Master Techniques in Rhinoplasty

CHAPTER TEN  Nasal Osteotomies
141
23. Roofe SB, Murakami CS. Treatment of the posttraumatic and
postrhinoplasty crooked nose. Fac Plast Surg Clin North Am.
2006;14:279–289.
24. Kim DW, Toriumi DM. Management of posttraumatic nasal
deformities: The crooked nose and the saddle nose. Fac Plast
Surg Clin North Am. 2004;12:111–132.
25. Bracaglia R, Fortunato R, Gentileschi S. Double lateral
osteotomy in aesthetic rhinoplasty. Br J Plast Surg.
2004;57:156–159.
26. Parkes ML, Kamer F, Morgan WR. Double lateral osteotomy
in rhinoplasty. Arch Otolaryngol. 1977;103:344–348.
27. Westreich RW, Lawson W. Perforating double lateral
osteotomy. Arch Fac Plast Surg. 2005;7:254–260.

143
C H A P T E R E L E V E N 
Cartilage Grafting in Rhinoplasty
and Nasal Reconstruction
Raffi Der Sarkissian
GENERAL PRINCIPLES
Maintaining or achieving structural integrity of the nasal
form is a formidable task in rhinoplasty and nasal recon­
struction. Maintaining the form and function of the nose
is an equally important objective as creating a pleasing
aesthetic contour. In this regard, numerous autograft,
allograft, and synthetic materials have been proposed as
the ideal replacement or augmentation matrix in nasal
surgery. Despite trials of use of various synthetics such as
Mersilene polyester fiber mesh, expanded polytetrafluor­
oethylene, porous high-density polyethylene, and numer­
ous others, cartilage grafting remains the most reliable
technique in providing nasal support, replacement of
structural components of the nose, and augmentation for
a variety of reasons.1–5
Because cartilage is a normal component of the native
nasal structure, it is logical to use it to replace deficiencies
and create structural, contour, and aesthetic enhance­
ments. Cartilage grafts are equally suited for structural
support of the nose as well as nonsupporting applications
such as camouflage grafts. Grafts can be of variable rigid­
ity based on site of harvest and how they are modified
prior to use. A whole spectrum of graft strength, thick­
ness, volume, and malleability can be achieved by use of
septal grafts, auricular grafts, costal cartilage grafts, or
combinations. Thick or rigid grafts are best suited for
supporting applications. Thin grafts are useful when
minimal visibility is desired as in areas of thin skin over
the nasal dorsum or in revision cases. Stacked and sutured
grafts can help create greater support or can be used in
augmentation cases when significant augmentation is
required. Morselized cartilage grafts can be applied in a
camouflaging fashion and will tend to “drape” more
smoothly over existing structures. Diced or crushed carti­
lage can be used as plumping grafts along the nasolabial
junction or wrapped with Surgicel, acellular dermis or
temporalis fascia to augment the dorsum.6,7,11 Cartilage
grafts can be modified to address the patient’s particular
need, whereas allografts are either solid and noncompress­
ible or soft and nonsupportive. An additional benefit in
using cartilage grafts is the ability to suture fixate the
grafts, thereby creating less movement and a tendency for
more rapid integration and vascularization.
As with any ideal implant, autologous cartilage is
biocompatible and in its native state has a relatively
minimal metabolic requirement allowing rapid integra­
tion. In addition, autologous cartilage is an ideal choice
for compromised tissue vascularity as commonly seen
in traumatic nasal deformity, revision rhinoplasty, and
patients with collagen vascular disorders and diabetes.
A further advantage of use of cartilage grafting is the
almost unlimited donor source such as septum, ear, and
costal cartilage. Nasal septal grafts are the easiest to
obtain in primary rhinoplasty or in secondary cases if the
septum was not previously harvested. Auricular cartilage
from one or both ears provides grafts of various shapes
and sizes often suitable for camouflaging or low-volume
augmentation grafting. Costal cartilage provides large
volumes of material that can be carved and shaped into
numerous grafting applications. Fortunately, donor site
morbidity is quite minimal in harvesting cartilage from
each of these sources. Donor sites for cartilage can be
easily camouflaged. Septal grafts are harvested via an
intranasal incision, auricular cartilage grafts can be
approached through the post auricular sulcus or a well-
concealed anterior incision, and costal cartilage can be
obtained via an inframammary crease incision.
Multiple uses of cartilage grafts have been well
described.5,8 In general, it is helpful to define the purpose
of the intended grafts. In so doing, the appropriate volume
of graft material of adequate strength and rigidity can be
harvested for the desired application. Areas suitable for
augmentation grafts are the nasofrontal recess, dorsum,
nasal tip, and columella. Replacement grafts are common
along the lateral crura of the lower lateral cartilages and
along the caudal margin of the upper lateral cartilages.
Structural grafts are commonly used in the columella in
the form of struts between the medial crura and in extended
tip graft configuration. Functional applications include
alar replacement grafts, lateral crural strut grafts, batten
grafts, spreader grafts, and alar rim supporting grafts.
Several sources of grafting cartilage are readily avail­
able for these applications. The decision regarding the

144
Raffi Der Sarkissian
hydrodissecting the submucoperichondrial plane with
local anesthesia (1% lidocaine with 1 : 100,000 epi­
nephrine, 27-gauge 114-inch needle). Adequate dorsal
and caudal septa (1.5 to 2.0 cm) must be preserved to
prevent nasal collapse. If the amount of cartilage seems
inadequate, it is better to seek an additional source rather
than compromise nasal support (Figure 11-2).
Complications of septal cartilage harvest include
compromise of dorsal or caudal support if adequate struts
are not maintained, septal hematoma, septal perforation,
and intranasal synechiae if raw mucosal surfaces are left
in contact postoperative. Careful dissection of flaps, par­
ticularly in secondary cases, maintenance of adequate
dorsal and caudal support, quilting sutures of 4-0 plain
gut, and/or use of Silastic septal splints helps minimize
these risks.
Disadvantages of septal cartilage are generally related
to inadequate supply. Inadequate amount of cartilage may
be harvested depending on the volume of cartilage required
in primary rhinoplasty and the amount that can be safely
removed without compromising the nasal support struc­
ture. The deficiency in septal cartilage is even greater in
secondary procedures where the septum has been treated
previously and there is an even greater need for rigidly
supporting grafts. Some patients have anatomically inad­
equate available cartilage even if the septum has not been
previously addressed. For instance, mesorrhine or platyr­
rhine noses more frequently present with larger than
normal ratio of bony to cartilaginous septum. Thinner
than average cartilage will also provide inadequate support
in primary or secondary applications.
source to be used is based on a number of variables
including the presence or absence of donor cartilage
related to prior surgery, volume of cartilage required,
structural support requirements, desired contour of the
grafted cartilage, graft rigidity, and donor site morbidity10
(Figure 11-1).
SEPTAL CARTILAGE
When an adequate supply is available, the most desirable
source of cartilage grafts is the nasal septum. As septo­
plasty is almost always performed concomitantly with
rhinoplasty, there is no additional cartilage harvest mor­
bidity. If used for nasal reconstructive purposes, the car­
tilage is within the field of reconstruction and easily
accessible. Quadrangular cartilage tends to be flat and
adequately rigid for structural support and can be scored,
morselized, diced, or crushed if softer applications are
desired. Grafts of various thicknesses can be harvested
based on the grafting requirements.
Septal cartilage is most commonly harvested through
a hemitransfixion or full transfixion incision as in a stand­
ard septoplasty. In external rhinoplasty, the cartilage can
be harvested using an endonasal approach or from above
through the medial crura. If there is a need for separation
of the upper lateral cartilage from the dorsal septum,
harvest from above is preferred. If the junction of the
upper lateral cartilages with the dorsal septum is to remain
intact, endonasal harvest is less destabilizing and requires
less soft tissue dissection. Flap elevation is facilitated by
Figure 11-1  Decision-making algorithm for anatomic source of cartilage grafts.
Need for cartilage grafting
Structural
grafting
Augmentation
grafting
Camouflage
grafting
Small volume
augmentation
Large volume
augmentation
(e.g. dorsal overresection
saddle nose deformity)
(e.g. struts, alar
replacement, spreader grafts)
Septal
cartilage
If septal cartilage
inadequate volume
or rigidity
Costal
cartilage
Septal cartilage
(if available)
Auricular
cartilage
Costal
cartilage
If septal
cartilage
inadequate
If septal
cartilage
inadequate
Morselized
Intact
Septal cartilage
(if available)
If septal cartilage
inadequate
Auricular
cartilage
Morselized
Intact
If septal/auricular
cartilage inadequate
*Rarely
Costal
cartilage

CHAPTER ELEVEN  Cartilage Grafting in Rhinoplasty and Nasal Reconstruction
145
of a visible scar. Composite grafts of cartilage and skin
are most frequently harvested from an anterior approach
with an attempt made to match the desired curvature of
the graft.
A posterior approach for auricular graft harvest is
chosen in the majority of patients as the donor site scar
AURICULAR CARTILAGE
When septal cartilage is inadequate in volume or rigidity,
the next most common anatomic site for harvest of carti­
lage grafts is the ear.8 Auricular cartilage is relatively easy
to harvest with minimal donor site morbidity and little
to no visible scarring or auricular deformity. Adequate
volume of grafts is generally available and bilateral
auricular cartilage can be harvested based on grafting
requirements (Figure 11-3). The natural curvature of
concha cymba and concha cavum reproduces the desired
concavities or convexities of the nasal contour. Composite
grafts can be taken with overlying skin as needed.
Auricular cartilage can be harvested from an anterior
or posterior approach. In both approaches, the area
that can be safely harvested is marked (Figure 11-4) and
both the anterior and posterior aspects of the conchal
bowl are infiltrated in a subperiochondrial plane with 1%
lidocaine with 1 : 100,000 epinephrine. Although it has
been proposed that vasoconstriction with epinephrine is
to be avoided in the ear, no ischemic events have been
documented using this technique. Anterior harvest is per­
formed through an incision along the inferior crus of the
antihelix down toward the antitragus. This incision is well
camouflaged if kept just anterior to the antihelix (on the
conchal side). Dissection is carried out in a subperichon­
drial plane anteriorly. Maintenance of the crus of the helix
helps prevent any deformity of the auricle post-operatively
(Figure 11-5). Anterior harvest is somewhat faster and
easier than the posterior approach but does carry the risk
Figure 11-2  Nasal septal anatomy. The shaded area can
be safely harvested for grafts.
Perpendicular
plate of
ethmoid
Vomer
Palatine
crest
Caudal
support
Dorsal
support
Quadrangular
cartilage
Cartilage
available
for graft
harvest
Maxillary
crest
Premaxilla
Figure 11-3  Auricular anatomy. The shaded area can be safely har­
vested without distorting the size or contour of the ear.
Crus of
helix
Concha
cymba
Concha
Concha cavum
Area of
available cartilage

