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Peter A. Adamson • Jason A. Litner • Peyman Solieman
cartilages. At times, one may find that infiltration
of the scar tissue with local anesthetic can aid in
hydrodissection.
Extreme care must be exercised in multiple revision
cases since thick scar tissue often complicates the dissec­
tion. Those surgeons who routinely perform revision rhi­
noplasty need not be told of how difficult this dissection
can be. Alar cartilage remnants may be abnormally thin,
tenuous, and easily penetrated by an excessively deep
dissection. In fact, scar tissue is sometimes the only tip
support remaining in the severely deformed tip. Similarly,
the subdermal plane may be filled with scar, predisposing
to dermal ischemia with an overly shallow dissection. The
safest initial approach in the heavily scarred patient may
be to leave a rind of scar tissue on the crura. This can be
further painstakingly dissected and excess scar tissue may
be discarded or saved for soft tissue augmentation else­
where. To compensate for the thick, inelastic skin that is
often encountered in a revision case, it is necessary to
undermine the soft tissue envelope widely to encourage
favorable redrapage. Once the tip and dorsum have been
adequately exposed, precise corrective maneuvers may be
undertaken.
VERTICAL ARCH DIVISION
Prior to any division, the cartilage is extensively released
from vestibular skin in the surrounding region to allow
for cartilage advancement. The location for arch division
is chosen in accordance with the desired alterations in tip
dynamics. The cut ends of cartilage are then overlapped
from 2 mm up to 6 mm in some cases and are secured
with 6-0 nylon mattress sutures. Two buried sutures are
placed in every case, the first to set the length of overlap,
and the second to set the longitudinal axis of the neoarch.
Alternatively, 4-0 Vicryl sutures may be used in the lateral
crus to fixate the cartilage segments through the underly­
ing vestibular skin. This is sometimes preferred since it
may be technically challenging to bury sutures in this
location. Overlapping suture fixation is a critical compo­
nent of this technique in order to avert inflaring or col­
lapse of the arch upon contraction of the skin–soft tissue
envelope. In general, the cartilage segment closest to the
tip-defining point represents the overlying segment when
overlapped (Figure 20-3).
CARTILAGE GRAFTING TECHNIQUES
Columellar Strut
Once fundamental tip parameters have been set, attention
is then directed toward reconstructing the nasal tip from
its base upward. This begins in nearly all instances with
placement of a strong cartilaginous columellar strut.
Septal cartilage is preferred to conchal cartilage, if avail­
able. A strut provides enduring support for the medial
crura and acts as a secure foundation for further lobule
grafting. While it will not inherently procure increased
projection, we believe that a strut is essential to sustain
the rotation and projection achieved with other maneu­
vers.24 The strut is best positioned directly on the maxil­
lary spine, if present, and assiduously secured to the
medial crura by two horizontal mattress sutures via long
Keith needles. To provide a reliable foundation for the
strut, the maxillary spine may be assiduously flattened
with a rongeur, although it should never be excised. The
strut is encased in a pocket by an anterior suture placed
through the strut and medial crura and a posterior suture
placed through the membranous septum just cephalic to
it. Placing just one suture through the strut minimizes the
risk of its fracture. These sutures set medial crural sym­
metry at the base, in both vertical and craniocaudal
dimensions. Columellar widening is prevented by dissec­
tion of intercrural ligaments and scar, which are either
preserved as a soft tissue columellar flap or free graft
within the premaxillary space, or are discarded when
nasolabial augmentation is undesirable.
Nasolabial Angle Augmentation Grafts
When further nasolabial augmentation is desired, we find
cartilaginous nasolabial grafts to be very efficacious.
These can be exploited to improve a posterior columellar
retraction or to increase apparent tip rotation. One or
more cartilaginous wafers are shaped and positioned
within a deep pocket in the premaxillary space (Figure
20-4). The authors prefer to secure these first to each
other and then either through the premaxillary skin or to
the caudal margins of the medial crura via peripheral
sutures. Conchal cartilage works well for this purpose.
Lobule Grafts
As a consequence of overresection, many postrhinoplasty
nasal tips appear overrotated and underprojected, giving
the nose a foreshortened appearance. Such situations call
for lobular grafts that, depending on their precise place­
ment, may secure greater lobule projection, definition,
counterrotation, lengthening, and camouflage of remain­
ing asymmetries. It is not uncommon for the authors to
use multiple grafts in revision tips; however, the fewest
necessary grafts should be used. In thick-skinned or
severely scarred tips, tiered grafts may often be necessary
to obtain any amount of tip definition. The authors do not
follow a defined formula for tip grafting but rather indi­
vidualize the configurations to each patient. The main
goal is to reconstruct the ideal aesthetic lobule utilizing
whatever surgical techniques are necessary. In most
instances, a shield-type25 infratip lobule graft, possibly
supported by one or two domal onlay grafts, will achieve
the desired lengthening and/or projection (Figure 20-5).
Increased projection or counterrotation can be selectively
favored by rotating the axis of the graft upon the underly­
ing lobule. Grafts are generally secured to the lobule by

CHAPTER TWENTY  Postrhinoplasty Nasal Lobule Deformities: Open Approach
249
placed to bridge the gap between the residual dorsal septal
remnant and the columellar strut. Occasionally, a unilat­
eral supratip depression may be resolved by apt position­
ing of a caudally situated spreader graft.
Lateral Crural Grafts
Lateral crural grafts may be used as support or contour
grafts. In cases of severe alar deficiency and associated
external valve collapse resulting from overresection, a
lateral crural graft is best designed as a batten spanning
from the dome to the hinge area over the pyriform margin.
This is usually placed in an onlay fashion in order to
peripherally placed 6-0 nylon sutures after the tip has
already been set and appropriate interdomal and inter­
crural sutures have been positioned. Careful feathering of
the graft edges is crucial, especially in thin-skinned indi­
viduals. When the columella also requires augmentation,
an extended infratip graft is usually placed to span the
columella as a batten. This is also fixated with transfixion
sutures of 6-0 nylon. Supratip deficiencies, occurring from
unbalanced resection of the anterior septal angle, may
also be addressed by grafting techniques. These may be
camouflaged by placement of a supratip onlay cartilage
graft. Alternatively, a dorsal septal extension graft may be
Figure 20-3  Intraoperative photos demonstrating vertical lobule division. A, Intended point of division is marked at the junction of the medial and
intermediate crus. B, Overlap of the divided cartilage segments. C, Suture stabilization with two horizontal mattress sutures. D, Final view showing the degree
of deprojection achieved.
A
C
D
B

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Peter A. Adamson • Jason A. Litner • Peyman Solieman
convexity. It is best positioned deep to the concave surface
in an underlay fashion (Figure 20-6). While very effec­
tive, care must be taken in appropriate placement of this
strut. Ideally, it should be located cephalically near the
scroll region so as to enhance support in this area and to
reduce potential valve collapse. Placement too close to the
marginal incision will increase the chances for postopera­
tive palpability and potential narrowing of the vestibular
inlet. Otherwise, patients will tend to complain of a pal­
pable lump within the vestibule.
SUTURING TECHNIQUES
Suture techniques provide invaluable versatility in revi­
sion tip surgery to help alter the length and contour of the
M-arch either independently or as an adjunct to other
maneuvers. The greatest applicability occurs in situations
requiring increased projection, rotation, and lobular nar­
rowing or refinement. Most surgeons are familiar with
various intradomal and interdomal suturing techniques
(Figure 20-7). The authors’ preferred suture protocol con­
sists of the use of single-dome unit mattress sutures to
individually narrow each domal arch as needed and a
Figure 20-4  Intraoperative photographs demonstrating nasolabial angle augmentation (NLA) grafting. A, Lateral view of the location of the NLA graft.
B, Horizontal mattress suture placement through the graft. C, Sutures being drawn through the premaxillary skin. D, Final view showing nasolabial augmenta­
tion achieved.
A
C
D
B
Figure 20-5  Intraoperative photograph demonstrating an infratip
lobule graft.
impart reinforcement and to enhance alar contour. A
native lateral crus that has adequate width, but requires
support and contour, such as for a concavity, is amenable
to placement of an alar strut graft. This is formulated as
a cartilaginous slab designed to provide an inversion of

CHAPTER TWENTY  Postrhinoplasty Nasal Lobule Deformities: Open Approach
251
safely resected. This tissue may be discarded or reserved
for volume filling of the nasolabial angle or for contour
grafting elsewhere in the nose. When the tip has been
significantly deprojected, it may be advisable to excise 1
to 2 mm of the distal columellar flap to reduce the chances
of skin redundancy imparting a hanging columella effect.
Conversely, in cases of substantially increased projection,
it may be necessary to develop an inferiorly based advance­
ment flap of the columellar skin to allow for a tension-free
closure. In very thin-skinned noses, soft tissue may be
placed over lobule grafts to camouflage their firmness, and
especially their perimeters.
ALAR BASE NARROWING
Patients in need of alar base narrowing postrevision are
those having undergone significant tip deprojection
causing alar flaring. Lobules that have been substantially
narrowed may also benefit from basal narrowing in an
effort to maintain a balanced, harmonious nasal appear­
ance. The desired amount of resection of the internal
(nostril circumference) and external (basal width) cir­
cumference is measured and marked within the sill.
Identical or asymmetric excisions may be performed. A
cut-back incision is made just above the alar-facial groove
to allow advancement-rotation of the alar flap. Alar wall
flaring may be treated simultaneously by excision of a
tissue wedge in this location. The incision is closed with
simple, well-everted 6-0 nylon sutures.
double-dome unit mattress suture to conjointly medialize
the domal arches. Lobular “bunching” mattress sutures
located more cephalically near the scroll region may also
aid in decreasing supratip fullness though overnarrowing
should be avoided. For this reason, the authors rarely
make use of this type of suture for fear of creating a post­
operatively pinched tip. Moderately increased projection
may be acquired with the lateral crural steal technique.5
A very powerful technique that the authors use regularly
is an intermediate crural horizontal mattress suture.
Transfixion of the caudal margins of the intermediate
crura is accomplished along a vertical axis. Depending on
its exact placement, this suture may be exploited to
strengthen the medial crural–strut complex, to set the
intercrural and alar-columellar angles, to narrow the
infratip columella, and to diminish a hanging infratip.
These techniques are applied in a graduated fashion to
achieve the ideal outcome. Great precision is attainable
through precise suture adjustment; 5-0 and 6-0 nylon
sutures are generally preferred, with the knots always
buried.
SOFT TISSUE TECHNIQUES
Resection of undesired soft tissue can be accomplished
guardedly and meticulously in the revision tip via the open
approach, especially in the lobular and lateral supratip
areas. This tissue can first be hydrodissected with local
anesthetic to create a bleb of scar tissue that may then be
Figure 20-6  Lateral crural grafts. A, Overlay alar batten grafts. B, Underlay alar strut grafts.
A
B

