, and
judgment are necessary tools to perform this technique.
In addition, the surgeon must be able to determine if the
amount of cartilage excised was symmetrical and exact in
nature. Another obstacle in learning the transcartilagi­
nous approach is the ability to make small changes to
control nasal tip projection and rotation. Every surgical
technique carries an associated learning curve; the authors
believe the transcartilagionous technique significantly

CHAPTER EIGHT  Endonasal Rhinoplasty: Transcartilaginous Approach
109
is less likely to disrupt nasal tip support as opposed to a
hemitransfixion or full transfixion incision. The septal
mucoperichondrium is then retracted with a brown forcep
and initially elevated with a Woodson elevator. If cartilage
grafting is needed, septal cartilage can be harvested along
the nasal floor just above the maxillary crest with a septal
knife. Not uncommonly, septal deviations can cause
airway obstruction and once removed will improve nasal
airflow; these include deflections of the perpendicular
plate and septal spurs along the nasal floor.
If manipulation of the anterior septum is required, a
retrograde septal mucosal approach can be used with a
spreading motion of the gooseneck dissecting scissors. If
exposure of the nasal spine or depressor septi muscle is
needed, a Parkes retractor can be utilized. Changes in
projection and rotation of the nose can be performed by
changing the length and shape of the caudal septum.
Deprojection of the nose and rotation can be performed
by precise resection of a portion of the anterior septal
angle. Shaving the caudal septal region will in part lead
to slight shortening of the nose, and can help rotate the
tip if wedge-shaped portion is excised. Counterrotation
can be performed by careful excision of the posterior
septal angle.
ADDRESSING THE NASAL TIP
The lower lateral cartilages are addressed by a transcar­
tilaginous approach. The surgeon must be able to accu­
rately predict how much cartilage must be excised and
how much is left in vivo to achieve the desirable aesthetic
outcome and prevent untoward sequelae. A two-pronged
retractor is used to retract the nostril, and the forefinger
is used to present the lower lateral cartilage into view. An
incision is first made through the vestibular mucosa only
along the midportion of the lower lateral cartilage, 6 to
9 mm superior from the alar rim.
The vestibular mucosa is bluntly elevated superiorly
during the excision, allowing for exposure of the lower
lateral cartilage. An incision is then made with a No. 15
blade scalpel on the lower lateral cartilage, outlining the
caudal extent to be resected. Gooseneck scissors are used
to dissect the soft tissues from the lower lateral cartilage
in a supraperichondrial plane to the cephalic edge of the
lateral crus. The superior portion of the lower lateral
cartilage, including a portion of the lateral, intermediate,
and medial lower lateral cartilage, is excised. Once the
cartilage has been excised, the lower lateral cartilages are
inspected externally and visual changes of the shape of
the nasal tip are inspected, preserving an intact strip of
lower lateral cartilage (Figures 8-1 and 8-2). The lateral
portion of the lower lateral cartilage is preserved, prevent­
ing potential alar collapse and unsightly alar pinching.
Vestibular skin in this area is treated with the utmost care
and is preserved.
Figure 8-1  The vestibular mucosa is exposed and the excess cartilage
is precisely sculpted to reshape the lower lateral cartilage.
10 mm cuff
preserved
Figure 8-2  The cartilage is removed from the nose, preserving an intact
strip of lower lateral cartilage.
10 mm of lower
lateral cartilage
preserved
Through the transcartilaginous incision, the scroll
area can be visualized. Precise excision of the cephalic
scroll allows for further definition of the nasal tip. In addi­
tion, doing so can allow for additional space for nasal tip
rotation.

110
Raj Kanodia • Anil R. Shah
CARTILAGE SCORING
At the conclusion of the case, some patients may have
excessive cartilaginous memory to the lower lateral carti­
lages. Vertical scoring incisions can be made using a No.
15 blade, weakening the lower lateral cartilage on the
vestibular side while still preserving its overall natural
contour. Vertical scoring is preferred because it reduces
the spring of the lower lateral cartilages, allowing for
convex cartilage shapes to become flatter over time. An
important technical point with vertical cartilage scoring
is symmetry in location and depth of the scoring maneu­
vers to allow for gradual symmetric reduction in the bul­
bosity of the nasal tip.
The mucosal incisions must be meticulously closed to
prevent synechiae and potential alar retraction or notch­
ing. Preservation of the vestibular mucosa allows for a
natural and physiologic nose. A thin sheet of compressed
Gelfoam is placed along the dorsum to allow for even skin
healing.
POSTOPERATIVELY
A small sheet of paper is placed against the dorsal surface
of the nose in an effort to protect it from contact from the
glue of the adhesive tape. Topical glues are avoided to
prevent skin sloughing, swelling, and minimize breakouts
to the nasal skin. Aquaplast is contoured to support the
nasal bones and maintain their position for 1 week post­
operative. Ice is applied for 48 hours.
DISCUSSION
A variety of techniques can be classified under the broad
term of cartilage splitting endonasal rhinoplasty with
pros and cons associated with each technique. The classic
transcartilaginous approach creates a bipedicled flap
based on an incision along the rim and a narrow blood
supply. In the direct transcartilaginous approach, one
incision is made along the vestibular skin and cartilage.
Some authors have reported using percutaneous punc­
tures to improve the accurate reshaping of the intermedi­
ate crus.4 The authors report that visualization and
palpation contribute to the ability to accurately assess the
intermediate lateral crus region.
As many trends in rhinoplasty seem to come and go,
the truest tests of any technique are time, predictability,
and results. Open structure rhinoplasty and other tech­
niques play a significant role and will continue to do so
in rhinoplasty. Unfortunately, in our opinion some sur­
geons are “overtreating” patients who present for primary
rhinoplasty surgery. It is important for novice surgeons to
realize that a longer or more invasive procedure does not
always necessarily translate into improved results and can
in some instances expose patients to complications.
ADJUSTING THE NASAL DORSUM
Through the same transcartilaginous incision, the dorsum
is skeletonized supraperichondrially and subperiosteally.
The nasal dorsum is visualized with the aid of a Parkes
nasal retractor. The dorsal septal cartilage is excised in a
precise, deliberate manner using a No. 15 blade knife in
a cephalic-to-caudal manner. Dorsal convexities can be
addressed with a gouge. The overlying surface of the nasal
bones is more dense cancellous bones, making it more
resistant to nasal rasping. Precise removal of nasal humps
with a gouge can be performed to “uncap” the nasal bones
and allow for medial movement of the nasal bones. Dif­
ferent gouges can be used depending on the length and
height of bone to be uncapped and opened.
An advantage that the endonasal technique offers
over an external rhinoplasty approach is the dorsal profile
adjustments. In external rhinoplasty, the soft tissues of
the nose may have additional swelling, making minute
changes of the dorsum difficult. When using endonasal
techniques, it is crucial to expose the anterior septal angle
to ensure that the supratip break can be visualized and
manipulated.
CLOSING THE OPEN ROOF DEFORMITY
The osteotomy site is injected with local anesthesia 5
minutes prior to the procedure, allowing for additional
vasoconstriction. A sharp soft tissue modified Parkes
gouge is used to allow a passage lateral to the nasal bone
for the osteotome and elevate the nasal periosteum. Oste­
otomies are performed with a guarded osteotome in a low
manner. Osteotomies take place along the widest portion
of the nasal bone to prevent a palpable and/or visual
stepoff and create a natural contour to the nose. Incom­
plete osteotomies can be completed with a Quisling oste­
otome. After the osteotomies have been performed, the
nose is evaluated. Ice is placed intraoperatively to allow
for natural vasoconstriction intraoperatively.
PLACEMENT OF SPREADER GRAFTS
Spreader grafts are placed into precise mucosal pockets if
there is anticipated potential weakness of the middle third
of the nose. The grafts are best fashioned from the septal
cartilage along the nasal floor, just along the maxillary
crest. This portion of the septal cartilage is the strongest.
Spreader grafts are placed by inserting the grafts in a
precise pocket 2 mm from the dorsal aspect of the septum.
Preservation of the dorsal mucosal cuff prevents the grafts
from pushing out dorsally. The grafts are secured with a
3-0 chromic suture. If there is a mild septal deviation,
asymmetric spreader grafts can be placed.3 Typically, a
larger spreader graft is placed on the side of the dorsal
septal deflection, to reposition the nasoseptal pyramid
over to the nondeviated side.

CHAPTER EIGHT  Endonasal Rhinoplasty: Transcartilaginous Approach
111
are now using the open approach more than 50% of the
time.5,6 While every rhinoplasty technique may have merit
in specific situations, many surgeons are now aggressively
treating primary rhinoplasty patients as revision cases. We
make the case for condition-related approaches, avoiding
resorting to the external approach for every nose.
As the field of facial plastic surgery advances, new
techniques and trends are often welcomed with unbridled
enthusiasm despite limited follow-up and experience. The
field of rhinoplasty is no different. Many new purported
advances have been mentioned, including alloplastic
implants, autologous, and other grafts such as acellular
human and porcine dermis, etc. However, the true measure
of a technique is consistently achievable and long-lasting
natural-appearing results.
CONCLUSION
The transcartilaginous approach is a versatile primary
rhinoplasty technique. It has the advantage of preserving
the lower lateral cartilage shape and form, the natural
features of the nose, maintaining the nasal anatomic
integrity (Figures 8-3 through 8-15).
Endonasal rhinoplasty is a technique quickly becom­
ing a lost art. A recent survey found that 50% of surgeons
Figures 8-3 through 8-8  Preoperative photographs demonstrate an
ideal candidate for finesse rhinoplasty. Her nose demonstrates overly strong
features which overpower the rest of her face.
Figure 8-4 
Figure 8-5 
Figure 8-6