146
Raffi Der Sarkissian
of the conchal bowl beyond which dissection should not
continue. Some surgeons outline this border preopera­
tively with a needle and methylene blue as would be done
in an otoplasty procedure (Figure 11-6).
In both anterior and posterior harvest techniques,
risks include visible scarring, auricular hematoma, and
auricular contour deformity. Meticulous closure of the
incision with 6-0 nylon minimizes scarring. Quilting
sutures of 5-0 fast absorbing gut are used to obliterate the
potential space between anterior and posterior perichon­
drial surfaces, to prevent hematoma. Limiting dissection
to the conchal bowl and sparing the crus of the helix
ensure adequate support and minimize the risk of defor­
mation of the auricle.
Disadvantages of auricular cartilage include fragility
of grafts, poor rigidity, and inadequate support, as well as
insufficient length. Grafts may occasionally need to be
stacked and sutured or used in multiple pieces to address
volume or strength requirements. These grafts tend not to
hold up well to morselization or crushing techniques.
Fragmentation of cartilage and loss of form are common.
Auricular cartilage in older patients tends to be brittle and
fragments more easily.
COSTAL CARTILAGE
Costal cartilage is an excellent option if stronger support
is required and in cases where septal and/or auricular
cartilage grafts have been previously used. Rib grafts
provide an almost unlimited supply of grafts in cases
where a larger volume of cartilage grafts are required.9,10
Costal cartilage is the most structurally supportive of all
autologous cartilage grafting material. The grafts can be
carved and shaped into various lengths, widths, and con­
tours to replace or augment the cartilaginous and bony
framework of the nose. Osteocartilaginous segments can
be harvested if a bony component is required. Overlying
perichondrium is frequently harvested and used as a
camouflaging “blanket” over dorsum and tip in thin or
compromised soft tissue (Figure 11-7).
Rib can be easily harvested by the rhinoplasty
surgeon. Many techniques have been described either
focusing on the fifth and sixth ribs or lower in the thorax
on the eighth and ninth ribs. Our preference is to harvest
segments of either the fifth or sixth rib through a well-
camouflaged inframammary incision. This approach is
used in male and female patients with minimal postop­
erative visibility. Careful dissection is required in patients
who have had previous augmentation mammoplasty to
avoid disruption of the implant. Rib harvest is always on
the right side so as not to be confused with chest pain of
a cardiac origin if the left side was used. Segments of
the eighth or ninth ribs may be chosen if longer segments
of cartilage or composite osteocartilaginous grafts are
required.
visibility is further minimized. The ear is infiltrated as in
the anterior approach and the incision is placed in the
postauricular sulcus. In planning this incision, it is prudent
to err 2 to 3 mm anteriorly up onto the posterior concha,
leaving the resultant scar directly in the sulcus rather than
onto the mastoid surface. Dissection is again subperichon­
drial and carried out to the edge of the conchal bowl.
Introduction of a 27-gauge needle helps define the edge
Figure 11-4  The shaded area of the conchal bowl can be safely
harvested.
Figure 11-5  Anterior harvest approach.

CHAPTER ELEVEN  Cartilage Grafting in Rhinoplasty and Nasal Reconstruction
147
Figure 11-6  A, Postauricular harvest approach. B, Template measuring amount of cartilage required. C, Postauricular skin elevation. D, A 25-gauge
needle can be passed to mark the anterior edge of the conchal bowl. E, Available cartilage for harvest. F, Templated amount of cartilage removed.
A
B
C
D
E
F

148
Raffi Der Sarkissian
Figure 11-7  A, Harvested costal cartilage (left) and perichondrium (right). B, Osteocartilaginous rib graft with cartilaginous component (left) and bony
component (right).
A
B
The skin is infiltrated with 1% lidocaine with
1 : 100,000 epinephrine. Upon encountering the extratho­
racic musculature, every effort is made to not transect any
fibers and instead to incise along and retract the fibers to
expose the glistening rib below. This careful dissection
significantly decreases postoperative pain and splinting,
which can lead to atelectasis. Upon identifying the selected
rib, the osteocartilaginous junction is easily identified.
Dissection is carried out anteriorly to expose more of the
cartilaginous component of the rib. If perichondrium is
required, parallel incisions are made at the upper and
lower edge of the rib. Extreme care must be taken not to
drop off the edge of the cartilage thereby preventing injury
to the neurovascular bundle or underlying pleura. The
incisions are connected vertically just anterior to the oste­
ocartilaginous junction. The perichondrium is elevated off
of the cartilage and a perichondrial graft of appropriate
length is harvested. A larger than required graft is often
taken to account for shrinkage of the graft. The cartilage
is now clearly visible. Based on the volume requirements,
a decision is made whether to take a full-thickness segment
of rib or to dissect a “chevron”-shaped segment from the
central portion.
If a full-thickness segment harvest is required, dissec­
tion in a subperichondrial plane is performed with a com­
bination of Freer and Doyen elevators. Upon ensuring that
the underlying pleura has been safely dissected free of the
undersurface of the rib, a segment can be harvested. The
wound is carefully examined for any evidence of bleeding
or violation of the pleura. The cavity is filled with saline
and the anesthesiologist is asked to apply a large positive
pressure to maximally inflate the lung. Presence of
bubbles indicate a pleural rent, which should be identified
and repaired. Upon identifying the pleural defect, a
purse string suture of 3-0 Vicryl is placed around a red
rubber catheter. While applying suction, the red rubber
catheter is slowly removed and the suture is cinched down
while the anesthesiologist maintains positive pressure.
A postoperative upright chest radiography should be
performed.
More frequently, a “chevron”-shaped segment is har­
vested, providing adequate grafting material while leaving
the rib contour intact and decreasing the risk of pleural
injury and significantly minimizing postoperative pain.
The absence of flail anterior and posterior segments of rib
markedly reduces pain on inspiration in these patients.
The technique begins with incising the rib cartilage along
the superior and inferior borders beveling toward the
center of the rib. Next an incision is made at the articula­
tion of the bony and cartilaginous rib, and, last, an inci­
sion is made anteriorly connecting the horizontal limbs.
The cartilage is dissected with a freer elevator maintaining
a shelf of cartilage on the pleural aspect of the rib. The
harvested cartilage is measured to assure adequacy of
length and volume. The cavity is tested for air leaks as
previously described (Figure 11-8).
Prior to closure, the area is infiltrated with 6 to 8 mL
of 0.25% bupivacaine with 1 : 200,000 epinephrine.
Closure is performed by obliterating the dead space with
3-0 vicryl and closing the skin edges with a 4-0 monocryl.
The appearance of the scar post­operatively is minimal
and well camouflaged in the inframammary crease
(Figure 11-9).
A drawback of costal cartilage is the need for a distant
secondary harvest site with risks of scarring, postoperative
pain, and pneumothorax. Additionally, many patients
express concern about having segments of rib(s) removed
for nasal surgery. Candid discussion with prospective
rib graft patients helps to allay many fears regarding
the procedure. Careful harvesting techniques and

CHAPTER ELEVEN  Cartilage Grafting in Rhinoplasty and Nasal Reconstruction
149
and camouflage of nasal cartilage (Figure 11-13). Costal
cartilage grafts provide an excellent source of autologous
cartilage in revision rhinoplasty patients who lack septal
or auricular cartilage. Individuals who require significant
augmentation or rigid support are also best treated with
use of costal grafting (Figure 11-14). The large volume
of harvested cartilage can be fashioned into dorsal aug­
mentation, alar replacement, batten, and columellar strut
grafts (Figure 11-15).
CONCLUSION
Cartilage grafting is one of the most important tools in
structural rhinoplasty and nasal reconstruction. There
is an abundance of autologous cartilage with varying
characteristics. Cartilage grafts are biocompatible and
incorporate seamlessly when properly used in areas of
adequate soft tissue coverage. Resorption is minimal
even with large-volume grafts. Complications seen with
management of postoperative pain are crucial to this end.
Other disadvantages of costal cartilage grafts include the
potential for warping, resorption, visibility under thin
or compromised soft tissue envelope, and difficulty in
morselizing or crushing the grafts.
INDICATIONS FOR CARTILAGE GRAFTING
The application of grafts once harvested is limited only
by the skill and creativity of the surgeon. Septal grafts
alone can be used for support and augmentation (Figure
11-10). Auricular donor cartilage can be fashioned
into planoconcave or planoconvex orientations to support
or replace absent or deficient nasal structures (Figure
11-11). Often, in camouflaging applications, the har­
vested cartilage will be rendered more pliable and con­
forming by gently morselizing the cartilage with a
morselizer or flattening contour irregularities with a Cottle
cartilage crusher (Figure 11-12). Numerous grafts from
multiple sources can be applied in both morselized and
nonmorselized applications in situations requiring support,
Figure 11-8  A, Planned incision for costal cartilage harvest. B, Ade­
quate exposure with limited incision. C, Checking for air leak after removal
of cartilage.
A
B
C
Text continued on page 157

150
Raffi Der Sarkissian
A
B
C
Figure 11-9  A, Well-healed incision in male patient. B, Inframammary
incision at 3 months postoperative. C, Inframammary incision within exist­
ing breast augmentation incision.

Figure 11-10  A, Loss of dorsal and tip support post nasal trauma. Preoperative oblique view. B, Postoperative oblique after septal cartilage dorsal onlay
and tip support grafting. C, Preoperative lateral. D, Postoperative lateral. E, Preoperative base view. F, Postoperative base view.
A
B
C
D
E
F

A
B
C
Figure 11-12  A, Rubin morselizer. B, Cottle cartilage crusher. C, Con­
forming “fishscaled” onlay graft.
A
B
C
Figure 11-11  A, Template for alar replacement grafts. B, Adequate-
sized templates created. C, Appropriately contoured and sized graft(s)
harvested from the ear.

CHAPTER ELEVEN  Cartilage Grafting in Rhinoplasty and Nasal Reconstruction
153
Figure 11-13  A, Contour abnormalities after three previous failed rhinoplasties. Preoperative frontal view. B, Postoperative frontal view after grafting with
septal and auricular cartilage. Nonmorselized grafts used for support and morselized grafts used for camouflage. C, Preoperative oblique view. D, Postop­
erative oblique view. E, Preoperative base view. F, Postoperative base view.
B
D
A
C
E
F

154
Raffi Der Sarkissian
Figure 11-14  A, Traumatic loss of dorsal support. Preoperative lateral view. B, Postoperative lateral view after costal cartilage graft rhinoplasty. C, Preop­
erative oblique view. D, Postoperative oblique view.
A
B
C
D

CHAPTER ELEVEN  Cartilage Grafting in Rhinoplasty and Nasal Reconstruction
155
A
B
C
D
Figure 11-15  A, Saddle nose deformity with complete loss of dorsal and tip support. Preoperative frontal. B, Preoperative base view. C, Complete
absence of tip support. D, Dorsal augmentation costal cartilage graft guided in with transcutaneous suture.
Continued

156
Raffi Der Sarkissian
E
F
G
H
E, Suture externalized and tied over a bolster. F, Numerous grafts fashioned from rib cartilage. G, Saddle nose deformity with
absent tip and dorsal support. Preoperative oblique. H, Postoperative oblique after dorsal, alar replacement, batten, tip, and columellar strut grafts.
Figure 11-15, cont’d.