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Peter A. Adamson • Jason A. Litner • Peyman Solieman
THE PINCHED LOBULE
A pinched lobule may be encountered for several reasons
in the revision nose. More often than not, this outcome is
the result of overzealous cephalic resection of the lateral
crura (Figure 20-8). In this case, poor lateral crural
support leads to postoperative in-flaring and apparent
pinching of the lobule. For this reason, the authors prefer
to preserve at least 8 mm of lateral crural width, at its
widest point, whenever a cephalic margin resection is
performed and especially in the setting of a scarred or
APPLICATION OF THE M-ARCH MODEL
TO SPECIFIC POSTRHINOPLASTY LOBULE
DEFORMITIES
Revision tip surgery often requires a combination of
reduction and augmentation techniques. Reduction
maneuvers are used in the modification of persistent
primary deformities. Conservation is the order of the day
where these techniques are used. Deformities caused by
overresection, on the other hand, will necessitate augmen­
tation techniques.
Figure 20-7  Intercrural suture techniques. A, Single-dome unit and intradomal sutures. B, Double dome unit. C, Intercrural horizontal mattress sutures.
B
A
C

CHAPTER TWENTY  Postrhinoplasty Nasal Lobule Deformities: Open Approach
253
Figure 20-8  A postrhinoplasty pinched lobule secondary to overresection. Preoperative and postoperative (A) frontal, (B) lateral, (C) oblique, and (D)
basal views. Schematic (E) showing tip correction with a right extended alar batten graft, left domal onlay graft, infratip lobule graft, columellar strut, inter­
domal spacer graft, and bilateral rim grafts.
A
B
C
D
E
thickened soft tissue envelope. In the revision setting,
restoration of lateral crural support often entails lateral
alar grafting in the form of alar batten grafts for severe
overresection and alar strut grafts for moderate in-flare
and/or support.
Another common cause for a pinched lobule is over­
aggressive suture techniques. While single-dome unit,
double-dome unit, and other suture maneuvers provide
near-infinite possibilities for tip contouring, they can also
be applied excessively. Our experience has been that tip

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Peter A. Adamson • Jason A. Litner • Peyman Solieman
deformity after many years in some patients. This occurs
because the natural elastic spring of the cartilaginous arch
is forfeited by interruption of its continuity. It is our con­
tention that any arch division technique must be accom­
panied by reconstruction of the arch by suture overlap of
the cut elements. We do not advise resection of intervening
cut cartilage when undertaking arch division. Rather, the
overlapped cut segments are always secured by two-point
fixation. In this fashion, arch continuity is upheld and, in
fact, the tip will be sturdier than it was prior to any inter­
vention. In secondary rhinoplasty, deformities owing to
in-flare of cut arch segments may be reconstructed by
suture overlap as they would in the primary setting. It
may be necessary to “buy back” lost projection by use of
a tip graft.
THE BROAD, UNDEFINED LOBULE
Rarely, a widened lobule may persist after primary
rhinoplasty because excess lateral crural width went
undertreated. This is unusual, however, because most rhi­
noplasties incorporate cephalic margin resection in the
hopes that this maneuver will decrease supratip fullness.
The problem lies in the fact that nondelivery approaches
to closed rhinoplasty render suture treatment of the lobule
more difficult. As a result, many surgeons rely too heavily
on cephalic margin resection to overcompensate for under­
correction of a broad interdomal angle. Horizontal cephalic
cartilage excision, as opposed to vertical division, may
achieve some small measure of lobule refinement and
rotation but may rather, in excess, promote alar retraction
and in-flaring, as mentioned. While excessive cephalic
margin resection is not intrinsically a significant induce­
ment to tip rotation, this maneuver will allow for excessive
rotation and shortening of the nose by alternate tech­
niques. When a persistently broad lobule is encountered,
it should be treated as in the primary setting by suture
techniques. Scoring of the lower lateral cartilage can be
very effective in narrowing a broad domal arch, flattening
a biconvex arch, and creating a new tip-defining point,
although caution must be exercised so as not to noticeably
weaken the arch.
A far more frequent cause for a broadened postrhino­
plasty lobule is the presence of excessive soft tissue thick­
ening. This is especially common in the thick-skinned
individual or in those undergoing multiple procedures
(Figure 20-9). When the lobule is overaggressively depro­
jected or thinned, intervening accumulation of scar tissue
within the dead space can undermine the intended gains.
At times, in the revision setting, the surgeon is confronted
with scar tissue that makes the dissection nearly impos­
sible in the face of cartilage that is weakened (Figure
20-10). In these cases, the surgeon is advised to sculpt the
cartilage–scar tissue block into the gross shape of a normal
tip. A semblance of tip refinement can then be achieved
by camouflage of the scar tissue block with a tip graft.
narrowing suture effects are increased by temporal con­
tracture of the skin envelope. So, every attempt should
be made in the primary setting to preserve a normal
or greater than normal alar–columellar relationship. We
prefer to maintain a 90-degree intercrural angle of diver­
gence to create an attractive diamond-shaped, two-point
light reflex at the tip-defining lines. Risks of a pinched
lobule and uni-tip deformity are elevated with an overly
snug double-dome suture or supratip bunching suture,
especially in the setting of weak cartilage.6 Fortunately,
the great advantage of suture techniques is their reversi­
bility, so these unwanted effects are easily remedied in the
revision case.
Poorly designed grafts may be at fault as well in
giving the appearance of a pinched lobule. A too promi­
nent columellar strut may abnormally fill the natural
interalar groove and may even give an unnatural “tent
pole” effect if it becomes the most projecting point within
the infratip lobule. This seems to occur more frequently
after a strut has been placed in an intercrural pocket via
a closed approach without adequate stabilization. A
shield-type tip graft25 that is too narrow by design or that
is placed too cephalically and too projected in relation to
the natural domes may give rise to the undesired effect of
a pinched appearance. This scenario owes to the fact that
the graft itself overtakes the function of single-handedly
creating the lobular contour without appropriately
merging with the lateral alar contour. This effect can be
corrected or prevented by fastidious attention to blending
and “feathering” of the graft edges. We also find that
stabilization of the crura behind the graft and peripheral
location of multiple fixation sutures helps to ensure that
the graft and intermediate crura appear as a single unit.
Placement of a vertical notch at the midpoint of a tip graft
may also preserve normal tip bifidity. When more projec­
tion is desired, use of a CAP graft (Cartilage Augmenta­
tion and Projection graft) similar to Peck’s originally
described onlay tip graft26 can be advantageous. The graft
is designed as a rectangular block of customizable thick­
ness that is commonly secured immediately behind and
cephalic to the shield graft. In this way, the graft acts as
both a buttress to support caudal projection of the shield
graft and a spacer to create a natural supralobular transi­
tion in contour. As with suture problems, pinched lobules
as a result of poor graft technique may be repaired by
graft alteration or replacement as necessary.
The final basis for a postrhinoplasty pinched lobule
is utilization of inadvisable methods for cartilaginous arch
division. Pinched lobules have been noted by the authors
in patients having previous Goldman-type lateral crural
division procedures27 due to in-flare of the “floating”
lateral crural remnants. While proponents of these tech­
niques point to tip stability in their practice experiences,
it has been our observation that the Goldman maneuver,
and its derivatives such as the “hockey stick” excision,
may place the lobule at risk for long-term instability and

CHAPTER TWENTY  Postrhinoplasty Nasal Lobule Deformities: Open Approach
255
Figure 20-9  A postrhinoplasty broad lobule secondary to overresection and bossae formation in a thick-skinned patient. Preoperative and postopera­
tive (A) frontal, (B) lateral, (C) oblique, and (D) basal views. Schematic (E) showing tip correction with a left underlay alar strut graft, columellar strut, bilateral
lateral crural overlay, single-dome unit sutures, and soft tissue thinning.
A
B
C
D
E