112
Raj Kanodia • Anil R. Shah
the integrity of the lower lateral cartilages. Primary rhi­
noplasties only need refinement and finesse, not a changed
rebuilt nose.
Many surgeons try to impose their vision of what is
beautiful and in effect take away natural features of the
face. Alar grafts, batten grafts, and radix grafts may have
a place in secondary rhinoplasty, but in primary noses,
they bulk up the nose. Furthermore, most grafts add a
certain rigidity to the nose, taking away its natural feel
and look. Although surgeons may be able to achieve the
desired amount of change, they do so at the expense of
While each rhinoplasty surgeon may have a philoso­
phy and artistic aesthetic sense, the senior author has
chosen to focus on emphasizing the existing natural beauty
of each nose, rather than trying to completely change its
character. One of the central tenets to this approach in
rhinoplasty is to preserve and enhance the existing nose.
The character of the nose, the natural features of the nose,
and the underlying structural integrity are all vital fea­
tures that must be left undisturbed. The senior author
makes changes in rotation, projection, and definition
by a combination of several techniques that protect
Figure 8-7 
Figure 8-8 
Figures 8-9 through 8-15  Postoperative result (surgery performed by
Dr. Anil R. Shah) demonstrates improvement in overall shape of nose while
still maintaining a natural appearance. The patient’s nose retains a slight high
point along the bridge so that her nose will have few, if any, stigmata of a
rhinoplasty.
Figure 8-10

CHAPTER EIGHT  Endonasal Rhinoplasty: Transcartilaginous Approach
113
Figure 8-11 
Figure 8-12 
Figure 8-13 
Figure 8-14 
Figure 8-15

114
Raj Kanodia • Anil R. Shah
the appearance of the rest of the nose. Collective small
changes can add up to a greater good, preserving natural
beauty.
REFERENCES
1. Parkes MH, Kanodia R, Kern EB. The universal tip: a
systematic approach to aesthetic problems of the lower lateral
cartilages. Plast Reconstr Surg. 1988;81(6):878–890.
2. Ingels K, Orhan KS. Measurement of preoperative and
postoperative nasal tip projection and rotation. Arch Facial
Plast Surg. 2006:8(6):411–415.
3. Oliveria PW, Pezato R, Gregorio LC. Deviated nose correction
by using the spreader graft in the convex side. Rev Bras
Otorrinolaringol. (Engl Ed) 2006;72(6):760–763.
4. Neto JC, Coffler HJ. A new and simple marker for the
transcartilaginous incision: The Cabas-Coffler marker. Plast
Reconstr Surg. 2008;121(3):126e–127e.
5. Constantian MB. Differing characteristics in 100 consecutive
secondary rhinoplasty patients following closed versus open
surgical approaches. Plast Reconstr Surg. 2002;109(6):
2097–2111.
6. Adamson PAA, Galli SK. Rhinoplasty approaches: current state
of the art. Arch Facial Plast Surg. 2005;7: 32–37.

115
C H A P T E R N I N E 
Reducing Complications
in Rhinoplasty
Daniel G. Becker • Madeleine A. Becker • Jason A. Bloom • David Gudis • Jacob Steiger
The nationally reported revision rate for primary rhino­
plasty ranges from 8% to 15%.1–9 Unfortunately, there will
likely never be a shortage of patients requiring revision
rhinoplasty. Experienced surgeons consistently achieve a
high level of satisfaction among their patients. Still, com­
plications can occur despite technically well-performed
surgery. All surgeons have complications.
Success in rhinoplasty is based on well-developed
judgment, wisdom, and accumulated knowledge and
experience. Similar to most surgeries, rhinoplasty is a
science and an art. Skill comes from experience and
wisdom, combined with a measure of talent, and the
surgeon must have a detailed understanding of the mul­
tiple anatomic variants encountered. The surgeon also
must have accumulated the appropriate surgical tech­
niques and experience. Specifically, the surgeon must
acquire knowledge of the surgical alternatives, and how
healing forces will affect the final surgical outcome. This
skill set is only acquired by careful follow-up of patients
operated over time.
There is no “standard” rhinoplasty. Each operation is
unique in that it must be tailored to the specific anatomic
components involved and the desires of the patient. By
developing a consistent, meticulous routine in which the
patient’s nose is analyzed with regard to its anatomic
components and their complex interrelationships, the
surgeon can best select the appropriate incisions,
approaches, and techniques for the patient’s nose. These
concepts are discussed in the first part of this chapter.
Having the opportunity in practice to examine numer­
ous revision rhinoplasty patients from across the United
States and around the world, the senior author has
observed a wide range of problems. By carefully studying
the problems encountered in a revision practice, the rhi­
noplasty student can improve their ability to address
problems encountered during both primary and revision
rhinoplasty. With this in mind, for the second part of
this chapter the senior author selected problems encoun­
tered in the course of his revision practice which warrant
highlighting. The selected problem patterns are either
encountered frequently or illustrate specific surgical tech­
niques that may be particularly useful in the rhinioplasty
surgeon’s armamentarium.
ANATOMY, NASAL ANALYSIS,
AND NASAL EXAMINATION
Although the anatomy of the nose has been fundamentally
understood for many years, only relatively recently has
there been an increased understanding of the long-term
effects of surgical changes upon the function and appear­
ance of the nose. A detailed understanding of nasal
anatomy is critical for successful rhinoplasty.10 Accurate
assessment of the anatomic variations presented by a
patient allows the surgeon to develop a rational and real­
istic surgical plan. Furthermore, recognizing variant or
aberrant anatomy is critical to preventing functional com­
promise or untoward aesthetic results.
The development of nasal and facial analysis skills is
an important part of the effort to reduce the risk of com­
plications. Nasal and facial analysis requires an under­
standing of the concept of the “aesthetic ideal.” A nose
that is considered “ideal” is one that is harmonious with
a patient’s other favorable facial features. This of course
will vary to a certain degree depending upon a patient’s
gender and ethnicity. Indeed, our perception of beauty
helps define what makes an ideal shape for a female or
male nose, so there is also always a slight artistic element
to this concept. While the “aesthetic ideal” cannot be
completely boiled down to simple lines and numbers
alone, guidelines or proportions do exist that represent an
aesthetic ideal.1,10 Examples include the nasolabial angle,
the nasofrontal angle, the nasomental angle, and others.
Artists have long made studies of beauty and aesthetic
proportions and, today, facial plastic surgeons must simi­
larly understand beauty in order to make changes that
can enhance their patients’ facial harmony and beauty. A
detailed study of nasal and facial anatomy, and the ideal
aesthetic proportions, is recommended.1,10

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Daniel G. Becker et al.
examination. For a detailed discussion of analysis, further
reading and study are recommended.9
FUNCTIONAL NASAL EXAMINATION
Anterior rhinoscopy should be undertaken in the rhino­
plasty patient and may identify abnormalities such as
deviated septum, inferior turbinate hypertrophy, syn­
echiae or scar bands, septal perforation, and other abnor­
malities. Examination also includes nasal endoscopy when
there are functional nasal complaints, such as nasal
obstruction (Figure 9-1).11,12 If indicated, a sinus com­
puted tomography scan may also be obtained.
Pownell et al.11 described diagnostic nasal endoscopy
in the plastic surgical literature. They trace the historical
development of nasal endoscopy, explain its rationale,
review anatomic and diagnostic issues including the dif­
ferential diagnosis of nasal obstruction, and describe the
Table 9-1  Analysis in Primary Rhinoplasty—
Guide to Nasal Analysis
General
Skin quality: Thin, medium, or thick
Primary descriptor (i.e., why is the patient here?): for
example, “big,” “twisted,” “large hump”
Frontal View
Twisted or straight: Follow brow—tip aesthetic lines
Width: Narrow, wide, normal, “wide—narrow—wide”
Tip: Deviated, bulbous, asymmetric, amorphous, other
Base View
Triangularity: Good versus trapezoidal
Tip: Deviated, wide, bulbous, bifid, asymmetric
Base: Wide, narrow, or normal. Inspect for caudal septal
deflection
Columella: Columellar/lobule ratio (normal is 2 : 1 ratio);
status of medial crural footplates
Lateral View
Nasofrontal angle: Shallow or deep
Nasal starting point: High or low
Dorsum: Straight, concavity, or convexity; bony,
bony—cartilaginous, or cartilaginous (i.e., is convexity
primarily bony, cartilaginous, or both)
Nasal length: Normal, short, long
Tip projection: Normal, decreased, or increased
Alar–columellar relationship: Normal or abnormal
Nasolabial angle: Obtuse or acute
Oblique View
Does it add anything, or does it confirm the other
views?
Many other points of analysis can be made on each view, but these are
some of the vital points of commentary.
AESTHETIC NASAL EXAMINATION
Detailed anatomic analysis of the nose is an essential first
step in achieving a successful surgical outcome. The study
of nasal anatomy in the unoperated and in the operated
nose is a lifetime learning endeavor. The surgeon con­
stantly seeks to add to his or her knowledge of the ana­
tomic variants, and the problems that can occur. The
senior author’s approach to nasal analysis in a primary
and secondary rhinoplasty is described (Tables 9-1 and
9-2).9,10 The preoperative analysis in revision rhinoplasty
carries the additional layer of complexity of a prior surgi­
cal intervention, with subsequent distortion of the preex­
isting anatomy.
Studying all standard preoperative photographic
views for rhinoplasty (frontal, base, lateral, oblique) allow
a systematic, detailed anatomic analysis that comple­
ments the physical examination process.
Analysis begins by examining all four views and
making an assessment of the overall stature of the patient,
the facial skin quality, and the symmetry of the face. The
principle of dividing the face into horizontal thirds and
vertical fifths is a useful tool to obtain a general sense of
any areas of the face that may play a key role in nasal
appearance and the outcome of nasal surgery. It is essen­
tial that these incongruent areas or asymmetries be rec­
ognized and discussed with the patient preoperatively.
Thickness and quality of the facial skin–subcutaneous
tissue complex must be determined, as it plays a critical
role in dictating the limitations of what can and cannot
be accomplished with aesthetic nasal surgery.
After completing the general assessment, the surgeon
should note and highlight the most striking characteristics
of the nose. These are typically the characteristics that
bring the patient for rhinoplasty, such as excessive size,
deviation, or a dorsal hump. These primary patient con­
cerns must be recognized, highlighted, and addressed
above all else.
As the surgeon reviews each photographic image, the
major aesthetic and technical points that can be evaluated
on a given view are noted first. Subtleties in analysis are
then addressed. It is important to recognize both the char­
acteristics of greatest concern to the patient and the more
subtle findings. The patient may not notice these other
subtle abnormalities if they are left unaddressed by the
surgeon. Postoperatively, the scrutinizing patient may
notice and point out these abnormalities. Stepwise,
methodical analysis of the patient and all photographic
views allows the well-trained surgeon to identify key ana­
tomic and aesthetic points to be addressed.10
As the preoperative analysis proceeds in revision rhi­
noplasty, a critical question that guides examination of
each area is, “Was it underresected, overresected, asym­
metrically resected, or appropriately treated?” Any unop­
erated areas of the nose are identified. Also, the presence
of possible grafts or implants is considered throughout the