CHAPTER ELEVEN  Cartilage Grafting in Rhinoplasty and Nasal Reconstruction
157
alloplastic material such as migration, extrusion, and
chronic infection are rarely seen with autogenous tissue.
Despite biomaterial research into alloplastic alternatives,
it is unlikely a graft with the same reliability and safety
profile will be available soon. With further research into
bioengineering, plastic surgeons should look forward to
the availability of “off-the-shelf” bioengineered cartilage
with similar characteristic with regard to rigidity, resist­
ance to resorption, ability to be carved, and host
compatibility.12
REFERENCES
1. Berghaus A, Stetler K. Alloplastic materials in rhinoplasty.
Curr Opin Otolaryngol Head Neck Surg. 2006;14(4):
270–277.
2. Acaturk S, Arslan E, Demirkan F, Unal S. An algorithm for
deciding alternative grafting materials in secondary
rhinoplasty. J Plast Reconstr Aesthet Surg. 2006;59(4):
409–416.
3. Romo 3rd T, Kwak ES. Nasal grafts and implants in revision
rhinoplasty. Fac Plast Surg Clin North Am. 2006;14(4):
373–387.
4. Godin MS, Waldman SR, Johnson Jr CM. Nasal augmentation
using Gore-Tex. A 10-year experience. Arch Fac Plast Surg.
1999;1(2):118–121.
5. Quatela VC, Jacono AA. Structural grafting in rhinoplasty.
Fac Plast Surg. 2002;18(4):223–232.
6. Erol OO. The Turkish Delight: A pliable graft for rhinoplasty.
Plast Reconstr Surg. 2000;105(6):2229–2241.
7. Daniel RK, Calvert JW. Diced cartilage grafts in rhinoplasty
surgery. Plast Reconstr Surg. 2004;113(7):2156–2171.
8. Becker DG, Becker SS, Saad AA. Auricular cartilage in
revision rhinoplasty. Fac Plast Surg. 2003;19(1):41–52.
9. Sherris DA, Kern EB. The versatile autogenous rib graft in
septorhinoplasty. Am J Rhinol. 1998;12(3):221–227.
10. Defatta RJ, Williams 3rd EF. The decision process in choosing
costal cartilage for use in revision rhinoplasty. Fac Plast Surg.
2008;24(3):365–371.
11. Cakmak O, Buyuklu F, Yilmaz Z, et al. Viability of cultured
human nasal septum chondrocytes after crushing. Arch Fac
Plast Surg. 2005;7(6):406–409.
12. Skodacek D, Brandau S, Deutschle T, et al. Growth factors
and scaffold composition influence properties of tissue
engineered human septal cartilage implants in a murine
model. Int J Immunopathol Pharmacol. 2008;21(4):807–816.

159
C H A P T E R T W E L V E 
The Middle Vault: Upper Lateral
Cartilage Modifications
Kate Elizabeth McCarn • Brian W. Downs • Ted A. Cook • Tom D. Wang
The importance of the middle third of the nose has been
increasingly recognized in recent years. Reductive rhino­
plasty techniques performed without regard for the struc­
tural integrity of this region can cause structural and
functional compromise. In this chapter, the anatomy,
physiology, and pathologies in this important region will
be described, followed by a discussion of the various tech­
niques that are used to address the middle third, including
hump reduction, spreader grafts, butterfly grafts, and
batten grafts. Focus will be placed on preserving or aug­
menting the support in the middle vault so that pleasing
functional and cosmetic results are maximized.
ANATOMY AND PHYSIOLOGY
The middle third of the nose is important both cosmeti­
cally and functionally. The middle nasal vault encom­
passes the region bounded superiorly by the rhinion,
inferiorly by the cephalic border of the lower lateral car­
tilages, and laterally at the piriform aperture.1 The soft
tissue envelope is the thinnest over the dorsum of the
middle third of the nose, making cartilaginous irregulari­
ties difficult to conceal and presenting a challenge to the
surgeon, especially in thin-skinned patients. The mucosa
lining the middle third of the nose is thin and tightly
adherent to the upper lateral cartilage and cartilaginous
septum.
The structural framework of the middle third of the
nose consists of the cartilaginous septum and the upper
lateral cartilages (Figure 12-1). Superiorly, the upper
lateral cartilages fuse with the deep surface of the caudal
edge of the nasal bones. Caudally, the upper lateral car­
tilage curves under and articulates with the lower lateral
cartilages in the scroll region, which is considered to be a
major tip support mechanism. Medially, the upper lateral
cartilages fuse with the cartilaginous dorsum via dense
fibrous attachments, while inferiorly the medial edge of
the cartilage is often free. It is important to note that the
cartilaginous septum widens to a T-like shape dorsally
where it articulates with the upper lateral cartilages,
forming a single unit that defines the dorsal subunit of the
nose. The lateral aspect of the upper lateral cartilage is
adherent to fibrous tissue that approaches the piriform
aperture and, if present, the sesamoid cartilages. Violation
of the support for the upper lateral cartilages can cause
cosmetic and functional problems, including nasal
obstruction and the inverted-V deformity.
The internal nasal valve is an important functional
anatomic unit. It is bounded medially by the septum,
superiorly by the caudal edge of the upper lateral carti­
lages and fibrofatty tissue adjacent to the piriform aper­
ture, and inferiorly by the anterior head of the inferior
turbinate and nasal floor. It is the point of maximum nar­
rowing of the airway and resistance to airflow on inspira­
tion.2 In Caucasians, the ideal angle between the upper
lateral cartilage and the septum is 10 to 15 degrees. The
valve measures between 55 and 83 mm2.
EXAMINATION
A thorough examination of the middle third of the nose
is critical for accurate diagnosis and surgical planning.
The examination is straightforward and is best achieved
in the office during the initial consultation. After a
detailed history has established the patient’s goals for
surgical intervention, the nose is examined in a systematic
fashion. With respect to the middle third of the nose, it
is important to notice the character of the soft tissue
envelope, the relation of the middle third to the patient’s
midline and the upper and lower thirds of the nose, the
brow-tip aesthetic line, and the radix. The surface of the
nose should be examined during quiet and deeper inspi­
ration from a frontal and base view, looking for collapse
of the internal or external nasal valves. The strength and
integrity of the upper lateral cartilages and the character
of the cartilaginous dorsum can be ascertained by palpa­
tion. Using a nasal speculum and headlight, all three
components of the nasal valve (side wall, septum, and
turbinate) should be examined. A cerumen curette can be
used to identify precisely the site of nasal collapse. Tar­
geted use of the curette provides more detailed informa­
tion than the traditional Cottle maneuver. Finally, if there

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Kate Elizabeth McCarn et al.
inherently short nasal bones, a thin soft tissue envelope,
and weak cartilages are particularly susceptible to post­
operative problems and therefore require careful planning
at the time of surgery to maintain the integrity of this
critical anatomic region.
Internal nasal valve obstruction can be static or
dynamic. Static valve obstruction can be caused by a
deviated dorsal septum, mucosal disease, or any other
anatomic variation that blocks the valve. Dynamic valve
collapse occurs when the strength of the upper lateral
cartilages and soft tissue of the valve are unable to with­
stand the forces of inspiration (Figure 12-2). Even small
changes in the radius of the valve can have an impact on
nasal airflow as predicted by Poiseuille’s law (proportional
to the radius to the fourth power).
MATERIALS FOR USE IN
THE MIDDLE THIRD
Grafting material used in the middle third falls into two
broad categories: structural and camouflage. The ideal
structural material in the middle third is biocompatible,
strong enough to provide support, soft enough to achieve
a natural feel, and able to be shaped or molded in order
to obtain a smooth contour. Septal cartilage is readily
available in the primary rhinoplasty patient. In patients
undergoing revision rhinoplasty or those patients with
insufficient septal cartilage, autologous costal cartilage is
useful but is associated with donor site morbidity in a
small number of patients. Alternatives include irradiated
homologous costal cartilage,3 calvarial bone, porous poly­
ethylene (Medpor; Porex, Newnan, GA), and autologous
conchal cartilage. Camouflage grafting materials include
is any question of allergic or other mucosal disease, the
nose can be sprayed with a topical vasoconstrictor and
the examination repeated to determine whether further
evaluation for allergic or other sinonasal pathology is
warranted. Endoscopy can also be a useful tool in evalu­
ating the internal nasal valve and in documenting valve
collapse.
PROBLEMS OF THE MIDDLE THIRD
The middle third of the nose must be harmonious with
the upper and lower thirds of the nose. The brow-tip
aesthetic line should be unbroken, and the width between
the brow-tip line should fall between the tip-defining
points laterally and philtral columns medially. The most
frequent request from cosmetic rhinoplasty patients is to
take down a dorsal hump. While it is important to respect
the patient’s wishes, it is also critical that they are aware
of the limitations posed by their anatomy and the conse­
quences of overresection including narrowing of the
dorsum and nasal obstruction.
Septorhinoplasty may cause collapse of the upper
lateral cartilages or excessive narrowing of the dorsum.
Destabilization of the upper lateral cartilages can result
in cartilaginous collapse, causing the caudal contour of
the nasal bones to become visible (the inverted-V deform­
ity). Overly aggressive resection of the cartilaginous
dorsum can cause a saddle nose deformity when the
septum is lowered or separated from the nasal bones. A
twisted or crooked middle third can result from septal
deviation or fracture, trauma, or prior surgery.
Functional problems of the middle vault can be
caused by a variety of pathologies. Those patients with
Figure 12-1  Middle nasal vault anatomy.
Upper
lateral
cartilage
Lower
lateral
cartilage
Sagital
Frontal
Dorsal
septum
Upper
lateral
cartilage
Axial
Nasal
bone
Dorsal
septum
Sesamoid
cartilage
A
B
C

CHAPTER TWELVE  The Middle Vault: Upper Lateral Cartilage Modifications
161
superficial musculoaponeurotic system (SMAS). Injection
of local anesthetic can assist in this dissection. Mucosa and
mucoperichondrium should be carefully dissected and left
intact. Mucosal tears or cartilage exposure can lead to
scarring, cosmetic deformity, and airway compromise.
TECHNIQUES
GENERAL
The sequence of maneuvers in rhinoplasty is a widely
debated topic among surgeons and ultimately a matter of
preference. One logical sequence, and the sequence used
at our institution in those patients requiring an open
structured approach, is to perform a standard external
approach via a transcolumellar and bilateral marginal
incisions. The soft tissue envelope is elevated, exposing
the upper lateral cartilages, and then elevation is contin­
ued in a subperiosteal plane over the nasal bones. After
adequate exposure is obtained, the septal cartilage is
exposed starting at the anterior septal angle. Dissection
continues dorsally to the junction of the upper lateral
cartilages and the septum. The upper lateral cartilages are
then sharply divided from the dorsal septum. The septum
is addressed and is often a source of cartilage for spreader,
tip, and onlay grafting. Care is taken to maintain the
continuity of the mucoperichondrium of the septum and
nasal lining and to leave behind a sufficient L-strut for
nasal support. The resected cartilage is placed in saline
for later use. Further modification of the middle vault is
GORE-TEX (Gore, Newark, DE), cartilage, fascia, and a
wide variety of injectable fillers.
APPROACHES
The middle third of the nose is readily accessible via either
the endonasal or external approach. Choice of approach
is ultimately up to the surgeon and should be determined
by the anatomy and the degree of exposure required based
on the preoperative evaluation. The endonasal approach
is useful for creating precise pockets for placement of
grafts, and it has the advantage of minimizing edema and
avoiding external scars. However, it affords less exposure
than the external approach. If the endonasal approach is
used and access to the dorsal septum is necessary (i.e.,
spreader grafts are going to be placed), a hemitransfixion
incision will provide better access than a Killian incision.
The external approach is useful in those cases, where, due
to trauma or previous surgery, the anatomy is uncertain
or in cases where modification of the tip or septum requires
the exposure afforded by this approach. The main advan­
tage of the external approach for the middle vault is that
it allows for accurate visualization and precise positioning
and securing of grafting materials. The proper approach
is the one that allows the surgeon adequate visualization
and the best control over the maneuvers that are being
performed while minimizing scarring and edema.
Regardless of the approach, careful attention to tech­
nique is important. Of particular importance in the middle
third is identifying the plane deep to the subnasal
Figure 12-2  A, Patient at rest. B, With inspiration, demonstrating dynamic valve collapse.
A
B