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Peter A. Adamson • Jason A. Litner • Peyman Solieman
may be placed in an overlay fashion to simultaneously
enhance both form and function.
THE ASYMMETRIC LOBULE
An asymmetric postrhinoplasty lobular deformity usually
results from unrecognized buckling of the domal arch
secondary to trauma, unequal lower lateral cartilage exci­
sion, or scar contracture forces acting on the medial or
lateral crura that cause the tip to twist.30 The surgical
maneuvers that contribute to bossae formation and tip
asymmetry are those that fail to produce or secure sym­
metric domal cartilages, those that promote separation of
the domes, and those that excessively thin the horizontal
width of the lateral crura by aggressive cephalic margin
resection.31 To avoid the sequelae of tip bossae or asym­
metry, a surgeon must always reconstitute the domes sym­
metrically, reinforce weak cartilage, and avoid excessive
cartilage excisions.
As a general rule, the simplest and fewest possible
techniques should be applied to achieve the desired
outcome (Figure 20-12). In the asymmetric lobule, it may
be possible to achieve normal symmetry by application of
asymmetric suture techniques such as unilateral or asym­
metric single-dome unit sutures. Once adequate symmetry
has been obtained, the authors prefer to set the tip complex
with a double-dome unit suture and an intercrural hori­
zontal mattress suture within the intermediate crus. This
suture is a very powerful way to simultaneously achieve
appropriate intercrural height, angulation, symmetry, and
support. Alternatively, when lobular contour is asymmet­
ric owing to attenuated or distorted arch segments, verti­
cal division within the domal arch segment may be used
to simultaneously correct arch length and asymmetry in
addition to irregularities of the lobular–columellar rela­
tionship such as a hanging infratip. Unilateral or asym­
metric cartilaginous arch divisions or combinations of
various maneuvers may be exploited in a graduated
fashion and customized to each patient’s particular
anatomy. An elongated columellar strut extending upward
between the intermediate crura can sometimes add the
required support and enhance symmetry. Finally, grafts
may be used to conceal any remaining asymmetries that
prove too problematic to correct by other means.
SUMMARY
Increasing acceptance and utilization of the open rhino­
plasty approach have provided for far greater diagnostic
and therapeutic exactitude in the management of post­
rhinoplasty lobule deformities. While the techniques
depicted here are powerful and dependable, the experi­
enced surgeon should not feel confined by this armamen­
tarium. The authors frequently find themselves exploring
novel variations in technique to uniquely tailor the
Occasionally, excessive scar in the scroll region may also
need to be cautiously excised to achieve greater narrowing
of the lateral supratip regions. It goes without saying that
functional needs should not be undercut in the pursuit of
aesthetic enhancement in these scenarios. It is especially
important in the revision patient with thick, scarred, and
inelastic skin to understand the need for augmentation
and projection to achieve any measure of lobule refine­
ment. In thin-skinned patients, scar contraction following
aggressive cephalic lower lateral cartilage resection can
lead to the triad deformity of thin skin, knuckling, and
intercrural bifidity.
THE BICONVEX LOBULE
A biconvex lobule is the term applied to a persistent
deformity in which the domal arch contour exhibits an
exaggerated natural convexity in both the longitudinal
and horizontal axes (Figure 20-11). This finding disposes
the M-arch to an abrupt “drop-off” lateral to the natural
highlight at the dome region.28 Externally, this can mani­
fest in the appearance of a deep and anteriorly displaced
alar groove. This deformity has been identified by
some as resulting from cephalically malpositioned lateral
crura.29 The authors are of the opinion that a distorted,
bowl-shaped lateral crural contour more readily accounts
for this observation. Reversal of this concavity may be
favorably obtained by use of alar grafts or arch division
techniques. When rotation and deprojection are also
desired, a lateral crural overlay technique can be very
effective in achieving all of these objectives with one
maneuver. In some cases, vertical lobule division will
decrease the length of the domal arch and achieve the
desired refinement. When the lateral crura are of adequate
form and projection, alar strut grafts may be placed in an
underlay fashion to increase crural support and straight­
ening without affecting contour. In the setting of severely
attenuated or asymmetric crura, larger alar batten grafts
Figure 20-10  Dissection of a heavily scarred tip.

CHAPTER TWENTY  Postrhinoplasty Nasal Lobule Deformities: Open Approach
257
Figure 20-11  Treatment of a persistent primary biconvex
lobule. Preoperative and postoperative (A) frontal, (B) lateral, and
(C) basal views. Schematic (D) showing tip correction with bilateral
onlay lateral crural grafts, a columellar strut, bilateral vertical lobule
division, and division of the medial crural footplates.
A
B
C
D

258
Peter A. Adamson • Jason A. Litner • Peyman Solieman
Figure 20-12  A postrhinoplasty asymmetric lobule secondary
to overresection and bossae formation. Preoperative and postop­
erative (A) frontal, (B) lateral, and (C) basal views. Schematic (D)
showing tip correction with a columellar strut, bilateral vertical
lobule division, hinge setback, and lateral crural scoring to create
inversion of convexity.
A
B
C
D

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9. Perkins SW. The evolution of the combined use of endonasal
and external columellar approaches to rhinoplasty. Facial
Plast Surg Clin North Am. 2004;12(1):35–50.
10. Adamson PA. The failed rhinoplasty. In: Gates GA, ed.
Current therapy in otolaryngology–head and neck surgery.
4th ed. Toronto, Ontario: BC Decker; 1990:137–144.
11. Adamson PA, Galli SK. Rhinoplasty approaches: current state
of the art. Arch Fac Plast Surg. 2005;7(1):32–37.
12. Foda HM. Rhinoplasty for the multiply revised nose. Am J
Otolaryngol. 2005;26(1):28–34.
13. Vuyk HD, Watts SJ, Vindayak B. Revision rhinoplasty: Review
of deformities, aetiology, and treatment strategies. Clin
Otolaryngol. 2000;25:476–481.

261
C H A P T E R T W E N T Y - O N E 
The Management of
Alar–Columellar Disproportion
Russell W. H. Kridel • Robert J. Chiu • Anand D. Patel
Often unappreciated in rhinoplasty is the alar–columellar
complex. Patients may present with a preexisting hanging
or retracted columella or abnormal alar rim or columellar
shape and configuration. In the patient with a preoperative
normal relationship, certain surgical maneuvers, made to
affect other desired changes elsewhere in the nose, may
leave the patient with an unattractive alar–columellar
complex after surgery. Alterations that are made to the
lower third of the nose must take into account the relation­
ship between the nostril border and ala to the columella.
A seemingly attractive nose may be aesthetically displeas­
ing if the alar–columellar relationship is not refined and
proportional. Compared to other aspects of rhinoplasty,
relatively little attention is devoted to the proper diagnosis
and treatment of alar–columellar disproportion. To
address this, it is paramount to discern the etiology of
the alar–columellar disproportion, which requires a full
understanding of the relevant nasal anatomy and com­
monly used rhinoplasty techniques that can alter it.
THE IDEAL ALAR–COLUMELLAR
RELATIONSHIP AND THE AGING NOSE
Normal columellar show is classically defined as between
2 and 4 mm of visible columella below the alar margin
on profile view1 (Figure 21-1). However, this definition
fails to differentiate between relative positions of the ala
and the columella. Tardy qualitatively described the ideal
appearance of the ala and columella on frontal view as a
gentle “gull-in-flight” configuration where the columella
represents the body of the gull and the alar margin rep­
resents the wings of the gull.2 On profile view, the alar
margin resembles a gentle S-shaped configuration. Gunter
quantified the alar–columellar relationship by drawing
horizontal lines through the tip-defining point, the alar
rim, and the columellar–alar–facial junction.3 This divided
alar–columellar disproportion into six categories, depend­
ing on if whether the position of the ala or columella (or
both) were contributing to the problem. Perhaps an all-
encompassing method of analysis is to consider all the
factors that contribute to a pleasing alar–columellar
relationship: width of columellar show, long axis of the
nostril, shape of the nostril, shape of the alar margin,
presence of a double break in the columella, length of the
upper lip, columella-to-lip ratio, columella-labial angle,
and the configuration of the lateral crus. With respect to
the nostril shape, an oval shape is desirable.
The anatomic components (Figure 21-2) that deter­
mine the position and shape of the columella include the
cartilaginous caudal septum, membranous septum, and
intermediate and medial crus of the lower lateral carti­
lages. Their contributions may vary. Typically, the caudal-
cephalic dimension of the medial crus is 4 mm,4 which we
refer to as the medial crural width. The position and shape
of the ala are established by the width and orientation of
the lateral crus of the lower lateral cartilages and the
insertion and resilience of the fibroadipose component of
the nasal ala.
Aging has a significant effect on these structures.
Weakening of fibroelastic attachments in the scroll region
as well as suspensory ligaments between the medial crura
lead to tip ptosis, divergence of the medial crural foot­
plates, and subsequent lengthening of the membranous
septum. Also, with aging there is bone recession in the
premaxillary region. In sum, these changes give the
appearance of narrowing of the nasolabial angle and
shortening of the columella, with a hanging columella
anteriorly and a retraction posteriorly.5–7
Alteration of the tip rotation and projection in this
case, in concert with adjunctive procedures, may itself
correct the hanging columella defect. Numerous methods
have been developed that define the ideal proportions
and angles of the nose and nasal tip projection.1,8–12 An
approach to create an ideal alar–columellar relationship
can only be undertaken after the desired tip projection
and rotation are set.
THE HANGING COLUMELLA DEFORMITY
The hanging columella deformity is a common cause of
alar–columellar disproportion. A retracted ala or alar
notching can give the appearance of a hanging columella

