Master Techniques in Rhinoplasty

195
C H A P T E R F I F T E E N 
Rib Grafting Simplified
Kevin Brenner • Jay Calvert
The use of rib grafting in rhinoplasty has revolutionized
the ability to treat complex nasal deformities. Its can be
helpful for both primary nasal deformities (including
posttraumatic, cocaine induced, and others), as well as
secondary nasal deformities (including postoperative
saddle
deformities
and
otherwise
graft-depleted
patients).1–4 Situations in which patients have had their
septal cartilage or the majority of their conchal cartilage
harvested during previous interventions leave few options
for autogenous graft material. In addition, some primary
nasal surgeries (i.e., patients with Binder syndrome) or
other complex nasal reconstructions require the incorpo­
ration of structural grafting material using cartilage
volumes that are not available even in the previously
unoperated concha or septum. Although other autogenous
material, homografts, and alloplastic materials are also
available, they can be associated with potential complica­
tions including absorption, infection, and extrusion.5,6 The
lower likelihood of complications associated with costal
cartilage grafts has popularized its use and made them
the standard for complex nasal reconstruction despite the
associated increased operative time and potential for
donor site morbidity.
Many preeminent surgeons have described their suc­
cessful use of rib grafts in reconstructive rhinoplasty.7
Daniel8 modernized the use of rib grafting.
Costal cartilage harvesting can be conceptualized as
the natural progression and modification of the standard
lateral and anterolateral thoracotomy exposures used
during thoracic and cardiothoracic operations.9 Currently,
harvesting the fifth and sixth ribs through an inframam­
mary incision is the most commonly used technique.10
However, this approach is technically demanding, pro­
vides limited graft alternatives, and leaves a scar in an
awkward location in male patients. The authors prefer a
subcostal approach because of its ease of exposure, limited
scarring, quick operative time (30 to 60 minutes), low
morbidity, and great versatility of available graft material
through the same incision. Furthermore, the subcostal
approach is technically less demanding, making it an
excellent choice for surgeons who are learning to incorpo­
rate costal grafting into their practice.
Costal cartilage harvesting is a safe technique, but the
selected rib (or ribs) to be harvested will vary based on
the specific grafting needs. Furthermore, rib anatomy will
vary between individual patients. This chapter will discuss
the technique of costal cartilage harvesting and will estab­
lish a practical approach toward rib selection based on
individual grafting needs. Several rib graft harvesting
techniques and choices are available, and each surgeon
may develop a preferred algorithm to select one. The
technique suggested here is meant to serve as a basic guide
such that any surgeon can decide which approach best
suits him or her.
EVALUATION OF THE PROBLEM
Describing the surgical decision-making process leading
to the plan behind a complex nasal reconstruction is
beyond the scope of this chapter. However, in the course
of configuring an operative plan several factors must be
incorporated. The plan begins with the defect to be
addressed, which incisions need to be made to provide
access to the surgical site, the operative maneuvers
required to accomplish the desired modification, and, spe­
cifically with regard to rib cartilage harvesting, which
grafts will need to be used. After having a clear idea of
the grafts to be used, the surgeon can then select an
appropriate donor site from which to harvest them, taking
into account the quality and amount of cartilage necessary
and available from each donor site (i.e., septum, conchae,
or ribs). It is important to be clear about the intrinsic
properties of cartilage and/or bone at each harvest site.
The experience with harvesting and cutting cartilage
grafts from different locations helps the surgeon to become
familiar with the varying degrees of cartilage strength and
consistency. The patient’s age is important, as costal
cartilage tends to ossify and become more brittle with
advancing age. Marin et al.10 have advocated preoperative
computed tomography imaging for selected patients in
order to assess for rib cartilage calcification.
As the surgeon selects the cartilage grafts necessary
to perform the operation, the donor site morbidity associ­
ated with each site should be considered, operative reports
from previous operations should be reviewed, and detailed
physical examination of the septum and conchae will
reveal if any residual cartilage remains to be harvested.

196
Kevin Brenner • Jay Calvert
INFRAMAMMARY FOLD INCISION
This incision is useful in that it is cosmetically favorable
for most women. We have found that some men find a
breast scar unacceptable. It allows excellent access to the
fifth, sixth, and sometimes even the seventh costal carti­
lage. Although it would seem that the risk of pneumotho­
rax would be higher with this incision, this has not been
found to be the case based on published studies.10 The
disadvantages to this approach include that it can be more
technically difficult for the novice surgeon and the amount
of cartilage harvested is typically less. Also, in patients
who have previously undergone a breast augmentation
procedure, there is a small yet distinct risk of damaging
the existing implant. Nonetheless, this approach is popular
and allows surgeons to accomplish the goal, and it rarely
requires drain placement.
ABDOMINAL SKIN INCISION
The authors recommend the subcostal approach, as pre­
viously advocated by Sheen and Daniel, for multiple
reasons (Figure 15-2).8,11 The incision is generally no
longer than 3 to 4 cm and is located well onto the abdomen,
making it inconspicuous and unobtrusive. Second, the
approach is safer, with a lower risk for pneumothorax
since there is relatively more connective tissue in between
the rib and the parietal pleura at this level. Third, and
most important, the volume and variability of cartilage
Figure 15-1  Inframammary fold and subcostal access incisions.
5
6
7
8
9
10
IMF incision
Subcostal
incision
Rectus
abdominis
muscle
Figure 15-2  Subcostal incision closed with ninth rib cartilage and a
portion of eighth rib cartilage.
4 cm
Secondary septal surgery is technically challenging and
rarely produces an adequate amount of cartilage. Even if
available in sufficient quantity, conchal cartilage often
lacks the structural strength required to counteract the
robust contractile forces resulting from cicatricial wound
healing in a reoperated nose.
Once the decision to use costal cartilage has been
made, the surgeon must next decide which rib or ribs will
best serve the purposes for the planned operation (Figure
15-1). Factors integral to this decision include both the
problem the surgeon is trying to solve with the cartilage
graft and the patient’s desires in terms of donor site mor­
bidity. The most important questions the surgeon must
ask are: What skin incision is required to obtain the neces­
sary exposure to harvest the costal cartilage, and which
rib or ribs will work best to carve the grafts? Of course
this choice is both patient and problem dependent, but
some guidelines to help make that decision will be
outlined.

CHAPTER FIFTEEN  Rib Grafting Simplified
197
medial retraction (instead of division) of the rectus muscle
and results in less postoperative pain and muscular den­
nervation. For a ninth rib graft, the mobile, medial carti­
laginous tip is identified and dissected in a retrograde and
extraperichondrial fashion. Since it is a “floating rib,” the
extraperichondrial dissection is extremely quick with a
total harvest time of less than 20 minutes in most cases.
For the eighth rib, subperichondrial hydrodissection is
performed using lidocaine 2-3 cc of 1% with epinephrine
1 : 100,000. Serial “H” incisions are carried out through
the ventral perichondrium to allow a subperichondrial
dissection. Frequently, these incisions must be carried
both laterally and medially beyond the required amount
of needed graft to facilitate dissection and prevent acci­
dental tearing of the perichondrium. The costal arch is
then freed with a periosteal elevator from the caudal
aspect of the seventh rib (at the syncytium) and then dis­
sected in a retrograde fashion to the bone–cartilage junc­
tion under direct vision. The bone–cartilage junction is
easily identified both by a palpable ridge and by the very
distinct color change from the white color of the cartilage
to the reddish-gray color of the associated bone. This dis­
section is facilitated with a Doyen retractor (Figure 15-5),
available at this location are much greater than with the
inframammary approach. Multiple ribs can be taken
through the same incision, and in cases where osteochon­
dral grafts are required, the incision simply needs to be
shifted or extended to a more lateral position.
COSTOCHONDRAL GRAFT HARVEST
With the patient in the supine position, a 3- to 4-cm inci­
sion is designed over the junction between the floating
ninth rib tip and the eighth rib above it (see Figures 15-1
and 15-2). The right rib cage is usually selected, particu­
larly in older patients where postoperative chest pain
could potentially mask cardiac-related pain. The incision
is injected with 10 cc of lidocaine 1% with epinephrine
1 : 100,000 prior to preparation and draping, observing
standard sterile technique. The incision is made and dis­
section is carried down through the external oblique
muscle to identify the interspace between the eighth and
ninth ribs (Figure 15-3). Commonly, the incision is carried
deep at a point that is lateral to the lateral edge of the
rectus abdominis muscle (Figure 15-4). Doing so allows
Figure 15-3  Right eighth rib interspace.
External
intercostal
muscle
9th
rib

198
Kevin Brenner • Jay Calvert
lateral decubitus position on a bean-bag. The incision
may need to be located slightly more laterally than for the
graft using just cartilage. Dissection is carried through the
subcutaneous tissue and external oblique muscle to iden­
tify the interspace between the ninth and tenth ribs. With
adequate retraction, the osteocartilaginous junction of the
ninth rib is identified. Hydrodissection using local anes­
thetic helps to facilitate subperiosteal retrograde dissec­
tion. The lateral portion (minimum 4 cm) of the osseous
rib is first dissected with a Doyen elevator to allow for
transsection of the rib. Then an antegrade dissection is
performed toward the medial cartilaginous portion along
the same plane. Although quantity requirements will
differ slightly between patients, a 4-cm cartilage segment
for the columella and a minimum 5-cm osteocartilaginous
segment for the dorsum frequently suffice for structural
support. The ninth rib is usually sufficient to provide both
a dorsal osteocartilaginous graft and a cartilaginous colu­
mellar strut. Should the rib stock be inadequate, harvest­
ing the tenth rib can be accomplished through the same
incision. The cartilaginous portion of the tenth rib is often
but caution must be heeded as tear of the intimately
associated underlying pleura can occur if too much force
is used. After the rib is transected under direct vision and
removed (Figure 15-6), pleural integrity check is per­
formed by filling the cavity with saline and having the
anesthesia provider simulate a Valsalva maneuver. The
wound is closed in different layers. Closure of the ventral
perichondrium helps to splint the interspace and reduces
postoperative pain. Closure of the external oblique fascia
must be performed meticulously to help prevent the
development of a postoperative hernia. Intramuscular and
subcutaneous infiltration of 10 cc of bupivicaine 0.25%
with Epinephrine during surgical closure greatly reduces
immediate postoperative discomfort.
OSTEOCHONDRAL RIB GRAFT HARVEST
If a dorsal replacement graft is needed to support a
severely shrunken skin envelope, a cantilevered bone–
cartilage graft can be used. The patient is placed into the
Figure 15-4  Dissection at lateral edge of the rectus abdominis muscle.
Medial
retraction
Rectus
abdominis
muscle

CHAPTER FIFTEEN  Rib Grafting Simplified
199
individual’s body habitus, a closed-suction drain may be
placed prior to closure. Infiltration with 10 cc of Marcaine
0.25% with epinephrine is carried out into the wound for
post-operative pain relief.
COMPLICATIONS
SEROMA AND HEMATOMA
Donor site seroma formation following rib graft harvest is
unusual. In obese patients and in some patients requiring
wide undermining, resulting in a larger than average dead
space, it is prudent to place a closed suction drainage
catheter. This allows efflux of any serous fluid and can be
removed at the time of nasal splint and suture removal as
long as the drainage output has decreased.
PLEURAL TEAR
If a pleural tear is identified intraoperatively, a purse-
string suture closure is performed around a red-rubber
suction catheter. The anesthesia provider produces and
short (less than 5 cm), which allows either a useable
osteocartilaginous dorsal graft or a cartilaginous columel­
lar strut. After checking for pleural integrity, layered
closure starts by approximating the ventral perichon­
drium. Depending on the extent of dissection and the
Figure 15-5  Doyen retractor facilitates rib dissection off of the posterior perichondrium.
Doyen rib
retractor
Junction of
bone and
cartilage
Figure 15-6  Posterior perichondrium with rib removed; ready for
pleural integrity check.

200
Kevin Brenner • Jay Calvert
literature.12 While warping is possible with cantilevered
grafts, the risk is significantly reduced and in fact is
almost totally eliminated when rib cartilage is used in
component reconstruction (with underlying structural
support below and underlying camouflage grafting super­
ficially) of the nose. In this way the major structural
support is buried underneath a superficial concealing
layer, such as diced cartilage wrapped in fascia. The
authors do not use axial K-wires as a means of reducing
or preventing graft warping. Attention to the carving
process following a well-described protocol will minimize
the likelihood of unpredictable warping.13
POSTOPERATIVE CARE
All operations are performed in an outpatient surgery
center without an overnight stay. Pain is easily controlled
using oral pain medications. Patients with low pain toler­
ance are recovered in a nurse-supervised facility to allow
for supplemental injectable medications if necessary.
Suture removal, dorsal cast, and Doyle intranasal splints
are managed conventionally.
CONCLUSION
Costal grafts have dramatically improved the results of
secondary and complex primary nasal surgery. We favor
the subcostal approach in our practice because of its
increased surgical exposure and the variable amount and
composition of donor material. The cartilaginous portion
of the ninth rib can provide a columellar strut, spreader
grafts, and alar rim or tip grafts. If additional material is
required, the eighth and tenth ribs can be harvested
through the same incision. For severely scarred soft tissue
envelopes requiring cantilevered support, the surgical dis­
section can be modified to include the bony component of
ribs 9 or 10. In our experience, the subcostal approach
has some advantages, including ease of harvesting, brevity,
flexibility, and variability of donor tissue.
REFERENCES
1. Shubailat GF. Cantilever rib grafting in salvage rhinoplasty.
Aesthet Plast Surg. 2003;27(4):281–285.
2. Cervelli V, Bottini DJ, Gentile P, et al. Reconstruction of the
nasal dorsum with autologous rib cartilage. Ann Plast Surg.
2006;56(3):256–262.
3. Yilmaz M, Vayvada H, Menderes A, et al. Dorsal nasal
augmentation with rib cartilage graft: long-term results and
patient satisfaction. J Craniofac Surg. 2007;18(6):
1457–1462.
4. Gurley JM, Pilgram T, Perlyn CA, et al. Long-term outcome
of autogenous rib graft nasal reconstruction. Plast Reconstr
Surg. 2001;108(7):1895–1905; discussion 1906–1907.
holds a Valsalva maneuver, while the surgeon simultane­
ously tightens the suture and removes the catheter. A
careful layered soft tissue closure is then performed. If
there is any question about the integrity of the repair,
an additional intraoperative Valsalva maneuver can be
performed.
A postoperative chest radiograph is not routinely per­
formed following rib graft harvest. However, in cases of a
pleural tear repair, it may be prudent to obtain an upright
chest radiograph in the recovery room. Small residual
pneumothoraces can then be treated with oxygen via nasal
cannula overnight. Since these pleural tears are almost
universally parietal (not visceral) in nature, treatment
with thoracostomy tubes is not needed.
POSTOPERATIVE PAIN
Pain following rib graft harvest is expected after the pro­
cedure. One of the keys to reducing postoperative pain lies
in the intraoperative sequence. Layered closure of the
ventral perichondrium and periosteum helps reduce the
intercostal space and splints together the adjacent ribs.
Care should be taken not to encircle the caudally located
intercostal neurovascular bundle, which will lead to post­
operative neuropathic pain. Injection of bupivacaine solu­
tion prior to closure as described above helps reduce
immediate postoperative pain, breaking up the pain cycle
and reducing narcotic requirements for most patients. We
have used indwelling pain pump catheters in the past.
However, patients find these cumbersome and are not
particularly useful for wounds requiring closed-suction
drainage.
GRAFT FRACTURE
Costal graft fractures are uncommon, except for those
exposed to significant trauma. In particular, rib grafts
used for component reconstruction virtually never
fracture.
INFECTION
Use of intraoperative and postoperative third-generation
cephalosporin antibiotics is routine for patients undergo­
ing nasal reconstruction with autologous rib grafting.
Donor site infection is virtually nonexistent as long as
sterile technique is followed meticulously. The incidence
of postoperative graft infection is very low but is still a
concern. The risk of infection increases significantly in
patients with traumatized intranasal lining and in those
with severely scarred nasal skin envelopes.
WARPING
Costal cartilage graft warping is a well-known risk and
complication and has been well documented in the

CHAPTER FIFTEEN  Rib Grafting Simplified
201
5. Caccamese Jr R, Ruiz B, Costello J. Costochondral rib
grafting. Atlas Oral Maxillofac Surg Clin.
2005;13(2):139–149.
6. Eppley BL. Donor site morbidity of rib graft harvesting in
primary alveolar cleft bone grafting. J Craniofac Surg.
2005;16(2):335–338.
7. Cakmak O, Ergin T. The versatile autogenous costal cartilage
graft in septorhinoplasty. Arch Fac Plast Surg. 2002;4(3):
172–176.
8. Daniel RK. Rhinoplasty and rib grafts: evolving a flexible
operative technique. Plast Reconstr Surg. 1994;94(5):597–
609; discussion 610–611.
9. Smith C, Kron I. Hemothorax. In: Cameron J, ed. Current
surgical therapy. 7th ed. St Louis: Mosby, 2001:762–765.
10. Marin VP, Landecker A, Gunter JP. Harvesting rib cartilage
grafts for secondary rhinoplasty. Plast Reconstr Surg.
2008;121(4):1442–1448.
11. Sheen JH, Sheen AP. Aesthetic rhinoplasty. 2nd ed. St Louis:
Quality Medical Publishing, 1998.
12. Gibson T, Davis WB. The distortion of autogenous cartilage
grafts: its cause and prevention. Br J Plast Surg. 1958;11:
177.
13. Kim DW, Shah AR, Toriumi DM. Concentric and eccentric
carved costal cartilage: A comparison of warping. Arch Fac
Plast Surg. 2006;8(1):42–46.