162
Kate Elizabeth McCarn et al.
Regardless of the technique used to take down the
dorsum, care must be taken to preserve the mucoperi­
chondrium at the angle of the upper lateral cartilage and
dorsal septum. Maintaining this tissue improves support
in this important area preventing collapse of the upper
lateral cartilages.
SPREADER GRAFTS
Spreader grafts are the workhorse of middle nasal vault
surgery. Many permutations of spreader grafts have arisen
since its original description by Sheen7 (Figure 12-4). The
original spreader graft is a matchstick-shaped graft that
is secured between the upper lateral cartilage and septum
extending from the bony–cartilaginous junction to the
anterior septal angle. The spreader graft has proved useful
in correction of the twisted nose, where it can be used to
help anchor the septum into a straighter configuration.
They can be used in primary rhinoplasty to re-secure the
upper lateral cartilages to the dorsal septum, helping to
carried out after the osteotomies have been performed.
Once the septum and bony pyramid have been addressed,
any inherent deviation of the remaining middle third is
corrected and structural grafting performed as needed.
Tip work is done last so that the tip is harmonious with
the upper two thirds of the nose
HUMP REDUCTION AND ONLAY GRAFTING
Taking down a dorsal hump is a common request of the
rhinoplasty patient and can be performed via the endo­
nasal or external approach. The cartilaginous dorsum can
be resected using a 10-mm osteotome, taking the cartilage
in continuity with the bony dorsum or via sharp dissection
using a No. 15 scalpel or sharp dissecting scissors. Hall
describes a modified Skoog dorsal reduction wherein the
cartilaginous hump is taken in continuity with the bone,
further resection is then carried out, the excised dorsum
is sculpted and replaced, and the remaining upper lateral
cartilages are suspended to the dorsal cartilaginous
remnant.4 The dorsal remnant essentially functions as a
dorsal onlay spreader graft. Gassner et al.5 describe the
use of septal cartilage as a dorsal onlay graft that is
sutured to the septum and upper lateral cartilages for
reconstruction of the middle vault. In those patients who
require narrowing of the dorsum and do not have nasal
valve compromise, selective resection of the medial portion
of the upper lateral cartilage can be performed such that
the incision is beveled in order to leave more cartilage on
the ventral surface (Figure 12-3). This bevel in the carti­
lage assists the cartilages in maintaining their convex
confirmation rather than bowing in to form a C-shape that
can pinch the middle third and narrow the nasal valve.6
Figure 12-3  Beveled resection of upper lateral cartilage to minimize
narrowing of the nasal vault.
Upper
lateral
cartilage
Septum
A
B
Figure 12-4  Grafting in the middle third of the nose cross-sectional anatomy. A, Spreader grafts. B, Horizontal spreader grafts. C, Autospreader grafts.
D, Butterfly graft. E, Lateral battens.
Spreader graft
Horizontal spreader graft
Autospreader graft
Butterfly graft
Lateral battens

CHAPTER TWELVE  The Middle Vault: Upper Lateral Cartilage Modifications
163
Figure 12-5  A, Intraoperative photo demonstrating the exposure and dissection used via the external approach to place spreader grafts. Note the
upper lateral cartilages have been separated from the dorsal septum. B, Spreader grafts in situ.
A
B
improve the structural integrity of the roof of the middle
nasal vault and preventing postoperative collapse and
inverted-V deformity. The use of spreader grafts has been
described in functional rhinoplasty. It is useful in address­
ing static narrowing of the nasal valve, but most surgeons
believe that it does little to address dynamic collapse
unless combined with other techniques such as flaring
sutures as described by Park.8
The spreader graft is most often fashioned from a
straight piece of septal cartilage, although any straight
piece of cartilage or other grafting material may be used.
Spreaders can be placed via either the external or endo­
nasal approach. When the endonasal approach is used,
precise mucoperichondrial flaps are raised along the
dorsal septum and the grafts placed within these pockets.
The graft measures 1 to 4 mm in width and 3 to 6 mm
deep, and the length should approximate the length of the
upper lateral cartilages so that the graft extends from the
osseocartilaginous junction to just past the anterior septal
angle. Using the external approach, the graft is placed
between the dorsal septum and upper lateral cartilages
under direct visualization (Figure 12-5). It is important
to position the graft so that the dorsal margin of the graft
is flush with the dorsal septum and no contour irregularity
is visible. PDS (polydiaxanone; Ethicon, Sommerville, NJ)
suture is used to secure the grafts in place via a horizontal
mattress suture through bilateral grafts and the dorsal
septum. If necessary, a straight 27-gauge needle can be
placed though-and-through to hold the grafts in position
while suturing. Papel describes suturing the caudal edge
of the upper lateral cartilage to the septum to provide
traction and prevent buckling of the upper lateral carti­
lage.9 Depending on the deformity that is being corrected,
slightly wider grafts or stacked multiple grafts can be used
unilaterally to achieve a more symmetric result or help
maintain the crooked dorsal septum in a straighter con­
figuration (Figure 12-6).
When spreader grafts are used in conjunction with
flaring sutures, measurable improvements in the area of
the nasal valve and nasal airflow are possible.10 The flaring
suture is a horizontal mattress suture extending across
both upper lateral cartilages and supports the upper
lateral cartilages. Critics of this technique site are con­
cerned about the long-term stability of the suture.
The autospreader graft11 can be used to restore
support to the middle vault after hump reduction. The
medial edge of the upper lateral cartilage is scored and
folded in onto itself and suture secured (see Figure 12-4).
This helps restore a convex configuration of the upper
lateral cartilages, thus resisting collapse of the internal
nasal valve. Figure 12-7 illustrates a case in which this
technique was applied in a primary rhinoplasty patient.
The horizontal spreader graft is used in those circum­
stances where sufficient width cannot be achieved with a
conventional spreader graft. It is a wide, flat piece of
cartilage resting atop the dorsal septum and secured to
both upper lateral cartilages. Securing this graft can be
challenging but it can yield more significant improve­
ments in the nasal airway and restore the width of the
overresected dorsum (Figure 12-8).
Extended spreader grafts are used to achieve purposes
beyond stabilization of the upper lateral cartilages, and
they have use in lengthening the short nose, stabilizing an
“open roof” of the nasal bones, and widening the pinched
dorsum.12 Caudal extension of the spreader graft can
lengthen a foreshortened nose and counteract the forces
of contraction and healing to maintain desired tip rota­
tion. The graft is fashioned in the usual manner but with
added length so that the tip is supported. If the graft
extends much beyond the septal angle, it can push the
domes laterally, producing a widened tip. In the upper
third, spreader grafts can be extended superiorly between
the septum and nasal bones to add width to the bony
dorsum in the pinched nose.

164
Kate Elizabeth McCarn et al.
Figure 12-6  A, Preoperative photo of patient with nasal asymmetry. B, After placement of a right-sided spreader graft.
Right unilat spreader
Figure 12-7  Upper left, Preoperative frontal view. Upper right, After primary rhinoplasty with removal of the dorsal hump and use of the autospreader
graft. Lower left, Preoperative base view. Lower right, Postoperative.
Auto spreader graft 01

CHAPTER TWELVE  The Middle Vault: Upper Lateral Cartilage Modifications
165
the dorsum and can cause some supratip fullness. Shaping
and placing the graft appropriately and resecting some
septal cartilage to create a bed for the graft can minimize
these potential pitfalls, as can counseling the patient pre­
operatively regarding the objectives of the procedure.
Figure 12-10 illustrates a case in which a butterfly graft
was placed.
LATERAL BATTEN GRAFTS
In those patients with internal valve collapse due to a
weak lateral nasal side wall, a cartilage graft in this area
can be helpful and avoids the dorsal deformity that can
sometimes result from a butterfly graft. This area is par­
ticularly prone to collapse in the aging patient and the
patient with facial paralysis.
A batten graft measuring up to 1.5 × 1.5 cm is fash­
ioned from either septal or conchal cartilage (Figure
12-11). The external or endonasal approach may be used,
creating a lateral pocket that approaches and overlaps the
piriform aperture. Care must be taken in ensuring hemo­
stasis as this region is well vascularized. The graft is
placed laterally over the lateral aspect of the upper lateral
cartilage and within the dense fibrous tissue that
approaches the piriform aperture (see Figure 12-4). The
graft may be secured with an absorbable suture.
DORSAL GRAFTING
Grafting of the nasal dorsum falls into one of two catego­
ries: structural or camouflage. Beyond spreader grafts,
BUTTERFLY GRAFTS
The butterfly graft is a useful tool in treating collapse of
the middle nasal vault.2 It is an oval-shaped cartilage that
is placed so that it lies on the dorsal surface of the upper
lateral cartilages. It addresses both dynamic and static
collapse by opening the angle between the upper lateral
cartilages and the septum and providing support for weak
upper lateral cartilages against the negative forces gener­
ated by inspiration.
Conchal cartilage is the ideal material for use as a
butterfly graft. The graft is harvested via the anterior
approach, elevating skin and perichondrium of the conchal
bowl. A curved piece of cartilage measuring at least 3 cm
in length by 1 cm in width is harvested, and the donor
site closed using an absorbable suture, with a bolster
placed to prevent hematoma accumulation. Donor site
morbidity and deformity are generally minimal.
The graft is shaped so that any irregularities are mini­
mized and the ends tapered to smooth the skin over the
graft. The graft can be placed either by creation of a
precise pocket via the endonasal approach or via the
external approach. Care must be taken with the endonasal
approach to create a pocket that will not allow shifting of
the graft. Via the external approach, the graft may be
sutured to the lower lateral cartilages with a permanent
monofilament suture. Figure 12-9 illustrates the harvest
and anatomic placement of a butterfly graft.
The butterfly graft gives patients seeking improve­
ment in their nasal airway good results. The complaint
that is sometimes encountered is that the graft broadens
Figure 12-8  Left, Preoperatively. Right, After placement of a horizontal spreader graft.
Horizontal spreader

166
Kate Elizabeth McCarn et al.
Figure 12-10  Left, This patient has undergone rhinoplasty and now presents with nasal airway obstruction. Right, After revision rhinoplasty with place­
ment of butterfly graft.
Butterfly graft 01
Figure 12-9  A, Harvest of conchal cartilage for use as a butterfly graft. B, Butterfly graft. C, Proper placement of the butterfly graft. D, Dressing for
donor site.
A
B
C
D