262
Russell W. H. Kridel • Robert J. Chiu • Anand D. Patel
Figure 21-1  Normal columellar show is defined as 2 to 4 mm.
2-4 mm
Figure 21-2  The anatomic components that help determine the posi­
tion and shape of the columella. (© 2009 Russell W. H. Kridel, MD; used
with permission.)
Lateral crus
Cartilaginous septum
Membranous
septum
Medial crus
4 mm
Figure 21-3  The hanging columella deformity can be the result of excess membranous septum, prominent caudal septum, excessively wide medial
and intermediate crus, downwardly curved medial crus, or overly long lower lateral cartilages (LLCs). (From Kridel RWH, Chiu RJ. Alar columellar dispropor­
tion. Facial Plastic Surgery Clinics November 2006; used with permission.)
Hanging
columella
Excessive
membranous
septum
Overly long or
prominent
caudal septum
Excessive
medial crural
“width”
Downwardly curved medial
crus or overly long lower
lateral cartilages
and must be differentiated, because the etiology and sur­
gical repair are different. The anatomic configurations
that make up the hanging columella deformity include
overdevelopment of the caudal septal cartilage, which
pushes down the medial crura, and/or the redundant
membranous septum (Figure 21-3). Additionally, the
medial and intermediate crura can be too wide,
excessively curved and convex, or vertically inclined. The
long medial crus, with an excessive C-shaped curvature,
has been cited as a prominent cause of the hanging colu­
mella deformity.13 Adamson cited a broad vestibular vault
and ptosis of the medial crura as additional causes.14 In
the senior author’s experience, a large nasal spine is rarely
the etiology because it is usually the septum that projects
more forward and caudally than ever does the spine.
A hanging columella can result from previous rhino­
plasty. Loss of tip projection and rotation causes loss of
tip support and relative redundancy of the columella with
apparent columellar show. Forward or caudal placement
of a columellar strut or caudal septal extension graft can
be the culprit. Suturing together previously bifid and lat­
eralized medial crura can make the columella more cau­
dally prominent. A tip graft that is too thick or a plumping
graft that is too large can create the same problem.

CHAPTER TWENTY-ONE  The Management of Alar–Columellar Disproportion
263
Treatment of the hanging columella deformity is
based on the underlying etiology. Previous descriptions of
surgical repairs have been separated into indirect and
direct.13,15 The direct repairs involve resection of the
caudal margin of the medial crura, whereas the indirect
repairs involve trimming the caudal septum or the mem­
branous septum. In the senior author’s experience, the
tongue-in-groove (TIG) technique is very effective in cor­
recting the hanging columella deformity in many cases,
including defects caused by long, convex medial and
intermediate crura, vertical inclination of the intermediate
crura, or overdevelopment of the caudal quadrangular
cartilage.16 The TIG technique does not burn any bridges.
In brief, mucoperichondrial flaps are developed on both
sides of the caudal septum, a pocket is developed between
the medial crura, and the caudal septum is positioned into
the developed pocket. After assessment of the appropriate
relationship, excess membranous septum is trimmed
bilaterally on the septal (cephalic) side of the incision,
allowing for the greatest excision in the area where the
columella hangs the most. After closure of the transfixion
incision, septocolumellar sutures are used to add strength
or to affect change in the tip height. In select cases where
the hanging columella defect still exists after the TIG
procedure due to an overdeveloped caudal quadrangular
cartilage, conservative excision of the caudal end of the
cartilaginous septum is carried out. In contrast to some
authors who have found a frequent need to reduce the
maxillary spine,17,18 the senior author rarely finds the need
to trim the nasal spine to correct the hanging columella
defect. Occasionally, the medial crura may be too caudally
projecting, and conservative trimming of the caudal edge
of the medial crura is performed and the medial crura are
sutured together. In the treatment of excessively curved
and long medial crura, division of the alar cartilages at
the angle of the medial and lateral crura has been advo­
cated with placement of a columellar strut to restore
strength and tip support.13,19 When the lower lateral car­
tilages are too long and are overdeveloped, a lateral crural
overlay (LCO) can be used to shorten the lateral crura
and rotate the tip, in concert with a TIG procedure to
correct the hanging columella deformity by setting the
medial crura back over the septum.20 Last, in revision
cases where previous graft placement is the causative
factor for the hanging columella defect, the offending
graft, whether it is a tip graft, columellar strut, or caudal
septal extension graft, is removed, replaced, or trimmed.
TREATMENT ALGORITHM FOR
THE HANGING COLUMELLA
Algorithms in rhinoplasty can only be guidelines since
patients and noses are different and each treatment must
be individualized. However, algorithms can help organize
an approach to the problem. An algorithm has been
developed to manage the hanging columella deformity in
a systematic approach (Figure 21-4).21 Once alar–
columellar disproportion has been identified, the presence
of a hanging columella is assessed. If a hanging columella
is not present, the surgeon is directed to the diagnosis and
treatment of alar retraction or notching with grafting. The
next step is the palpation of the caudal septum at the
columella to determine any contribution to the problem.
At this point, the treatment algorithm diverges. If the
caudal septum is normal, the surgical procedure to correct
the hanging columella defect begins by performing a TIG
procedure. Most cases of hanging columella with a normal
caudal septum position will be resolved by a TIG proce­
dure with trimming of the membranous septum. Con­
versely, if there is significant caudal septal excess, the
caudal septum is trimmed first, followed by a TIG proce­
dure. After reevaluation for persistent hanging columella,
further conservative trim of the caudal septum may be
performed, making sure to preserve an adequate caudal
septal strut when septoplasty is also performed. If the
hanging columella deformity persists, a TIG procedure
involving medial crural setback on the caudal septum is
considered and performed. Consideration is also given to
the occasional presence of a prominent maxillary spine,
with attendant reduction. We then proceed with external
rhinoplasty to identify additional causes for any residual
persistent hanging columella. Any cartilage grafts previ­
ously placed that are contributing to a hanging columella,
including a columellar strut graft, tip graft, caudal septal
replacement graft, caudal septal extension graft, or colu­
mellar batten grafts, are removed. If a hanging columella
is still present, trimming of the caudal medial crura is
performed, and consideration is given to a medial crural
overlay (MCO) technique22 in cases of long intermediate
or convex intermediate crura, or an LCO technique in
cases of excessively long lower lateral cartilages.
THE RETRACTED ALA
A retracted ala is usually encountered after previous rhi­
noplasty, but it can be secondary to a previously unrec­
ognized disproportion. Familial variants contributing to a
retracted ala include a highly arched alar lobule margin
with high insertion into the cheek laterally or a plunging
nasal tip with high-arched ala.2 Vertically oriented lower
lateral cartilages may significantly contribute to bilateral
retracted alae.
More often, the retracted ala is due to aggressive
excisional surgery or as a result of normal scar contracture
from prior surgery. The cephalic trim of the lower lateral
cartilage is a commonly used technique in rhinoplasty to
refine and narrow the tip and to cause rotation of the tip
via scar contracture at the scroll area. The degree of scar
contracture is difficult to predict, and varying amounts of
cephalic trim of the lateral crus can cause the alar margin

264
Russell W. H. Kridel • Robert J. Chiu • Anand D. Patel
cartilage can be repositioned inferiorly in this manner. If
tip rotation is needed as well, the Boccieri modification of
the Kridel LCO technique is an excellent way to address
this problem.24 In the senior author’s experience, double-
dome sutures can solidify the position of the lower lateral
cartilages and counteract the tendency for retraction,
especially when the domes are brought together with a
caudal rotation of the lower lateral cartilages. Retraction
with high insertion of the lateral crus can also be treated
with alar base resection and repositioning.25 Alar rim
grafts can be used to treat mild to moderately retracted
alae or as a preventive measure to counteract floppy alae
or potential future scar contracture with later retraction.
Alar rim grafts can be placed through a closed or open
technique via a precise pocket created in the alar rim
(Figure 21-5). A properly sized graft is fashioned to fit
the exact pocket, and the medial aspect is sewn to the alar
rim soft tissue so as to prevent migration of the alar rim
graft. If an alar base excision is to be carried out addition­
ally, the rim graft may be inserted through that incision
from lateral to medial. Alternatively, an alar batten onlay
graft with an extension in the alar rim can be used
to retract and result in alar–columellar disproportion.
Other excisional techniques that can predispose to this
condition include excision of the lateral-cephalic portion
of lateral crura and vertical interruption of the lower
lateral cartilages. Often specific to the closed rhinoplasty
approach and causing a more difficult situation is the
possibility that the vestibular skin under the lower or
upper lateral cartilages was inadvertently trimmed via an
intercartilaginous, intracartilaginous, or transcartilagi­
nous incision, which, coupled with a cephalic trim, can
predispose to alar retraction. Additionally, a tightened
lateral crural spanning suture may be yet another iatro­
genic cause for alar retraction, which can be relieved with
removal and repositioning.23 And, in the open technique,
a tightened closure of the marginal incision may also
predispose to such retraction.
In treating the retracted or notched ala, management
depends first on the identification of any tissue deficiency.
In cases of mild retraction with no tissue deficiency,
the lateral crus can be detached after wide undermining
of the scroll area, followed by repositioning of the lateral
crus more inferiorly. A vertically oriented lower lateral
Figure 21-4  Treatment algorithm for managing the hanging columella deformity. (From Kridel RWH, Chiu RJ. Alar columellar disproportion. Facial Plastic
Surgery Clinics November 2006; used with permission.)
Alar columellar disproportion identified.
Hanging columella present?
No
No
No
No
No
Palpate caudal septum.
Caudal septal excess
present?
Correct alar
retraction/notching
TIG with
membranous
septum excision
Excision caudal
septum [in cases with
large excess TIG with
membranous septum
excision]
Hanging
columella?
Hanging
columella?
Done
Done
Yes
Yes
Yes
Consider further
caudal septal
cartilage trim
Perform medial crural
setback on caudal
septum (TIG) and
consider maxillary
spine prominence
and trim
Persistent
hanging
columella?
External
rhinoplasty
approach
Removal of previously
placed grafts (columellar
strut/batten, tip graft)
Trim caudal
medial crura
MCO for long/convex
intermediate crus
LCO for long
lower lateral
cartilage
Yes
Yes