203
C H A P T E R S I X T E E N 
Calvarial Bone Grafting in Rhinoplasty
Robin W. Lindsay • Tessa A. Hadlock • Mack L. Cheney
Calvarial bone grafting is an established method of cranio­
facial reconstruction in facial plastic surgery. Konig1 and
Muller2 were the first to describe autogenous calvarial
bone grafting in 1890, advocating a combined osteocuta­
neous flap. Smith, Abramson, and Tessier3–5 popularized
the technique for modern craniofacial reconstruction.
More recently, split calvarial bone grafts have been shown
to be safe and effective grafts for nasal reconstruction6,7
and a viable alternative to autogenous cartilage and allo­
plastic implants for dorsal nasal augmentation.8,9
Two groups of patients undergoing rhinoplasty and/
or nasal reconstruction require materials to augment the
nasal dorsum. The first group has saddle nose deformity,
arising from traumatic, infectious, idiopathic, or iatro­
genic conditions. The second group of patients has a con­
genitally platyrrhine nose, characterized by a low, wide
dorsum, poor tip projection and definition, and an acute
nasolabial angle.10 In modern reconstruction of the nasal
dorsum, an ideal implant provides structural support,
long-lasting augmentation, limited mobility, and reason­
able resistance to infection.
Four categories of facial implants are in use today:
alloplastic
materials,
homografts,
xenografts,
and
autografts. Alloplasts are implants made of chemically
composed polymers. Homografts refer to grafts obtained
from a donor of the same species and include irradiated
and nonirradiated cartilage, bone, and soft tissue.
Xenografts refer to materials obtained from different
species and are not used in contemporary augmentation
rhinoplasty. Autografts are materials harvested from the
patient’s own body and include bone, cartilage, and soft
tissue grafts.8,10
ALLOPLASTS
Presently, the literature supports the use of both alloplas­
tic and autogenous material for nasal reconstruction.
Employing alloplastic materials shortens the length of an
operation by eliminating the harvesting step, eliminates
donor site morbidity, and can be easily tailored to conform
to the defect. These materials are available in unlimited
quantities and undergo minimal resorption.10 However,
there are several important disadvantages to their use that
have prompted many surgeons to avoid their use when
possible. These disadvantages include foreign body reac­
tion at the implant–tissue interface, a limited ability to
withstand infection, and a tendency to migrate. These
implants must be placed under highly sterile conditions,
preferably in a bed of healthy, robust native tissue; tension
over the implant and compromise to the vascular supply
of the recipient bed must be avoided.8
HOMOGRAFTS
Homografts represent another option for nasal reconstruc­
tion, and irradiated costal cartilage has been advocated
as the preferred graft for dorsal nasal reconstruction by
some surgeons, especially for those with extruded nasal
alloplastic implants.11,12 Irradiated costal cartilage is har­
vested from cadavers that meet the same criteria required
for organ donation (Venereal Disease Research Labora­
tory, hepatitis B, human immunodeficiency virus, tuber­
culosis, and slow virus testing).8 After harvest, the graft
is irradiated with 30,000 to 40,000 Gy of ionizing radia­
tion to eradicate potential pathogens.10 Benefits of ho­
mografts include their availability, low infection rates,
minimal host immunogenic response, and decreased op­
erative times.8,10,11 The use of homografts is limited by
their tendency to resorb, sometimes unpredictably; re­
sorption rates as high as 80% have been reported at 2
years.8,13 Symmetric contouring of the graft, placement in
areas of low mobility (such as the nasal dorsum), and
K-wire insertion are techniques that have been developed
to decrease the rate of absorption.8,14 Homologous rib is
best reserved for the elderly, to decrease operative times
and donor site morbidity.8
AUTOLOGOUS IMPLANTS
Given the shortcomings of allopasts and homografts,
many nasal surgeons believe that the preferred type of
implant for correction of saddle nose deformities or severe
structural deficiencies is autogenous cartilage or bone.7,8
Autologous tissue is favored for its biocompatibility, low
rate of infection and extrusion, and limited inflammatory

204
Robin W. Lindsay • Tessa A. Hadlock • Mack L. Cheney
demonstrates a thicker cortical plate, a smaller endocor­
tical cancellous area, and stronger intracortical struts.18
Clinical advantages to calvarial bone grafting include
decreased donor site pain, a hidden donor site, proximity
of the donor site to the surgical field, and excellent graft
shape.6,7,19 An additional benefit of calvarial bone is its
ability to establish a bony union, decreasing the risk of
displacement. Calvarial bone can also be used safely in
patients with infection, destructive infectious processes,
and noninfectious inflammatory diseases.
ANATOMIC CONSIDERATIONS IN
CALVARIAL BONE GRAFTING
The calvarium is composed of single frontal and occipi­
tal bones, along with paired parietal and temporal bones
(Figure 16-1). The sagittal, coronal, lambdoid, and
squamosal sutures separate these bones. There are three
distinct layers in the adult human skull: the outer corti­
cal layer, the middle spongy cancellous layer (also
termed the diploic layer), and the inner cortical layer.
The goal of the split calvarial bone technique is to
harvest only the outer cortical layer (Figure 16-2). The
dura adheres very closely to the undersurface of the
inner calvarial layer, making it susceptible to tearing if
the inner calvarium is inadver­tently violated. The under­
surface of the inner cortex is imprinted with numerous
concavities formed by the underlying intracranial vascu­
lature. The venous sagittal sinus is located in the midline
and is approximately 1 to 1.5 cm wide. The temporal
line represents the superior attachment of the temporal
muscle, and both the outer cortical and the middle
diploic layers are unacceptably thin lateral to this land­
mark. Moreover, the area above the temporal line pos­
sesses a natural curvature that mimics the nasal dorsum.
Midline calvarial bone grafts place the sagittal sinus at
risk, so bone within 2 cm of the midline should be left
undisturbed.19 The bone also becomes thin in the area of
the sutures (Figure 16-3).19 The parietal bone has been
consistently noted to have the thickest bone.23 Bone is
thicker in males than in females by 1 or 2 mm.3,6 With
these anatomic areas in mind, the safest area to harvest
a split calvarial bone graft is on the parietal bone
between the temporal line, the sagittal sinus, and suture
lines.
METHODS AND SURGICAL TECHNIQUES
The patient’s hair is not shaved but instead is parted and
coated with bacitracin ointment. The donor site and the
recipient are prepped with povidine-iodine or alcohol and
infiltrated with lidocaine (Xylocaine) with epinephrine
(1 : 100,000) to promote hemostasis. Consideration should
be given to using the nondominant side of the scalp, to
response. It also lacks the risk of disease transmission that
is present in homologous implants. Despite the limited
availability and donor site morbidity, autologous implants
remain the standard to which all other implants are
compared.
CARTILAGE
Cartilages is an extremely popular graft material for most
rhinoplasty surgeons and can be harvested from the
septum, concha, or rib. Septal and conchal cartilages do
not provide sufficient material for repair of most saddle
nose deformities or severe tip structural deficiencies. Rib
is the only source of cartilage that provides the structural
support required for major nasal reconstruction. A signifi­
cant advantage of rib is that it is readily available, although
moderate absorption rates and a tendency to warp have
been reported.11,13–16 Removal of the perichondrium,
accompanied by symmetric carving using the central core
of cartilage for dorsal augmentation, is one technique
described to reduce warping.8 Internal fixation of the graft
with a K-wire can also potentially reduce warping and
decrease delayed graft malposition.14 Donor site morbidi­
ties include the possibility of pneumothorax, a likelihood
of postoperative pain, temporary atelectasis, potential
chest wall deformity, and a visible scar. In older patients,
ossification of the cartilage can make carving and shaping
of costal cartilage difficult.
BONE
Autologous bone is rigid, provides excellent support, and
can be contoured with an otologic drill to create the
desired contour. For nasal reconstruction, osseous rib
and iliac crest are common sources of endochondral
bone, while calvarium is the most common source of
membranous bone. Osseous rib has an unpredictable
pattern and amount of absorption, with an inherent
tendency to distort its shape over time. The iliac crest
yields plentiful bone, which can be fashioned to fit a
variety of defects, similar to calvarial grafts. However,
absorption has been problematic, and donor site issues,
includ­ing pain and walking impairment, have been
substantial.17,18
CALVARIAL BONE
Calvarial bone offers advantages for nasal reconstruction
based on its membranous origin. Experimental evidence
suggests that graft volume is more consistently main­
tained in bone of membranous origin than from
endochondral bone grafts.7,19–24 When compared mor­
phologically to endochondral bone, membranous bone

CHAPTER SIXTEEN  Calvarial Bone Grafting in Rhinoplasty
205
Figure 16-1  Typical donor site for harvesting the calvarial bone graft. Site should be superior to the superior temporal line and should not involve the
central calvarium to avoid exposure of the sagittal sinus.
Frontal
bone
Parietal bone
Area of
graft harvest
Superior
temporal
line
Temporalis
muscle
Figure 16-2  Technique for harvesting the outer table calvarial bone
graft. The outer table troughs are created to the level of the diploic layers.
Using Tessier osteotomies, the graft is elevated from the inner table of the
calvarium.
Elevation
with
osteotome
Drill used to
outline graft
Outer and
inner plates
of skull
Dura
mater
Diploë
Figure 16-3  The bone graft is fashioned into a fusiform shape and
introduced into the nasal pocket after rasping the nasal bones.
Graft shaped
appropriately

206
Robin W. Lindsay • Tessa A. Hadlock • Mack L. Cheney
protect the dominant motor cortex in the event of a neu­
rologic complication. A sagittal temporoparietal incision
is made over the superior temporal line. An incision posi­
tioned medial to the superior temporal line risks exposure
if male pattern baldness develops, and an incision placed
laterally risks hematoma from dissection around the tem­
poralis muscle and cerebrospinal fluid leak from calvarial
dissection in the thinner bone of this region. After the
incision is made to the level of the calvarium, the peri­
cranium is elevated medially and laterally. Using an oto­
logic cutting drill, a 1.5 × 4.5-cm graft is outlined, with
the longest dimension in the sagittal plane. A trough is
created around the graft with the cutting burr. The diploic
level is identified when spongy bone and bleeding are
encountered. The margins of the trough are beveled to
facilitate the positioning of the osteotomes. The oste­
otomes are positioned in a plane tangential to the skull to
prevent dural injury (Figure 16-4). A series of sequen­
tially larger curved osteotomes are used circumferentially
to separate the outer table calvarium from the inner table
through the diploic layer. If dura is exposed during eleva­
tion, the margins should be burnished with a diamond
drill. Typically, no further measures are necessary. The
donor site defect can be obliterated by filling with methyl
methacrylate, although this may occasionally lead to a
pain syndrome, and also harbors all of the usual risks of
a foreign body. The defect when left untreated is fre­
quently imperceptible, given its location under hair-
bearing scalp, and most patients are not bothered by the
slight palpable depression in that zone. The wound is
closed in a single layer over a suction drain, and a head
wrap is placed. The calvarial bone graft is then brought
to a separate sterile field and irrigated copiously with a
bacitracin-containing solution. At this point, the bone
graft normally measures approximately 1.0 × 3.5 cm. An
otologic drill is used to carve a fusiform shape to match
the nasal defect. The graft is fashioned slightly wider
caudally if correction of the internal nasal valve is required.
The undersurface of the graft is hollowed along its central
axis to prevent displacement.
Prior to or simultaneously with the harvest of the
calvarial bone, the nasal dorsum is exposed via a closed
or open nasal approach. Most frequently, a transcolumel­
lar incision is made, and the nasal flap is raised off the
cartilaginous and bony framework of the nose. The peri­
osteum is elevated from the nasal bones, facilitating
assessment of the defect and helping to determine the
volume of bone to be harvested. The nasal bones are
freshened with a rotating burr or a rasp to provide good
contact with the diploic layer of the calvarial graft. With
the open nasal approach, this step is performed under
direct vision. The sculpted calvarial bone is placed under
the nasal soft tissue envelope, and the columellar incision
is closed with 6-0 nylon sutures. The vestibular incisions
are closed with 5-0 chromic suture to ensure that the graft
is isolated from the nasal cavity.1,2,19,25
IMPORTANT TECHNIQUE ISSUES
There are a few important technical points that tend
to improve graft survival. Theoretically, graft survival
improves by limiting the interval between bone graft
harvest and implantation to less than 45 minutes and
by avoiding bone temperatures above 42°C.26 To avoid
thermal injury to the bone graft, copious irrigation should
be used while harvesting and contouring the bone graft.7
Additionally, the position of the bone graft as it
bridges the upper two thirds of the nasal dorsum is of
utmost importance. The bone graft should not project
beyond the caudal margin of the upper lateral cartilages
and the anterior septal angle. Using this principle, the
nasal lower third will maintain its natural flexibility. If the
graft does extend beyond this point, the nasal tip will
become frozen and unnatural in appearance and feel.
Dead space between the nasal bones and the bone
graft must be avoided. The diploic layer of the bone graft
must interface directly and securely with the nasal bones.
Proper preparation of the nasal bones with the cutting
burr and careful sculpting of the graft so that irregular
areas of contact are eliminated both ensure optimal inter­
facing. This technique promotes early fusion between the
diploic layer and the bony nasal pyramid and eliminates
the need for additional stabilizing measures such as plates,
screws, or wires. Dead space between the cartilaginous
framework of the middle one third of the nasal pyramid
and the bone graft is acceptable and may be beneficial in
selected cases.
A tight soft tissue pocket reduces the risk of graft
migration and has a positive effect on the internal nasal
valve. A tight subperiosteal pocket enables the surgeon
to place the bone graft along the nasal dorsum with
external casting alone.7,27–30 Many surgeons do fixate the
graft with wires, screws, or microscrews8,25,31,32 based on
experimental data supporting that fixation is necessary
to maintain graft position and reduce the risk of resorp­
tion.33 However, even groups using fixation have shown
that mobile grafts have not decreased in size and that
grafts were solidly fused to the underlying bone between
14 and 21 days.25 Radiographic postoperative studies
have demonstrated capacity for bone to bone healing
with calvarial bone grafts.7,27 In addition, experimental
studies have shown that when bone grafts are placed in
an area of limited motion, rigid fixation offers no advan­
tage over placement of the graft in a compact soft-tissue
envelope.29,30
EFFECTS OF CALVARIAL BONE GRAFTING
ON FUNCTION
The mechanism by which a calvarial bone graft influ­
ences the internal nasal valve is by displacing the
upper lateral cartilages laterally. Two factors influence the

CHAPTER SIXTEEN  Calvarial Bone Grafting in Rhinoplasty
207
COMPLICATIONS OF CALVARIAL
BONE GRAFTING
DONOR SITE
Donor site complications include hematoma/seroma (1%
to 8.3%), infection (1% to 2%), alopecia (2.8%), loss of
sensation (2.8%), and dural tears (<1%).6,7,19,27 However,
amount of lateralization that can be achieved. First,
increasing the width of the bone graft, especially caudally,
increases lateral displacement of the upper lateral carti­
lages from the nasal septum. Second, maintaining the
attachments of the upper lateral cartilages to the overly­
ing soft tissue when dissecting the soft-tissue pocket
widens the internal nasal valve when the graft is placed
(Figure 16-5).
Figure 16-4  A, The hair is parted at the superior temporal line and the incision is carried to the outer calvarium after copius introduction of local
anesthesia with epinephrine. B, Using an otologic drill with a cutting bit, an outline of the outer calvarium is performed. The average dimension is 3 cen­
timeters by 1.5 centimeters. C, Troughs are created to the mid-diploic layer of the calvarium with attention to flattening the shoulder of the troughs so the
osteotomies can easily be introduced. D, Using Tessier osteotomes, the bone graft is removed from the inner calvarium. Hemostatis is obtained with bone
wax. E, Appearance of the bone graft after harvest and prior to creating a fusiform shape.
A
B
C
D
E