CHAPTER TWELVE  The Middle Vault: Upper Lateral Cartilage Modifications
167
helping to blend the graft in with the surrounding tissue
and minimize contour deformities. Finally, for slight
contour irregularities in the postoperative patient, a wide
variety of injectable fillers are available and, though none
have U.S. Food and Drug Administration approval for use
in the nose, their use for this purpose is growing.
CONCLUSION
The middle third of the nose is important both structur­
ally and functionally; simple maneuvers such as taking
down a dorsal hump can violate the integrity of this
region. Providing support for the upper lateral cartilages
is possible via a variety of methods and can prevent cos­
metic deformity and nasal airway obstruction. The well-
equipped surgeon will have a familiarity with a variety of
techniques to achieve functionally and aesthetically pleas­
ing results that will withstand the test of time.
REFERENCES
1. Tardy ME, Hendricks D, Alex J, Dayan SH. Surgical anatomy
of the nose. In: Bailey B, ed. Head and neck surgery–
Otolaryngology. 2nd ed. Philadelphia: Lippincott; 1998:
641–660.
2. Clark JM, Cook TA. The ‘butterfly’ graft in functional
secondary rhinoplasty. Laryngoscope. 2002;112(11):
1917–1925.
3. Weber SM, Cook TA, Wang TD. Irradiated costal cartilage in
augmentation rhinoplasty. Oper Tech Otolaryngol. 2007;18:
274–283.
4. Hall JA, Peters MD, Hilger PA. Modification of the Skoog
dorsal reduction for preservation of the middle nasal vault.
Arch Fac Plast Surg. 2004;6:105–110.
5. Gassner HG, Friedman O, Sherris DA, et al. An alternative
method of middle vault reconstruction. Arch Fac Plast Surg.
2006;8:432–435.
6. Thomas JR, Prendiville S. Overly wide cartilaginous middle
vault. Fac Plast Surg Clin N Am. 2004;12:107–110.
7. Sheen JH. Spreader graft: a method of reconstructing the roof
of the middle nasal vault following rhinoplasty. Plast Reconstr
Surg. 1986;73:230–239.
8. Park SS. The flaring suture to augment the repair of the
dysfunctional nasal valve. Plast Reconstr Surg. 1998;101(4):
1120–1122.
9. Papel ID Management of the middle vault. In Papel ID,
Frodel J, Holt GR, et al, eds. Facial plastic and reconstructive
surgery. 2nd ed. New York: Thieme; 2002:407–414.
10. Schlosser RJ, Park SS. Surgery for the dysfunctional nasal
valve: cadaveric analysis and clinical outcomes. Arch Fac
Plast Surg. 1999;1:105–110.
11. Steve BH, Mead RA, Gonyon DL. Using the autospreader flap
in primary rhinoplasty. Plast Reconstr Surg. 2007;119(6):
1897–1902.
12. Palacin JM, Bravo, FG, Zeky R, Schwarze H. Controlling
nasal length with extended spreader grafts: A reliable
technique in primary rhinoplasty. Aesthet Plast Surg.
2007;31:645–650.
dorsal grafts can also be used to reconstruct the middle
third of the nose in the patient with a severely injured,
weak, or cartilage-depleted nose. Dorsal grafting material
must be compatible with use in the middle third, keeping
in mind that the thin skin overlying the dorsum here will
readily reveal any contour irregularity. Autologous and
irradiated rib are useful tools in dorsal grafting—the com­
plication of warping can be minimized by using a central
portion of cartilage and by soaking the cartilage in saline
so as to reveal and address any deformity. Using irradiated
rib can yield good results with minimal resorption3 and
minimizes the potential donor site morbidity associated
with costal cartilage harvest. Stacked conchal or septal
cartilage may be used but often is not available in those
patients who truly need substantial dorsal grafting. Cal­
varial bone is strong but hard in comparison with carti­
laginous grafts and can require rigid fixation techniques
to secure.
In those patients who are unable or unwilling to
undergo calvarial bone or costal cartilage harvest, porous
polyethylene has also been used to graft the dorsum.
Infection and extrusion are the main complications that
may be encountered, but meticulous technique such as
distancing the graft from the incision can be helpful in
avoiding them. Extruding porous polyethylene dorsal
grafts can be replaced with irradiated costal cartilage in
a single stage.
Camouflage can become necessary in the manage­
ment of the middle nasal vault, particularly in thin-
skinned individuals requiring structural grafts. Morselized
cartilage and fascia are useful biocompatible materials for
this purpose. The 1-mm GORE-TEX sheets can be used
for this purpose as well. The sheets may be stacked to
provide additional thickness and achieve a stronger dorsal
profile. A press can be used to crimp and taper the edges,
Figure 12-11  Harvested conchal cartilage with batten grafts outlined.

169
C H A P T E R T H I R T E E N 
The Mobile Tripod Technique:
A Universal Approach to
Nasal Tip Modification
Robert A. Glasgold • Alvin I. Glasgold • Sanjay P. Keni
One of the most important and difficult aspects of
rhinoplasty surgery is creating a nicely shaped, natural-
appearing nasal tip. This generally involves altering nasal
tip definition, width, projection, and/or rotation. Nasal tip
appearance is primarily determined by the shape and
strength of the lower lateral cartilages (LLCs). In addi­
tion, the tip shape and position are affected by the rela­
tionship of the LLCs with adjacent support structures
(i.e., septum and upper lateral cartilages [ULCs]) and the
characteristics of the overlying skin envelope. Changing
nasal tip appearance is usually accomplished by modify­
ing the shape or configuration of the LLCs to create a new
tip structure. Reshaping the cartilages requires both
maneuvers to release the tip’s support mechanisms creat­
ing a mobile structure, followed by reconstructive maneu­
vers to establish a cartilaginous foundation that will
translate into a structurally sound and aesthetically pleas­
ing appearance. Many techniques have been described to
accomplish these changes.1–4 The ideal technique for mod­
ifying the LLCs should be flexible enough to address a
variety of issues, as well as provide predictable and lasting
results. The central component of our preferred technique
for modifying the nasal tip is vertical angle division of the
LLCs to create a “mobile tripod.”5 This separates the
lateral crura from the medial and intermediate crura,
creating a structure that is more amenable to reshaping
as seen in this patient (Figure 13-1).
A description of this technique, and an explanation
of its rationale, must be prefaced with a description of the
anatomy and relevant terminology. The LLCs consist of a
lateral crus, a medial crus, and the variable presence of
an intermediate crus between these two. The angle of the
LLC is the junction of the medial (or intermediate) crura
and lateral crura (Figure 13-2). The dome of the LLC is
generally the most prominent portion of the lateral crus,
and is located lateral to the angle. The major and minor
tip support mechanisms have been reviewed previously in
the text. Some of these structural relationships must be
released in order to modify nasal tip shape, appearance,
projection, and rotation.
Anderson’s6 tripod concept provides a simplified
explanation of how alterations to the crural components
of the LLCs change the external nasal appearance. This
relies on conceptualizing the LLCs as a tripod in which
the combined medial-intermediate crura comprise a single
inferior limb and each lateral crura comprises the remain­
ing two limbs (Figure 13-3). Altering any one limb of the
tripod will affect the position of the lower third of the
nose, whether through a change in its projection, rotation,
or length. Practical implementation of these concepts may
be more challenging as the intact crural arch resists many
of the desired changes to the tripod. In the technique
described in this chapter, vertical angle division is the
centerpiece to developing a “mobile tripod” by removing
the forces resisting alar restructuring.5
Three key steps isolate the limbs of the “mobile
tripod” for subsequent manipulation: (1) releasing the
membranous septal attachment between the medial crura
and caudal septum; (2) vertical angle division, separating
medial (and intermediate) crura from lateral crura; and
(3) freeing the cephalic margin of the lateral crura from
the ULCs. These steps allow for the individual limbs of
the tripod to be modified and repositioned independent of
one another. Having released structural supports to facili­
tate changes to the LLCs, an emphasis must be placed on
reestablishing a solid structural foundation to provide a
durable result.
The distinction between vertical angle division and
traditional dome division technique cannot be emphasized
enough. Dome division involves transecting the LLC at
the domal portion of the lateral crura; similar to perform­
ing a lateral crural steal, with the medial post consisting
of the medial, intermediate, and a portion of the lateral
crus (Figure 13-4). The resulting tip structure is defined
by the apex of the medial post with the lateral crura rem­
nants collapsing to its side. The most common problems

170
Robert A. Glasgold • Alvin I. Glasgold • Sanjay P. Keni
TECHNIQUE
OVERVIEW
All cases are performed through an open/external rhino­
plasty approach using an inverted-V columellar incision.
A relatively consistent sequence of steps is adhered to in
this technique, as outlined next.
• Skin flap elevation
• Separate medial crura and identify caudal septum
• Septal mucoperichondrial flap elevation
associated with this technique were tent pole deformities,
due to a narrow pointed medial post defining the tip, and
alar collapse, due to inadequate support of the lateral
crura remnant. In contrast, vertical angle division transects
the LLC at the angle, the natural junction between medial-
intermediate crura and lateral crura. The entire lateral
crura remain intact. The tip structure is created by the
contoured medial edge of the lateral crura overriding the
slightly splayed medial-intermediate crural complex
(Figure 13-5). This produces a more natural and attrac­
tive nasal tip appearance and avoids the problems associ­
ated with dome division.
Figure 13-1  A–D, Preoperative and postoperative photographs of patient undergoing rhinoplasty using a vertical angle division to create nasal tip
narrowing, definition, rotation, and deprojection.
A
B
C
D

CHAPTER THIRTEEN  The Mobile Tripod Technique
171
Figure 13-2  Intraoperative photograph demonstrating the compo­
nents of the lower lateral cartilages: lateral crura (LC), intermediate crura (ic),
medial crura (MC), angle (Ang), and dome.
Dome
LC
Ang
IC
MC
Figure 13-3  Illustration demonstrating lower lateral cartilages forming the nasal tripod. The combined medial crura form one limb and each lateral crura
represents the remaining two tripod legs.
Central limb
of tripod
Combined
medial crura
form one limb
Figure 13-4  A, B, Schematic diagram demonstrating location of lower lateral cartilage transaction with classic dome division. The medial crural post
forms the tip and the lateral crura collapse to its side.
Dome division
of lower lateral
cartilages
A
B
• Septal shortening (as needed)
• Septal cartilage harvest
• Closure of septal mucosal flaps
• Elevate vestibular mucosa from under the angle
• Vertical angle division
• Medial crura sutured together
• Mucosal elevation under cephalic margin of lateral
crura and separation of lateral crura from ULC (scroll)
• When additional rotation is needed—release and
transaction of the lateral tail of the lateral crura
• Cephalic trim of lateral crura
• Graft creation (columella strut) from septal cartilage
• Placement and suture fixation of columella strut in an
intra­crural premaxillary pocket
• Medial (and intermediate) crural modification—height
and shape
• Membranous septal sutures (as needed)
• Extended shield graft (if needed)
• Dorsal modifications

172
Robert A. Glasgold • Alvin I. Glasgold • Sanjay P. Keni
Following the takedown of the membranous septum
and elevation of the septal mucosal flaps, caudal septal
length is evaluated to determine the need for septal short­
ening (Figure 13-7). An excessively long septum may
interfere with efforts to rotate or shorten the nasal tip
impairing free mobilization of the LLC. Septal length is
also assessed to ensure adequate room to place a columella
strut graft without changing nasal length. After address­
ing caudal septal length, the septal cartilage is harvested
and the mucoperichondrial flaps are sutured together
using a quilting suture technique.
LOWER LATERAL CARTILAGES
The angle of the LLC is identified at the junction of the
medial (or intermediate) and lateral crus (Figure 13-8).
This angle varies in appearance: it can be a well-defined
breakpoint or a more subtle and less-defined transition
point between medial (or intermediate) and lateral crura.
Figure 13-5  Illustration demonstrating vertical angle division with the tip complex being formed by the lateral crura overriding the splayed apices of the
medial crura.
Lateral
crura
Angle division of
lower lateral
cartilage
Figure 13-6  Anterior approach to septum. The medial crura are sepa­
rated and the membranous septum is dissected through to expose the
caudal septum. The membranous septum, separating the left lower lateral
cartilage and the caudal septum, is indicated by the white line.
Figure 13-7  The medial crura are retracted to allow for shortening of
the caudal septum with a No. 15 blade.
SEPTUM
The caudal septal cartilage is attached to the LLC through
the membranous septum. By virtue of this relationship the
caudal septum affects nasal tip projection, length, and
rotation. The external anterior approach to harvesting
septal cartilage requires separation of the medial crura
and taking down the membranous septum (Figure 13-6).
Releasing this attachment deprojects, shortens, and rotates
the nasal tip. Even when these are not the primary goals
for a particular patient, this release will also facilitate
subsequent efforts to lengthen, counterotate, and/or
project the nasal tip freely.