CHAPTER TWENTY-ONE  The Management of Alar–Columellar Disproportion
265
Figure 21-5  A, Schematic showing the technique of placing an alar rim graft via an open rhinoplasty approach. B, C, Actual intraoperative views showing
the technique of placing an alar rim graft via an open rhinoplasty approach. (From Kridel RWH, Chiu RJ. Alar columellar disproportion. Facial Plastic Surgery
Clinics November 2006; used with permission.)
A
B
C
effectively to treat a retracted ala. For the nose with a
pinched nasal tip, an alar spreader graft can effectively
treat the tip as well as the alar retraction.26
In many revision cases, however, retraction is accom­
panied by scar contracture and lack of mobile tissue to
reposition the ala more caudally. In these cases, extra
tissue must be obtained to “push” the alar rim inferiorly.
The mainstay for management is the composite auricular
skin–cartilage graft. The auricular skin and cartilage are
harvested as a composite graft from an anterior approach,
using a well-camouflaged incision (Figure 21-6). The
composite auricular graft may be placed along the
cephalic edge of the lateral crura, or scroll area, and can
be sutured into the intercartilaginous incision through an
endonasal approach (Figure 21-7). Alternatively, in the
open technique, it may be sutured directly to the caudal
edge of the lower lateral cartilage on the vestibular side
(Figure 21-8). These composite grafts have a high take
rate and are often necessary to correct a severely retracted
or notched ala. One needs to allow for shrinkage of the
grafts, but sometimes it is later necessary months down
the line to intranasally trim any remaining bulk; however,
it is preferable to overcorrect initially than to remain shy
of the necessary correction. Alternatively, Guyuron has
described using an internal lining V-Y advancement to
lower the alar rim, in combination with structural carti­
lage reconstruction for any missing lateral crus.27 For
very severe alar retraction, reconstruction using a cutane­
ous alar rotation flap and autogenous cartilage batten
grafts was described.28

266
Russell W. H. Kridel • Robert J. Chiu • Anand D. Patel
excessive curve to the alar rim margin are suggestive of
alar retraction as the etiology for excessive columellar
show. In revision rhinoplasty, significant contributions
from both the hanging columella defect and alar retraction
commonly result in very significant amounts of columellar
show. Failure to address the hanging columella in the
original surgery, coupled with overly aggressive excisional
techniques of the lateral crus, can result in this predica­
ment. In these cases, the hanging columella defect is
usually addressed first using the TIG technique, trimming
of the membranous septum, and possible trimming of the
caudal cartilaginous septum. After addressing the hanging
columella, the surgeon can better assess the severity of the
alar retraction and the amount of correction needed to
achieve a columellar show less than 3 mm. The mainstay
of treating severe retraction is the composite auricular
cartilage graft, but in some cases, alar rim grafts can also
be effective. Using a full armamentarium of techniques
available to address the hanging columella and alar retrac­
tion, one can achieve an aesthetically pleasing columellar
relationship, even in cases of severe alar–columellar dis­
proportion (see Case Examples 5 and 6).
THE HANGING COLUMELLA COMBINED
WITH A RETRACTED ALA
Often in revision rhinoplasty, the surgeon encounters con­
currently the presence of a hanging columella defect with
a retracted ala. In these cases, it is essential to arrive at
the correct diagnosis and assess the relative contributions
of each deformity. Only then can the correct techniques be
selected to achieve an aesthetically pleasing alar–columellar
relationship. Once again, attention is given to the shape of
the nostril, the tip rotation, the presence of alar notching,
the strength and volume of the lower lateral cartilages, the
shape of the alar margin, the size of the quadrangular
cartilage, and the relationship of the tip and columella to
the upper lip. Excessive nostril show with a ptotic tip,
rounding of the caudal nostril margin, short upper lip, long
lateral crus, and relatively strong lateral crus with no
apparent notching are all suggestive of a hanging colume­
lla etiology. Conversely, the presence of alar notching,
weak lateral crura, retraction of the alar margin, and
Figure 21-6  A, Harvest of free auricular composite grafts from both the concha cymba and concha cava. B, Conchal cartilage is taken with anterior
conchal skin. C, The harvest leaves a symmetric defect. D, Closure is possible without auricular deformity. (© 2009 Russell W. H. Kridel, MD; used with
permission.)
A
B
C
D

CHAPTER TWENTY-ONE  The Management of Alar–Columellar Disproportion
267
THE RETRACTED COLUMELLA
A retracted columella, in comparison, is commonly seen
in primary or secondary rhinoplasty or posttraumatically.
Etiologies unrelated to previous nasal surgery include
normal anatomic variation and congenital causes. Patients
with cleft lip and palate deformity can present with colu­
mellar retraction, secondary to an underdeveloped pre­
maxilla. In addition, numerous processes that erode the
cartilaginous septum or cause septal perforation may
cause a columella to be retracted. A variety of rhinoplasty
techniques can induce the columella to retract. Excessive
resection of the caudal septum or medial crura causes
columellar retraction, especially in the long term. Exces­
sive resection of membranous septum, without cartilage
manipulation, can result in the same predicament. The
TIG maneuver is an effective technique to reposition a
hanging columella.16 However, excessive setback of the
THE HANGING ALA
The hanging ala, or alar hooding, is a relatively more
uncommon diagnosis and can represent a normal ana­
tomic variant previously unrecognized. A prominent ala,
including excessive alar flare, can contribute to a hanging
ala. In correcting alar flare, improper insetting of the ala
after alar wedge resection can cause a hanging ala
deformity. Other causes of the hanging ala include
improperly placed grafts along the alar rim. Simple repo­
sitioning of the ala with a deep stitch via a lateral alar-
facial incision, as one might make for alar wedge
reduction, may often solve the problem. The hanging ala
also can be corrected by directly removing an ellipse of
the alar rim or extra alar lining and underlying subcuta­
neous tissue.3,29 Alternatively, techniques that promote
alar retraction, including cephalic trim, can in this case
help correct a hanging ala.
Figure 21-7  A composite cartilage graft can be placed in the scroll area to “push” the alar rim inferiorly. (From Kridel RWH, Chiu RJ. Alar columellar
disproportion. Facial Plastic Surgery Clinics November 2006; used with permission.)
A
B
C
D

268
Russell W. H. Kridel • Robert J. Chiu • Anand D. Patel
onto the caudal septum, the surgeon needs to reposition
the medial crura through bilateral elevation of septal
mucoperichondrial flaps to free up the membranous
septum and then use suture techniques to recreate the
fibrous attachments between the medial crura and the
septum. Finally, cases of columellar retraction secondary
to a large septal perforation repair may require cartilage
augmentation of the columella.
PREVENTION OF IATROGENIC
ALAR–COLUMELLAR DISPROPORTION
A thorough understanding of the ideal alar–columellar
relationship and the surgical maneuvers that can modify
it is of paramount importance in the prevention of iatro­
genic alterations. Clearly, overly aggressive resections
should be avoided, but even then, alar–columellar dispro­
portions may result from normal scar contracture, as well
as from the vagaries of wound healing that are beyond the
control of a properly executed rhinoplasty. This is particu­
larly true in revision cases.
Prevention of columellar show relies on the careful
use of grafts used in the nasal tip or columella or for septal
medial crus on the caudal septum can cause columellar
retraction. Failure to stabilize the medial crural relation­
ship to the caudal septum can lead to columellar retrac­
tion onto the caudal septum.
Treatment of the retracted columella in revision rhi­
noplasty also depends on identifying the causative factor
for the defect. In cases where the diagnosis of retracted
columella was missed in the initial surgery and where it
represents a natural anatomic variant, one can place a
columellar batten graft or place a cartilage or crushed
cartilage onlay in the columella. Where additional strength
of tip support is also desired, an extended tip graft with
a caudal component can be used to correct the retracted
columella. Alternatively, a columellar strut can be fash­
ioned to extend caudally beyond the caudal border of the
medial crura (Figure 21-9). The columellar strut should
be fashioned so that the most caudal extent of the strut is
positioned in the area of greatest retraction. In cases where
the caudal septum is weak or missing, a septal extension
graft or a caudal septal replacement graft30 can help
improve tip support and correct the retracted columella
(Figure 21-10). A plumping graft will specifically augment
retraction near the columellar-lip angle (see Case Example
3). If the etiology is an improperly positioned medial crura
Figure 21-8  A composite auricular cartilage graft is placed on the caudal edge of the lower lateral cartilage to treat the retracted/notched ala.
A
B
C
D

CHAPTER TWENTY-ONE  The Management of Alar–Columellar Disproportion
269
Figure 21-9  A, B, Intraoperative photographs showing that
the columellar strut can be fashioned to extend caudally beyond
the caudal border of the medial crura to treat the retracted colu­
mella. C, Preoperative photograph of the same patient, showing a
retracted columella. D, Postoperative photograph of the same
patient, showing an improved alar–columellar relationship. (From
Kridel RWH, Chiu RJ. Alar columellar disproportion. Facial Plastic
Surgery Clinics November 2006; used with permission.)
A
B
C
D
Figure 21-10  In cases where the caudal septum is weak or missing, a septal extension graft or a caudal septal replacement graft can help improve tip
support and correct the retracted columella (intraoperative view). (From Kridel RWH, Chiu RJ. Alar columellar disproportion. Facial Plastic Surgery Clinics
November 2006; used with permission.)