CHAPTER NINE  Reducing Complications in Rhinoplasty
117
Table 9-2  Nasal Analysis in Revision Rhinoplasty—Simplified Algorithm Visual and Manual Examination
General
Skin quality: Integrity, vascularity, mobility, skin thickness (thin, medium, or thick)
Identify primary concerns leading patient to seek revision
For each issue and anatomic area, is problem due to underresection, overresection, asymmetric resection?
Frontal
Width: Narrow, wide, normal, “wide–narrow–wide”
Dorsum: Twisted or straight: follow brow-tip aesthetic lines.
Open roof? Rocker deformity? Visible or palpable deformities? Prior osteotomies? If so, normal or abnormal?
Middle vault: Assess width. Inverted V? Underresected, overresected, asymmetric?
Tip: deviated, bulbous, asymmetric, amorphous. Symmetry, bossae? Tip support (palpate). Status of all prior incisions.
Assess for presence of grafts. Alar side wall pinching or retraction?
Base
Tip: Deviated, wide, bulbous, bifid, asymmetric.
Symmetry, bossae? Status of caudal septum. Projection. Tip support (palpate). Status of all prior incisions. Assess for
presence of grafts.
Triangularity: Good versus trapezoidal.
Base: Wide, narrow, or normal
Inspect for caudal septal deflection.
Assess status of all external incisions.
Columella: Columellar–lobule ratio (normal is 2 : 1 ratio)
Status of medial crural footplates
Lateral
Nasofrontal angle: Shallow or deep
Nasal starting point: High or low
Dorsum: Straight, concavity, or convexity: bony, bony-cartilaginous, or cartilaginous (i.e., is convexity primarily bony,
cartilaginous, or both?). Visible or palpable irregularities? Overresected, underresected, or both? Pollybeak? Saddle
nose?
Nasal length: Normal, short, long
Tip: Projection (normal, increased, decreased), rotation (nasolabial angle), double break, alar-columellar relationship,
bossae? Status of caudal septum. Tip support. Status of all prior incisions. Assess for presence of grafts.
Oblique
Does it add anything, or does it confirm the other views?
There are many other points of analysis that can be made on each view, but these are some of the vital points of commentary.
Figure 9-1  Nasal endoscopy may be performed with either a rigid or
flexible telescope, and allows improved diagnosis in the evaluation of nasal
obstruction.
selection of equipment and correct application of tech­
nique, emphasizing the potential for advanced diagnostic
potential.
Levine12 reported that 39% of patients with a com­
plaint of nasal obstruction had findings on endoscopic
examination that were not identified with traditional rhi­
noscopy. Many of Levine’s patients had seen other physi­
cians for this problem and had not received appropriate
treatment.
Becker et al.13,14 described that, in patients seeking
cosmetic nasal surgery who also had nasal obstruction,
nasal endoscopy allowed the diagnosis of additional
pathology not seen on anterior rhinoscopy, including
obstructing adenoids, enlarged middle turbinates with
concha bullosa, choanal stenosis, nasal polyps, and chronic
sinusitis (Figure 9-2). In their series, additional surgical
therapy was undertaken in 28 of 96 rhinoplasty patients

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Daniel G. Becker et al.
anatomy, appropriate incisions, approaches, and tip-
sculpturing techniques may be selected.1,10,21
The selection of the planned incisions, approaches,
and surgical techniques for a particular patient is of
course the central decision of the rhinoplasty process.
An operative algorithm may provide a helpful starting
point in selecting the incisions, approaches, and tech­
niques used in nasal surgery.1,10,21 In every case, the
patient’s anatomy dictates the selection of an appropriate
technique. As the anatomic deformity becomes more
abnormal, a graduated, stepwise approach is taken.
However, other factors, such as the need for spreader
grafts, complex nasal deviation, surgeon preference, and
other factors may also appropriately affect the ultimate
selection of approach.
The endonasal approaches may be generally preferred
for patients requiring conservative profile reduction, con­
servative tip modification, selected revision rhinoplasty
patients, and other situations in which conservative
changes are being undertaken. Advantages of less invasive
approaches include less dissection, less edema, and less
“healing.” However, less invasive approaches provide by
their very nature less exposure, which in some cases may
be a disadvantage.
Indications for external rhinoplasty approach10,21–23
generally include asymmetric nasal tip, crooked nose
deformity (lower two thirds of nose), saddle nose deform­
ity, cleft-lip nasal deformity, secondary rhinoplasty requir­
ing complex structural grafting, and septal perforation
repair. Other indications may include complex nasal tip
deformity, middle nasal vault deformity, and selected
nasal tumors. Some surgeons prefer the open approach for
less complex nasal tip deformities due to the precision that
they believe it offers them, in their hands, compared to
the endonasal approach.
due to findings on endoscopic exam. Thirteen patients
underwent endoscopic sinus surgery. Nine patients had a
concha bullosa requiring partial middle turbinectomy.
Three patients—all revision surgeries—had persisting
posterior septal deviation requiring endoscopic septo­
plasty. Two patients underwent adenoidectomy. One
patient required repair of choanal stenosis.
Static and dynamic nasal valve collapse are com­
monly encountered in revision rhinoplasty patients.15–20 In
Becker et al.’s report, 19 of 21 patients with nasal valve
collapse reported a past history of rhinoplasty.20
Pinching of the nasal sidewall and alar retraction are
hallmarks of nasal valve collapse. Observing the patient
performing normal and deep nasal inspiration may lead
directly to the diagnosis of nasal valve collapse (Figure
9-3). A “modified” Cottle maneuver, in which the lateral
nasal sidewall is supported and elevated slightly with a
cerumen curette or similar device, is strongly supportive
of the diagnosis when the maneuver results in the patient’s
report of significant subjective improvement in nasal
breathing.
INCISIONS AND APPROACHES
Incisions are methods of gaining access to the bony and
cartilaginous structures of the nose and include transcar­
tilaginous, intercartilaginous, marginal, and transcolu­
mellar incisions. Approaches provide surgical exposure of
the nasal structures including the nasal tip and include
cartilage-splitting (transcartilaginous incision), retro­
grade (intercartilaginous incision with retrograde dissec­
tion), delivery approach (intercartilaginous and marginal
incisions), and external (transcolumellar and marginal
incisions). After analyzing the individual patient’s
Figure 9-2  A patient seeking revision rhinoplasty had persisting nasal obstruction despite a history of prior septoplasty at the time of her rhinoplasty.
Endoscopic examination was suggestive of a large concha bullosa (A). CT scan was confirmatory (B).
A
B

CHAPTER NINE  Reducing Complications in Rhinoplasty
119
A central tenet of rhinoplasty decision-making has
been the concept of a graduated approach.10,21 This
concept is based on the idea that achieving the desired
goals with the least amount of surgical dissection provides
the best chance of success. However, the critical issue is
how much exposure is needed for reliable execution of
any specific technical maneuver. Adamson24 has astutely
Advantages of the external approach include the sur­
gical exposure available, potentially allowing more accu­
rate anatomic diagnosis. The external approach also
provides the opportunity for precise tissue manipulation,
suturing, and grafting. Disadvantages include the transcol­
umellar incision, wide field dissection resulting in poten­
tial loss of support, and nasal tip edema.
Figure 9-3  Nasal valve collapse may be apparent on normal inspiration, as seen here. Alar batten grafts may be placed via an external rhinoplasty
approach, or into a precise pocket made through an endonasal incision as shown here. This graft is nonanatomic and is typically placed caudal to the lateral
crura where there is maximal collapse of the lateral nasal wall and supra-alar pinching. If alar batten grafts are placed too far cephalic, excessive fullness over
the middle vault will be noted. Patients should be told that there will be temporary fullness in the area of the graft. This fullness will typically decrease over
2 to 3 months. For maximal support, the alar batten graft should extend over the bone of the pyriform aperture. A, Preoperative; B, preoperative with
normal inspiration; C, postoperative; D, E, intraoperative, endonasal approach; F, diagrammatic of alar batten graft.
Alar batten
graft
A
B
C
D
E
F