CHAPTER THIRTEEN  The Mobile Tripod Technique
173
domal portion of the lateral crura to medialize. Reducing
the interdomal distance produces a more narrow and
defined tip (Figure 13-12).
Once separated, the lateral and medial crura can be
reshaped and manipulated independently of one another.
This is especially helpful when addressing ala-columellar
disproportions, particularly in the setting of excessive
columellar show where the inherent shape of the LLCs
create an unfavorable relationship of lateral to medial
The vestibular mucosa is elevated from the undersurface
of the angle (Figure 13-9). Vertical angle division is per­
formed with a Converse scissors without violating the
underlying mucosa (Figure 13-10A, B). The medial (and
intermediate) crura are sutured together below their apex
using a 5-0 PDS reconstructing the single medial limb of
the tripod (Figure 13-11). These two maneuvers narrow
the tip by bringing together the medial (and intermediate)
crura, which normally splay apart, and allowing the
Figure 13-8  The angle of the lower lateral cartilage is identified at the
junction of the medial (or intermediate) crus with the lateral crus. In this
patient, the angle appears as a well-delineated crease.
Figure 13-9  The vestibular mucosa is elevated from the undersurface
of the angle prior to angle division.
Figure 13-10  A, The right lower lateral cartilage angle has been transected; the left remains intact. B, Following transaction of the right and left angles,
the medial (and intermediate) crura are sutured together.
A
B

Figure 13-11  Following vertical angle division, the medial crura are sutured together below their
apex. The visible overlap of the medial aspect of the lateral crura creates a supratip fullness, which
is subsequently corrected during lateral crura modification.
Figure 13-12  A, Intraoperative base view of a wide nasal tip after elevation of the nasal skin. B, Following vertical angle division and suturing of the
medial crura. The lateral crura override the medial component. The tip structure is visibly narrowed. C, Preoperative photograph of the same patient.
D, Postoperative photograph showing the tip narrowing and rotation that was obtained with vertical angle division.
A
D
C
B

CHAPTER THIRTEEN  The Mobile Tripod Technique
175
Care is taken to preserve at least 7 mm of the lateral crura
in vivo to prevent alar collapse. Following domal angle
division and separation of the lateral crura from the ULC,
the medial ends of the lateral crura may overlap and
produce supratip fullness. Reduction of the cephalic
portion of the lateral crura is done primarily in the medial
two-thirds of the lateral crura to narrow the tip and reduce
supratip fullness. Releasing the lateral crus–ULC attach­
ment (scroll) facilitates lateral repositioning of the lateral
crura, and thus nasal tip rotation. Additional rotation can
be achieved, when necessary, by dissecting out and
transecting the lateral most aspect of the lateral crura,
crura.7 After completing the vertical angle division, the
lateral and medial crura can be effectively repositioned to
reestablish an appropriate relation with less vertical sepa­
ration of the lateral and medial crura (Figure 13-13).
Lateral Crura
The lateral crura are released by freeing their cephalic
margin from the ULCs (Figure 13-14). The mucosa under­
lying the cephalic margin is elevated prior to dividing the
LLC–ULC attachment (scroll). This allows for lateral
crura freeing and trimming of the cephalic component,
without violating the underlying mucosa (Figure 13-15).
Figure 13-13  Preoperative photographs (A, B) of a patient who previously had rhinoplasty resulting in alar-columella disharmony and a blunted tip.
Postoperative photographs (C, D) following revision rhinoplasty, the patient demonstrates correction of the alar-columella disharmony with vertical angle
division.
A
D
C
B

176
Robert A. Glasgold • Alvin I. Glasgold • Sanjay P. Keni
Figure 13-14  The cephalic border of the lateral crus is separated from
the upper lateral cartilage.
Figure 13-15  Before (A) and after (B) cephalic trim of the lateral crura. Reduction of the medial cephalic border narrows the tip and reduces supratip
fullness.
A
B
where they abut the sesamoid cartilages (Figure 13-16).
This lateral release allows the lateral crura to further
migrate out toward the pyriform aperture.
Medial Crura
Having isolated and modified the lateral crura, attention
is shifted to addressing the medial and intermediate crural
complex. The medial crura are now relatively mobile,
having been separated from the lateral crura and freed
from the caudal septum. Modifications to the medial crura
are aimed toward modifying tip projection, rotation, and
columellar position. Separating the medial from the lateral
crura provides tremendous flexibility to alter nasal tip
projection. In an overprojected nose, the apex of the
medial crura can be reduced as much as needed for depro­
jection (Figure 13-17). Even in cases where deprojection
is not needed, the apex of the medial–intermediate crural
complex will generally need to be modified after angle
division. Following vertical angle division, the cephalic
portion of the apical (free) margin of the medial-
intermediate crura will generally project higher than the
caudal portion. Trimming the cephalic portion of the free
apical edge of the intermediate crura is often necessary to
prevent supratip fullness (Figure 13-18). Once the desired
nasal projection has been established, a columella strut
graft is sutured into place to prevent loss of tip projection
during the healing process. When addressing an under­
projected nose, a longer columella strut graft can be used
to increase tip projection.
COLUMELLAR STRUT GRAFT
A columella strut graft is used in all patients, even when
deprojecting the tip, to ensure maintenance of tip position
(Figure 13-19). It is also useful for modifying the shape
of the medial-intermediate crura complex. An overly
curved medial-intermediate crura may lead to a hanging
columella postoperatively. The columella strut graft can
be used to straighten the medial–intermediate crural
complex, as a means to address the alar–columella rela­
tionship. The columella strut graft is ideally carved out of

CHAPTER THIRTEEN  The Mobile Tripod Technique
177
Figure 13-16  Additional tip rotation is facilitated by dissecting out and
transecting the lateralmost aspect of the lateral crura. The scissor is posi­
tioned under the most lateral portion of the lateral crura.
Figure 13-17  Preoperative (A) and postoperative (B) photographs demonstrating tip deprojection accomplished through vertical angle division followed
by reduction of the medial crural height.
A
B
a relatively strong strip of septal cartilage. It is approxi­
mately 2.5 cm long and 0.5 cm wide, tapering to a narrow
base. An intercrural pocket is created between the feet of
the medial crura staying anterior to the maxillary spine
(Figure 13-20). The graft is placed with its narrow base
into the pocket, then slid between the medial crura with
its apex positioned immediately under the suture binding
the medial crura together. The graft length is modified as
needed to fit into the pocket. A longer graft can be used
to increase projection. When using a longer columellar
strut to increase projection, it is important to bear in mind
that as the apex of the graft pushes against the medial
crura suture, increased rotation of the nasal tip will be
accomplished, thereby opening the nasolabial angle
(Figure 13-21). Projection and rotation should be assessed
before suture-fixating the graft. The skin is redraped and
the tip height, narrowing, position, and rotation are
reassessed.
MEMBRANOUS SEPTUM
During the process of LLC modification, emphasis is
placed on reinforcing the anatomic supports that may
have been weakened, in order to create a long-lasting and
functional result. The columella strut graft, as described
earlier, provides structural reinforcement of the medial
crura and is used to maintain the newly established nasal
tip projection and rotation. Another structure that often
needs to be reinforced is the membranous septum. The
open approach to the septum eliminates the space between
the medial crura and caudal septum, leaving a potential
space where the membranous septum had been. This
allows the medial crura to drop back against the caudal
septum, facilitating rotation, shortening, and deprojection
(see Figure 13-6). The columella strut helps compensate
for some of the loss of support from membranous septum
take-down, but reestablishment of the membranous
septum is generally needed to further modify nasal length
and tip rotation. The membranous septum can be variably

178
Robert A. Glasgold • Alvin I. Glasgold • Sanjay P. Keni
Figure 13-19  Columella strut graft carved out of septal cartilage.
Figure 13-20  A, The columella strut is placed in an intracrural pocket
with its base extending in front of the maxillary spine. B, Schematic showing
the position of the columella strut and placement of sutures for fixation.
A
Columella
strut
graft
B
Figure 13-18  Fullness in the supratip is prevented by reducing the
cephalic portion of the medial crural apex (cartilage reduction performed
along white line).
recreated depending on the changes that need to be made
to the tip. Conceptually, the potential membranous septum
can be envisioned as having a low, middle, and high com­
ponent, each of which can be addressed independently.
The membranous septum is reconstituted by placing a 4-0
chromic suture through the portion of the membranous
septum that needs to be reestablished. The suture is placed
through mucosa only. If the columella is retracting, a low
and mid suture will lengthen these portions of the nose,
bringing out the columella. If the tip is rotating too much
and overshortened, a high membranous septal stitch will
prevent its collapse in the cephalad direction, creating a
longer, less rotated tip.
Having modified both the lateral and medial crura, a
new tip structure has now been created. This new nasal
tip is formed by the medial ends of the lateral crura over­
riding the apical portion of the medial–intermediate crural
complex. As the skin flap is pulled down, the lateral crura
are pulled forward and medial into their final position
overriding the apex of the medial crura, and the nasal tip
is evaluated with the skin flap redraped (Figure 13-22).
Based on evaluation of the tip, the need for further tip
grafting is needed.
EXTENDED SHIELD GRAFT
In some cases, the above-mentioned steps may fall short
of producing the desired tip definition, projection, narrow­
ing, or overall appearance. This is more often seen in
patients with thicker skin, for whom the tip structure is

CHAPTER THIRTEEN  The Mobile Tripod Technique
179
Figure 13-21  Preoperative (A, B) and postoperative (C, D) photographs demonstrating the effect of a strong columella strut after vertical angle division.
The columella strut can rotate and project the tip, opening the nasolabial angle.
A
C
D
B
not adequately defined or narrowed, and for patients
undergoing revision rhinoplasty procedures in whom the
LLCs have been previously altered by either aggressive
resection or reshaping, leaving an inadequate tip struc­
ture. In these instances, a new tip-defining structure needs
to be created. An extended shield graft is an effective
means for creating a more defined tip structure.8,9 This
graft is versatile and can be used to lengthen the nose,
increase projection, narrow the tip, or even widen a
pinched tip from prior surgery (Figure 13-23). The
extended shield graft is a columella-lobular graft, with a
shield shape at its lobular component. It is placed into a
pocket in front of the medial crura and becomes the new
tip-defining structure (Figure 13-24). This relegates the
medial aspect of the lateral crura (previously the tip-
defining structure) as the new supratip structure. The
extended shield graft is carved out of septal cartilage or,
alternatively, conchal cartilage. The graft is approximately
2.5 cm in height and 10 mm in width at its apex, narrow­
ing toward its base (Figure 13-25). The apical edges of
the graft are thinned and beveled and the apical corners
are blunted to better camouflage it under the tip skin. If
the effect of the graft on tip shape and height is appropri­
ate, it is then carefully sutured in place, taking care not
to leave any exposed sharp edges that can later become
visible. The skin envelope is then redraped and the effect

180
Robert A. Glasgold • Alvin I. Glasgold • Sanjay P. Keni
Figure 13-22  Preoperatively (A, B), this patient had an overprojected, wide, and ptotic tip. Rhinoplasty included vertical angle division, reduction of the
cephalic margin of both the lateral crura and apex of the medial crura, and placement of a columellar strut graft. Postoperative (C, D) photographs demon­
strate the ability to deproject, rotate, narrow, and improve tip definition with these techniques.
A
C
D
B

CHAPTER THIRTEEN  The Mobile Tripod Technique
181
Figure 13-23  Preoperatively (A, B), this patient had a wide, poorly defined ptotic tip. Rhinoplasty, including vertical angle division, lower lateral cartilage
cephalic trim, and columella strut placement were performed. An extended shield graft was needed to create appropriate tip definition (C, D) due to her
relatively thick nasal skin.
A
C
D
B