270
Russell W. H. Kridel • Robert J. Chiu • Anand D. Patel
LCO technique. However, this did not completely address
the hanging columella, and resection of both caudal car­
tilaginous and membranous septum was required. A TIG
maneuver, as well as binding of the domes, helped set the
position and strengthen the nasal tip.
CASE EXAMPLE 2
A 39-year-old woman desires surgical correction of func­
tional and aesthetic nasal concerns as well as severe acne
scars. On examination, she has a deviated nasal septum;
thick skin envelope with acne scars; dorsal hump with a
tension septum; ptotic, underprojected tip with appear­
ance of alar notching; and hanging columella with an
excess cartilaginous component (Figure 21-12).
Plan
• Septoplasty
• Dorsal reduction
• Trim membranous and cartilaginous septum with TIG
• Lateral crural steal (LCS)31 and dome binding
• Alar rim grafts
This patient underwent rhinoplasty and CO2 laser treat­
ment of the face (excluding the nose). The hanging colu­
mella was addressed with a conservative resection of
cartilaginous and membranous caudal septum and a TIG
maneuver. Preoperatively, it seemed that the notched
appearance to the ala was due to ptosis and an underpro­
jected nasal tip. However, after rotating and projecting the
tip with use of the LCS technique, persistence of a notched
appearance demanded the use of alar rim grafts not only
for correction but also to prevent further progression.
CASE EXAMPLE 3
A 27-year-old woman who 2 years earlier had undergone
primary rhinoplasty, which had included the placement
of a tip graft and alar base reduction with two minor
revisions, is still dissatisfied with the overall size of her
nose and bulbosity of the nasal tip. On examination, the
patient has a thick skin envelope; a cartilaginous polly­
beak deformity; an overprojected, bulbous tip; an anterior
hanging columella; and a posteriorly retracted columella
with an acute nasolabial angle (Figure 21-13).
Plan
• Cephalic trim and cartilaginous dorsal reduction
• Trim anterior portion of membranous septum with TIG
• MCO
• Columellar strut
• Premaxillary graft
In this patient, the caudal cartilaginous septum was
normal, but the medial crura were long and excessively
extension and replacement. When placing such grafts, the
surgeon should always remain attentive to resultant
changes in the alar–columellar relationship and conser­
vatively trim the offending components as needed. The
retracted columella can be prevented by stabilization of
the relationship between the caudal septum and colu­
mella. With the increasing popularity of the external rhi­
noplasty approach, one needs to take a judicious approach
when handling the septum via an open septoplasty tech­
nique. The failure to reestablish the medial crura attach­
ments and precisely reposition the relationship between
the caudal septum and medial crura can cause the colu­
mella to retract onto the caudal septum. Oftentimes, a
septocolumellar stitch has to be placed to separate the
caudal septum from the columella complex to prevent
retraction. The senior author prefers an endonasal septo­
plasty approach when using a TIG technique, as well as
septocolumellar stitches.
The prevention of alar retraction requires judicious
excision of the cephalic margin of the lateral crura,
keeping an intact vestibular skin and avoiding excessive
resection of tissue in the scroll area so as to not create a
large space for potential retraction. Not all iatrogenic
causes of alar retraction involve overresection or excision.
The senior author strongly believes in suturing the mar­
ginal and intercartilaginous incisions to decrease the
chances of alar notching. However, we have noted that the
tight closure alone of the marginal incision in the open
approach can pull up the ala. At times, “air-knotting” the
closure of this incision avoids pulling up the ala. The
creation of a hanging ala can be prevented by precise
placement of alar grafts such that the edges do not push
the ala caudally. Also, care must be taken during alar base
corrections not to reposition the ala to an unfavorable
position in relationship to the columella.
CASE EXAMPLE 1
A 64-year-old man who broke his nose in a childhood car
accident presents with chronic nasal airway obstruction.
The patient also has concerns about nasal tip ptosis,
which has continued to progress with age. On examina­
tion, the patient has a deviated nasal septum; a deep radix
coupled with a dorsal hump; weak, ptotic, and overpro­
jected nasal tip; and hanging columella with an excess
cartilaginous component (Figure 21-11).
Plan
• Septoplasty
• Dorsal reduction
• Crushed cartilage radix graft
• Trim membranous and cartilaginous septum with TIG
• LCO and dome binding
This patient has the classic characteristics of the aging
nose. The nasal tip was rotated and deprojected using the

CHAPTER TWENTY-ONE  The Management of Alar–Columellar Disproportion
271
On examination, the patient has a deviated nasal septum;
irregular dorsal hump; underrotated, overprojected tip
with asymmetries; hanging columella with wide medial
crura; and alar retraction (Figure 21-14).
Plan
• Septoplasty
• Dorsal reduction
• Trim membranous septum and medial crura with TIG
• Dome sutures
• Alar rim grafts
Here, mild hanging of the columella coupled with alar
retraction is causing significant columellar show. The
cause for the hanging columella, in this case, is not excess
caudal septum. A slight trim of the wide medial crura and
curved, which produced a hanging columella anteriorly.
The MCO and a localized resection of membranous septum
helped to address this problem. A columellar strut was
placed to maintain support to this region. A premaxillary
cartilage graft was placed to address the posterior colu­
mellar retraction.
CASE EXAMPLE 4
A 37-year-old woman presents with a history of unsatis­
factory primary rhinoplasty 18 years earlier, as well as
subsequent nasal trauma in an automobile accident. She
desires improved nasal breathing, a shorter nasal tip, and
smaller nose overall with less show of her nostrils. The
patient also had concerns about having a protrusive chin.
Figure 21-11  Case example 1. A–C, Preoperative photographs. D–F, Postoperative photographs (8 months).
A
B
C
F
D
E

272
Russell W. H. Kridel • Robert J. Chiu • Anand D. Patel
columella, composed of cartilaginous and membranous
septum; and severe alar retraction (Figure 21-15).
Plan
• Dome truncation and binding sutures
• Trim of membranous and cartilaginous septum with
TIG technique
• Alar batten grafts
This patient’s severe alar retraction was likely a result of
overly aggressive cephalic trim of the lower lateral carti­
lages. Here, alar rim grafts would not be sufficient, and
instead, alar batten grafts were secured to the lateral crus
membranous septum and the placement of alar rim grafts
are relatively conservative maneuvers that additively
create a substantial effect on columellar show. The patient
also underwent placement of a chin implant.
CASE EXAMPLE 5
A 38-year-old woman who previously underwent rhino­
plasty 22 years earlier, and had a satisfactory result, has
noticed increasing droop and asymmetry of her nasal tip
with more show of her nostrils over the past decade. On
examination, she has a ptotic, overprojected tip; hanging
Figure 21-12  Case example 2. A, B, Preoperative photographs. C, D, Postoperative photographs (2 years).
A
B
C
D

CHAPTER TWENTY-ONE  The Management of Alar–Columellar Disproportion
273
external approach using rim incisions. She is concerned
with a “scooped-out” appearance to her nasal dorsum, her
unrefined nasal tip, and increased nostril show. On exami­
nation, we find an overresected nasal dorsum; boxy tip;
hanging columella; and alar retraction. The patient has
very little residual septal cartilage (Figure 21-16).
Plan
• Dorsal augmentation with irradiated rib cartilage
• Trim of membranous and cartilaginous septum with
TIG technique
remnants. The hanging columella required a conservative
excision of caudal septal cartilage and membrane with a
TIG maneuver.
CASE EXAMPLE 6
A 28-year-old woman presents with a history of nasal
trauma during childhood and primary septorhinoplasty 4
years earlier, with resection of nearly all the cartilaginous
septum, dorsal reduction, and some tip work through an
Figure 21-13  Case example 3. A–C, Preoperative photographs. D–F, Postoperative photographs (1 year).
A
B
C
F
D
E

274
Russell W. H. Kridel • Robert J. Chiu • Anand D. Patel
recruited to the area via an auricular composite graft,
which was sutured to the caudal edge of the residual lower
lateral cartilages.
CONCLUSION
The problem of alar–columellar disproportion in rhino­
plasty presents a challenge to all surgeons. It is very
important to proceed only after careful analysis of the
• Dome binding sutures
• Alar grafting with composite auricular tissue
Here the rotation and projection of the tip do not need to
be altered much, and so will not affect the alar–columellar
relationship. The hanging columella was addressed with
a conservative trim of caudal cartilaginous and membra­
nous septum. Overresection of cephalic lower lateral car­
tilages coupled with alar rim incisions likely contributed
to this patient’s alar retraction. New tissue needed to be
Figure 21-14  Case example 4. A–C, Preoperative photographs. D–F, Postoperative photographs (1 year). (From Kridel RWH, Chiu RJ. Alar columellar
disproportion. Facial Plastic Surgery Clinics November 2006; used with permission.)
A
B
D
C
F
E

CHAPTER TWENTY-ONE  The Management of Alar–Columellar Disproportion
275
Figure 21-15  Case example 5. A–C, Preoperative photographs. D–F, Postoperative photographs (112 years). (From Kridel RWH, Chiu RJ. Alar columellar
disproportion. Facial Plastic Surgery Clinics November 2006; used with permission.)
A
B
C
F
D
E

276
Russell W. H. Kridel • Robert J. Chiu • Anand D. Patel
REFERENCES
1. Powell NP, Humphries B. Proportions of the aesthetic face.
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defect and correct diagnosis of the problem. The surgeon
then can choose among the myriad of approaches the
particular techniques that will achieve the desired rela­
tionship between the alar margin and columella and
create an aesthetically pleasing result. Keys to prevention
are a heightened sensitivity to the maneuvers and mishaps
that may lead to alar–columellar disproportion.
Figure 21-16  Case example 6. A–C, Preoperative photographs. D–F, Postoperative photographs (8 months).
A
B
C
F
D
E

CHAPTER TWENTY-ONE  The Management of Alar–Columellar Disproportion
277
19. Adamson PA. Commentary: Anatomical considerations in the
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thickening. ENT. 1982;61:452–455.
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lateral crural overlay technique. Arch Otolaryngol Head Neck
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management of the hanging columella. Arch Fac Plast Surg.
2000;2:173–177.
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columella. J Otolaryngol. 1990;19:319–323.
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columella. Plast Reconstr Surg. 1980;65:513–516.
16. Kridel RWH, Scott BA, Foda HM. The tongue-in-groove
technique in septorhinoplasty. Arch Fac Plast Surg. 1999;1:
246–256.
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excess nasal deformity. Arch Fac Plast Surg. 2005;7:124–134.
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2003;5:338–344.