208
Robin W. Lindsay • Tessa A. Hadlock • Mack L. Cheney
Figure 16-6  A–C: Preoperative photographs of a patient who suffered severe nasal collapse secondary to extensive nasal infection as a child.
A
B
C
Figure 16-5  A, B: Additional structural support may be incorporated
into the bone graft by using a tongue in groove technique to introduce a
columellar strut into the dorsal bone graft.
A
B
in a series by Kline and Wolfe of 586 cranial bone har­
vests, no neurologic complications were reported.34 Supe­
rior sagittal sinus laceration has been reported; however,
it occurs extremely infrequently and can be avoided by
being familiar with the surgical technique.35
MANAGEMENT OF DONOR SITE
COMPLICATIONS
In case of dural exposure, the surgeon has several options.
In most cases, the area of exposed dura is small and no
attempt at osseous closure is needed. Bone dust may be
placed in this defect or, if the defect is large (>2 cm),
another split calvarial graft may be needed to repair the
defect.36
In the case of a dural tear, it is important to visualize
the laceration completely by removing additional bone.
The dura is then carefully elevated and the brain exam­
ined for injury. If no injury exists, the dura is repaired
with a 4-0 silk suture. If injury is suspected, there should
be a low threshold for neurosurgical consultation.19
RECIPIENT SITE
Recipient site complications have been reported in the
literature and include resorption, overcorrection, mobility,
infection, graft exposure, graft fracture, and displacement
of the graft.6,7,37 In the series of 35 nasal reconstruction
patients by Cheney and Gliklich, there was one case that
was thought to be overcorrected, but no cases of graft dis­
placement, mobility, extrusion, or significant resorption,
and in the series of 87 calvarial bone graft patients by
Emerick et al., one patient had a postoperative infection
and three grafts became mobile (Figures 16-6 and 16-7).7,27

CHAPTER SIXTEEN  Calvarial Bone Grafting in Rhinoplasty
209
9. Romo 3rd T, Jablonski RD. Nasal reconstruction using split
calvarial grafts. Otolaryngol Head Neck Surg. 1992;107:
622–630.
10. Romo 3rd T, Pearson JM. Nasal implants. Fac Plast Surg Clin
North Am. 2008;16:123–132, vi.
11. Clark JM, Cook TA. Immediate reconstruction of extruded
alloplastic nasal implants with irradiated homograft costal
cartilage. Laryngoscope. 2002;112:968–974.
12. Kridel RW, Konior RJ. Irradiated cartilage grafts in the nose.
A preliminary report. Arch Otolaryngol Head Neck Surg.
1993;119:24–30; discussion 30–31.
13. Congdon D, Sherris DA, Specks U, et al. Long-term follow-up
of repair of external nasal deformities in patients with
Wegener’s granulomatosis. Laryngoscope. 2002;112:731–737.
14. Gunter JP, Clark CP, Friedman RM. Internal stabilization of
autogenous rib cartilage grafts in rhinoplasty: a barrier to
cartilage warping. Plast Reconstr Surg. 1997;100:161–169.
15. Adams Jr WP, Rohrich RJ, Gunter JP, et al. The rate of
warping in irradiated and nonirradiated homograft rib
cartilage: a controlled comparison and clinical implications.
Plast Reconstr Surg. 1999;103:265–270.
16. Strauch B, Wallach SG. Reconstruction with irradiated
homograft costal cartilage. Plast Reconstr Surg. 2003;
111:2405–2411; discussion 12–13.
17. Silber JS, Anderson DG, Daffner SD, et al. Donor site
morbidity after anterior iliac crest bone harvest for single-
level anterior cervical discectomy and fusion. Spine.
2003;28:134–139.
18. Hardesty RA, Marsh JL. Craniofacial onlay bone grafting: a
prospective evaluation of graft morphology, orientation, and
embryonic origin. Plast Reconstr Surg. 1990;85:5–14;
discussion 15.
19. Frodel Jr JL, Marentette LJ, Quatela VC, et al. Calvarial bone
graft harvest. Techniques, considerations, and morbidity. Arch
Otolaryngol Head Neck Surg. 1993;119:17–23.
20. Chen NT, Glowacki J, Bucky LP, et al. The roles of
revascularization and resorption on endurance of craniofacial
CONCLUSIONS
Calvarial bone is an excellent source of grafting material
for saddle nose deformities and congenitally platyrrhine
noses. It provides structural support, long-lasting aug­
mentation, limited mobility, and resistance to infection.
These properties allow surgeons to utilize the graft in
patients with destructive infectious processes and nonin­
fectious inflammatory diseases. However, a detailed
knowledge of the local anatomy and surgical technique is
required to perform the operation safely.
REFERENCES
1. Konig F. Der knocheme Erstz grosser Schadelfekte. Zentralbl
Chir. 1890;17:497–501.
2. Muller W. Zur Frage der temporaren Schadeldefekten an
Stelle der Trepanation. Zentralbl Chir. 1890;17:65–66.
3. Tessier P. Autogenous bone grafts taken from the calvarium
for facial and cranial applications. Clin Plast Surg. 1982;9:
531–538.
4. Tessier P. Aesthetic aspects of bone grafting to the face. Clin
Plast Surg. 1981;8:279–301.
5. Sheen JH, Sheen, AP. Aesthetic Rhinoplasty, 2nd ed. St.
Louis: Mosby; 1987; pp. 383–402.
6. Jackson IT, Choi HY, Clay R, et al. Long-term follow-up of
cranial bone graft in dorsal nasal augmentation. Plast
Reconstr Surg. 1998;102:1869–1873.
7. Cheney ML, Gliklich RE. The use of calvarial bone in nasal
reconstruction. Arch Otolaryngol Head Neck Surg. 1995;121:
643–648.
8. Lovice DB, Mingrone MD, Toriumi DM. Grafts amd implants
in rhinoplasty and nasal reconstruction. Otolaryngol Clin
North Am. 1999;32:113–141.
Figure 16-7  A–C: Postoperative result at 1 year after utilizing a calvarial bone graft with an integrated columellar strut for dorsal restoration.
A
B
C

210
Robin W. Lindsay • Tessa A. Hadlock • Mack L. Cheney
30. Lin KY, Bartlett SP, Yaremchuk MJ, et al. The effect of rigid
fixation on the survival of onlay bone grafts: an experimental
study. Plast Reconstr Surg. 1990;86:449–456.
31. Staffel G, Shockley W. Nasal implants. Otolaryngol Clin
North Am. 1995;28:295–308.
32. Sullivan PK, Varma M, Rozzelle AA. Optimizing bone-graft
nasal reconstruction: a study of nasal bone shape and
thickness. Plast Reconstr Surg. 1996;97:327–335; discussion
36–37.
33. Phillips JH, Rahn BA. Fixation effects on membranous and
endochondral onlay bone-graft resorption. Plast Reconstr
Surg. 1988;82:872–877.
34. Kline Jr RM, Wolfe SA. Complications associated with the
harvesting of cranial bone grafts. Plast Reconstr Surg.
1995;95:5–13; discussion 14–20.
35. Cannella DM, Hopkins LN. Superior sagittal sinus laceration
complicating an autogenous calvarial bone graft harvest:
report of a case. J Oral Maxillofac Surg. 1990;48:741–743.
36. Sammartino G, Marenzi G, Colella G, et al. Autogenous
calvarial bone graft harvest: intraoperational complications.
J Craniofac Surg. 2005;16:312–319.
37. Sheen JH. The ideal dorsal graft: a continuing quest. Plast
Reconstr Surg. 1998;102:2490–2493.
onlay bone grafts in the rabbit. Plast Reconstr Surg.
1994;93:714–722; discussion 723–724.
21. Zins JE, Whitaker LA. Membranous versus endochondral
bone: implications for craniofacial reconstruction. Plast
Reconstr Surg. 1983;72:778–785.
22. Smith JD, Abramson M. Membranous vs endochondrial bone
autografts. Arch Otolaryngol. 1974;99:203–205.
23. Pensler J, McCarthy JG. The calvarial donor site: an anatomic
study in cadavers. Plast Reconstr Surg. 1985;75:648–651.
24. Hunter D, Baker S, Sobol SM. Split calvarial grafts in
maxillofacial reconstruction. Otolaryngol Head Neck Surg.
1990;102:345–350.
25. Jackson IT, Smith J, Mixter RC. Nasal bone grafting using
split skull grafts. Ann Plast Surg. 1983;11:533–540.
26. Young VL, Schuster RH, Harris LW. Intracerebral hematoma
complicating split calvarial bone-graft harvesting. Plast
Reconstr Surg. 1990;86:763–765.
27. Emerick KS, Hadlock, TA, Cheney, ML. Nasofacial
reconstruction with calvarial bone grafts in compromised
defects. Laryngoscope. 2008;118(9):1534-1538.
28. Albreksson T. Scand J Plast Reconstr Sur. 1980;14:1–12.
29. Fry H. Cartilage and cartilage grafts: the basic properties of
the tissue and the components responsible for them. Plast
Reconstr Surg. 1967;40:526–539.

211
C H A P T E R S E V E N T E E N 
Mandibular Implants
William A. Kennedy III • Babak Azizzadeh • William J. Binder
Over the past two decades, great improvements have been
made in the design of facial implants. Facial implants are
able to enhance facial contour and provide permanent
volumetric replacement. Facial implants can be used in
many anatomic regions of the face, including the cheek,
midface, nose, and mandible. Here we discuss the applica­
tion of implants for the correction of profile imbalance as
well as the rejuvenation of the lower third of the face.
Mandibular augmentation is perhaps the simplest and
most powerful aesthetic procedure available to the surgeon.
Mentoplasty can create a stronger mandibular profile
and improve the appearance of the nose by making it
appear smaller and less imposing. In addition, augmenta­
tion of the prejowl sulcus and the mandibular angle can
help enhance the effects of rhytidectomy by creating
a sharper cervicofacial angle. Successful surgical results
will be determined by the proper technique. The goals
of mandibular augmentation are to reconstruct facial
contour deformities or deficiencies with a high degree of
predictability.
GENERAL CONSIDERATIONS
INDICATIONS FOR MANDIBULAR
AUGMENTATION
The primary indications for mandibular augmentation
include:
1. Stand-alone procedure for mandibular
augmentation
2. Adjunctive procedure to rhinoplasty with an
emphasis on profileplasty
3. Adjunctive procedure to rhytidectomy, which is
often essential for patients with microgenia and/or
prominent prejowl erosion
The key to mandibular augmentation lies in the res­
toration of anterior projection and/or expansion of lateral
contour. In the aging process, the anterior mandible may
develop flattening of the soft tissue button of the chin and
form a deepening of the prejowl sulcus.
Augmentation of the bony mandible occurs over one
of three zonal areas (Figure 17-1). The first zone is the
central chin area, which extends from the mentum to
mental foramen (Zone 1). The midlateral zone is defined
by a line extending from the mental formen posteriorly to
the oblique line of the horizontal body of the mandible
(Zone 2). The third and last zone of the premandibular
space ecompasses the posterior half of the horizontal body,
including the angle of the mandible and the first 2 to 4 cm
of the ascending ramus (Zone 3).
Augmenting a recessed central chin area is a key
componenet of profileoplasty which can additionally
improve the aesthetic outcome of rhinoplasty. The projec­
tion of the chin directly affects the illusory projection of
the nose in an inverse relationship. The traditional chin
implants, placed only within the central area (Zone 1)
without lateral extension into the midlateral zones (Zone
2) often created suboptimal results (Figures 17-2 to 17-4).
These early implants, unidimensionally designed and with
a single vector, were often bulky and nonanatomic. This
often resulted in a round chin protuberance, which can
appear abnormal and unattractive. Similarly, a smaller
implant, placed centrally had a greater tendency to shift
or rotate than a larger more extended implant.
Most of these early problems were corrected with the
design of the extended mandibular implants that occupied
Zones 1 and 2. Placement of an implant that extends into
at least two zones (central chin and midlateral) also results
in a natural widening of the anterior jawline as well as an
increased vertical dimension of the lower third of the face
(Figure 17-5).
Augmentation of the posterior-lateral zone widens the
jaw to produce a stronger posterior jawline contour. This
can be achieved using a mandibular angle implant to
augment the posterior lateral zone of the mandible (the
posterior half of the horizontal body including the angle
of the mandible and the first 2 cm to 4 cm of the ascend­
ing ramus).
Mentoplasty can also have a powerful impact in facial
rejuvenation in addressing the structural elements of the
jaw and neck. The prejowl and prejowl–chin implants can
be used as stand-alone procedure or serve a complemen­
tary role to liposuction and rhytidectomy (Figures 17-6

212
William A. Kennedy III • Babak Azizzadeh • William J. Binder
sulcus, and/or marionette lines (skin crease that extends
from the oral commissure to the mandible). The mario­
nette lines emerge due to the attachment of the depressor
labii inferiorus muscle and depressor angulii oris to the
inferior mandible.1 These attachments create a point
resistance by which drooping skin is caught producing a
to 17-8). Causative factors leading to the aging and ptotic
face include loss of volume or atrophy of soft tissue and
skin elasticity overlying Zones 1 and 2 of the mandible.
Over the lower third of the face, this is seen as a loss of a
straight jaw line and the development of jowling, prejowl
Figure 17-1  The mandible can be anatomically divided into three
zones. The first zone extends from the mentum to mental foramen (CM-
Zone 1). The midlateral zone is defined by a line extending from the mental
formen posteriorly to the oblique line of the horizontal body of the mandi­
ble (ML-Zone 2). The third and last zone of the premandibular space ecom­
passes the posterior half of the horizontal body, including the angle of the
mandible and the first 2 to 4 cm of the ascending ramus (PL-Zone 3). (From
Binder W, Schoenrock L, eds. Facial contouring and alloplastic implants.
Philadelphia: WB Saunders, 1994, Facial Plastic Surgery Clinics of North
America.)
Figure 17-2  The traditional chin implants, as depicted in this photo­
graph, were placed only wthin the central area (Zone 1) without lateral
extension into the midlateral zones. These early implants were
unidimensionally-designed utilizing a single vector.
Figure 17-3  Traditional central implants placed in Zone 1 often created
suboptimal results. This often gave the appearance of an abnormal and
unattractive round chin protuberance.
Figure 17-4  A smaller implant, placed centrally had a greater tendency
to shift or rotate than a larger more extended implant.

CHAPTER SEVENTEEN  Mandibular Implants
213
Figure 17-5  Placement of an implant that extends
into at least 2 zones (central chin & midlateral) results
in a natural widening of the anterior jawline as well as
increasing the vertical dimenstion to the lower third
of the face. A, C Pre-op; B, D Post-op photo after chin
augmentation. The implant resides “low” on the man­
dible preserving a normal labiomental sulcus.
B
A
C
D
“hammock”-like bulge of skin. By removing these attach­
ments, the skin is allowed to fall more naturally and the
marionette lines are reduced or softened.
Careful evaluation leads to realization that an area of
volume deficiency exists anterior to the jowl called the
prejowl sulcus. The prejowl sulcus is a specific area ante­
rior to the jowl exhibiting a marked dropoff in soft tissue
volume and bony mandibular projection. The sulcus or
depression can occur from several factors such as a defi­
ciency of bone, congenitally narrow mandible, or aggrega­
tion of soft tissue around the mandibular ligament that
contributes to the jowl. The skin overlying the prejowl
sulcus is also significantly thinner than the skin lateral or
medial to this location. As the aging process advances, the
anterior mandibular groove deepens, which further accen­
tuates the jowls.
Treatment of mandibular jowling and creation of a
smooth mandibular line primarily require rhytidectomy,
which repositions and tightens the soft tissue along the
lower third of the face. Rhytidectomy alone, however, may
not completely address the prejowl sulcus. Therefore, a
secondary procedure that directly addresses this defect
using a prejowl implant is required. A series of prejowl
and chin implants have been designed for this use. The
implants used in conjunction with facelift surgery increase
its ability to create a smooth and straight jaw line.