182
Robert A. Glasgold • Alvin I. Glasgold • Sanjay P. Keni
Figure 13-24  A, B, An extended shield graft is placed in a precrural pocket. The graft becomes the new tip and the lower lateral cartilages are now
suptratip structure.
A
B
Figure 13-25  The extended shield graft is double suture-fixated to the
medial crura and columella strut.
Extended
shield graft
of the graft reassessed. Again, it is useful to place a suture
to reapproximate the columella incision so as to accurately
assess the result of the graft.
CONCLUSION
Vertical angle division is a useful technique for altering
the LLCs to modify nasal tip appearance. Formation of a
fully mobile tripod with this technique facilitates modifi­
cation of each of the pods independently of one another.
In conjunction with structural cartilage grafts, this tech­
nique is applicable in all primary and revision rhinoplas­
ties and has provided consistent long-term results.
REFERENCES
1. Toriumi DM. New concepts in nasal tip contouring. Arch Fac
Plast Surg. 2006;8:156–185.
2. Adamson PA, McGraw-Wall BL, Morrow TA, et al. Vertical
dome division in open rhinoplasty. An update on indications,
techniques and results. Arch Otolaryngol Head Neck Surg.
1994;120:373–380.
3. Quatela VC, Slupchynskyj OS. Surgery of the nasal tip. Fac
Plast Surg. 1997;13:253–268.
4. Kamer FM, Pieper PG. Nasal tip surgery: a 30-year experience.
Fac Plast Surg Clin North Am. 2004;12:81–92.
5. Glasgold AI, Glasgold MJ, Rosenberg DB. The mobile tripod
technique: the key to nasal tip refinement. Fac Plast Surg Clin
North Am. 2000;8:487–502.
6. Anderson JR, Ries WR. Surgery of the nasal base: setting tip
projection and location. In: Anderson JR, Ries WR, eds.
Rhinoplasty: emphasizing the external approach. New York:
Thieme; 1986:63–78.
7. Joseph EM, Glasgold AI. Anatomical considerations in the
management of the hanging columella. Arch Fac Plast Surg.
2000;2:173–177.
8. Glasgold MJ, Glasgold AI. Tip grafts and their effects on tip
position and contour. Fac Plast Surg Clin North Am. 1995;3:
367–379.
9. Kridel RW, Soliemanzadeh P: Tip grafts in revision rhinoplasty.
Fac Plast Surg Clin North Am. 2006;14:331–341.

183
C H A P T E R F O U R T E E N 
Suturing Techniques to Refine
the Nasal Tip
Ronald P. Gruber • Kenton Fong • Chia Chung
Controlling the shape of the nasal tip can be one of the
most challenging problems rhinoplasty surgeons face in
practice. Prior to the advent of suture techniques, the
cartilages of the nose were largely controlled, by excision,
crushing, and scoring. At the time, these methods were
thought to be the easiest method to create a new nasal
shape. Unfortunately, they all potentially damaged the
cartilage and consequently often led to instability, col­
lapse, contour irregularities, and a host of secondary prob­
lems including alar retraction, pinched tips, retracted
alae, and external valve collapse.
In the late 1980s, Tardy et al.1 used what is now
called a transdomal suture to narrow the tip cartilages in
a closed (endonasal) rhinoplasty, and soon Daniel2,3 began
using this technique in the open approach, which was
described as the “dome-definition suture.” Emphasizing
the need for nondestructive methods of controlling carti­
lage shape, Tebbetts4 provided a comprehensive approach
to suture techniques, including his lateral crural spanning
suture that reduced tip convexity and narrowed the overall
width of the nasal tip. Since that time, a wide variety of
suture techniques have been proposed to control the width
and position of the tip and to reduce lateral crural bulbos­
ity. Rohrich et al.5 provided an algorithm for the boxy tip,
and most recently, Guyuron et al.6 used sutures to control
the shape of the foot plates and reviewed the entire subject
of suture techniques. Over the past decades, suture tech­
niques have gradually come into vogue and now represent
a quantum leap in the ability to control the shape of the
nasal architectural framework. However, suture tech­
niques should not be considered as an all-encompassing
substitute for cartilage grafting. When there are major
changes to be made in the nasal region, cartilage grafting
may be necessary as an adjunct to suturing techniques.
The choice of suture techniques chosen here represents the
personal favorite of the authors.
FUNDAMENTAL PRINCIPLES
FOR SUTURE-BASED MODIFICATIONS
OF THE NASAL TIP
1. Models facilitate sculpting
In planning what could be termed “suture tiplasty,” it
is important to have a structural shape and goal in
mind (Figure 14-1). A generic tip would consist of the
following: the lateral crus should be fairly flat (not
convex or concave) and at least 5 to 6 mm wide. The
tip cartilages resemble McDonald’s arches. The actual
domes are separated from one another at the cephalic
end by about 3 mm. Each dome has an axis, and the
two axes form the “angle of domal separation” approx­
imating 70 to 90 degrees.7 On lateral view, one will
note that the angle formed by the medial/middle
crus is anywhere from 15 to 30 degrees. The tip
will commonly lie 6 to 8 mm above (anterior) to the
dorsal septum. Commercially available anatomic
models can aid the novice surgeon in sculpting the tip
cartilages to these dimensions. As any commercial
artist will tell you, copying is much easier than creat­
ing from memory.
2. Cephalic resection of the lateral crus
Before implementing the suture techniques to control
the shape of the nasal tip during a primary rhino­
plasty, the cephalic component of the lateral crus is
typically trimmed. Cephalic resection should result in
a lateral crus that is never narrower than 6 mm wide
(Figure 14-2). There are two reasons for carrying out
this maneuver in this fashion: (1) the shape of the
lateral crus can more precisely be controlled to reduce
its convexity and (2) the integrity of the lateral crus
(which effectively constitutes the external valve) is
maintained. After the cephalic trim is performed, one
can use suture techniques to reduce any remaining

184
Ronald P. Gruber • Kenton Fong • Chia Chung
BASIC ALGORITHM (FOUR-SUTURE
TECHNIQUE)
It is helpful to have a suture algorithm for the tip carti­
lages.2,3,5,6,9 In the senior author’s experience, four types
of sutures9 can control the entire tip shape in most cases
(hemitransdomal, interdomal, lateral crural mattress, and
columellar-septal). A few others are occasionally used.
HEMITRANSDOMAL SUTURE
Until recently, the senior author’s first line and most com­
monly used suture was a transdomal suture to narrow the
domal width. However, a modification of that technique
developed by Tardy for the closed (endonasal) approach
and further adapted by Daniel for the open (external)
approach has become our first suture choice. The hemi­
transdomal suture is intended to narrow the cephalic end
of the dome, thereby causing a small amount of eversion
of the lateral crus and minimizing the chance of a col­
lapsed marginal rim of the lateral crus.
The vestibular skin of the dome is infiltrated with
local anesthesia to avoid needle penetration into the ves­
tibular skin. A hemitransdomal suture (5-0 PDS) is then
placed in the cephalic end of the dome. In essence, the
cephalic end of the middle crus (posterior or deep to the
dome) is pinched to the cephalic end of the lateral crus
convexity or concavity. Even if the lateral crus is
cephalically oriented, as is commonly the case, the
convexity of the entire lateral crus can and should be
converted to a normal flat orientation with the aid of
suturing techniques.
3. Suture choice
We have not found the suture type and size to be criti­
cally important factors. However, we routinely use 5-0
or 4-0 polydioxanone (PDS) sutures to control carti­
lage shape. We previously used nylon, but experience
has demonstrated that the alar cartilage retains its new
shape even after the PDS dissolves. Moreover, the
potential problems of suture exposure in the nasal
cavity are avoided given the dissolvable nature of the
PDS suture. Suture color does not seem to be a critical
issue either. Tapered needles are preferable because
they are less likely to “cut through” the cartilage.
However, cutting needles will work satisfactorily if
round needles are not available.
4. Intraoperative delayed suturing effect
Cartilages will sometimes change their shape slightly
after sutures are placed. This can be attributed to the
local anesthetics diffusing through the soft tissues or
to the gradual change of the shape of the cartilage over
time.8 Whatever the cause, it is helpful to plan to reas­
sess the effect of the sutures that have been applied
intraoperatively before completing the case. Minor
warping changes can occur anywhere up to 45 minutes
after a suture is placed in the cartilage. Fortunately,
undesired changes are almost always reversible by
removing and replacing the suture if the intended
effect is not accomplished.
Figure 14-1  Anatomic model. The desired anatomical configuration of
the tip cartilages are easier to sculpt with suture techniques if there is an
anatomic model from which to copy.
Figure 14-2  Cephalic trim of the lower lateral cartilage. Before begin­
ning suture techniques on the nasal tip, a cephalic trim of the lateral crus is
almost always needed in the primary rhinoplasty because there is almost
always some tip bulbosity. At least 6 mm of lateral crus is maintained. This
makes it easier to reshape and reposition the tip using suture techniques,
preserving the integrity of the lower lateral cartilage both aesthetically and
functionally.

CHAPTER FOURTEEN  Suturing Techniques to Refine the Nasal Tip
185
Figures 14-4 and 14-5 demonstrate the effect of a
hemitransdomal suture intraoperatively. Note that the
cephalic part of the dome is narrowed but the caudal part
of the dome is not narrowed much, if any. You can also
notice that the caudal edge of the lateral crus is more
everted, or at least not inverted, and that the caudal edge
of the rim is not forced into concavity. A single hemi­
transdomal suture is usually all that is required to reshape
(posterior or deep to the dome) (Figure 14-3). The needle
enters the cartilages parallel to the surface of the dome.
The suture is usually located 2 to 3 mm below dome level.
The lower the suture is placed from the dome, the more
it tends to evert the lateral crus. Also, a more generous
purchase into the cephalic dome will reduce the dome
width. Typically, a short learning curve is involved before
one corrects the dome with one attempt only.
Figure 14-3  Schematic depiction of the hemitransdomal suture. The needle enters the cartilages parallel to the surface of the dome. The suture is usually
placed 2 to 3 mm below the dome level. The lower the suture is placed from the dome, the more it tends to evert the lateral crus. Also, the larger the
purchase of the cephalic dome, the more the dome width is reduced.
Figure 14-4  Intraoperative effect of the hemitransdomal suture. The cephalic aspect of the dome is narrowed. The caudal part of the dome is minimally
narrowed if at all. Also note that the caudal border of the lateral crus is everted somewhat (or at least not inverted). Consequently, the caudal border of the
rim is not forced to become concave.