279
C H A P T E R T W E N T Y - T W O 
Evaluation and Correction
of the Crooked Nose
Michael J. Brenner • Peter A. Hilger
GENERAL CONSIDERATIONS
The crooked nose is neither a single entity nor a specific
description. Crooked noses represent a spectrum of nasal
deformities, most commonly of traumatic origin, that are
associated with a deviated or irregular appearance to the
nose. For the casual onlooker, the crooked nose may be
unsettling because of its disharmony with the rest of the
face, much like a picture frame that sits askew on a wall.
In common usage, “crooked” connotes not only a lack of
straightness but also traits of dishonesty or unsavory char­
acter, as contrasted to the forthright person who is “playing
it straight.” The term “crooked nose” is thus apt because
it not only captures the distinctive external appearance of
a misaligned, deviated nose but also suggests the potential
for social stigmatization. The surgeon should thus be
attentive to not only the anatomic characteristics of the
crooked nose but also the potential effects of this defor­
mity on the patient’s self-image.
Correction of the crooked nose remains a notoriously
difficult challenge for the rhinoplasty surgeon. The
complex interplay of functional and aesthetic considera­
tions is coupled with the predilection of this deformity for
gradual recurrence, often despite initially successful surgi­
cal treatment. The contracture forces of scar formation
combined with cartilage thickening and deformation may
resist definitive correction. Cartilage’s elastic memory, the
progressive formation of adhesions, and the collapse of a
weakened septum are all contributory factors. An under­
standing of the relevant anatomy and pathogenesis of the
deformity informs the surgical approach. This chapter
covers the etiology, analysis, and surgical correction of the
crooked nose.
ANATOMY OF THE CROOKED NOSE
The anatomy of the crooked nose is best understood rela­
tive to the constituent components of the osseocartilagi­
nous framework. The upper third of the nose comprises
the bony pyramid with its paired nasal bones and ascend­
ing processes of the maxillae. Bone thickness tapers along
the nasal bones’ caudal aspect. The lower two thirds of
the nose are cartilaginous, including the nasal septum, the
paired upper lateral cartilages, and the alar cartilages.
The cartilage of the septum is relatively wide along the
floor of the nose, flattens in the midportion, and is thickest
near the dorsum, adjacent to the takeoff of the upper
lateral cartilages.
Crooked noses exhibit greater diversity in their pat­
terns of deformity than do isolated bony fractures. This
heterogeneity is a reflection of the ability of cartilage to
not only fracture but also twist, bend, and remodel in
response to injury. The nasal septum behaves much like
the rudder of a boat that both acutely and chronically
guides the direction of the external nose, lending credence
to the surgical maxim, “Where the septum goes, so goes
the nose.” Traumatic injury may cause angulation, tele­
scoping, stepoffs, flattening, or splaying of the framework
of the nose. The entire nasal pyramid may be deviated to
one side, or a canted bony pyramid may be at an angle
with the mid vault or lower third of the nose.
CLASSIFICATION OF THE CROOKED NOSE
The common patterns of crooked or deviated noses are
the C-, S-, and I-type deformities shown in Figure 22-1.
The C-shaped deformity usually begins cephalad at the
nasal dorsum, proceeds posteroinferiorly through the per­
pendicular plate of the ethmoid, and then extends into the
cartilaginous septum. The S-shaped deformity is charac­
terized by a serpentine twisting of the external nose,
usually with corresponding septal deviation. The I-shaped
deformity corresponds to a deviation of the entire nasal
pyramid. The nose is considered truly deviated if it departs
from the midline position, with or without curvature.
These deformities are associated with varying degrees of
nasal obstruction.
Not all crooked noses fit neatly into this classification
scheme. Prior rhinoplasty, pathologic disease processes,
and saddling may all produce unpredictable patterns of
asymmetry. Some noses that appear crooked do not have
a true deviation. For example, when a laterally directed

280
Michael J. Brenner • Peter A. Hilger
patients, who are more prone to nasal bone comminution.
As a general rule, nasal trauma associated with septal
fracture requires extensive reconstruction and is unlikely
to be adequately treated with closed reduction. The
surgeon should also consider psychological repercussions
of the incident; such factors may influence the patient’s
readiness to undergo an elective surgical intervention.
The crooked nose deformity may reflect either the
acute outcome of a traumatic episode or a remote injury
that has been compounded by years of scarring and soft
tissue contracture. The cartilaginous septum is the primary
shock absorber of the nose, with lesser contributions from
the upper lateral cartilages, alar cartilages, and bony com­
ponents. Patients with untreated or inadequately reduced
nasal fractures may develop a crooked nose gradually,
with surface irregularities and asymmetries becoming
more conspicuous with the passage of years. Cartilage has
a low metabolic rate and frequently heals with scar forma­
tion. In cases of remote trauma, the patients may recount
a worsening of the deformity with time, often associated
with progressive nasal airway obstruction due to disrup­
tion of nasal support mechanisms. Repetitive fractures
may cause profound structural deficiency, and comminu­
tion often will induce aberrant growth.
force causes unilateral collapse of a nasal bone, the result­
ing concavity makes the nose appear deviated to the oppo­
site side. Unilateral infracture of the bony pyramid side
wall is often not associated with displacement of the
septum. This infracture injury has a more favorable long-
term prognosis with surgery and requires less extensive
reconstruction than does a true deviation.
ETIOLOGY AND PATHOGENESIS
OF THE CROOKED NOSE
TRAUMATIC CAUSES
The nasal bones are the most commonly fractured bones
in the face, and nasal injury is the most common cause of
the crooked nose. True deviation is indicative of a high
energy injury and requires greater force than an isolated
nasal bone depression or fracture. Usually a significant
frontal vector is required for deviation to occur. With
trauma, the nasal septum is often fractured or displaced
from the maxillary crest. Because the nasal framework
becomes more ossified and brittle with age, younger
patients tend to have larger fracture segments than older
Figure 22-1  Examples of crooked nose deformities. A, C-shaped deformity. B, I-shaped deformity. C, S-shaped deformity.
Nasal
septum
Nasal
turbinates
A
Nasal
septum
Nasal
crest
B
Nasal
septum
Nasal
turbinates
C

CHAPTER TWENTY-TWO  Evaluation and Correction of the Crooked Nose
281
occurred during birth. Forceps delivery and breach deliv­
ery are risk factors, although the head is also subjected to
powerful compressive forces during normal passage
through the birth canal. Such early deformities may
first become evident during adolescence, as shown in
Figure 22-2.
IATROGENIC CAUSES
Prior nasal surgery is an important cause of the crooked
nose. Asymmetric or incomplete osteotomies often result
in deviation and step-off deformities of the upper third of
Many patients with a crooked nose do not remember
the inciting traumatic injury. The patient with a severely
twisted nose and without history of antecedent trauma is
likely to have sustained a childhood injury that was over­
looked. Relatively minor cartilage trauma may lead to
dramatic deformation over time with chondrocyte growth.
The pediatric nose lacks a well-developed bridge and is
capable of absorbing substantial energy without showing
irregularity until later in life. Children’s noses are mostly
cartilaginous and are susceptible to injuries that produce
progressive deformation over subsequent years of growth.
In some cases, septal subluxation or fracture may have
Figure 22-2  Patient with no history of antecedent nasal trauma. The patient developed progressive nasal deformity during adolescence. Examination
demonstrated facial asymmetry with maxillary midline shifted to the right and nasal framework twisted and canted to the right, as well as a broad nasal tip.
A shim spreader graft was created by drilling holes through a bone graft derived from the perpendicular plate of ethmoid. Medial and lateral osteotomies
were performed to restore the nose to midline, and a dorsal onlay crushed cartilage graft was placed.
A
B