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Daniel G. Becker et al.
explains to patients, it is not a guarantee and should not
be taken to offer even the slightest implication of a guar­
antee. The senior author does not provide the patient with
printouts of the computer imaging.
Having said this, the senior author finds computer
imaging to be extremely useful. He routinely prints out
the preoperative photos and shared-surgical-goal photo­
graphs and has them for intraoperative reference point.
The senior author reviews his notes and these photographs
preoperatively and also throughout surgery to keep the
goal of surgery foremost in his mind as surgery progresses.9
PSYCHOLOGY OF RHINOPLASTY
Although a separate chapter will address this specific
topic, some points are worth mentioning. Patients seeking
cosmetic rhinoplasty are generally healthy patients who
are unhappy about the appearance of their nose. The
psychology of human appearance and the psychological
benefits of cosmetic surgery have been well studied. It is
important for the surgeon to consider psychological factors
when evaluating a patient for rhinoplasty.26
Although the rate of psychiatric disorders among cos­
metic surgery patients is essentially unknown, it is prob­
ably safe to say that all of the major psychiatric disorders
can coexist among patients who desire cosmetic surgery.
Body dysmorphic disorder (BDD) is a psychiatric disorder
that warrants mention here because it does appear to
occur with increased frequency among rhinoplasty
patients. BDD is defined by the DSM-IV-TR as a preoc­
cupation with an imagined or slight defect in appearance
that results in significant emotional distress or impairment
in daily functioning.27 Few studies have examined the rate
of BDD among rhinoplasty patients.26
Psychological assessment of rhinoplasty patients is an
important part of the preoperative evaluation. Efforts
should be made to help determine whether patients’ pre­
operative motivations and expectations are realistic, to
identify the patients appearance concerns and whether
they are proportionate to the abnormality, and to identify
patients with psychiatric conditions that may contraindi­
cate surgery. The reader is referred to an overview of this
subject by Crerand et al.26 for more detailed information
on this important subject.
TECHNICAL OVERVIEW OF POTENTIAL
COMPLICATIONS—SPECIFIC
PROBLEMS TO AVOID
OVERRESECTION OF LATERAL CRURA
Overresection of the lateral crus is perhaps the most
common problem seen in a revision rhinoplasty prac­
tice.9,10,28–30 Overresection of the lateral crus leads to the
observed that there is no ideal approach—each surgeon
will develop a unique approach based upon the concepts
outlined and based on the techniques and experiences
he or she has developed in the course of an eclectic
training.
Perkins25 describes an evolution in his personal phi­
losophy that reflects some of the issues involved in this
decision-making process and provides valuable insight
into the evolution in the decision making that has occurred
over the past 15 to 20 years. While the concept of a gradu­
ated approach to achieve a pleasing aesthetic result has
been foremost in his personal philosophy, the evolving
need to achieve more refined results and prevent late
complications has resulted in his increased use of the open
approach, which allows the opportunity to use certain
grafting techniques. Perkins continues to strongly advo­
cate the philosophy that the approach selected should
provide the least intervention in the shortest time to
achieve a satisfactory result and satisfy the patient’s goals.
However, his choice of approach has changed due to late
complications that he has seen occur. The two areas where
he finds most commonly occurring late complications in
rhinoplasty are the midnasal pyramid and lateral alar
sidewalls. He emphasizes the paramount importance of
providing a structural foundation for the middle vault
(i.e., spreader grafts). While issues such as these can be
addressed using the endonasal approach, Perkins indi­
cates that it is sometimes far easier to place structural
grafts via the external approach. Also, he maintains that
when marked reduction of overprojection is required, it is
often easier to use the external columellar approach.
Regardless of approach, one must be mindful of the
need to maintain appropriate structural support. When
the approach is disruptive of tip support, countermea­
sures, such as the placement of a columellar strut, are
warranted. When the support to the upper lateral carti­
lages has been disrupted, spreader grafts may be
appropriate.
COMMUNICATION WITH PATIENT
It is important that the communication between patient
and surgeon regarding the goal of surgery be a clear one.
This is discussed in detail in other chapters in the book,
as well as in other articles.9 Clear and thorough commu­
nication between patient and surgeon is extremely helpful
in reducing complications in rhinoplasty. The authors rec­
ommend that the rhinoplasty surgeon give considerable
and careful thought to his or her approach during the
office consultation, with the goal of optimizing communi­
cation with the patient about their proposed procedure.
With this in mind, computer imaging warrants spe­
cific discussion. Computer imaging is a “video game.” It
is simply a way to communicate a shared surgical goal. It
does not generate an “after” picture. As the senior author

CHAPTER NINE  Reducing Complications in Rhinoplasty
121
In some cases, this situation can be anticipated. An
anatomic study of the alar base recognized that in a
normal patient population, 20% of patients had a thin
alar rim. This anatomic variation must be recognized, and
cephalic resection probably should be avoided or mini­
mized in these patients to minimize the risk of inducing
alar retraction or external nasal valve collapse.29 These
changes are not always predictable, however, and are not
always avoidable.
For example, bossae are caused by a knuckling of
lower lateral cartilage at the nasal tip owing to contrac­
tural healing forces acting on weakened cartilages. Patients
predictable changes of alar retraction, pinching, bossae,
and tip asymmetry (Figure 9-4). Excision of vestibular
mucosa in primary rhinoplasty also may contribute to scar
contracture with alar retraction. A conservative approach
to cephalic resection is warranted in rhinoplasty.
In many revision cases, the amount of lateral crus that
remained seemed ample; that is, it falls within the “guide­
line” of 6 to 9 mm that typically is cited. In these cases,
the scar contracture secondary to healing apparently over­
powered the remnant cartilage. If the tip cartilages are
soft and weak and if the scar contracture is profound,
undesirable changes can occur.
Figure 9-4  Overresection of the lateral crura in this patient resulted in the predictable, unfavorable changes described in the text. Reconstruction
included bilateral alar batten grafts. The patient also required shortening of the persistently overprojected tip cartilages via vertical dome division with exci­
sion and suture reconstitution. A–C, preoperative; D–F, postoperative.
A
B
F
E
D
C

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Daniel G. Becker et al.
MINIMIZING COMPLICATIONS
OF THE NASAL DORSUM
Sharp osteotomes are essential to provide a clean, precise
bony hump excision. When the osteotome is dull, the
chance of an asymmetric resection or overresection of the
bony hump increases. Some surgeons have at least two
sets of osteotomes and rotate them—one set is always out,
being sharpened. Other surgeons sharpen their osteotomes
manually, with a sharpening stone, during each case. Both
approaches are effective.9,10,31
An anatomic approach is preferable. Detailed ana­
tomic nasal analysis should guide surgery. When under­
taking a hump reduction, the surgeon should examine the
excised tissue, assessing its symmetry, and whether it was
the desired excision (Figure 9-7). (If the bony dorsum is
rasped, this of course is not possible.) Similar anatomic
examination of the remaining cartilaginous and bony
nasal dorsum also must be undertaken. It is expected that
additional, calibrated refinement would be needed and
should be undertaken with dogmatic adherence to the
anatomic examination. Preoperative markings on the skin
may be helpful to some surgeons for hump reduction and
for osteotomies. Persistent irregularities of the bony
dorsum may be addressed by rasping. The senior author
finds that a powered rasp may be preferable to manual
rasping in this situation (Figure 9-8).9,32,33
Larrabee has pointed out that while there is a ten­
dency to treat the bony pyramid in an essentially closed
fashion when using either the closed or open approach,
the benefits of increased exposure to the dorsum available
with thin skin, strong cartilages, and nasal tip bifidity are
especially at risk. Excessive resection of lateral crus and
failure to eliminate excessive interdomal width may play
some role in bossae formation.9,10,29
Understanding that the healing forces are not com­
pletely predictable, it is important to take a conservative
approach when undertaking cephalic resection. Although
risk cannot be eliminated, it can be reduced in this manner.
Alar batten grafts are the first-line treatment of alar
retraction and nasal valve collapse10,15,20,29 (see Figure
9-3). Batten grafts have been well described in the litera­
ture and are generally most effective in less severe cases
(1- to 2-mm deficit).10,15,20,29
Auricular composite grafts commonly are used in
more severe cases9,30,31 (Figure 9-5). The skin and carti­
lage of the anterolateral surface, just inferior to the infe­
rior crus, of the opposite ear (e.g. left ala, right ear)
provide the best donor site and the best contour. When a
smaller graft is needed, direct closure of the donor incision
can be undertaken. When a larger graft is needed, a
“revolving door” postauricular flap may be used to close
the defect (Figure 9-6). For placement of the composite
graft, an incision several millimeters from the nostril rim
is followed by careful dissection freeing adhesions, creat­
ing a defect and displacing the alar rim inferiorly. Volume
and support must be restored to hold the nostril rim in
position. This role is fulfilled by the composite graft. The
fashioned composite graft is sutured carefully into
place.9,30,31 Typically, the senior author uses 6-0 plain gut
suture. A cotton ball or other light dressing is applied
intranasally to apply light pressure for 1 to 3 days.
Figure 9-5  Composite grafts are useful in the treatment of severe alar retraction.
A
B

CHAPTER NINE  Reducing Complications in Rhinoplasty
123
the senior author uses a powered rasp under direct
visualization.33,34
THE POLLYBEAK DEFORMITY
Pollybeak refers to a specific problem of the nasal
dorsum—postoperative fullness of the supratip region,
with an abnormal tip–supratip relationship (Figure 9-10).
This problem may have several causes, including failure
to maintain adequate tip support (postoperative loss of tip
with the open rhinoplasty approach should be exploited
whenever possible (Figure 9-9).34
In the senior author’s experience, a closed approach
has been reliable for addressing most bony profile prob­
lems. However, when performing an open rhinoplasty, the
senior author now prefers to undertake hump reduction
under direct visualization. When using an osteotome, an
8- to 10-mm nonguarded osteotome is generally used
(wider osteotomes can create an injury to the skin–soft
tissue envelope). While rasping during open rhinoplasty,
Figure 9-6  When composite graft harvest leaves a defect that is challenging to close primarily, a “revolving door” flap is a useful reconstructive option.
A
C
D
E
F
B