186
Ronald P. Gruber • Kenton Fong • Chia Chung
lateral crus well below the cephalic margin resulting in a
pinched nasal tip. He suggested correcting this with the
use of an alar rim graft. However, in our experience, ever­
sion of the lateral crus often times cannot be achieved by
just putting the transdomal suture at the cephalic end.
Thus, the final result may on occasion still be a pinched
nasal tip. One solution to this problem is to place the
suture posterior (deep) to the very cephalic end of the
dome and let it fully evert the lateral crus while narrowing
the cephalic end of the dome.
TRANSDOMAL SUTURE
(OCCASIONALLY USED)
When the transdomal suture is needed it is executed as
follows (Figure 14-6): The vestibular skin of the under­
surface of the dome is first infiltrated with local anesthesia
to thicken that layer temporarily to prevent the needle
from penetrating the underlying epithelial surface. Usually
a 5-0 PDS (sometimes 4-0) mattress suture is applied
such that the knot is on the medial side of the dome. To
verify that the needle did not penetrate the vestibular
skin, the needle is momentarily left sitting in the cartilage
after taking a bite of it. The needle holder is then used to
palpate the undersurface of the lateral crus for metal.
INTERDOMAL SUTURE
The second suture that is often, but not always, necessary
is the interdomal suture2–6,9,10 (Figures 14-7 and 14-8).
Also known by other names, it is used when (1) asym­
metry of the domal height is noted, (2) when a reduction
the dome; however, some patients with a very broad or
thick-walled dome may also require a transdomal suture
as well.
The classic transdomal suture may inadvertently
result in a pinched appearance that exhibits slight concav­
ity of the alar rims. This suture may also unintentionally
cause twisting of the lateral crus such that the alar rim is
turned medially or inverted. Guyuron6 and Daniel2,3 sug­
gested placing the transdomal suture at the cephalic end
of the dome to minimize this side effect. Toriuimi10 warned
that tip sutures can displace the caudal margin of the
Figure 14-5  Hemitransdomal suture. View from head of bed.
Figure 14-6  Transdomal (dome defining) suture. A horizontal mattress suture through the dome effectively reduces its width.
A
B

CHAPTER FOURTEEN  Suturing Techniques to Refine the Nasal Tip
187
The interdomal suture is made by approximating the
middle crura with a 5-0 PDS at a level that is about 3 to
4 mm posterior to the dome. It is important to select a
suture location level that is far enough posterior to the
domes so that there is a normal separation between the
domes (approximately 3 mm) yet holds the middle crura
together in symmetric fashion.
LATERAL CRURAL MATTRESS SUTURE
Horizontal mattress suture reduce and eliminate any car­
tilage convexity.11 The lateral crural mattress suture
(Figures 14-9 and 14-10) is useful to correct the broad
or bulbous or ball and boxy tip.9 The vestibular skin is
hyperinfiltrated with local anesthesia just prior to insert­
ing the lateral crural mattress suture. The lateral crus is
grasped with Brown-Adson forceps at the apex of the
convexity and a 5-0 PDS on a P-3 needle is inserted on
one side of the forceps perpendicular to the direction of
the lateral crus. The point of entry for the needle should
stay on the caudal side of the lateral crus so that the knot
ends up on that side (rather than the cephalic side where
it is more likely to be palpable). A second purchase with
the needle is made on the other side of the forceps approx­
imately 6 mm away from the first pass. A slip knot is used
to adjust tension on the suture until the lateral crus reaches
the desired level of flatting.
If the spacing between each pass is too small, the
convexity of the cartilage may not be sufficiently cor­
rected. If the spacing is too wide, the convexity is corrected
but the cartilage will tend to buckle and stability is lost.
If the spacing is ideal, the convexity is largely eliminated
and the lateral crus is approximately 30% stronger than
in interdomal width is desired, or (3) the domes feel weak
or tend to splay apart easily when pressed upon with a
finger. Symmetry and interdomal width are best appreci­
ated from the head of the operating table. Asymmetry can
be more noticeable following placement of transdomal
sutures.
Figure 14-7  Schematic of interdomal suture. An interdomal suture pro­
vides symmetry and strength to the tip cartilages. It is applied by approximat­
ing the middle crura with a 5-0 PDS at a level that is about 3 to 4 mm
posterior to the dome.
Figure 14-8  Intraoperative view of interdomal suture. View from the top of the head (A) and oblique view (B).
A
B

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Ronald P. Gruber • Kenton Fong • Chia Chung
it was before the suture was placed. If the convexity is not
completely corrected (as occurs if the lateral crus is convex
from one end to the other), a second mattress suture is
placed adjacent to the first in order to correct convexity
not corrected by the first suture. On occasion, a total of
three such sutures are placed on a very convex and dif­
ficult to control lateral crus. Each suture provides addi­
tional strength to the cartilage.
Figure 14-9  Schematic of lateral crural mattress suture placement. It
consists of one or two horizontal mattress sutures applied to the most
convex portion of the lateral crus following cephalic trim with the purpose
of removing most of the unwanted convexity. The needle pass is perpen­
dicular to the long axis of the lateral crus. A second pass is made 6 to 8 mm
from the first one.
6-8 mm
distance
Figure 14-10  Intraoperative view of lateral crural mattress suture. As
the knot is tied, the convexity tends to disappear. With further tightening of
the suture, a small degree of concavity will result. A lateral crural mattress
suture has the added benefit of applying a lateral vector, which tends to
open the external valve slightly. This is particularly evident if one of the lateral
crural mattress sutures is placed at the posterior end of the lateral crus.
Another advantage of the lateral crural mattress
suture is its concurrent improvement in external valve
function. As the mattress suture knot is tightened, the
posterior aspect of the lateral crus tends to become more
stable and is slightly lateralized. It does so by imposing a
flaring vector force on the posterior aspect of the lateral
crus. Thus, to a limited extent, the external valve is opened
slightly and is stabilized. This is particularly noticeable
for mattress sutures placed on the posterior aspect of the
lateral crus.
COLUMELLA-SEPTAL SUTURE
There are four potential applications for this suture: (1)
to reestablish tip support that may have been lost by a
transfixion/intercartilaginous incision; (2) to provide a
subtle degree of tip projection; (3) to help increase tip
rotation, which can help address a hanging columella; and
(4), in some selected instances, to help deproject the tip.
Before placing the columella-septal suture, it is helpful
to determine the desired domal height in relation to the
dorsal septum. Generally speaking the domes should lie 6
to 8 mm above the level of the dorsum. Thicker-skinned
patients may require up to 10 mm, and thinner-skin
patients less than 4 to 6 mm.
A 1-inch 27-gauge needle is used to impale the caudal
septum between the middle crura. The hub of the needle
is then clipped off, the skin is replaced over the alar car­
tilages (sutured with one stitch if needed), and the nasal
profile is reexamined to evaluate if the desired degree of
tip projection and rotation have been achieved. After sat­
isfactory adjustments in height are made, the final suture
is placed and the needle is then removed.
The suture is placed using a 4-0 PDS thrown between
the leaves of the middle crura (Figures 14-11 to 14-13).
The needle is then brought out into the transfixion space
if there is one. If no transfixion incision has been made,
the needle is passed between the medial crura. The needle
is then passed through the septal cartilage usually at the
level of the anterior septal angle. Then it is passed back
between the middle crura.
Care is taken to prevent securing the suture too tightly,
thereby creating an iatrogenic columellar retraction. After
redraping the skin envelope, the tip is evaluated by obser­
vation and palpation aiming for a tip position projected
just beyond the level of the dorsum. Slight firmness to
palpation is desired to ensure adequate tip support. This
will minimize the likelihood of a postoperative drop, tip
counterrotation, or the development of a supratip deform­
ity. The angle between the medial and middle crus (the
columella/lobule angle) is evaluated. If columellar retrac­
tion exists, the suture is replaced. If a hanging columella
is seen, the knot is secured until the desired angle and
relation are accomplished.
In the case of an overprojected tip, the stabilizing
needle is positioned posteriorly and the lower lateral

CHAPTER FOURTEEN  Suturing Techniques to Refine the Nasal Tip
189
INTERCRURAL SUTURE
At times, intercrural suture technique (Figure 14-14) can
also be helpful during tiplasty.12,13 This technique can
reduce the width and flaring of the middle crura for nasal
tips that exhibit widening at the level of the middle crus.
Intercrural suture technqiue also helps create better sym­
metry. 5-0 PDS is typically used as a simple mattress
suture that pulls the middle crura together but not too
tightly.
CASE EXAMPLE
The patient shown in Figures 14-15 through 14-17 com­
plained of a broad and bulbous tip. Physical findings
confirmed a broad nasal tip, dorsal hump, broad nasal
bones, and slightly long nose. At surgery, the following
maneuvers were performed:
• Inverted-V columellar and marginal incisions
• Cephalic trim of lateral crus
• Hemitransdomal sutures
• Interdomal suture
• Columella-septal suture (to prevent tip drop)
• Lateral crural mattress sutures
The patient also underwent a dorsal hump reduction,
osteotomies, and slight caudal shortening. At 13 months
postoperatively, there is an improvement in tip bulbosity
as shown.
Figure 14-11  Schematic depiction of columella-septal suture.
Septal
cartilage
Figure 14-12  Columella-septal suture secures the tip complex to the caudal septum. A 4-0 PDS is passed between the leaves of the medial crura (A).
The needle is then passed through the desired part of the caudal septum (anterior septal angle to increase projection and through the posterior septal angle
to deproject the tip) (B).
A
B
cartilages are set back by securing them onto the posterior
aspect of the caudal septum in order to decrease tip pro­
jection. This is one of the options available to deproject
the nose.

190
Ronald P. Gruber • Kenton Fong • Chia Chung
• Stair-step columellar and marginal incision
• Cephalic trim of lateral crus
• Transdomal sutures
• Interdomal suture
• Columella-septal suture
• Lateral crural mattress sutures
The patient also underwent a dorsal hump reduction
and osteotomies. At 23 months after surgery, there is a
significant improvement in tip bulbosity.
FOUR-SUTURE ALGORITHM IN
ENDONASAL RHINOPLASTY
During endonasal rhinoplasty, a similar algorithm to
external rhinoplasty can be used. The lower lateral carti­
lages are delivered onto the surgical field, one through
each nostril via rim and intercartilaginous incisions. A
hemitransdomal suture is then applied to one or both
domes as needed (Figure 14-21). If any dome or tip asym­
metry is detected externally and/or if the tip seems weak
to palpation, both domes can be delivered through one
nostril and an interdomal suture is applied.
If the delivered lateral crus exhibits convexity or if
lateral crus convexity is seen externally, a lateral crural
mattress suture is applied as in the open approach. If the
tip can use slightly more projection or if it is weak upon
palpation externally, a columellar-septal suture is applied.
The columellar-septal suture is more technically challeng­
ing to perform through the endonasal approach than
through the external approach. Marginal and transfixion
CASE EXAMPLE
The patient in Figures 14-18 through 14-20 complained
of a bulbous tip and preferred an endonasal approach.
Physical findings confirmed a broad or bulbous tip. The
patient also exhibited slightly broad nasal bones and a
small dorsal hump. At surgery the following maneuvers
were performed:
Figure 14-13  Columella-septal suture. The needle is passed back between the leaves of the medial crura from whence it came (A). The fibers between
the medial crura are strong enough to provide a good support of the tip cartilages (B). Care must be taken not to overtighten the suture or it will cause colu­
mellar retraction. Placing a clamp between the tip cartilages and the caudal septum helps prevent that from happening.
A
B
Figure 14-14  An intercrural suture may need to be placed between the
caudal aspects of the middle or medial crura to reduce the flare, which can
cause a wide columella. It can also help create symmetry.

Figure 14-15  This patient presented
with a broad tip and underwent a primary
open rhinoplasty including the four-
suture algorithm as well as hemi­
transdomal suture. She also underwent
a
dorsal
hump
reduction,
caudal
shortening and osteotomies. A, Front
view preoperatively. B, Front view
postoperatively.
A
B
Figure 14-16  Same patient as in Figure 14-15. A, Lateral view
preoperatively. B, Lateral view postoperatively.
A
B
Figure 14-17  Same patient as in
Figure 14-15. A, Base view preop­
eratively. B, Base view postopera­
tively.
A
B

192
Ronald P. Gruber • Kenton Fong • Chia Chung
Figure 14-18  This patient presented with a
broad tip and underwent a primary endonasal rhi­
noplasty including the four-suture algorithm,
dorsal hump reduction, and osteotomies. A, Front
view preoperatively. B, Front view postopera­
tively.
A
B
Figure 14-19  Same patient as in Figure 14-18. A, Lateral view
preoperatively. B, Lateral view postoperatively.
A
B

Figure
14-20  Same
patient as in Figure 14-18.
A, Base view preoperatively.
B, Base view postoperatively.
A
B