214
William A. Kennedy III • Babak Azizzadeh • William J. Binder
with minimal tissue ingrowth.6 Each implant material
causes unique tissue–implant interactions. Ideal tissue–
implant interaction will not cause significant tissue
ingrowth and permanent fixation of the implant. As with
any implantable material, ease of removal and replace­
ment is essential to the quality of any implant, whether it
be a breast implant or cardiac pacemaker. In aesthetic
surgery, it is particularly important if the patient desires
further change.7
The shape of the implant should also have tapered
edges to ensure a smooth transition from implant to bony
foundation. In newer generations of silicone implants,
design efforts are focused on making the undersurface of
the implant more malleable. Greater conformation to the
irregular bony surfaces of the mandible prevents the for­
mation of dead space and thereby reduces the movement
and migration.8
IMPLANT COMPOSITION
BIOMATERIALS
Polymetric Materials
In use since the 1950s, silicone has proved to be a safe
and effective implant material. Silicone is polymerized
dimethylsiloxane and can take the form of a gel, solid, or
liquid depending on the degree cross-linking and poly­
merization. The gel form of silicone has the potential to
leak, but the most recent studies finds no cause-and-effect
relationship between silicone and the development of
lupus, scleroderma, or other autoimmune diseases.9–11
IMPLANT CHARACTERISTICS
The ideal implant material for bony manidibular augmen­
tation should be inert, easily shaped, conformable yet able
to maintain its desired shape over the long term (Figure
17-9). The implant should be easily customized and mod­
ified for the needs of the patient while not compromising
the integrity of the implant. Implant immobilization is
partly related to the degree of encapsulation. All implants
have some level of encapsulation.6 Implants made from
silicone elastomer have a high degree of encapsulation,
while
implants
made
from
polytetrafluoroethylene
(ePTFE; W.L. Gore & Asssociates, Inc., Flagstaff, AZ)
encapsulate to a lesser degree yet provide some fixation
Figure 17-6  The prejowl and prejowl–chin implants along with other
procedures such as liposuction and rhytidectomy address the structural
elements of the lower face and the manifestations of aging.
Figure 17-7  A, Pre-op; B, Post-op after chin augmentation and submental liposuction.

CHAPTER SEVENTEEN  Mandibular Implants
215
larger implants through relatively smaller openings can be
difficult and even impossible. Preformed implants also
lack the ability to conform to the vagaries of underlying
bone.
Polyethylene
In the porous form, also known as MEDPOR (Porex Surgi­
cal, Inc., Newnan, GA), polyethylene can be developed to
take on a variety of forms and consistencies. It elicits
minimal amounts of inflammatory cell reaction. The
material is rigid and thus difficult to mold to fit the under­
lying bony foundation. The porosity of the implant allows
for significant tissue ingrowth and tissue stability, but as
a drawback the biomaterial is therefore difficult to remove.
Solid silicone has a higher degree of inertness than gel
silicone with no evidence of toxicity or allergic reactions.12
Tissue reaction to solid silicone consists of the formation
of a fibrous capsule around the implant but without tissue
ingrowth. Capsular contraction and secondary implant
deformity are rare and occur secondary to an implant that
is placed improperly at a superficial plane. Seroma forma­
tion or inflammatory tissue reaction usually occurs as a
result of implant mobility.
Polymethacrylate (Acrylic) Polymers
These can be supplied as a powdered material or pre­
formed. The powder is mixed at the time of surgery to
form a hard material. Due to its rigidity, placement of
Figure 17-8  A, C, Pre-op; B, D, Post-op after chin augmentation.
A
C
D
B

216
William A. Kennedy III • Babak Azizzadeh • William J. Binder
Expanded Polytetrafluoroethylene (ePTFE)
Originally produced for cardiovascular applications, this
material has the benefit of producing minimal tissue
ingrowth, capsule formation and inflammatory reaction.
Given its limited tissue ingrowth, ePTFE is ideally suited
for subcutaneous tissue augmentation where ease in sec­
ondary modification or removal may be desired.
Polytetrafluoroethylene
Formerly marketed under the brand name of Proplast,
this group of materials is no longer marketed in the United
States secondary to its complications with temporoman­
dibular joint use. Under high mechanical stress, this
implant often broke down and elicited intense inflamma­
tory reaction, thick capsule formation, and extrusion
Figure 17-9  Newer shapes of implants have extended the number
of indications for mentoplasty.

CHAPTER SEVENTEEN  Mandibular Implants
217
Mesh Polymers.
The mesh polymers include Marlex (Chevron Phillips
Chemical Company, The Woodlands, TX), Dacron (Unify,
Inc., Greensboro, NC), and Madrilène (Ethicon, Cincin­
nati, OH). They have similar advantages of being able to
be folded, sutured, and shaped with ease. Unfavorable
characteristics include ingrowth of fibrous tissue. Supra­
mid (Resorba Wundversorgung, Nurnberg, Germany) is a
polyamide mesh derivative of nylon that is unstable in
vivo. It elicits a mild foreign body reaction and over time
causes implant degradation and resorption.13
METALS
Metals consist mainly of stainless steel, vitallium, gold,
and titanium. Gold and titanium are commonly used for
upper eyelids for facial reanimation. Titanium has become
the metal of choice for long-term implantation. It has high
biocompatibility and a low corrosive index and is prima­
rily used in craniofacial reconstruction.
CALCIUM PHOSPHATE
Calcium phosphate or hydroxyapatite is not an osteocon­
ducive material but does provide a substrate into which
bone can be deposited.14 The granule form of hydroxy­
apatite has been shown useful for augmentation of the
alveolar ridge in oral surgery and as an interposition graft
in mandibular osteotomies, although it has been shown to
have little value in facial augmentation. This is due to the
product’s brittleness, difficult contouring, and inability to
mold to bony surface irregularities.
AUTOGRAFTS, HOMOGRAFTS,
AND XENOGRAFTS
Autografts are available as autogenous bone, cartilage,
and fat and are limited by donor site morbidity and
availability. Both autograft and processed homograft car­
tilage are additionally limited by eventual resorption and
fibrosis.15
TISSUE-ENGINEERED BIOCOMPATIBLE
IMPLANTS (TEBIS)
TEBIs offer the advantage of minimal donor site morbidly,
precise three-dimensional design, long-term effects, and
reduced operative time. Although still in the developmen­
tal stage, the technique involves the seeding of cells in a
suspension that provides a three-dimensional structure
that promotes matrix formation. The three-dimensional
structure anchors the cell and permits nutrition, and gas
exchange provides for the ultimate formation of a new
gelatinous tissue in the precise shape desired.16 Several
tissue-engineered implants have previously been used for
joint articular cartilage, tracheal rings, and auricular car­
tilage.17 The field of tissue engineering has advanced in
recent years in parallel with advances in material science,
tissue culture, and transplantation, and its usefulness in
creating contoured facial implants is currently under
evaluation.
SURGICAL PROCEDURE
PREOPERATIVE CONSIDERATIONS
Controlling the size, shape, and position of the implant is
important in determining the overall final outcome.
Examination and evaluation of the patient’s mandible as
well as the overlying soft tissue are paramount to appro­
priately selecting the necessary and anatomically correct
implant.
Evaluation of a person’s lower face centers on the
mandible. The lower border of the mandible defines the
jaw line and should be a smooth and consist straight line
extending from the midline of the chin to the angle of the
mandible.
In general, profileplasty has always emphasized an
endpoint whereby the chin should project to the level of
the vermillion border based on the Gonzalez-Ulloa verti­
cal line (perpendicular from the Frankfort horizontal).
However, it is extremely important to differentiate between
males and females when trying to define goals and end­
points of size (Figures 17-10 and 17-11). Females gener­
ally require less projection anteriorly than male patients.
It is also most important to assess the entire mandible
including the need for lateral augmentation, particularly
within the prejowl area. Augmentation of the chin with
implants such as a small anterior button-type implant can
have the unwanted effect of actually increasing the jowls
and accentuating the prejowl sulcus.
The location of the mental foramen must be deter­
mined preoperatively (Figure 17-12). The area of the
mental nerve marks the point of maximal resorption of
the alveolar process. Edentulous patients often exhibit
excessive thinning in the region. However, resorption of
the jaw, particularly associated with the edentulous
patient, is primarily from the superior alveolar ridge
downward. The area below the mental nerve remains rela­
tively stable in dimension. It should also be noted whether
the patient has had previous dental implants, posts, or
plates that may influence the positioning of the implants,
as well as history of fractures or other mandibular trauma.
CHOICE OF IMPLANTS
Choosing the correct mandibular implant is crucial to
achieving a good outcome. There are many designs of
extended mandibular implants that are available for

218
William A. Kennedy III • Babak Azizzadeh • William J. Binder
Figure 17-10  In general, profileplasty has
always emphasized an endpoint whereby the chin
should project to the level of the vermillion border
based on the Gonzalez-Ulloa vertical line. However,
it is important to differentiate between males and
females when trying to define goals and endpoints
of size. These pre- and post-operative photos dem­
onstrate that the old definitions of profileplasty are
not necessarily desirable in females.
Figure 17-11  A, C; Pre-op; B, D; Post-op after man­
dibular augmentation and rhinoplasty. Females generally
require less projection anteriorly than male patients. It is
also most important to assess the entire mandible includ­
ing the need for lateral augmentation particularly within
the prejowl area.
A
C
D
B
“More subtle in females”
(slightly less than G-U profileplasty line)

CHAPTER SEVENTEEN  Mandibular Implants
219
SURGICAL TECHNIQUE
On the day prior to surgery, patients are typically started
on broad-spectrum antibiotics for a total of 7 days. Intra­
operatively, intravenous antibiotics and dexamethasone
are given. Prior to surgery, the patient is placed in the
upright position and the precise area to be augmented is
outlined with a marking pen. At this time, final decisions
are made to anticipate implant size, shape, and position.
Chin implants can be placed through either an
intraoral or external approach. The intraoral route pro­
vides the obvious advantage of leaving no external scars
(Figure 17-13). The entry wound is a transverse incision
through the mucosa anterior to the incisors at the level of
the gingival-buccal border. The mentalis muscle is divided
vertically in the midline raphe to avoid transaction of the
muscle belly or detachment from the bone. The midline
incision provides for adequate access to the inferior edge
of the mandible and prevents potential weakness from
transsection of the mentalis muscle.
The external approach utilizes a 1- to 1.5-cm incision
in the submental crease, located approximately 2 to 3 cm
below the level of the inferior edge of the mandible (Figure
17-14). The advantages of the external route include
avoidance of intraoral bacteria, direct access to the infe­
rior mandibular bone, limited retraction of the mental
nerve, and ease of fixation of the implant to the perios­
teum at the inferior border of the mandibular. We
prefer the external approach since it avoids disinsertion
of the mentalis muscle. The external approach will keep
the attachment of the superior-most portions of perios­
teum to the area below the labial mental sulcus. This is
extremely important in preventing the implant from being
patients who require both anterior augmentation of the
chin and a softening of the prejowl sulcus. They are avail­
able in multiple sizes and serve to augment both the chin
and jaw line.
Injectable soft tissue fillers, such as hyaluronic acids,
calcium hydroxyapatite, and collagen, offer a temporary
option for improving the jaw line aesthetics in minor cir­
cumstances. Fillers, however, as opposed to implants, lack
the ability to provide significant dimensional contour
change of the bony skeleton or a major degree of perma­
nent volume enhancement.
Figure 17-12  Extended anatomical implants are placed just inferior to
the mental foramen.
Figure 17-13  Chin implants can be placed either
through an intraoral or external approach. The intraoral
route provides the obvious advantage of leaving no external
scars. The entry wound is a transverse incision through the
mucosa anterior to the incisors at the level of the gingival-
buccal border. The mentalis muscle is divided vertically in
the midline raphe to avoid transaction of the muscle belly
or detachment from the bone. The midline incision provides
for adequate access to the inferior edge of the mandible and
prevents potential weakness from transection of the menta­
lis muscle.

220
William A. Kennedy III • Babak Azizzadeh • William J. Binder
positioned in an undesirable superior location, which
would have the potential of reducing the vertical dimen­
sion and natural contour of the labiomental sulcus (Figure
17-9). To ensure the same critical positioning via an
intraoral approach would require the use of a permanent
screw fixation system. In addition, the external approach
provides a more direct route of access for dissection along
the inferior mandible, which reduces the risk of injury to
the mental nerve.
Whatever route of insertion is chosen, there are five
golden rules that will help ensure safe and successful
mandibular enhancement:
1. Stay on bone through the subperiosteal approach.
This ensures a firm and secure attachment to the
bony skeleton for the implant.
2. Elevate the soft tissues gently.
3. Ensure the dissection space is slightly larger than the
implant.
4. Avoid the mental nerves by compressing the tissues
around the mental foramen with the opposite hand.
This helps to direct the elevator away from the
nerve and along the inferior border of the mandible
(Figure 17-15).
5. Maintain a dry operative field to ensure accurate
visualization, precise dissection, and proper implant
placement and to prevent postoperative hematoma
or seroma.
Figure 17-14  The external approach utilizes a 1–1.5 cm incision in the
submental crease, located approximately 2–3 cm below the level of the
inferior edge of the mandible. The advantages of the external route include
avoidance of intraoral bacteria, direct access to the inferior mandibular
bone, limited retraction of the mental nerve and ease of fixation of the
implant to the periosteum at the inferior border of the mandibular.
Figure 17-15  During the periosteal dissection, the mental nerves
should be avoided by compressing the tissues around the mental foramen
with the opposite hand. This helps to direct the elevator away from the
nerve and along the inferior border of the mandible.
THE EXTERNAL APPROACH
The incision is initially made through the subcutaneous
tissue. From this point, either scissors or cautery is used
to carry the incision down to the level of the mandibular
periosteum. With a small two-prong or Parkes retractor,
the periosteum is incised and the elevator is inserted;
subperiosteal dissection is carried over Zone 1, making
sure to leave a cuff of soft tissue at the superior edge of
the pocket (see Figure 17-10). There are some who leave
the periosteum attached anteriorly and continue laterally
in a subperiosteal plane, believing that there is less bone
resorption if the implant resides in a supraperiosteal
plane. However, there is potential for implant mobility if
it is placed in the supraperiosteal plane. Bone resorption
does occur with all implants; however, it has not been
considered to be clinically significant.18
At this point, the pocket is further developed laterally
to access Zone 2. The most important part of accessing
the lateral component of the mandible via the anterior
approach is to appreciate the areas of condensations of
fibrous tissue similar to a ligamentous attachment. These
ligamentous attachments at the level of the periosteum

CHAPTER SEVENTEEN  Mandibular Implants
221
shape to validate the choice of the implant. The average
projection needed for the central portion of the chin in
men is between 6 and 9 mm, and in women, it is between
4 to 7 mm. Occasionally, in patients with severe micro­
genia, implants with 10 to 12 mm of projection are neces­
sary to create a normal profile and broad jaw line.
The authors find that an end result representing a
square shape to the anterior chin is desirable in males.
Men usually desire and can accept a larger and more
square appearance to the mandible. In the majority of
cases in females, particularly when larger implants are
required to achieve the desired level of anterior projection,
it becomes necessary to modify the extended implant to
achieve a rounder anterior shape to the chin (see Figure
17-16). The areas of the implant that represent the posi­
tion over the anterior-lateral areas of the chin are identi­
fied and reduced in projection to ensure a rounder
appearance to the chin (Figure 17-17). Asymmetry is
compensated for in similar fashion by reducing specific
areas over the external surface of the implants.
The pocket is then irrigated with antibiotic solution.
The implant is then removed from antibiotic solution and
inserted into the lateral portion of the pocket on one side
and then folded upon itself whereby the contralateral
portion of the implant is inserted into the other side of the
pocket (Figure 17-18). Care is taken to place the implant
inferior to the mental nerve and positioned so it is not
buckled or folded onto itself. It is important to extend the
pocket beyond the extent of the implant. The pocket
closes down rapidly, so there is no worry of a pocket being
made too large. Displacement or infolding of an implant
is usually secondary to a pocket that is too small with the
surrounding soft tissue impinging on a particular area of
the implant.
The implant is then palpated externally to check for
symmetry and to ensure the implant does not extend
beyond the inferior border, especially the lateral tip. Once
the position is confirmed, the anterior edge of the implant
Figure 17-16  In the majority of cases in females, particularly when
larger implants are required to achieve the desired level of anterior projec­
tion, it becomes necessary to modify the extended implant to achieve a
rounder anterior shape to the chin. This will often prevent a “square” chin
from occurring in females.
Modification
of extended
implant
are identified just lateral to the midline of the mentum
and transected bluntly with its periosteal elevators. This
enables an easy plane of dissection directed posteriorly
along the most inferior border of the mandible. This
avoids inadvertent misdirection of the elevator and poten­
tial injury to the mental nerve.
Using a Joseph or 3- or 4-mm periosteal elevator, a
subperiosteal tunnel is then created along the inferior
mandibular border that extends 6 to 7 cm laterally. The
length of this lateral tunnel is confirmed with a flexible
malleable retractor. It is important during the dissection
that adequate length of the tunnel and dissection inferior
to the mental nerve is achieved. Elevation onto the nerve
or compression of the nerve can lead to injury and result­
ant hypoesthesia, bleeding, or malposition of the implant.
Once the pocket has been created, sizing of the
implant is undertaken with sets of blue “Sizers” (Figure
17-16). Once the shape and size of the intended implant
are assessed, the smaller and larger sizes are purposely
inserted into the pocket and also assessed for size and
Figure 17-17  A, B, The areas of the implant that represents the position over the anterior-lateral areas of the chin are identified and reduced in projec­
tion to ensure a rounder appearance to the chin.
A
B