124
Daniel G. Becker et al.
Figure 9-7  En bloc resection of the nasal hump allows careful anatomic examination as the surgeon assesses the need for additional, calibrated refine­
ments of the nasal dorsum.
Dorsal
hump
A
B
Figure 9-8  After creation of an “open roof” by hump removal, the bony margins should be smoothed with a rasp. Any bony fragments should be
removed, ensuring that all obvious particles are removed from under the skin–soft tissue envelope. Failure to remove all fragments may lead to a visible
or palpable dorsal irregularity. The powered rasp (Linvatec-Hall Surgical, Largo, FL) oscillates at speeds of 15,000 rpm with minimal back-and-forth excur­
sion of only several millimeters. The senior author finds the powered rasp more precise and preferable to manual rasping.
A
B
Figure 9-9  An unguarded osteotome of appropriate size allows en bloc resection of the dorsal hump under direct visualization.
B
A

CHAPTER NINE  Reducing Complications in Rhinoplasty
125
Figure 9-10  Patient with cartilaginous and soft tissue pollybeak after rhinoplasty. A–B, preoperative; C–D, postoperative.
B
C
D
A
projection), inadequate cartilaginous hump (anterior
septal angle) removal, or supratip dead space or scar
formation. Treatment of the pollybeak deformity depends
on the anatomic cause.9,35 The best treatment constitutes
its avoidance. If the cartilaginous hump was underre­
sected at the anterior septal angle, however, the revision
surgeon should resect additional dorsal septum. Adequate
tip support must be ensured; maneuvers such as place­
ment of a columellar strut may be beneficial. If a polly­
beak deformity is a result of excessive scar formation,
triamcinolone (Kenalog) injection or skin taping in the
early postoperative period should be undertaken before
any consideration of surgical revision.
OVERRESECTION AND SADDLE NOSE
Saddle nose refers to the appearance of the nose after loss
of support of the nasal vault with subsequent collapse
(Figure 9-11). This deformity has been described after
overresection of the septum, with failure to preserve an
adequate septal “L-strut.” A minimum of 15 mm of car­
tilage is recommended as a rule of thumb—if a dorsal
hump resection is planned, this must be accounted for in
planning adequate L-strut for nasal support. Other causes
of saddle nose deformity include septal hematoma, septal
abscess, and severe nasal trauma. Excessive dorsal hump
resection also leads to saddle nose deformity.

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Daniel G. Becker et al.
INVERTED-V MIDDLE VAULT COLLAPSE
In inverted-V middle vault collapse deformity, the caudal
edges of the nasal bones are visible in broad relief. Inad­
equate support of the upper lateral cartilages after dorsal
hump removal can lead to inferomedial collapse of the
upper lateral cartilages and an inverted-V deformity
(Figure 9-13).41 Inadequate infracture of the nasal bones
is another significant cause of inverted-V deformity. The
anatomic cause of inverted-V deformity must be recog­
nized. Osteotomies with infracture of the nasal bones,
spreader grafts, or both should be performed when
appropriate.
Narrowing of the middle nasal vault that occurs when
the T configuration of the nasal septum is resected with
dorsal hump removal may be problematic in the high risk
patient.10,41 Spreader grafts act as a spacer between the
upper lateral cartilage and septum, preventing excessive
narrowing in the high risk patient or correcting an over-
narrow middle vault when it exists.
Use of spreader grafts in primary rhinoplasty is
becoming much more common.10,41 Spreader grafts can be
effective in maintaining the contour of the middle vaults
after hump reduction. While it may be technically easier
to place spreader grafts via an external approach, spreader
grafts can be placed via the endonasal or the external
(open) approach.10,25,39,41
It should be noted that the use of the external rhino­
plasty approach may lead to a greater need for spreader
grafts to preserve the nasal valve and middle nasal width,
which may be put at risk due to the loss of support to the
upper lateral cartilages caused by more extensive skin
undermining.
Onlay cartilage grafting can effectively camouflage
and correct mild and moderate saddle deformities
(see Figure 9-11). Single or multiple layers of septal
cartilage, auricular cartilage are commonly used effec­
tively.36,37 Severe saddle nose deformity may require
major reconstruction with cantilevered cartilage or bone
grafts.38–40
Precise pocket grafting can be effectively used when
this is an isolated problem9 (see Figure 9-11). The pocket
is dissected over the anterior septal angle, via bilateral
limited marginal incisions. Bilateral incisions are used to
ensure symmetry of the pocket, so that the graft will lie
straight. Asymmetric dissection of the pocket can be a
cause for graft shifting.
When a patient has thin skin, Alloderm or temporalis
fascia may be used to provide some additional cushion.
While it appears that this may provide some lasting
benefit, the long-term fate of Alloderm is unknown.
ALLOPLASTS
The senior author’s experience with alloplasts has been to
remove them. The author has removed alloplasts for dif­
ferent indications including patient discomfort/pain, an
unacceptable cosmetic result, infection, and because of
extrusion into the nose and through the skin. There is
disagreement among rhinoplasty surgeons regarding the
use of alloplasts. The nose fulfills few of the requirements
for use of alloplastic materials. If the alloplast extrudes
through the skin, the skin–soft tissue envelope is perma­
nently and irreparably damaged (Figure 9-12). The senior
author discourages the use of alloplasts in primary and
revision rhinoplasty.9
Figure 9-11  Precise pocket, triple layer cartilage onlay grafting effectively treated this patient’s saddle nose deformity. A, preoperative; B, postoperative.
B
A

CHAPTER NINE  Reducing Complications in Rhinoplasty
127
despite accurate diagnosis and technically well-performed
surgery. Persisting deviation of the nasal bones may occur
because of greenstick fractures or other problems with
osteotomies.42,43 Inherent deviations in the cartilage of the
middle nasal vault may prove especially challenging. Also,
hump removal may uncover asymmetries that result in
postoperative deviation where none existed previously. Tip
asymmetry may be overlooked preoperatively, or it may
due to asymmetric excision of lateral crura, asymmetric
placement of a columellar strut, or placement of a overly
long columellar strut, among other causes. Numerous
surgical maneuvers are available to address the
deviated nose.42,43
TWISTED NOSE—NEWLY OR
PERSISTENTLY TWISTED
The surgical treatment of a twisted nose can range from
simple to complex. The numerous techniques described to
address a twisted nose speaks to its complexity. A gradu­
ated, stepwise approach, guided by precise anatomic diag­
nosis, is recommended (Figure 9-14).1,42
Persisting deviation after rhinoplasty may occur at
the upper third, middle third, or tip of the nose or may
occur postoperatively in a previously straight nose. Preop­
erative anatomic diagnosis is a crucial component of suc­
cessful treatment. Still, deviations may occur or persist
Figure 9-12  If the alloplast extrudes through the skin, the skin–soft tissue envelope is permanently and irreparably damaged. A, C, preoperative; B, D,
postoperative after removal of alloplast.
A
B
C
D

Figure 9-13  This patient had prior rhinoplasty in
which it appears that the overprojection of the nasal tip
and the need for support of the middle nasal vault was
unrecognized. He presented for correction of his tip
abnormalities and his inverted-V deformity.
A
B
Figure 9-14  Treatment of the twisted nose requires
precise anatomic diagnosis and a graduated, stepwise
approach. A, C, preoperative; B, D, postoperative.
C
D
B
A