222
William A. Kennedy III • Babak Azizzadeh • William J. Binder
antibiotic irrigation of the subperiosteal tunnels, and peri­
operative antibiotics. Rates of displacement can be reduced
with tacking sutures attaching the implant to the
periosteum.
Mobility of the implant is enhanced if dissection of
the tunnel is carried below and inferior to the mandible
and should therefore be avoided. One should also be cog­
nizant that preoperative asymmetries in the patient’s
mandible will be present postoperatively and should be
pointed out to the patient preoperatively.18
ANGLE OF THE MANDIBLE IMPLANTS
Access to the angle of the mandible is achieved through a
2- to 3-cm mucosal incision at the retromolar trigone.
This gives direct access to the angle of the mandible. Dis­
section is then performed on the bone and beneath the
masseter muscle to elevate the periosteum upward along
the ramus and anteriorly along the body of the mandible.
A curved (90-degree) dissector is used to elevate the peri­
osteum around the posterior angle and ramus of the man­
dible. This permits accurate placement of the angle
implants that are designed to enhance the posterior border
of the ascending ramus and thus angle definition. These
is secured to the periosteum with two sutures of 4-0 clear
nylon or 5-0 Prolene. The wound is again irrigated and
closed in two layers with a deep subcutaneous suture and
skin closure.
COMPLICATIONS
Complications with mandibular implants are rare. Most
common among them is unilateral hypoesthesia or par­
esthesia of the lower lip or chin. Reports of incidence
range from approximately 8% to 35%.2,3 A reduced com­
plication rate has been attributed to direct visualization
of the lateral subperiosteal dissection tunnel using a head-
light and ribbon retractor that does not stretch the mental
nerve. If hypoesthesia manifests, it lasts approximately 1
to 2 weeks. Dysesthesia is rare and usually unilateral and
can be caused by the malposition of the implant imping­
ing on the mental nerve. All implant material induces the
formation of fibroconnective tissue, which encapsulates
the implant and acts as a barrier between the host and
the implant.4,5 Therefore, infection rates and displacement
of the implant are rare. Rates of infection can be further
reduced by care in the handling of the implant, soaking
the implant in antibiotic solution, meticulous hemostasis,
Figure 17-18  A-D, The implant is inserted into the lateral portion of the pocket on one side and then folded upon itself whereby the contralateral portion
of the implant is inserted into the other side of the pocket.
A
C
D
B

CHAPTER SEVENTEEN  Mandibular Implants
223
7. Broadbent TR, Mathews VI. Artistic relationships in surface
anatomy of the face. Application to reconstructive surgery.
Plast Reconstr Surg. 1957;20:1.
8. Belinfante LS, Mitchell DI. Use of alloplastic material in the
canine fossa-zygomatic area to improve facial esthetics. J Oral
Surg. 1977;35:121.
9. Binder W, Schoenrock L, eds. Facial contouring and
alloplastic implants. Philadelphia: WB Saunders, 1994, Facial
Plastic Surgery Clinics of North America.
10. Gabriel SE, O’Fallon WM, Kurland LT, et al. Risk of
connective-tissue diseases and other disorders after breast
implantation. N Engl J Med. 1994;330:1697.
11. Park AJ, Black RJ, Sarhadi NS, Chetty U, Watson ACH.
Silicone gel-filled breast implants and connective tissue
diseases. Plast Reconstr Surg. 1998;101:261.
12. Park JB, Lakes RS. Polymeric materials. In: Biomaterials: An
Introduction. New York: Plenum; 1994:164.
13. Brown BI, Neel III HB, Kern EB. Implants of Supramid,
Proplast, Plasticpore, and Silastic. Arch Otolaryngol Head
Neck Surg. 1979;105:605.
14. Alexander H. Calcium-based ceramics and composites in bone
reconstruction. CRC Crit Rev Biocompat. 1987;4:43.
15. Salyer KE, Hall CD. Porous hydroxyapatite as an onlay bone
graft substitute in maxillofacial surgery. Plast Reconstruc
Surg. 1989; 84:236.
16. Rodriguez A, Vacanti CA. Characteristics of cartilage
engineered from human pediatric auricular cartilage. Plast
Reconstr Surg. 1999;103:1111.
17. Langer R, Vunjak G, Freed L, et al. Tissue engineering:
Biomedical applications. Tissue Eng. 1995;1:151.
18. Terino EO. Complications of chin and malar augmentation.
In: Peck G, ed. Complications and problems in aesthetic
plastic surgery. New York: Gower Medical; 1991.
implants are then secured with titanium screws. No screws
are needed if custom implants such as three-dimensional
Accuscan are used.
CONCLUSION
Chin augmentation is an extremely important tool in aes­
thetic surgery. When assessing facial form, it is imperative
to apply a three-dimensional approach to facial contour­
ing so that the correct implant can be chosen for achieving
the optimum result. Identifying components related to
facial size, form, dimension, and factors of aging are all
important in determining the correct implant shape and
size to optimize the results in mandibular contouring.
REFERENCES
1. Anderson J. Grants Atlas of anatomy. 7th ed. Baltimore, MD:
Williams & Wilkins, 1978:7–17.
2. Mittleman H. The anatomy of the aging mandible and its
importance to facelift surgery. Fac Plast Surg Clin North Am.
1994;2(3):301–309.
3. Cortez EA. Extended pre-jowl implants enhance lower face.
Cosmet Surg Times. 2004;14.
4. Anderson JM, Miller KM. Biomaterial biocompatibility and
the macrophage. Biomaterials. 1984;5:5
5. Ziats NP, Miller KM, Anderson JM. In vitro and in vivo
interactions of cells with biomaterials. Biomaterials. 1988;9:5.
6. Binder WJ, Azizzadeh B, Tobia GW, eds. Aesthetic facial
implants. In: Facial Plastic and Reconstructive Surgery, 3rd
edition, New York: Thieme Medical Publisher; 2009.

225
C H A P T E R E I G H T E E N 
Alloplasts in Nasal Surgery
Anthony P. Sclafani
Few concepts in rhinoplasty engender as much discussion
and conflict as the use of alloplasts in the nose. Clear
divisions within the specialty have developed, with some
surgeons using alloplastic implants liberally while others
staunchly maintaining that alloplasts should never be
used in rhinoplasty. Central to this dichotomy is the risk
versus benefit analysis and the thresholds one sets as
acceptable. Should an alloplast ever be used in cosmetic
or reconstructive rhinoplasty? Does sparing the patient an
additional incision and operative site with additional risks
(including potential intracranial or thoracic penetration)
and donor site morbidity outweigh a small but finite risk
of implant material extrusion or infection? Can an allo­
plast effectively simulate the tissue characteristics (such
as bulk, shape, texture, and stability) it is designed to
replace? Unfortunately, it is often the patients who most
need significant bulk and/or structural support, due to
prior surgery, trauma, or inflammatory disease, who may
be the worst candidates for alloplastic augmentation. Sig­
nificant scarring or a thinned, devascularized skin–soft
tissue envelope may lead to poor implant integration,
skin erosion, and breakdown, as well as implant mobility
and/or exposure. This chapter will review the benefits and
risks of alloplastic nasal augmentation and will discuss
the use of implants in the nose in the context of implant
biocompatibility and as related to wound healing.
HISTORY
At its most basic level, rhinoplasty is an alteration in the
form and function of the nose by removal, modification,
or augmentation of existing nasal structures. Historically,
nasal mutilation was inflicted with the intention of leaving
a visible marker of a degraded social status for thieves,
adulterers, and military or political prisoners. The syphilis
epidemic in Western Europe in the sixteenth and seven­
theenth centuries caused a significant number of saddle
nose deformities and left victims with conspicuous seque­
lae of sexual promiscuity. Military wounds also left victims
with nasal deformities requiring treatment.
The simplest form of augmentation is the prosthesis.
Justinian II (“Rhinotmesis”), a Byzantine emperor whose
nose was amputated after he was deposed (nasal and
facial deformities precluded individuals from ruling),
wore a nasal prosthesis when he reclaimed his throne.
Tycho Brahe, the Danish astronomer, wore a silver pros­
thesis to camouflage a nasal deformity.
Soft tissue reconstruction of the nose with forehead
or cheek skin flaps dates from as early as the sixth century
BC in India, and forearm pedicled flap repair was well
known in Italy prior to Tagiacozzi’s publication in the
sixteenth century. These early surgical interventions in the
preanesthetic era were intended to replace large amounts
of nasal volume and skin coverage. More focused recon­
struction of nasal deformities—in particular, the saddle
nose deformity—began in earnest in the late nineteenth
to early twentieth centuries, as modern anesthetic tech­
niques and antisepsis were introduced. While subtler than
the earlier treatment of more dramatic nasal amputations,
the repair of these injuries was primarily aimed at restora­
tion of nasal volume and skin coverage. Some of the
materials used, including stones from the Black Sea, duck
breastbone, pearls, and ivory, may seem inexact and
perhaps more than a little odd, but the deformities being
treated were severe and even modest improvements were
appreciated. At best, the materials may have been well-
tolerated foreign bodies with fibrous encapsulation, but it
seems obvious they were chosen more for their physical
qualities than for their biocompatibility.
The development of synthetic polymers in the mid to
late twentieth century led to the greatest increase in the
use of nasal implants. In particular, solid silicone implants
were introduced and are still in use today. These were
designed primarily for dorsal augmentation but some
later designs incorporated struts for columellar and tip
support. These implants are fairly well tolerated, but
implant infections and extrusions have been reported and
will be discussed later in this chapter. Other implants
have also been developed over the past two decades for
isolated columellar support, premaxillary augmentation,
and nasal valve support; their use will also be covered in
this chapter.

226
Anthony P. Sclafani
preservation of volumization but loss of tip support
reported when IRC is used. Considerable warping can also
occur over time.4-6
Another homograft, acellular dermal matrix (ADC;
LifeCell Corp., Branchburg, NJ), has been used as a dorsal
onlay implant, either alone or in combination with autolo­
gous cartilage. ADC provides a three-dimensional collagen
scaffold for host tissue ingrowth and fibrosis and can be
used to provide subtle volume augmentation (especially
in the radix). It can also be used to camouflage irregulari­
ties of the dorsum or from other cartilage grafts. At best,
only a portion of the volume of ADC will persist long
term.7
Finally, temporary injectable fillers such as hyaluronic
acids and calcium hydroxylapatite have been described
for nasal contouring.8,9 These are generally simple and
effective but temporary solutions, and the long-term
safety of permanent filler material in this area is unclear.
IMPLANT BIOCOMPATIBILITY
The body’s biologic response to an alloplast is dependent
on factors related to both host and implant. The chemical
composition, surface electrical charge, surface texture, and
porosity all contribute to the specific response that occurs
around an alloplastic implant. Simply put, a nasal implant
is a rather large subcutaneous or submuscular foreign
body. Following implantation, the implant is coated with
host proteins such as fibrin, fibronectin, and other proteins
that become partially denatured on contact with the
implant. These proteins are essential for the subsequent
host inflammatory response. The severity, cellular activity,
and longevity of this response are determined in large part
by the qualities of the implant. Neutrophils and monocytes
migrate to the implant surface. When the initial inflamma­
tory response subsides, the neutrophilic content decreases,
giving way to macrophage increase and accumulation of
giant cells, fibroblasts, and some lymphocytes around the
material. A fibrotic response ultimately results, with a
capsule of fibrosis around the implant; any fragments, left
behind in the manufacturing of the implant, related to
surgical technique, or formed as a result of implant degra­
dation in situ, will promote additional inflammatory reac­
tions around each particle of material. Some early implants
no longer in use today were found to undergo degradation
and released new fragments into the surrounding tissues;
a vibrant secondary foreign body response developed and
persisted around the implant causing significant collateral
damage. By contrast, the three most commonly used solid
nasal alloplasts today (expanded polytetrafluoroetheylene
[e-PTFE], porous high density polyethylene [PHDPE],
and silicone) are associated with quite different early
responses, which represent different points on a common
spectrum. These implants have been designed to avoid
particulate degradation.
ANATOMY
Five main areas can typically be considered for alloplastic
nasal augmentation: the dorsum, premaxilla, nasal valve,
ala, and columella. Additionally, some implants will
include aspects designed to augment the nasal tip. Con­
genitally shallow nasal dorsal profiles often seen in Asian
and African American patients are amenable to dorsal
onlay implants. In patients with limited or weak tip pro­
jection and support, a single-piece implant can be used to
both augment dorsal height and to provide tip support. A
retruse premaxilla can be augmented with an implant to
restore proper balance to the lower third of the nose.
Recently, new implants have been introduced to modify/
support the internal nasal valve without adding excessive
bulk. Implants can be added to the nasal ala to correct
alar contour, while implants placed in the columella can
aid in augmenting tip projection, altering tip rotation
or reshaping the columella itself. In general, space-
occupying implants are better tolerated than those that
provide structural support; there are exceptions to this
rule, and factors such as the health and vascularity of the
local soft tissues, implant stabilization, and the physical
and chemical characteristics of the implant itself will also
have a significant impact on implant success.
ALTERNATIVES
Traditional teaching of rhinoplasty techniques dictates the
use of autologous materials whenever possible. Autolo­
gous septal, conchal, and costal cartilage are the most
commonly used material for nasal grafting. They are
readily harvestable, have minimal donor site morbidity,
can generally provide sufficient volume of cartilage, are
relatively easy to carve, and provide fairly predictable
results. Alternatively, outer table calvarial or iliac crest
bone grafts can be used, but due to their rigidity, they are
only practical for dorsal onlay (and columellar support)
grafts. Temporalis fascia can be used to soften graft edges
but provides neither volume augmentation nor support.
Erol and colleagues1,2 described the use of the “Turkish
Delight” graft: minced cartilage is mixed with autologous
blood and wrapped in oxidized cellulose. The subsequent
fibrotic response provides bulk augmentation for the nasal
dorsum but cannot be used in structural settings.
Homografts, such as irradiated rib cartilage (IRC),
can be considered as an alternative if autologous tissue is
unavailable or insufficient or the patient refuses a second
surgical incision. IRC is harvested from human cadavers
and processed to reduce the potential for infection trans­
mission or immunologic host rejection. It has been in use
for over 20 years and the literature is mixed as to the
ultimate fate of irradiated cartilage. Schuller et al.3 ini­
tially described good results using IRC. However, subse­
quent long-term follow-up in these cases is mixed with