CHAPTER NINE  Reducing Complications in Rhinoplasty
129
10. Toriumi DM, Becker DG. Rhinoplasty dissection manual.
Philadelphia: Lippincott, Williams and Wilkins; 1999.
11. Pownell PH, Minoli JJ, Rohrich RJ. Diagnostic nasal
endoscopy. Plast Reconstr Surg. 1997;99(5):1451–1458.
12. Levine HL. The office diagnosis of nasal and sinus disorders
using rigid nasal endoscopy. Otolaryngol Head Neck Surg.
1990;102:370.
13. Becker DG. Septoplasty and turbinate surgery. Aesthet Surg J.
2003;23:393–403.
14. Lanfranchi PV, Steiger J, Sparano A, et al. Diagnostic and
surgical endoscopy in functional septorhinoplasty. Fac Plast
Surg. 2004;20:207–215.
15. Toriumi DM, Josen J, Weinberger MS, Tardy ME. Use of alar
batten grafts for correction of nasal valve collapse. Arch Otol
Head Neck Surg. 1997;123:802–808.
16. Constantian MB, Clardy RB. The relative importance of septal
and nasal valvular surgery in correcting airway obstruction in
primary and secondary rhinoplasty. Plast Reconstr Surg.
1996;98(1):38–54.
17. Goode RL. Surgery of the incompetent nasal valve.
Laryngoscope. 1985;95:546–555.
18. Sheen JH. Spreader graft: A method of reconstructing the roof
of the middle nasal vault following rhinoplasty. Plast Reconstr
Surg. 1984;73(2):230–237.
19. Constantian MB. The incompetent external nasal valve:
Pathophysiology and treatment in primary and secondary
rhinoplasty. Plast Reconstr Surg. 1994;93(5):919–933.
20. Becker DG, et al. Alar batten grafts for treatment of nasal
valve collapse. J Long-Term Effects Surgical Implants. 2003.
21. Tardy ME, Toriumi DM. Philosophy and principles of
rhinoplasty. In: Cummings C, et al, eds. Otolaryngology—
Head and neck surgery. 2nd ed. St Louis: Mosby–Year Book;
2003:278–294.
22. Johnson Jr CM, Toriumi DM. Open structure rhinoplasty.
Philadelphia: Saunders; 1990.
23. Adamson PA. Open rhinoplasty. In: Papel ID, Nachlas NE,
eds. Facial plastic and reconstructive surgery. St Louis:
Mosby–Year Book; 1992:295–304.
24. Adamson PA. Nasal tip surgery in open rhinoplasty. Fac Plast
Surg Clin N Am. 1993;1(1):39–52.
25. Perkins SW. The evolution of the combined use of endonasal
and external columellar approaches to rhinoplasty. Fac Plast
Surg Clin N Am. 2004;12:35.
26. Crerand CE, Gibbons LM, Sawrer DB. Psychological
characteristics of revision rhinoplasty patients. In: Becker DG,
Park SS, eds. Revision rhinoplasty. New York: Thieme;
2007:32–41.
27. American Psychiatric Association. Diagnostic and statistical
manual of mental disorders. 4th ed. text rev. Washington, DC:
American Psychiatric Press; 2000.
28. Tardy ME, Chang EY, Jernstrom V. Misadventures in nasal tip
surgery. Otolaryngol Clin N Am. 1987;20(4):797–823.
29. Becker DG, Weinberger MS, Greene BA, Tardy ME. Clinical
study of alar anatomy and surgery of the alar base. Arch
Otolaryngol Head Neck Surg. 1997;123(8):789–795.
30. Tardy ME, Toriumi DM. Alar retraction: Composite graft
correction. Fac Plast Surg. 1989;6(2):101–107.
31. Becker DG, Bloom J. 5 Techniques that I cannot live without
in revision rhinoplasty. Fac Plast Surg. 2008;24(3):358–364.
32. Becker DG, Park SS, Toriumi DM. Powered instrumentation
for rhinoplasty and septoplasty. Otolaryngol Clin N Am.
1999;32(4):683–693.
33. Becker DG.The powered rasp: Advanced instrumentation for
rhinoplasty. Arch Fac Plast Surg. 2002;4:267–268.
SKIN–SOFT TISSUE ENVELOPE
In the unoperated nose, the skin–soft tissue envelope has
well-defined tissue planes in which avascular dissection
may be undertaken. Vascular supply and lymphatics are
found superficial to the nasal musculature.44,45 Dissection
in the proper tissue planes (areolar tissue plane, i.e., sub­
musculoaponeurotic) preserves nasal blood supply and
minimizes postoperative edema. Operating in the more
superficial planes not only leads to a bloody surgical field
but also risks damage to the vascular supply with poten­
tial damage to the skin. When the skin–soft tissue enve­
lope is damaged, it can never be restored fully, creating
an esthetically displeasing appearance.9,44,45
SUMMARY
The dedicated rhinoplasty surgeon continues to acquire
throughout his or her career an increasingly detailed
understanding of the anatomy and the problems that
occur related to rhinoplasty and a growing armamentar­
ium of techniques to achieve their improvement or cor­
rection. In addition to the study of the unoperated nose,
much can be learned from the study of revision rhino­
plasty that applies to both primary and revision rhino­
plasty patients. This chapter outlines aspects of the
authors’ approach and discusses selected technical prob­
lems and approaches to minimize their occurrence. Focus­
ing on the two essential goals—making patients happy
and making their current procedure the patient’s last
nasal surgery—both primary and secondary rhinoplasty
can be a uniquely rewarding experience for both patients
and surgeons.
REFERENCES
1. Tardy ME. Rhinoplasty: The art and the science.
Philadelphia: WB Saunders; 1997.
2. Kamer FM, Pieper PG. Revision rhinoplasty. In: Bailey B, ed.
Head and neck surgery otolaryngology. Philadelphia:
Lippincott; 1998.
3. Rees TD. Postoperative considerations and complications. In
Rees TD, ed. Aesthetic plastic surgery. Philadelphia: WB
Saunders; 1980.
4. McKinney P, Cook JQ. A critical evaluation of 200
rhinoplasties. Ann Plast Surg. 1981;7:357.
5. Thomas JR, Tardy ME. Complications of rhinoplasty. Ear
Nose Throat J. 1986;65:19–34.
6. Tardy ME, Cheng EY, Jernstrom V. Misadventures in nasal tip
surgery. Otolaryngol Clin N Am. 1987;20(4):797–823.
7. Simons RL, Gallo JF. Rhinoplasty complications. Fac Plast
Surg Clin N Am. 1994;2(4):521–529.
8. Becker DG. Complications in rhinoplasty. In: Facial plastic
and reconstructive surgery. 2nd ed. New York: Theime; 2009.
9. Becker DG. My personal philosophy of revision rhinoplasty.
In: Becker DG, Park SS, eds. Revision rhinoplasty. New York:
Thieme; 2007.

130
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40. Fedok FG, Preston TW. Managing the overresected dorsum.
In: Becker DG, Park SS, eds. Revision rhinoplasty. New York:
Thieme; 2007:96–111.
41. Toriumi DM. Management of the middle nasal vault. Oper
Tech Plast Reconstr Surg. 1995;2(1):16–30.
42. Toriumi DM, Ries WR. Innovative surgical management of
the crooked nose. Fac Plast Surg Clin North Am. 1993;
1(1):63–78.
43. Murakami CS, Bloom DC, Most SP. Managing the persistently
twisted nose. In: Becker DG, Park SS, eds. Revision
rhinoplasty. New York: Thieme; 2007:85–95.
44. Rettinger G, Zenkel M. Skin and soft tissue complications.
Fac Plast Surg. 1997;13(1):51–59.
45. Toriumi DM, Mueller RA, Grosch T, et al. Vascular anatomy
of the nose and the external rhinoplasty approach. Arch Otol
Head Neck Surg. 1996;122:24–34.
34. Larrabee Jr WF. Open rhinoplasty and the upper third of the
nose. Fac Plast Clin N Am. 1993;1(1):23–38.
35. Tardy ME, Kron TK, Younger RY, Key M. The cartilaginous
pollybeak: etiology, prevention, and treatment. Fac Plast
Surg. 1989;6(2):113–120.
36. Tardy ME, Schwartz M, Parras G. Saddle nose deformity:
Autogenous graft repair. Fac Plast Surg. 1989;6(2):121–134.
37. Gunter JP, Rohrich RJ. Augmentation rhinoplasty: Dorsal
onlay grafting using shaped autogenous septal cartilage.
Plast Reconstr Surg. 1990;86(1):39–45.
38. Daniel RK. Rhinoplasty and rib grafts: Evolving a flexible
operative technique. Plast Reconstr Surg. 1992;94(5):
597–611.
39. Murakami CS, Cook TA, Guida RA. Nasal reconstruction with
articulated irradiated rib cartilage. Arch Otolaryngol Head
Neck Surg. 1991;117:327–330.

131
C H A P T E R T E N 
Nasal Osteotomies
Ravi S. Swamy • Sam P. Most
In 1898, Jacques Joseph was one of the first surgeons to
promote the concept of the nasal osteotomy as a way to
reshape and reposition the bony vault.1 The primary indi­
cations for osteotomies are to straighten a deviated nasal
dorsum, narrow the nasal side walls, and close an open
nasal vault. While the objectives remain clear, osteotomies
continue to be a source of trepidation for rhinoplasty
surgeons. Whether the approach to rhinoplasty is external
or endonasal, osteotomies rely predominantly on a tactile
sense rather than direct visualization. Its execution
requires careful planning, intimate knowledge of the
anatomy, and appreciation of the dynamics between the
upper one-third bony vault and lower two-thirds cartilagi­
nous framework as there is a fine line between inadequate
and overmobilization of the nasal bones. We will review
important anatomic principles and describe the different
techniques of osteotomies to achieve better precision and
consistency in attaining superior aesthetic results without
compromising nasal function.
NASAL ANALYSIS
Achieving success in rhinoplasty is based on careful pre­
operative planning and assessment. The relationship of
the nose to the face has been studied for centuries. Objec­
tive measurements of contour, angles, and proportions
have been proposed and accepted to help provide the
facial plastic surgeon with guidelines that define ideal
standards of beauty and aesthetic facial harmony. One of
these guidelines states that the aesthetically pleasing face
can be divided equally into vertical fifths, with the nasal
base width equal to the intercanthal distance.2 The width
of the upper two thirds of the nose should be approxi­
mately 75% of the width of the nasal base (Figure 10-1).
The nasal dorsum should also follow a gentle curvilinear
path from the medial brow to the nasal tip. The dorsum
should also be perpendicular to a line drawn vertically
from the midglabella to the menton (Figure 10-2). The
external contour of the upper third of the nose is defined
by the two side walls: the dorsum and the nasofrontal
angle. The nasofrontal angle is the external landmark
identifying the deepest or most posterior portion of the
nasal dorsum, and by this definition is synonymous with
the radix, or soft tissue nasion. The bony nasion is the
junction between the frontal and nasal bones. The rhinion
is the osseocartilaginous junction of the nasal bones infe­
riorly with the superior edge of the upper lateral carti­
lages. The bony nasal vault and its intimate attachment
to the upper lateral cartilages make it the main determi­
nant of nasal width of the upper and middle third of the
nose.3 Precise manipulation of the bony pyramid is essen­
tial to provide balance with any nasal tip work and create
overall aesthetic harmony. Failure to complete proper
osteotomies can negate the effects of intricate tip maneu­
vers and leave the patient with a “washed-out” or poorly
defined nose on frontal view, even though the patient may
have an improvement on profile and oblique views.4
PERTINENT NASAL ANATOMY
The nasal bones are paired structures that attach superi­
orly to the frontal bone and laterally to the nasal process
of the maxillary bones. Together, these bones form the
bony nasal vault. The perpendicular plate of the ethmoid,
a portion of the bony septum, attaches to the undersurface
of the nasal bones in the midline. The nasal bones are thin
inferiorly and become thick superiorly.5,6 Figure 10-3
demonstrates this by transillumination of the skull. The
variable thickness of the bony structures of the nose will
influence osteotomy placement. The nasal septum sup­
ports the nose along its entire length. The septum serves
to support the dorsal profile, and loss of this structure can
result in the classic saddle-nose deformity. Preservation of
adequate (>1 cm) dorsal and caudal septal struts is neces­
sary to preserve support after any nasal surgery. The
anterior nasal spine supports the caudal septum and the

132
Ravi S. Swamy • Sam P. Most
supported by the lateral crura and a variable number of
small accessory cartilages between the lateral crura and
pyriform aperture.6
DORSAL HUMP REDUCTION
Prior to instituting maneuvers to mobilize and shift the
bony nasal vault, it is critical to evaluate the contribution
of the dorsal hump to the nasal profile and whether a
Figure 10-1  A, The nasal base width should be equal to the intercanthal width. B, The width of the of the lateral bony walls should be 75% of the width
of the nasal base. (From Orten SS, Hilger PA. Facial analysis of the rhinoplasty patient. In Papel ID, editor. Facial plastic and reconstructive surgery. New
York: Thieme, 2002, pp. 361–368.)
feet of the medial crura. When excessive in size, the nasal
spine may actually blunt the nasolabial angle.6
The paired upper lateral cartilages are triangular and
fused medially to the dorsal septum. The cartilages attach
to the undersurface of the nasal bones at their superior
extent and are connected to the frontal process of the
maxilla by dense fibrous connective tissue. The paired
lower lateral cartilages support the nasal lobule and nos­
trils. This fibrocartilaginous arch is supported medially by
the caudal septum and nasal spine. Laterally, the arch is
Figure 10-2  A, The brow-tip aesthetic line should follow a gentle curve from the medial brow to nasal tip. B, Nasal deviation can be assessed by drawing
a vertical line from the midglabella to the menton. (From Orten SS, Hilger PA. Facial analysis of the rhinoplasty patient. In Papel ID, editor. Facial plastic and
reconstructive surgery. New York: Thieme, 2002, pp. 361–368.)