CHAPTER EIGHTEEN  Alloplasts in Nasal Surgery
227
answers to these questions will help select the most appro­
priate implant.
In assessing patients preoperatively, standard func­
tional and aesthetic rhinologic evaluation should be per­
formed. Specific aesthetic and structural needs should be
identified. The intended volume augmentation should be
assessed, as should the anticipated amount and quality of
autogenous cartilage available. In general, autogenous
cartilage is better tolerated and more forgiving in the nose
(especially in revision and posttraumatic cases), and
should be considered as a “first-line” choice. If septal and/
or conchal cartilage is insufficient for the patient’s needs,
costal cartilage and calvarial bone grafts are considered.
Patient preference and the potential associated morbidity
of these autografts make consideration of alloplasts rea­
sonable. Both short- and long-term risks and benefits
should be fully discussed with the patient. The decision
to use an alloplastic implant is made jointly.
A major factor affecting the success of nasal alloplasts
is the integrity of the skin–soft tissue envelope beneath
which the implant is placed. The overlying tissues must
be sufficiently thick and healthy to withstand contact with
and pressure from a solid implant. Patients with excep­
tionally thin skin may be more prone to skin compromise
when an alloplast is used; likewise, the multi-revised rhi­
noplasty patient or patients with known vascular compro­
mise will have an increased risk of implant/soft tissue
complications due to diminished vascularity. Patients with
septal perforation are also at an increased risk of compli­
cations because of diminished local tissue vascularity sec­
ondary to prior surgery or trauma. Additionally, chronic
nasal crusting of the perforation edges may allow tran­
sient bacterial seeding of the local tissues. When an allo­
plast is present, this can lead to chronic inflammation or
infection around the implant. When present, septal per­
foration should be closed if an alloplast is used, and if
there is any uncertainty as to the anticipated success of
the perforation repair, placement of the alloplast should
be deferred. Tobacco use, while always a hindrance to
wound healing, is especially problematic in the postopera­
tive period after placement of a nasal implant; success of
the alloplast is dependent on proper healing of the soft
tissue pocket surrounding the implant, especially in the
early postoperative period.
SPECIFIC ALLOPLASTS
Silicone
Silicone refers to a family of polymers of the compound
dimethysiloxane ([(CH3)2SiO2]x). Silicone implants have
been used extensively for dorsal augmentation and
enhancement of tip projection, while single L-shaped sili­
cone implants can be used for both purposes. As silicone
is nonporous and is surrounded by a fibrous capsule,
stability of the implant depends primarily on creation of
SILICONE
Silicone nasal implants are nonporous and smooth sur­
faced. The inert nature of the polymer generally is associ­
ated with a thin fibrous capsule with quiescent fibroblasts
and rare giant cells. There is no tissue ingrowth making
removal simple but predisposing the implant to infection
(from early contamination or late bacteremia) and insta­
bility within the implant pocket. As there is no rigid fixa­
tion of the implant, the micromotion of the implant can
cause a synovial reaction within the implant.
e-PTFE
e-PTFE is a soft and pliable microporous material.
The most commonly used e-PTFE was produced by W.L.
Gore & Associates but the manufacturer has ceased
production. Currently, a preformed composite e-PTFE/
silicone implant is available (Implantech Associates, Inc.,
Ventura, CA). These implants have a solid silicone core
with a bonded e-PTFE coating. The e-PTFE acts as a
cushion between the firm silicone core and the soft tissue
envelope, and the porous surface of the e-PTFE allows
limited tissue ingrowth into the periphery of the implant.
This ingrowth effectively binds the implant to the sur­
rounding tissue and seals it from the outside environment,
eliminating dead space and potential micromotion, while
the silicone core can provide structural support. The sur­
rounding capsule is composed of a few thin layers of col­
lagen and relatively quiescent fibroblasts.
PHDPE
PHDPE (MEDPOR; Stryker Corp., Kalamazoo, MI) is a
rigid implant with pores averaging 150 microns in size.
These larger pores promote a more vibrant fibrovascular
soft tissue ingrowth than e-PTFE, and ultimately the
implant, which is 50% porous, is completely ingrown by
host tissue. This provides a dense attachment to the sur­
rounding soft tissue and assists with implant fixation.
Porous implants have been shown to be more susceptible
to early infections (prior to soft tissue invasion of the
implant) but more resistant to late infections (because of
the protective effect of host tissue invasion and integration
of the implant) compared to solid implants.
SPECIAL CONSIDERATIONS
A careful assessment of surgical needs for which the
implants will be used to address is critical in choosing
the correct implant. Each area is examined to assess the
patient’s surgical requirements. Is dorsal augmentation
necessary, and if so, to what degree? If the dorsum is to
be augmented, is tip projection required as well? Does the
alar base or the columella need additional volume? The

228
Anthony P. Sclafani
postoperatively coapts the nasal tip skin to the nasal tip
portion of the implant yielding an acceptable form. A thin
PHDPE sheet (0.85 or 1.5 mm thick) can be cut into an
ovoid or rectangle shape, for use as an alar batten or a
columellar strut, respectively.
Because of the rough surface of the PHDPE, these
implants do not slide easily into position and will catch
on the surrounding soft tissue. A wider dissection pocket
than required for a silicone implant must be created; this
is especially true for columellar and dorsal placement. A
useful trick is to wrap the implant in its sterile plastic liner
prior to placement; this will allow the implant to slide into
position more easily. Once properly positioned, the
wrapper can be advanced out, leaving the implant
in the desired location. Stabilization of dorsal PHDPE
implants is not mandatory, although this can be per­
formed with a monocortical titanium screw placed through
the implant into the nasal bone. This is recommended
when premaxillary implants are placed. Implants at other
sites can be secured much in the same was as cartilage
grafts, although effective soft tissue apposition to the
implant is essential for long-term success.
e-PTFE
e-PTFE implants are porous materials that also promote
soft tissue ingrowth. The pore size in e-PTFE is notably
smaller than in PHDPE, which limits the fibrous ingrowth
of the implant to the outer few tenths of a millimeter.
e-PTFE does not result in a well-developed capsule.
This degree of ingrowth stabilizes the implant and
isolates its interior from bacteria, while allowing for rela­
tively simple implant removal when necessary. e-PTFE
alone, however, is soft and flexible and cannot be used to
provide structural support. Numerous studies have been
published documenting the safety and efficacy of e-PTFE
implants.10-12
Recently, preformed e-PTFE nasal implants have
become unavailable, and e-PTFE–coated dorsal as well as
dorsal/columellar silicone implants have been introduced.
(Implantech Associates, Inc, Ventura, CA). These implants
are covered by a thin layer of e-PTFE bonded to a silicone
core. The e-PTFE integrates the implant with surrounding
soft tissues and serves as a cushion between the overlying
skin and soft tissues and the firmer silicone, while the
central silicone portion of the implant maintains a consist­
ent shape and structure. In theory, these implants should
perform as well as standard e-PTFE implants; however,
e-PTFE implants were never used to provide structural
support, and in this setting these implants may behave
similarly to all-silicone implants. Care should be taken to
avoid applying excessive pressure of the implant against
the skin.
Again, the implant is placed into the dissected pocket,
sliding easily into position. e-PTFE/silicone implants
require a relatively precise pocket; alternatively, the edge
a precisely positioned and sized pocket, one that allows
neither implant movement nor excessive pressure against
the overlying soft tissue. The implant should be placed
directly over the nasal bone periosteum from the nasal
root to just above the anterior septal angle. If an L-shaped
implant is chosen, the vertical strut portion is placed in
between the medial crura of the lower lateral cartilages
and rests anterior to the anterior nasal spine. These
implants can be placed via an external approach, but
creation of a discrete implant pocket may be more effec­
tive via an endonasal approach. All incisions should be
closed meticulously so as to establish a distinct and sepa­
rate cavity from the external environment.
PHDPE
PHDPE implants are made of a highly porous material
that facilitates fibrous ingrowth. The standard nasal
dorsal implant should rest directly over the nasal bones
from the nasal root to rest over the cartilaginous dorsum.
In patients with reasonable tip support and form, the
implant can be used without the nasal tip portion; however,
in patients with thick nasal tip skin or those with limited
nasal tip architecture, the nasal dorsum/nasal tip implant
can be used. In general, the soft tissue fibrosis that occurs
Figure 18-1  A dorsal nasal implant provides bulk augmentation of the
nasal dorsum. To ensure a smooth, continuous dorsal line, the implant is
placed so as to overlay the nasal bones and dorsal septum, ending at the
anterior septal angle. Piecemeal dorsal augmentation is generally discour­
aged to avoid irregularities.
Nasion
Anterior
septal
angle
Dorsal
onlay
implant

CHAPTER EIGHTEEN  Alloplasts in Nasal Surgery
229
e-PTFE and silicone, will slide into smaller pockets more
easily; fibrovascular tissue ingrowth into both PHDPE and
e-PTFE occurs fairly rapidly, further stabilizing these
implants. Silicone becomes encapsulated by fibrous tissue,
and excessive motion of the implant will promote a thicker
capsule and greater inflammation.
Combined onlay-strut implants are placed similarly,
except that the additional strut portion rests between the
medial crura (see Figure 18-2). Care should be taken to
ensure that the domes rest at a higher point than the angle
of the L-strut and cushion the overlying skin from the
implant. Also, a thick nasal tip skin is preferred when
using this type of implant; scarred or thinned nasal tip
soft tissues, as often seen in revision rhinoplasty, increase
the risk of implant exposure and extrusion.
NASAL VALVE IMPLANTS
Two types of nasal valve implants are available. Individ­
ual pieces of thin PHDPE can be used in a fashion similar
to cartilage in reconstructing the internal nasal valve as
an alar batten spanning from the pyriform aperture to the
dorsal septum to stabilize and reinforce a flail internal
nasal valve (Figure 18-3). A more recent addition is a
combined e-PTFE–coated titanium “butterfly” shape
(Monarch Adjustable Implant, Hanson Medical Inc.,
Figure 18-2  An “L-strut”-type implant can be used to augment the
dorsum and simultaneously provide tip support. The dorsal segment rests
on the bony and cartilaginous dorsum, while the caudal strut portion is
sutured in between the medial crura and rests over the nasal spine.
Combined
onlay-strut
Medial crus
Nasal spine
can be sutured to the surrounding soft tissue to maintain
implant position.
SPECIAL MANEUVERS AND
TECHNICAL PEARLS
GENERAL CONSIDERATIONS
It is essential to ensure that no fragments of material are
unintentionally implanted. All implants should be sterilely
rinsed prior to use. Prior to placement, all implants should
be soaked in an appropriate antibiotic solution, and any
small particles remaining from carving should be rinsed
off the implant prior to placement.
To facilitate antibiotic diffusion into porous implants,
the implant should be placed in a 20-mL syringe filled
with an antibiotic solution; all air should be expelled from
the syringe. With a gloved finger over the tip of the syringe,
the plunger is pulled back creating a vacuum; air bubbles
can be seen emerging from the implant pores, being
replaced by the antibiotic solution.
Implants should be placed in the smallest dissection
pocket possible, to limit the potential for early implant
migration. Adequate fixation with titanium screws or
sutures is essential. Implants should be kept as far away
as possible from suture lines, and excessive soft tissue
pressure against the implant should be avoided. PHDPE
implants can be heated in sterile hot water and bent to
the most appropriate shape; they are then held in this
shape while they cool and subsequently will hold this
shape. Consideration should be given to the use of autolo­
gous platelet/fibrin gel (Selphyl®, Aesthetic Factors, Inc.,
Wayne, NJ) to enhance and accelerate wound healing.
Postoperatively, the nose should be taped appropriately to
limit edema and obliterate any dead space in the area
surrounding the implant.
DORSAL ONLAY AND COMBINED
ONLAY-STRUT IMPLANTS
Dorsal onlay implants are the simplest implants to use.
They should rest symmetrically over the nasal dorsum
from the nasal root to the anterior septal angle (see Figure
18-1). While these implants can be placed endonasally,
an external approach is preferred to reduce the potential
for contamination with nasal bacteria. The rough surface
of PHDPE implants prevents sliding along the dorsum
into position, so the nasal soft tissues need to be ade­
quately elevated to allow the implant to be inserted into
the pocket before it is allowed to contact the surrounding
soft tissues. As discussed previously, this requires dissec­
tion of a more ample pocket than other implant materials.
However, the rough surface generally stabilizes the
implant well and generally precludes the need for rigid
fixation. Implants made of smoother materials, such as

230
Anthony P. Sclafani
Figure 18-4  In cases of isolated weakness or inadequacy of the medial
limb of the nasal tripod, a semirigid implant can be sutured in between the
medial crura and used to strengthen columellar support.
Columellar
strut
Medial
crura
Figure 18-5  Limited maxillary and premaxillary retrusion can be treated
with a peri-alar premaxillary implant placed via a transoral approach.
Premaxillary
implant
Figure 18-3  Semirigid implants, if thin enough, can be used to rein­
force and strengthen the area of the internal nasal valve. Nonelastic implants
should span from the nasal septum to the pyriform aperture; in cases of
prior resection of lateral crura when the remnant crura are weak or col­
lapsed, the cartilage can be sutured and suspended directly to the implant.
Lateral
crus
Nasal valve
implant
Pyriform
aperture
Kingston, WA), which spans over the nasal dorsum and
is designed to “spring open” and enlarge the nasal valve
area.13,14 The PHDPE implant is placed and secured
through an external approach, while the Monarch implant
requires a direct dorsal incision.
COLUMELLAR STRUT IMPLANTS
Silicone implants are not recommended for use as isolated
columellar struts due to the high incidence (over 50% in
some reports) of extrusion when used in this location.15
PHDPE, though, is generally well tolerated and can add
strength and support to the medial limb of the nasal tip
tripod. However, great care must be taken to preserve
some soft tissue between the nasal spine and the columel­
lar implant above. It is also essential to completely bury
the implant between the medial crura, ensuring complete
soft tissue coverage (Figure 18-4). The medial crura can
be sutured onto the implant, increasing tip support and
projection.
PREMAXILLARY IMPLANTS
Patients with medial maxillary and/or premaxillary defi­
ciency can be augmented with preformed PHDPE
implants.16 These are best placed at the pyriform rim
through a sublabial approach and should be secured in
place with titanium screws (Figure 18-5). In cases of mild
premaxillary retrusion, small particulate implants of
PHDPE (2- to 3-mm pieces) can be placed directly
through the columellar incision.
RADIX AND RIM IMPLANTS
Radix and rim implants are more technically challenging
to place. In patients with isolated nasal root deficiency, a
small implant can be placed to create a smooth dorsal

CHAPTER EIGHTEEN  Alloplasts in Nasal Surgery
231
encapsulated postoperatively by fibrous tissue, e-PTFE is
invaded peripherally, and PHDPE is ultimately com­
pletely invaded by the patient’s fibrovascular tissue. Thus,
infection or exposure almost certainly dooms a silicone
implant at any point in time. In contrast, after an initial
critical healing period and soft tissue ingrowth, PHDPE
and e-PTFE implants are less likely to become infected,
as the patient’s immune response has access to sites of
bacterial seeding.18
Indeed, in cases of late experimental exposure, PHDPE
implants have healed by secondary intention and have
(after debridement) supported full-thickness skin grafts.19
After fibrovascular tissue has developed around the
implant surface over the first few weeks, any signs of
infection around the implant should be treated aggres­
sively with prolonged antibiotic treatment using both a
quinolone and a macrolide antibiotic. Bacterial coloniza­
tion of a synthetic surface can be extremely difficult to
treat. Mucopolysaccharides secreted by the pathogenic
bacteria can form a protective covering for the bacterial
colonies, making antibiotic penetration and eradication
of infection slow and difficult. Antibiotic coverage should
be continued for at least 4 to 6 weeks, to ensure full pene­
tration and elimination of any biofilm, which may have
developed at the implant surface.
Because of the stabilization of the implant by the
patient’s fibrous response around the implant, extrusion
Figure 18-6  An isolated deep nasal root can be augmented with an
implant placed at the deepest point of the root. Care should be taken to
place the implant in a deep pocket and to avoid extension beyond the sides
of the nose.
Glabella
Nasion
Radix
implant
Figure 18-7  A retracted alar rim can be repaired by placing an implant
between the skin of the rim and the caudal end of the lateral crura. Extreme
caution should be used in these cases to avoid excessive skin tension and
possible implant extrusion.
Lateral
crus
Rim
implant
Alar rim
profile. Any implant placed in this location should be
feathered at its edges to blend in smoothly with the nasal
sidewalls as well as the caudal and dorsal contours of the
radix (Figure 18-6).
An alar rim implant can be placed caudal to the
lateral crus to correct a retracted ala (Figure 18-7). An
implant here should be used with great caution, as these
tissues often are scarred and exposure/extrusion of the
implant is not uncommon. Generally, sufficient amounts
of autologous cartilage can be found for these areas and
are preferred to any type of alloplastic implant.
COMPLICATIONS
One must discuss the issue of complications of nasal
implants in the proper perspective. Most rhinoplasties in
which alloplasts are used fall into one of the following
categories: major revision rhinoplasty, major trauma, con­
genital deformity, or need for large volume augmentation.
These situations entail a high degree of complexity and
are associated with higher complication rates. In light of
this, a 3% to 6% removal rate of alloplasts17 can be con­
sidered acceptable. A thoughtful appreciation of the bio­
logic events that occur around the implant after surgery
not only explains this risk but suggests rational manage­
ment options as well. As described earlier, silicone is