CHAPTER TEN  Nasal Osteotomies
133
hump reduction will be required.7 To gain proper access
to this area, sharp dissection of the midline raphe of de­
cussating periosteal fibers should be completed up to the
level of the nasofrontal angle. Care should be taken to stay
midline to avoid lateral disruption of supportive soft tissue
attachments to the nasal skeleton. It is also important to
consider the variation of thickness of the skin soft tissue
envelope over the nasal dorsum. The skin is thickest in
the nasion and supratip areas and thinnest over the
rhinion; therefore, resection of the dorsal hump at the
rhinion should be performed with extreme care8 (Figure
10-4). In fact, to achieve a straight soft tissue profile, the
cartilaginoskeletal framework at the rhinion should be
kept slightly convex.6
Several techniques are available to reduce the bony
dorsum. An osteotome or a rasp can be used, depending
on the surgeon’s experience and preference. Most surgeons
use an osteotome for larger humps and a rasp for smaller
reductions and refinements. The dorsal septum and upper
lateral cartilages can be reduced sharply with a scalpel.
For removing larger humps, a conservative correction is
performed with an osteotome (often double-guarded) and
refinements are then made with a tungsten carbide pull
rasp or scalpel.6 It is critical not to violate the attachments
of the upper lateral cartilages to the undersurface of the
caudal margin of the nasal bones as lack of support of the
cartilages may lead to inferomedial collapse and cause an
inverted-V deformity9 (Figure 10-5).
The orientation of the bony vault must be considered
and evaluated before dorsal hump removal. If the vault is
shifted toward one side, the hump removal should not be
symmetric. Less bone should be excised from the side of
the deviation7 (Figure 10-6). Performing a hump reduc­
tion with this technique more closely approximates a
midline vertical orientation of the lateral nasal bones and
prevents excessive reduction in their height.7 Dorsal hump
Figure 10-3  Transillumination of the skull reveals the variable thickness
of the nasal bones, which are mobilized with osteotomies in rhinoplasty.
The nasal bones are thicker superiorly (arrowhead) and thinner inferiorly
(double arrowheads). (From Most SP, Murakami CS. A modern approach
to nasal osteotomies. Fac Plast Surg Clin North Am. 2005;13:85–92.)
Figure 10-4  A, The skin is thicker at the nasion and supratip and thinner
at the rhinion. Dorsal resection limiting resection at the rhinion will result
in a straighter postoperative profile. B, A more aggressive dorsal resection
that creates a straight orientation of the underlying cartilaginoskeletal frame­
work will give a concave postoperative profile appearance due to the dif­
ference in thickness of the overlying skin. (From Toriumi DM, Hecht DA.
Skeletal modifications in rhinoplasty. Fac Plast Surg Clin North Am. 2000;8:
413–423.)
Nasion
Supratip
Limit
resection
at rhinion
Before
Post-operative result
More
aggressive
resection
Before
Post-operative result

134
Ravi S. Swamy • Sam P. Most
Figure 10-5  Elevation of the periosteal flap is begun with a Cottle elevator, and may be continued to the nasofrontal suture using the same instrument
or a periosteal elevator. Care should be taken to preserve the lateral periosteal attachments as this will help reduce the risk of a flail bone.
Elevation
with blunt
dissection
Incision in
periosteum
Swab
Periosteum
Sharp
dissection
Development
of lateral pockets
Release of
midline attachments
B
C
A
Figure 10-6  A, In crooked noses, the dorsal hump resection should
be performed in a tangential plane by removing more bone and cartilage
on the convex side (dotted line) rather than approaching it with a straight
perpendicular cut (solid line). B, Illustration of the position and height of
nasal bones after hump removal and osteotomies are performed to
straighten the bone. Note. If the tangential plane was taken, the nasal bones
will be more symmetric. (From Toriumi DM, Ries WR. Innovative surgical
management of the crooked nose. Fac Plast Surg Clin North Am.
1993;1:63–78.)
Correct
Incorrect
Correct
Incorrect
reduction may lead to an open roof deformity that sets
the stage for osteotomies.
MEDIAL OSTEOTOMIES
By definition, a medial osteotomy is a cut separating the
nasal bones from the bony septum in the midline. This
technique is used in conjunction with the lateral osteot­
omy to create a predictable site of back fracture for the
lateral osteotomies. The medial osteotomy should be used
in cases of an extremely wide or deviated nose, an iatro­
genic open roof difficult to close with a lateral osteotomy,
an increased bony width above the infraorbital rim, and
in the presence of thicker nasal bones.10 Medial osteoto­
mies are generally difficult to perform and should be used
judiciously. As previously described, the bony vault varies
in thickness regionally, and the nasal skin in the midline
tends to be the thin; therefore, bony irregularities can be
more evident.
Typically, when performing a medial osteotomy, a
small osteotome is placed at the caudal margin of the
nasal bone just lateral to the septum. As the osteotome is
driven upward, a slight lateral trajectory of 15 degrees
should be taken to meet up with the planned superior
extent of the lateral osteotomy (Figure 10-7). Several
studies have shown more reliable and consistent results
with this medial “oblique” osteotomy versus a more

CHAPTER TEN  Nasal Osteotomies
135
Figure 10-7  Medial osteotomy. Either a straight or a curved osteotome
creates a controlled fracture adjacent to the septum and up to the transition
to the thicker frontal bone. A straight path remaining midline or a more
oblique angle of 15 degrees laterally can be taken and this will help with
mobilization of the bone once the lateral osteotomy is completed. (From
Most SP, Murakami CS. A modern approach to nasal osteotomies. Fac Plast
Surg Clin North Am. 2005;13:85–92.)
straight medial osteotomy.11 As nasal bone thickness
increases from caudal to cephalic and from lateral to
medial, there exists a curvilinear bone thickness transition
zone. This transition in bone thickness provides a natural
cleavage plane for the medial oblique osteotomy.10 Less-
angulated medial osteotomies can lead to cuts into the
thicker frontal bone that could lead to a less desirable
contour and higher likelihood of rocker deformities.
LATERAL OSTEOTOMIES
The lateral osteotomy is the workhorse osteotomy and will
narrow the bony vault, improve contour of the brow-tip
aesthetic line, and close an open roof deformity created
by dorsal hump reduction.10 When Joseph first described
the lateral osteotomy in 1898, he described the technique
of using a saw to make a low, continuous osteotomy.1 The
path of his osteotomy extended from the inferior pyriform
aperture up into the nasal process of the frontal bone. The
aggressive mobilization of the nasal bones by Joseph and
other early surgeons revolutionized aesthetic rhinoplasty;
however, any hope of preserving an adequate nasal passage
for breathing fell by the wayside and resulted in high rates
of postoperative nasal airway compromise. The recogni­
tion that preservation of the periosteum and lateral
suspensory ligaments of the lower lateral cartilage helped
to lower the incidence of postoperative airway compro­
mise has been an important positive technical modifica­
tion.6 Thus, modern techniques of osteotomy have evolved
to consider the effects of bony repositioning on functional
as well as aesthetic outcome. It was not until the introduc­
tion of the high–low–high lateral osteotomy in the late
1970s that an exceptional aesthetic outcome could be
achieved in conjunction with sufficient nasal airway.12 The
terms “high” and “low” refer the path of the osteotomies
along the nasal sidewall (Figure 10-8). “Low” means
closer to the maxilla and “high” is towards the nasal
dorsum. The lateral osteotomy can be completed in two
ways: the linear (single-cut) technique or the perforating
technique.
The linear osteotomy technique is completed entirely
intranasally. First, the monopolar cautery is used to make
an incision in the mucosa above the anterior attachment
of the inferior turbinate, along the pyriform aperture. An
osteotome is used to start the lateral osteotomy at or above
the anterior end of the inferior turbinate and is initially
directed at an angle perpendicular to the face (Figure
10-9). This starting point above the inferior turbinate
helps protect a small triangle of bone at the base of the
pyriform aperture from being disturbed.13 This ensures
preservation of the lateral attachments of the suspensory
ligaments and the natural position of the inferior tur­
binate, thereby maintaining the patency of the nasal
airway.12,14 The osteotome is leveled off as it approaches
the ascending process of the maxilla, and then the oste­
otomy is finished at the level of the medial canthus.
To help with mobilization of the nasal bones superi­
orly, several techniques may be used. With the osteotome
still engaged near the medial canthus, medial rotation
with digital pressure allows for completion of a greenstick
fracture. A percutaneous transverse superior osteotomy
may be necessary if the bones are thick. A 2-mm oste­
otome is used percutaneously midway between the nasal
dorsum and the medial canthal region. Through a single
skin puncture, the osteotome may be used to create three
to four small perforating osteotomies, allowing the nasal
bone to be mobilized without disrupting the overlying
periosteal support. When more precision is necessary, the
lateral osteotomy can be connected to a previously com­
pleted medial oblique osteotomy.6 If medial and lateral
osteotomies are taken too high into the thick frontal bone,
the superior aspect of the osteotomized nasal bone may
project laterally when the bone is infractured, thus causing
a rocker deformity9 (Figure 10-10).
PERFORATING OSTEOTOMIES
An alternative to the linear technique for lateral osteot­
omy is the perforating technique. Proponents of this tech­
nique assert that it provides a controlled, stable fracture