232
Anthony P. Sclafani
10 or 15 blade. It is essential that all implant edges are
feathered, and that the implants are rinsed to remove any
adherent loose particles, as these will increase the risk of
foreign body granulomatous response around the implant.
Any changes to the nasal tip should be made first, so that
the amount of dorsal augmentation can suit the tip
projection.
Should overcorrection be noted postoperatively, the
implant can be removed, trimmed down or replaced with
a smaller implant more easily in the case of silicone
implants. On the other hand, the fibrovascular tissue
ingrowth into PHDPE and e-PTFE implants that helps
stabilize these implants makes implant removal more
of e-PTFE and PHDPE implants is uncommon. However,
silicone implants, once exposed, generally extrude or
require removal. Careful attention to technique, mainte­
nance of healthy soft tissues around the implant, avoid­
ance of wound tension, and placement of the implant
distant from any suture lines are essential to the successful
use of any nasal implants but especially those made from
silicone.
Undercorrection or overcorrection of the nasal dorsum
is due to an error in judgment. While most nasal dorsal
implants come in a variety of sizes, implants may require
tailoring to suit the patient’s needs by shaving the implant
to a desired size. This can generally be done with a No.
Figure 18-8  Preoperative (A-C) and postoperative (D-F) views of female Filipino patient who sustained blunt nasal trauma as a child and matured with
an underprojected nasal tip and dorsum. Reconstruction required septal cartilage for spreader, columellar strut, and shield grafting, while an e-PTFE–coated
silicone dorsal implant was used to provide dorsal augmentation.
A
C
D
F
E
B

CHAPTER EIGHTEEN  Alloplasts in Nasal Surgery
233
augmentation: A 1-year follow-up of clinical observations and
histological findings. Arch Fac Plast Surg. 2001;3(2):
101–103.
8. Stupak HD, Moulthrop TH, Wheatley P, et al. Calcium
hydroxylapatite gel (Radiesse) injection for the correction of
postrhinoplasty contour deficiencies and asymmetries. Arch
Fac Plast Surg. 2007;9(2):130–136.
9. de Lacerda DA, Zancanaro P. Filler rhinoplasty. Dermatol
Surg. 2007;33(Suppl 2):S207–S212.
10. Queen TA, Palmer FR. Gore-Tex for nasal augmentation: A
recent series and a review of the literature. Ann Otol Rhinol
Laryngol. 1995;104:850–852.
11. 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.
12. Conrad K, Torgerson CS, Gillman GS. Applications of
Gore-Tex implants in rhinoplasty reexamined after 17 years.
Arch Fac Plast Surg. 2008;10(4):224–231.
13. Hurbis CG. An adjustable, butterfly-design, titanium–
expanded polytetrafluoroethylene implant for nasal valve
dysfunction. Arch Fac Plast Surg. 2006;8:98–104.
14. Hurbis CG. A follow-up study of the monarch adjustable
implant for correction of nasal valve dysfunction. Arch Fac
Plast Surg. 2008;10:142–143.
15. Milward TM. The fate of Silastic and Vitathrene nasal
implants. Br J Plast Surg. 1972;25:276–278.
16. Pessa JE, Peterson ML, Thompson JW, et al. Pyriform
augmentation as an ancillary procedure in facial rejuvenation
surgery. Plast Reconstr Surg. 1999;103:683–686.
17. Peled ZM, Warren AG, Johnston P, Yaremchuk MJ. The use of
alloplastic materials in rhinoplasty surgery: A meta analysis.
Plast Reconstr Surg. 2008;121:85e–92e.
18. Sclafani AP, Thomas JR, Cox AJ, Cooper MH. Clinical
and histologic response of subcutaneous expanded
polytetrafluoroethylene (Gore-Tex) and porous high density
polyethylene (MEDPOR) implants to acute and early
infection. Arch Otolaryngol Head Neck Surg. 1997;123:
328–336.
19. Sclafani AP, Romo T, Silver L. Clinical and histologic
behavior of exposed porous high-density polyethylene
implants. Plast Reconstr Surg. 1997;99:41–50.
difficult. In removing these implants, the surgeon should
dissect down directly against the implant, leaving as much
fibrous tissue on the overlying flap. In densely adherent
areas, hydrodissection by injecting 1 to 2 mL of local
anesthetic directly onto the implant surface can aid in
dissecting the implant from the surrounding tissues.
CONCLUSIONS
Autologous tissue is the preferred material for nasal recon­
struction. However, in carefully selected patients, with
specific indications and in discrete locations, thoughtfully
chosen alloplasts can be successfully used in rhinoplasty
(Figure 18-8).
REFERENCES
1. Erol OO. The Turkish Delight: A pliable graft for rhinoplasty.
Plast Reconstr Surg. 2000;105:2229–2241.
2. Velidedoeglu H, Demir Z, Sahin U, et al. Block and Surgicel-
wrapped diced solvent-preserved costal cartilage homograft
application for nasal augmentation. Plast Reconstr Surg.
2005;115:2081–2093.
3. Schuller DE, Bardach J, Krause CJ. Irradiated homologous
costal cartilage for facial contour restoration. Arch
Otolaryngol. 1977;103:1–15.
4. Welling DB, Maves MD, Schuller DE, Bardach J. Irradiated
homologous cartilage grafts. Long-term results. Arch
Otolaryngol Head Neck Surg. 1988;114(3):291–295.
5. Burke AJ, Wang TD, Cook TA. Irradiated homograft rib
cartilage in facial reconstruction. Arch Fac Plast Surg.
2004;6(5):334–341.
6. Kridel RW, Konior RJ. Irradiated cartilage grafts in the nose.
Arch Otolaryngol Head Neck Surg. 1993;119:24–31.
7. Sclafani AP, Romo 3rd T, Jacono AA, et al. Evaluation of
acellular dermal graft (AlloDerm) sheet for soft tissue

235
C H A P T E R N I N E T E E N 
Correction of the Pinched Nasal
Tip Deformity
Santdeep H. Paun • Gilbert Nolst Trenité
The “pinched nasal tip” is a deformity caused primarily
by collapse of the lateral crura of the lower lateral car­
tilages. Such collapse may be congenital due to inherent
hypoplasia, weakening, or malposition of the cartilagi­
nous support but is often secondary to acquired, com­
monly iatrogenic, causes. The resultant pinching effect
gives an unaesthetic appearance characterized by an alar
groove, which extends to the alar rim, causing shadowing
between the tip and alar lobules. Such shadows give rise
to a ball-shaped tip, and the basal view exhibits a typical
pinched appearance. At its worst, it can lead to severe
knuckling and bossae formation in the nasal dome region
with resultant nasal obstruction by impedance of the
airflow on inspiration.1–3 Correction of the functional and
aesthetic components to this problem is achieved with
restoration of the alar cartilaginous strength and structure
and requires appropriate, ideally autogenous, grafting
material. This chapter describes the relevant anatomical
basis for the deformity, causes and prevention of iatro­
genic problems, and techniques for correction.
ANATOMY OF THE NASAL VESTIBULE
The ideal aesthetic of the basal view of the nasal tip is
that of an equilateral triangle. The lateral crura should
have an outward convexity of the posterior alar rims and
gentle rounding in the dome region; specifically there
should be no pinching of the lateral alar walls. Various
factors, including thickness of the overlying skin, muscu­
lature (dilators), and strength and position of the lower
lateral cartilages, can directly influence the tip shape and
dynamics.
The caudal margin of the lateral crus should ideally
lie in a horizontal plane such that it lies just inferior to
the cephalic margin. If the cartilage is angulated such that
there is a significant superior to inferior relationship
between the cephalic and caudal margins, this may pre­
dispose to loss of support in the lateral alar region and
consequent pinched tip deformity4 (Figures 19-1 and
19-2).
Inherent or postoperative weakness in the lateral crus
can cause the anterior and midportion of the tip to col­
lapse. Posterolaterally, there is thick alar soft tissue and
skin, so fewer problems are encountered.
CAUSES OF DEFORMITY
Weakness of the lateral cartilaginous support leads to the
nostril rim contracting inwards under the weight of the
thick alar skin and soft tissue envelope. Inspiration may
exacerbate this collapse. The basal view exhibits a typical
appearance resembling a teat on a baby’s bottle5 (Figure
19-3).
CONGENITAL
Congenitally weak lower lateral cartilages predispose to
this deformity. The lateral nasal rim is typically convex
and its most severe form can buckle in so dramatically so
as to restrict the nasal airway even in the resting state.
ACQUIRED/IATROGENIC
By far the most common cause for this deformity is iatro­
genic weakening of the lower lateral cartilages due to
overresection of the cephalic edge of the lower lateral
cartilages with subsequent weakening of the intact rim
strip. The useful edict of leaving behind more cartilage
than that resected should always be remembered
although the authors recommend an absolute minimum
of 6-mm cartilaginous support but leaving more may be
favorable.
Knuckling of the lower lateral cartilages in the domal
area forms “bossae” (Figure 19-4).
The inexperienced rhinoplasty surgeon may not be
aware of the triad of thin skin, strong alar cartilages, and
bifidity of the tip, which together predispose to their for­
mation when there is an excess cephalic strip reduction
and inadequate narrowing of the domes.6 Postoperative
scar contracture in this area causes the deformity.

236
Santdeep H. Paun • Gilbert Nolst Trenité
Controversy surrounds the predisposition of vertical dome
division techniques to formation of the pinched tip and
bossae, and distinguished authors have both suggested7
and refuted8 this possibility.
Overzealous cephalic strip resection can further lead
to alar retraction due to the visoring effect caused by
contraction as healing occurs. If vestibular mucosa is not
preserved, this complication, too, can contribute to con­
tracture and promote further retraction.
Aggressive domal suturing with its resultant altera­
tion in tip orientation and dynamics can cause notching
in the dome region predisposing to a pinched tip effect.
Ensuring the suture is not tied overtightly such that sig­
nificant pinching of the domes occurs should reduce the
risk of this.9
Other more unusual causes of this deformity include
collapse of the alar cartilaginous region following inflam­
matory conditions (see Fig. 19-5) such as Wegener’s gran­
ulomatosis, but this may also occur following cocaine
abuse.
ASSESSMENT
A complete and discerning history regarding the perceived
cosmetic problem and function, any prior procedures, and
accurate chronologic detailing of postoperative changes is
important when considering revision surgery. As ever,
copies of a detailed prior operative report are helpful but
rarely available for the revision rhinoplasty surgeon.
Overall, it is vital to ensure that the patient’s concerns and
expectations are elucidated early in the consultation. Dis­
satisfaction expressed by the patient should be specific
rather than general and should be perceived as realistic
and true by the evaluating specialist.
The surgery is best not performed if the patient’s
expectations are thought to be unrealistic. When in doubt,
sensitive counseling of the patient and referral for psychi­
atric review is always prudent, and surgery is deferred
pending this.10
Diagnosis of the underlying anatomic deformity is
essential prior to embarking upon a surgical plan. Inspec­
tion and palpation of the integrity of lower lateral support
are equally important. It may not be possible to assess
whether there is an intact strip of the lower lateral carti­
lage, and prior operative notes may be helpful in this
regard.
Specific assessment for analysis of the pinched nasal
tip includes analysis of functional obstruction. It is impor­
tant to check whether there is alar collapse on inspiration,
but in its absence, valve collapse cannot be excluded.
Assessment with the Cottle maneuver is often advocated
but can be nonspecific11 and lateralizing the alar cartilage
with a probe or cotton tip applicator may be a better
evaluator.
Figure 19-1  The caudal aspect of the lateral crus is situated ideally in
the horizontal plane with the cephalic margin just superior to it.
Figure 19-2  With a more vertical orientation of the lateral crus, the alar
lobule is weaker and may further be weakened by cephalic rim excision,
predisposing to a pinched tip appearance.
Figure 19-3  Typical “baby bottle teat” appearance of the pinched nasal
tip.

CHAPTER NINETEEN  Correction of the Pinched Nasal Tip Deformity
237
of the lower lateral cartilages that can be repositioned and
modified as required. Small specific pockets can also allow
batten grafts to be inserted to correct concavities caused
by weakness of the cartilage. An isolated aesthetic defor­
mity caused by inherent concavity of the lateral crus may
be corrected by complete mobilization of the lower lateral
cartilage from the vestibular skin. An incision is then
made just lateral to the domal area and the lateral crus
flipped over such that the concavity now becomes a
OPERATIVE TECHNIQUES
ENDONASAL APPROACH
Correction of the pinched tip deformity can be achieved
in a variety of ways. For a minor deformity, an endonasal
approach may prove adequate for placement of support­
ing grafts in primary surgery or to correct prior overzeal­
ous tip suturing.5 Marginal incisions may allow delivery
Figure 19-4  A, B, Tip bossae. Knuckling occurs due to inherent strength of the lower lateral cartilage, excessive cephalic reduction, and inadequate
narrowing of the nasal domes. C, D, Bossae are excised by trimming and gentle scoring of the knuckled cartilages. E, Suture reconstitution of the domes.
F, Intraoperative tip configuration after bossae correction.
A
B
C
D
E
F

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Santdeep H. Paun • Gilbert Nolst Trenité
A
B
C
Figure 19-5  A, Preoperative view of inflammatory nasal deformity
with complete bilateral vestibular stenosis. B, Early and C, late postope­
rative views after reconstruction using rib cartilage, composite auricular
cartilage grafting, application of topical mitomycin C and medium term
use of a custom made vestibular stent.
convexity. The rotated, reconstructed crus is then sutured
to the medial segment. Figure 19-6 outlines such a recon­
struction, albeit performed via an external approach.
EXTERNAL APPROACH
It is our preference to employ the external approach for
most revision cases. This allows accurate evaluation of the
orientation, integrity, and strength of the alar cartilages.
CARTILAGINOUS AUGMENTATION
Restoration of cartilaginous support is paramount with
this deformity. The firmness and straightness of septal
cartilage may be advantages for alar batten and lateral
crural strut grafting, but auricular cartilage can be carved
to shape very well even if it is a little weaker. Rib cartilage
may be the preferred option in severe postinflammatory
contraction and in the presence of multiple other grafting
needs. Other nonautogenous material is generally not
advocated by the authors.5,12
ALAR BATTEN GRAFTS
Alar batten grafts are fashioned from curved auricular or
septal cartilage and placed to support the alar rim. A
precise pocket is created, and the graft is placed from
laterally over the pyriform aperture to the area of maximal
collapse. The graft may need to extend to the caudal
lateral crus. A more anatomically placed such graft
extending along the weakened lateral crus to the pyriform
aperture is termed a lateral crural graft (Figure 19-7).
The convex side of the graft is placed laterally to help
correct the pinch deformity. It is important to maintain as
much skin and soft tissue cover to reduce the risk of the
graft showing postoperatively. If inserted into a specific
“hand in glove” manner, fixation may not need to be
necessary, particularly if performed via an endonasal
approach. When an open approach is preferred, the grafts
can be suture fixated to the lateral crus.
When using tip or shield grafts, particularly when
they project 3 mm beyond the domes, a pinched type
appearance may be created. Lateral crural grafts and alar
rim grafts placed into a pocket along the caudal margin
of the marginal incision can help to recreate the gentle
curve to the nasal tip contour.4
LATERAL CRURAL STRUT GRAFTS
Lateral crural strut grafts are placed in a pocket between
the lateral crus and vestibular skin such that they extend
laterally to the pyriform aperture (Figure 19-8). They are
not to be confused with lateral crural grafts, which are
positioned between the external skin and lateral crus (see
section on alar batten). While they essentially have the
same function as alar battens, they have the advantage of
causing less visible distortion externally in thin-skinned
patients. Such grafts are also useful in providing support
when cephalically malpositioned lateral crura are reposi­
tioned caudally in patients with a “parenthesis”-type tip
deformity.13
Careful dissection is required between the vestibular
skin and lateral crus, making this technically more diffi­
cult than alar battens. Care has to be taken to avoid the
graft protruding into the airway.
Dome suturing is used to narrow the domal angle but
may also cause significant concavity or occasionally con­
vexity of the lateral crus in the process. If such deformity

CHAPTER NINETEEN  Correction of the Pinched Nasal Tip Deformity
239
along the caudal margin of the marginal incision along
the alar rim border (Figures 19-9 and 10). Care is taken
to remain as close to the vestibular skin as possible to
avoid any risk of puncture through the alar skin and to
reduce potential postoperative visibility of the graft. The
medial-most border of the graft is particularly prone to
such visibility and is thus camouflaged by crushing the
cartilage in that region. The grafts are suture-fixated to
the regional soft tissue. Alar rim grafts act to support and
cannot be resolved by repositioning of the sutures, lateral
crural strut grafts can effectively flatten this area, giving
rise to an aesthetic contour.4
ALAR RIM GRAFTS
Alar rim grafts are fashioned from thin, soft cartilage.
They are approximately 2 to 3 mm wide. A pocket is
created between the external skin and vestibular skin
Figure 19-6  Diagram to illustrate the technique of “flipping” of a concave lateral crus to produce a favorable convexity of the alar lobule. A, Significant
concavity of the lateral crus causing a pinched, collapsed effect. B, C, The lateral crus is fully mobilized from vestibular skin and then marked and divided in
domal area. D, E, The lateral crus segment is “flipped” over and reconstituted with permanent sutures. F, A natural convexity to the lateral crus is restored.
A
B
C
D
E
F

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Santdeep H. Paun • Gilbert Nolst Trenité
Figure 19-7  Lateral crural (alar batten) grafts fashioned to reconstruct
alar collapse following prior dome division of the lower lateral cartilages.
Figure 19-8  Lateral crural strut grafts.
elevate the alar margin. They can also be used to displace
the alar margin inferiorly, which may be helpful where
there is an alar–columellar disproportion. They usefully
reduce any pinching deformity following dome suturing
by eradicating any significant visible transition between
the domal area and the alar lobule.14,15
ALAR SPREADER GRAFTS
When an overresected rim of cartilage is found to be
causing the pinching effect, a bar-type graft can be placed
horizontally in the space between the remnants to correct
the collapse. Such an “alar spreader graft” acts to lateral­
ize the concavities16 (Figure 19-11). Pockets are dissected
between the vestibular skin and alar cartilage at the area
of maximal collapse. A preferred septal cartilage graft is
fashioned to sit into the created pockets and trimmed to
a length such that the concavity in the alar cartilages
becomes a gentle convexity. The cartilage is then sutured
with an absorbable suture to the lateral crura to ensure
stability. The skin–soft tissue envelope is replaced, and it
is ensured that there is no evidence of nostril flaring neces­
sitating trimming of the graft. A triangular or butterfly-
shaped graft can be inserted instead of a single bar. The
graft is partially incised in the midline to give a lateral­
izing spring effect. This may have the additional benefit
of correcting internal nasal valve collapse by splaying the
upper lateral cartilages laterally.17
REORIENTATION OF LATERAL CRURA
Ideal orientation of the caudal margin of the lateral crus
should be in a horizontal plane such that it lies just infe­
rior to the cephalic margin. A loss of support in the lateral
alar region may be predicted if there is a significant
superior-to-inferior relationship between the cephalic and
caudal margins and subsequent pinching anticipated. A
cephalically positioned lateral crus may also give rise to
lack of support laterally in the alar lobule with fullness
cephalically giving rise to the “parenthesis deformity” of
the nasal tip.18 Reorientation of the cartilage into a more
caudally placed ideal form can be achieved by dissecting

CHAPTER NINETEEN  Correction of the Pinched Nasal Tip Deformity
241
Figure 19-9  Alar rim graft.
Figure 19-10  A pinched tip can result from overly suture techniques. In this example, the issue is remedied with alar rim grafts.
Alar rim graft
A
B
C
resection of the domal knuckling with suture reconstruc­
tion of the lower lateral cartilages. If resection is required,
it should be conservative to avoid significant deprojection
of the tip. Isolated bossae deformities may be corrected
through a small marginal incision with careful undermin­
ing to separate the knuckled cartilages from the underly­
ing vestibular skin, which should be preserved intact
wherever possible. More significant deformities are better
visualized and managed via an external approach.
Approximation of the domes with sutures is important to
prevent recurrent postoperative splaying of the nasal
domes predisposing to further bossae formation. A crushed
or bruised cartilaginous tip graft may usefully camouflage
any minor underlying irregularity remaining after the
domal area has been reconstituted5 (Figures 19-4, 19-12,
and 19-13).
SUMMARY
The pinched nasal tip deformity is an unaesthetic conse­
quence of weakness in the lateral alar region. Such weak­
ness may be congenital but is often iatrogenic, most
commonly due to excessive cephalic reduction of the
lateral crus in primary rhinoplasty surgery. Other causes
may include the lack of recognition of the pinching effect
of dome suturing that may lead to concavity of the lateral
crus. Similar unaesthetic changes may occur after inser­
tion of a protruding shield or tip graft, which gives the
effect of a transition between the tip dome lobule and the
alar lobule. Cephalically positioned lateral crura give rise
to bulkiness in the tip region, but the absence of more
laterally based support of the alar lobules can cause a
pinching effect leading to the “parenthesis”-type defor­
mity of the nasal tip. Similarly, malpositioned lateral
crura such that the caudal edge does not lie just inferior
to the cephalic edge may predispose to pinching.
the lateral crus fully from the vestibular skin. A lateral
crural strut is attached to the freed edge to provide struc­
tural support. This extends laterally to the pyriform aper­
ture. An appropriately fashioned caudally placed pocket
is created to hold the lateral crus with attached strut in
position. The resulting position should be at near to 45
degrees to the midline. This deals with the laterally based
pinching effect and gives significant lateral support to this
area.
TREATMENT OF NASAL BOSSAE
Nasal tip bossae are often associated with other postop­
erative problems, including alar collapse. Clearly, carti­
laginous augmentation procedures as described here may
be required in addition to the specific correction of the
bossae. Treatment options include trimming or complete

242
Santdeep H. Paun • Gilbert Nolst Trenité
Figure 19-12  Pre and post operative views of a revision rhinoplasty to correct for bossae caused by excessive cephalic resection of the lateral crus and
surrounding soft tissue with scar contracture.
Figure 19-11  Alar spreader grafts are placed to lateralize collapse of the
alar cartilages.
A
B
Grafting techniques as described here act to flatten
the lateral crural region and add stability and support to
this area, thus addressing both functional and aesthetic
concerns with this deformity. The curved nature of conchal
cartilage lends itself well to such grafting but can be a
little weak at times. Gently scored septal cartilage to
encourage curving may be better from a structural, func­
tional point of view. As with all grafting procedures, there
is a risk of postoperative visibility and care has to be taken
to ensure pockets created for graft insertion are deep
enough within the skin–soft tissue envelope and that such
grafts are feathered and crushed appropriately.

CHAPTER NINETEEN  Correction of the Pinched Nasal Tip Deformity
243
Figure 19-13  Deformities of dorsum and nasal tip improved with hump reduction, osteotomies, tip deprojection, and improvement of the irregular
bossae type deformity.

244
Santdeep H. Paun • Gilbert Nolst Trenité
REFERENCES
1. DesPrez JD, Kiehn CL. Valvular obstruction of the nasal
airway. Plast Reconstr Surg. 1975;56(3):307–313.
2. Cottle MH. The structure and function of the nasal vestibule.
AMA Arch Otolaryngol. 1955;62(2):173–181.
3. Haight JS, Cole P. The site and function of the nasal valve.
Laryngoscope. 1983;93(1):49–55.
4. Toriumi DM, Checcone MA. New concepts in nasal tip
contouring. Fac Plast Surg Clin North Am. 2009;17(1):
55–90, vi.
5. Paun SH, Nolst Trenite GJ. Revision rhinoplasty: an overview
of deformities and techniques. Fac Plast Surg. 2008;24(3):
271–287.
6. Nolst Trenite G, ed. Rhinoplasty: a practical guide to
functional and aesthetic surgery of the nose. 3rd ed.
Amsterdam: Kugler Publications; 2008.
7. Kamer FM, ed. Revision rhinoplasty. Philadelphia: JB
Lippincott; 1998.
8. Gillman GS, Simons RL, Lee DJ. Nasal tip bossae in
rhinoplasty. Etiology, predisposing factors, and
management techniques. Arch Fac Plast Surg.
1999;1(2):83–89.
9. Nolst Trenite GJ, Paun, S. External rhinoplasty. In: Watkinson
J, ed. Scott Brown’s Otolaryngology. 7th ed. London: Arnold;
2008.
10. Vuyk HD, Zijlker TD. Psychosocial aspects of patient
counseling and selection: a surgeon’s perspective. Fac Plast
Surg. 1995;11(2):55–60.
11. Constantian MB. The incompetent external nasal valve:
pathophysiology and treatment in primary and secondary
rhinoplasty. Plast Reconstr Surg. 1994;93(5):919–931;
discussion 32–33.
12. Nolst Trenite GJ. Grafts in nasal surgery. In: Nolst Trenite GJ,
ed. A practical guide to aesthetic surgery of the nose. 3rd ed.
Amsterdam: Kugler Publications; 2005:49–67.
13. Gunter JP, Friedman RM. Lateral crural strut graft: technique
and clinical applications in rhinoplasty. Plast Reconstr Surg.
1997;99(4):943–952; discussion 53–55.
14. Toriumi DM. Structure approach in rhinoplasty. Fac Plast
Surg Clin North Am. 2005;13(1):93–113.
15. Rohrich RJ, Raniere J Jr, Ha RY. The alar contour graft:
correction and prevention of alar rim deformities in
rhinoplasty. Plast Reconstr Surg. 2002;109(7):2495–2505;
discussion 506–508.
16. Gunter JP, Rohrich RJ. Correction of the pinched nasal tip
with alar spreader grafts. Plast Reconstr Surg. 1992;90(5):
821–829.
17. Clark JM, Cook TA. The “butterfly” graft in functional
secondary rhinoplasty. Laryngoscope. 2002;112(11):
1917–1925.
18. Sheen JH, Sheen AP. Aesthetic rhinoplasty. 2nd ed. St Louis:
CV Mosby; 1987.

245
C H A P T E R T W E N T Y 
Postrhinoplasty Nasal Lobule
Deformities: Open Approach
Peter A. Adamson • Jason A. Litner • Peyman Solieman
Older reduction tip rhinoplasty techniques are effective in
altering tip contour and definition, yet they depend on
aggressive cartilage resection, morselization, and sacrifice
of tip supports to achieve these goals. Weakening of the
crura in this manner, when subjected to long-term forces
of contracture, may lead to tip distortion and commonly
seen postrhinoplasty deformities. Beginning in the 1980s,
advancements in understanding of nasal tip anatomy and
dynamics allowed for technical innovations in tip altera­
tion that emphasize more conservative handling of the tip
while better preserving structural support and functional
integrity.1–6 Despite these developments, the incidence of
revision rhinoplasty remains considerable. Kamer,7 in a
1981 review, reported rates of revision rhinoplasty in the
range of 8% to 15%, while more recent reports place the
incidence closer to 5% in the hands of experienced sur­
geons.8,9 The senior author (P.A.A.) previously reported10
a 6% revision rate in a cohort of his patients. The general
decline in revision rates has been attributed in part to
increasing acceptance and employment of open rhino­
plasty approaches11 but may also be due to better public
understanding of the need to choose experienced rhino­
plasty surgeons when undergoing this procedure.
Residual and iatrogenic aesthetic deformities are the
primary indications for revision; however, a functional
deficit coexists in roughly two-thirds of patients.12,13 While
the authors’ experience reflects a higher revision rate for
mid-vault abnormalities, several studies spanning five
decades suggest tip deformities are the leading reason for
revision surgery.8,13–15 Failures of philosophy and ability
to accurately diagnose and properly implement techniques
during the primary procedure account for the patterns of
deformities seen. Even when accurate diagnosis is possi­
ble, the capacity to execute surgical goals may be dimin­
ished in revision surgery for several reasons: (1) tip
anatomy is typically distorted, (2) tip supports are often
compromised, necessitating augmentation procedures, (3)
aesthetic goals are sometimes supplanted by functional
needs, and (4) the skin envelope is often scarred and
inelastic, rendering redrapage unpredictable and less
forgiving.10
This chapter will discuss the most frequently seen
postrhinoplasty lobule deformities and summarize indica­
tions and techniques for their correction.
ANATOMY AND NASAL TIP DYNAMICS
The techniques available for manipulation of the nasal tip
are widely known. Yet, the challenge is in knowing when
to apply specific techniques to achieve the appropriate
correction. Another way of looking at this is that the
surgeon must have both a clear aesthetic understanding
of the surgical goals as well as the technical expertise to
recognize which procedures will achieve them.
In the revision scenario it is especially important to
have a clear conceptual framework with which to create
a surgical plan. The Tripod Concept, first advanced by
Jack Anderson, M.D.,16 is widely taught in training pro­
grams and still represents a useful algorithm for nasal tip
reduction. However, the Tripod Concept was conceived at
a time when reduction tip rhinoplasty using a closed tech­
nique was the norm. Thus, it does not provide for under­
standing of techniques for achieving greater projection or
for better understanding of the need for tip stabilization
in open cases. In addition, the Tripod Concept predates
the further characterization of the intermediate crura, and
so it does not address the effects of alteration of this
structure to achieve refinement of the lobule.
A contemporary model of nasal tip dynamics, termed
the M-arch model,17,18 has been proposed in an effort to
expand on the Tripod Concept (Figure 20-1). This model
views the lower lateral cartilages as paired parabolic car­
tilaginous arches having their vertices at the tip-defining
points. The most significant determinants of tip-alteration
are the overall length of the arch and the specific site of
the alteration (Figure 20-2). Shortening the arch in close
proximity to the vertex will have a greater effect on depro­
jection (such as a vertical lobule division), while shorten­
ing by the same amount farther from the tip-defining
point will have a greater influence on rotation (such as a
lateral crural overlay technique). Furthermore, shortening

246
Peter A. Adamson • Jason A. Litner • Peyman Solieman
of the arch lateral to the tip-defining point serves to
deproject, rotate, and shorten the nose, whereas shorten­
ing medial to this point will deproject, counterrotate, and
lengthen the nose.
The same principles may be applied to understanding
of the relative effects of arch-lengthening maneuvers such
as suture or tip-grafting techniques. Suture techniques
such as the lateral crural steal5 effectively increase the
vertical arch segment by borrowing length from the more
horizontal segment just lateral to the tip-defining point.
Lobular grafts, on the other hand, achieve improvements
in projection by adding apparent length or vertical height
to the M-arch. In our practice, columellar struts are
routinely used to stabilize the length and strength of the
medial crura and thereby uphold the nasal tip projection
without, in and of themselves, actually increasing arch
length.
The M-arch model allows for application of specific
arch-altering maneuvers to achieve simultaneous predict­
able changes in nasal length, projection, rotation, and tip
definition. Division at the medial crural feet will generate
tip deprojection and some counterrotation and may be
used to diminish excessive flaring of the medial crural
footplates if the soft tissue attachments between the foot­
plates have been released. Division in the mid-medial
crus may be used to adjust columellar asymmetries, in
addition to providing counterrotation and deprojection.
Division at the angle or junction of the medial and inter­
mediate crus will yield primarily tip deprojection and
vertical shortening and may also diminish a hanging
infratip lobule. Division within the intermediate crus or
at the dome will deproject the tip and engender greater
acuity of the domal arch, thus producing lobular refine­
ment. Asymmetric division in this region may be used to
improve lobule symmetry with sutures concealed within
the infratip. Division in the mid-lateral crus, known as
a lateral crural overlay, represents the most powerful
maneuver for obtaining rotation along with deprojection.
Finally, division at the hinge area will achieve mild tip
deprojection and rotation. This setback technique is pre­
ferred when lobular contour is acceptable; however, this
is rarely the circumstance in revision tip surgery. Further­
more, occasionally it can lead to crural in-flaring and
obstruction within the vestibule, so we avoid this maneu­
ver if possible. In our practice, the vertical lobule division
and lateral crural overlay are the workhorse techniques
for obtaining the desired alterations in major nasal
parameters.
Vertical arch manipulations represent extraordinarily
powerful techniques for achieving predictable changes in
lobular contour. In fact, it is the experience of the authors
that such techniques are the only reliable method for
accomplishing meaningful modification of tip projection
and rotation. Maneuvers that do not cause real or appar­
ent changes in arch length cannot, therefore, achieve
real or apparent changes in tip projection. By example,
Figure 20-1  The anatomy of the tripod arch seen from the basal view.
The central segment of the M-arch is termed the domal arch or lobular arch
and comprises the intermediate crus and the most medial aspect of the
lateral crus.
Figure 20-2  The various locations that have been described as sites to
divide the lower lateral cartilages: (1) hinge area, (2) lateral crural flap, (3)
Goldman maneuver, (4) vertical lobule division, (5) Lipsett maneuver, and
(6) medial crural feet.
1
2
3
4
5
6