136
Ravi S. Swamy • Sam P. Most
Figure 10-8  Lateral osteotomy. The dashed line depicts high–low–high path along nasal side wall. “Low” refers toward the maxilla and “high” is toward
the dorsum.
High-low-high path
First hand
position
Second
hand
position
with less nasal airway narrowing, hemorrhage, edema,
and ecchymosis.15 Using a sharp 2-mm straight oste­
otome, a series of “postage stamp” perforations are placed
along the desired fracture site using a transcutaneous
approach. With the advent of small, sharp microoste­
otomes, more intense and efficient force can be applied
onto the nasal bones. Moreover, less force will be required
to cut the bone, resulting in less chance of an uncontrolled
fracture line.16 Given the direct nature of this technique
on the skin, there is the advantage of more precise place­
ment of the osteotomy. Studies have shown that there is
less mucosal disruption and violation of branches of the
lateral nasal and angular arteries, resulting in less bleed­
ing and postoperative edema.15,17 The perforating osteot­
omy, of course, necessitates incisions through the skin;
however, these small incisions heal without significant
scars and are undetectable in majority of cases.17,18
The “inside-out” perforating technique can also be
used to widen the excessively narrow bony nasal pyramid,
the cause of which may be congenital or secondary to
previous trauma or surgery.12,19 This technique is per­
formed by making a series of osteotomies beginning infe­
riorly near the attachment of the inferior turbinate and
proceeding superiorly. The direction of the force vector is
directed laterally, which aids in proper displacement of
the bony segment in the desired direction.19 Studies have
shown this technique to be more effective and provide
greater preservation of the periosteal support of the bony
segments than a continuous osteotomy.19,20
The perforating osteotomy can be effective in patients
with short nasal bones as this technique prevents overmo­
bilization of the delicate, short bones, and preserves
maximal soft tissue support.6 This is also true in difficult
cases such as revision rhinoplasty or posttraumatic nasal

CHAPTER TEN  Nasal Osteotomies
137
Figure 10-9  The lateral osteotomy is begun at the anterior end of the inferior turbinate and is first made perpendicular to the face. The surgeon should
place his or her hand on top of the osteotome and, once seeded in the bone, supinate and grip the osteotome from below and proceed up the bone
using the other hand to guide the osteotome toward the medial canthal area.
Medial
canthal
area
Anterior
end of inferior
turbinate
Figure 10-10  A, Medial and lateral osteotomies
that are taken too high cephalically into the thicker
frontal bone can cause a rocker deformity. B, The
forces on the upper thicker bone cause a lateral shift
and a fulcrum effect will force the lower segment to
rotate medially. If the upper segment is pushed back
medially, the lower segment may “rock” laterally out
of position. A transverse osteotomy in the thinner
nasal bone below will be needed to rectify this issue.
(From Toriumi DM, Hecht DA. Skeletal modifications
in rhinoplasty. Fac Plast Surg Clin North Am.
2000;8:413–423.)
Osteotomy
taken too far
cephalad
Resulting
rocker deformity
A.
B.

138
Ravi S. Swamy • Sam P. Most
of intermediate osteotomy or lateral osteotomy. A single
lateral osteotomy can be beneficial to medialize the convex
side of the nose. The concave side can then be addressed
with placement of onlay or spreader graft.23
A unilateral intermediate osteotomy may be effective
on the deviated nasal bone at the area of maximal convex­
ity24 (Figure 10-11). In patients with history of extensive
nasal trauma, there may be areas of fibrous unions along
surgery, in which maintenance of structural support is
critical.15 Cadaveric studies have demonstrated preserva­
tion of considerably more periosteal support with the per­
forating technique compared with the linear technique.15,18
With increased accuracy and decreased morbidity, this is
often the preferred technique, especially in inexperienced
hands; however, patients with severe deviations and thick­
ened nasal bones are more appropriately treated with the
single-cut linear osteotomy technique.13
INTERMEDIATE OSTEOTOMIES
The intermediate osteotomy is essentially a bone cut along
the nasal sidewall in a region between the medial and
lateral osteotomy. The exact placement of the osteotomy
may vary depending on surgical goals. The open rhino­
plasty approach affords more precision with this tech­
nique due to direct visualization when setting the
osteotome, while in a closed approach, an intercartilagi­
nous incision is required and the osteotomy is completed
with careful tactile feedback. These osteotomies are gener­
ally completed through exceedingly thin bone and require
minimal force from the mallet to prevent an unintentional
fracture line.21 In situations where both intermediate and
lateral osteotomies are required, the intermediate osteot­
omy should be performed prior the lateral osteotomy, as
the intermediate cut cannot be made easily after the nasal
bone is mobilized by a lateral osteotomy. Once again, it is
imperative that the soft tissue attachments be maintained
to the nasal bone for additional support and prevention
of nasal collapse.
Bilateral intermediate osteotomies are frequently used
in patients with a wide nasal dorsum. At the midline, the
lateral nasal bones fuse with the perpendicular plate of
the ethmoid bone. This union has both a vertical and
transverse component. In patients with a widened dorsum,
the transverse component is a contributing factor.21 By
completing medial osteotomies followed by intermediate
osteotomies 4 mm lateral to the medial osteotomies, a thin
strip of bone can be removed (Figure 10-12). Lateral
osteotomies can then be completed to close the roof. This
technique will narrow the apex without reducing vertical
height.22
ASYMMETRIC OSTEOTOMIES
The primary indications for unilateral or asymmetric oste­
otomies are to straighten a severely deviated nose where
one side wall is much longer than the other or to correct
a markedly convex nasal bone. An asymmetric or unilat­
eral osteotomy executed on the deviated side will help
with recontouring of the nasal wall into a more normal
curvature that better coincides with the opposite side.8
Typically, the asymmetric osteotomy can be in the form
Figure 10-11  A single intermediate osteotomy can be placed on the
convex side of the deviation between the medial and lateral osteotomies.
The intermediate osteotomy should precede the lateral osteotomy as it
would not be possible to complete the intermediate cut after the lateral cut
has been made.
Medial
osteotomy
Intermediate
osteotomy
Lateral
osteotomy
Figure 10-12  Medial osteotomies are made followed by intermediate
osteotomies that are completed 2 mm lateral to them. The intervening thin
strip of bone (shaded area) between the septum and paramedian osteoto­
mies can be removed. Lateral osteotomies are then completed to close
resulting open roof deformity. The nasal pyramid can be narrowed without
losing dorsal height with this maneuver. (Adapted from Cochran CS, Ducic
Y, Defatta RJ. Rethinking nasal osteotomies: an anatomic approach. Laryn­
goscope. 2007;117:662–667.)
2mm lateral
to medial
osteotomies

CHAPTER TEN  Nasal Osteotomies
139
Figure 10-13  The keystone area. This is the junction of the bony and
cartilaginous septum with the bony dorsum. Septal deviations in this area
can often contribute to a deviation in the dorsum and should be addressed
with care not to disrupt these critical support attachments.
Keystone
area
Bony
septum
Cartilaginous
septum
Figure 10-14  To correct a severely deviated nose, sequential osteoto­
mies are performed in a fashion similar to opening a book. The osteotomies
are begun on the concave side, beginning laterally and moving toward the
opposite side. In this way, the depressed side is elevated and the convex
side is deprojected.
the nasal bones where previous fractures have healed. The
osteotome will tend to follow these fibrous connections
because they offer less resistance than intact bone. In such
cases, the surgeon must take extra care to guide the oste­
otome in the desired direction.24
Another technique calls for two lateral osteotomies on
the more convex side, and is known as the “double lateral
osteotomy.” Proponents believe that part of the asymme­
try is due to longer and often thicker nasal bones at the
maxillary process on the convex side.25 By completing two
lateral osteotomies on the convex side, one can achieve
better mobilization of this thicker bone and better sym­
metry with the opposite side. This technique will also
decrease the chance of a palpable bony stepoff that may
be encountered with an intermediate osteotomy completed
at the site of maximal convexity.25–27. These osteotomies
can be accomplished as a linear cut or through the perfo­
rated technique.26,27
High septal deviations are commonly seen in patients
with crooked nasal pyramids and should be identified and
addressed appropriately. If the septal deviation is at the
keystone area, care should be taken to completely mobi­
lize the segments of the bony pyramid while maintaining
the support attachments between the bony dorsum and
the cartilaginous and bony portions of the septum13
(Figure 10-13).
When approaching the severely crooked nasal vault,
the sequence of osteotomies should commence on the
concave side of the deviation (the opposite side of
deviation), then move to the midline, and end on the
convex (the deviated side). This is analogous to turning
the pages of an open book, with the nasal walls and
septum simulating the pages (Figure 10-14). This allows
creation of a space in which to realign the deviation.5,6 If
the septal deviation persists in this area despite these
maneuvers, delicate scoring of cartilage may be com­
pleted. Disruption of the keystone area, however, can lead
to a postoperative saddle-nose deformity that can require
extensive reconstructive surgery to correct.13 Despite
proper utilization of osteotomies, small deviations may
persist, and while perfection may be the enemy of good,
camouflaging grafts may be beneficial.
COMPLICATIONS
Complications of osteotomies can be aesthetic, functional,
or both. The most common complication of osteotomy is
likely continued or de novo creation of bony irregularities.
Indeed, the term complication may be an inaccurate term,