282
Michael J. Brenner • Peter A. Hilger
are unaware of asymmetry of the facial bones or soft
tissues that may influence the perceived straightness of
the nose. One of the defining features of the crooked nose
is disruption of the brow–nasal tip aesthetic line, a line
that runs from the medial brow to the ipsilateral nasal tip
defining point. Identification of a break in this contour
line helps localize the site of fracture or deformity that
will require correction. Visual inspection and palpation
are complementary in the nasal analysis.
The bony pyramid, nasal mid vault, and lower third
of the nose are then systematically evaluated. The bony
pyramid may be canted or have palpable surface irregu­
larities. Angulation is often present at the transition of the
upper and lower two thirds of the nose. Careful examina­
tion of the mid vault region will differentiate true devia­
tion from isolated unilateral collapse of a nasal bone and/
or upper lateral cartilage. The nasal tip is assessed for
asymmetry, deviation, presence of bossae, and alar retrac­
tion. Poor recoil of the tip to gentle finger pressure is
indicative of compromised tip support. The anterior septal
angle is palpated for its location and orientation. Basal
view demonstrates caudal septal deviation and subluxa­
tion of the caudal septum off the maxillary crest. The
anterior nasal spine serves as an anchoring point for the
septum. Malposition of the septum due to prior trauma or
surgery will alter nasal alignment and is best appreciated
upon inspection of the nasal base.
Internal nasal examination is crucial from both a
functional and aesthetic standpoint because septal defor­
mity is the primary driver of the external appearance of
the crooked nose. The nose should be examined both
before and after constriction of the nasal mucosa to visu­
alize potential sites of obstruction. The nasal lining will
provide clues as to the extent of scarring and inflamma­
tion. Septal fractures, spurs, deviations, and other deform­
ities are noted. The attachment of the upper lateral
cartilage to the septum should create an angle of at least
10 to 15 degrees to avoid internal nasal valve collapse.
The Cottle maneuver, performed by retracting the cheek
soft tissues laterally, decreases the nasal obstruction from
internal nasal valve collapse. Dynamic alar collapse with
inspiration indicates external nasal valve collapse. Recur­
vature of the lower lateral cartilage into the nasal airway
makes an often unrecognized contribution to airway nar­
rowing and is an impending source of deformity following
tip surgery. Turbinate hypertrophy may require a reduc­
tion or submucosal resection.
Photography is necessary in all patients with crooked
nose, including those with purported interest in the relief
of nasal obstruction only. Photography allows for precise
recording of deformities and for computer imaging during
patient consultation. In addition to the standard 7 rhino­
plasty views (frontal, base, bilateral three-quarters, bilat­
eral side, and lateral smiling views), the authors find it
helpful to include a helicopter or sky view from above the
nose highlighting any twisted configuration. Analysis of
the nose. With green-stick fractures, the bony vault may
be subject to residual memory and deviating forces from
scarring. Alternatively, if adequate osteotomies are per­
formed but the underlying septal deformity is not
addressed, the nasal pyramid will often regress to its origi­
nal, deviated position. Removal of a dorsal hump in the
nose with a straight dorsum and a caudal deviation may
unmask an underlying deformity that was not previously
visible. Closed reduction of a nasal fracture may result in
persistence or creation of a crooked nose if the fracture is
not adequately reduced.
Reduction rhinoplasty deserves special consideration
due to its potential for creating severe asymmetries that
usually become apparent years after surgery. Resection of
the nasal osseocartilaginous framework disrupts nasal
support mechanisms, often with insidious destabilizing
effects. Over the course of years, the contractile forces of
scar formation, gravity, and aging conspire to warp and
collapse the attenuated nasal scaffold. Such distortions
may require major reconstruction years later to address
progressive disfigurement and impairment of nasal func­
tion. Most rhinoplasty techniques have effects in adjacent
zones of the nose during healing. Thus, unexpected devia­
tions often occur from manipulations elsewhere, for
example mid vault narrowing and upper lateral cartilage
collapse occurring after dorsal hump reduction.
DISEASES INVOLVING THE SEPTUM AND
INTERNAL NOSE
Several relatively rare pathologic processes may lead to a
crooked nose. The surgeon should inquire about symp­
toms of nasal obstruction and history of epistaxis, allergy,
and systemic disease. Autoimmune or immunologically
mediated diseases may cause resorption of bony or carti­
laginous nasal structures. Granulomatous disease, such as
Wegener’s granulomatosis or sarcoidosis, and collagen
vascular/connective tissue disorders are important diag­
nostic considerations, particularly in patients with nasal
septal perforation or saddling. A history of inhalant abuse,
such as cocaine, oxymetazoline, nasal steroids, or NeoSyn­
ephrine use, should be considered in cases of mucosal
atrophy, ulceration, or nasal perforation. The surgeon
should also be alert to infectious etiologies such as tuber­
culosis, syphilis, and HIV infection. Sinonasal polyposis
or neoplastic disease may also induce remodeling and/or
splaying of nasal framework.
EVALUATION
PHYSICAL EXAMINATION AND NASAL ANALYSIS
The physical examination begins with an assessment of
overall facial symmetry to ensure that all nasal pathology
is viewed in relation to facial asymmetries. Many patients

CHAPTER TWENTY-TWO  Evaluation and Correction of the Crooked Nose
283
the patient followed by review of photographs taken in
these views will assist the surgeon to determine whether
camouflaging, structural reorientation, or both are needed.
SELECTION OF SURGICAL APPROACH
The decision to undertake anatomic reconstruction (struc­
tural reorientation) versus masking of the deformity
(camouflage) will dictate the surgical approach. Camou­
flage techniques will best preserve existing structural
support but fail to introduce new support and often
involve some compromise in the aesthetic outcome. In
contrast, structural reorientation can achieve excellent
contour and can correct airway obstruction but does so at
the expense of more extensive surgery and the potential
risk for collapse if support mechanisms are not reconsti­
tuted. In performing nasal analysis, the surgeon should
differentiate between the intrinsic forces and extrinsic
forces that contribute to the nasal deformity. Intrinsic
forces are due to aberrant growth and development of the
cartilaginous septum. Extrinsic forces result from devia­
tion of the nasal pyramid. Extrinsic forces are transmitted
to the nasal septum through attachments to the nasal
bones, the upper and lower cartilages, the vomer and
perpendicular plate, and the maxillary crest.1 For more
severe deformities, especially those with airway compro­
mises, we often use a combination of structural realign­
ment and camouflage of residual minor deformities.
When nasal airway obstruction is present or when
there is concern for impending nasal airway compromise,
a structural reorientation approach is preferred. This
approach involves release and deconstruction followed by
rebuilding of structural elements of the osseocartilaginous
skeleton. In such cases, an open rhinoplasty approach is
advised. Camouflaging methods, which create the illusion
of correction without actual manipulation of the deviated
framework, do not influence nasal airway patency. In the
absence of nasal obstructive complaints, camouflage alone
may be adequate for correcting limited deformities. Cam­
ouflage techniques, when used in isolation, are usually
conducive to an endonasal approach. It should be kept in
mind that this method may only partially correct the
crooked appearance and grafts may become visible in
patients with thin skin. In some cases, it is desirable to
use both techniques, as shown in Figure 22-3.
The Role of Closed Reduction
Closed reduction is best reserved for simple nasal fractures
resulting from lateral forces. With such injuries, the nose
may appear deviated but the actual deformity is usually
limited to a single depressed bone fragment of the nasal
side wall. The ipsilateral upper lateral cartilage may also
be pulled medially. The casual observer will often errone­
ously perceive the nasal dorsum to being deflected to the
opposite side. With either closed reduction or rhinoplasty,
this type of injury carries a favorable prognosis. Closed
reduction should be performed within 24 hours of the
injury, prior to the onset of edema, or at 10 to 21 days,
by which time soft tissue edema has resolved. For unilat­
eral nasal bone fracture, the Boies elevator usually suffices
to restore the bone to its native position. Closed reduction
is also useful in the neonatal period, when a difficult
delivery is associated with a displaced septum and can be
reduced with blunt forceps.
Unfortunately, the aesthetic outcomes following closed
reduction are frequently unsatisfactory for the deviated or
crooked nose. Closed reduction has limited precision in
realigning bony and cartilaginous structures that are
askew, telescoping, or markedly displaced. Walsham and
Asch forceps are designed to reduce the displaced septum
and impacted nasal bones, respectively. However, revision
rates after closed reduction are unacceptably high when
significant septal pathology is present.2 Another drawback
is the possibility of mucosal crushing injuries, synechia
formation, and septal hematoma. In general, closed reduc­
tion can be unsatisfying for traumatic deformities that
have bony comminution, extensive cartilaginous injury, or
septal fracture.
If one chooses to perform a closed reduction, assess­
ment of postreduction fragment stability is essential. Most
fractures are, in fact, comminuted injuries that tend to
collapse readily with minimal pressure. In adults, we often
wait 10 to 21 days following their injuries when the frag­
ments start to get “sticky.” In this early phase of healing,
the fragments are more stable. In addition, we will often
support unstable fragments with a section of compressed
cellulose sponge that can be wedged beneath the mucosal
surface of the bone and anchored with absorbable sutures.
The sutures are passed through the dorsal fracture frag­
ments and nasal skin and then taped to the dorsum. These
splints eliminate the need for traditional nasal packing
and are removed within 5 to 7 days.
External Approach to the Crooked Nose
Much debate has centered on the indications for use of
external versus endonasal approaches in rhinoplasty. In
the authors’ opinion, the preferred surgical approach is
the one that confers the highest likelihood of a successful
and durable surgical outcome. The literature confirms
that the columellar scar from the external approach is a
concern in less than 1% of patients. This figure is quite
small compared to the overall published revision rates for
rhinoplasty. Therefore, we use the external approach
whenever improved exposure and precise graft placement
can provide a meaningful advantage. These two criteria
are met in the majority of patients with crooked noses.
The external approach affords the surgeon unparal­
leled exposure for counteracting the intrinsic and extrinsic
forces responsible for cartilaginous septal deviation.
Release of diffuse scar tissue, realignment of collapsed or
twisted lateral cartilages, and repair of septal deviations
involving the dorsal or caudal septum are all cumbersome

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Michael J. Brenner • Peter A. Hilger
opportunity for achieving symmetry in the deviated or
twisted nasal tip.
Endonasal Approach to the Crooked Nose
The endonasal approach is useful for a more limited
subset of crooked noses. One of the most significant
advantages of this approach is that is allows for precise
pocket preparation for camouflage grafts. In addition,
this approach decreases operative time, avoids a columel­
lar incision, may decrease postoperative edema, and obvi­
ates the need to reconstitute the structural elements
through intranasal incisions. Using the external approach,
the surgeon can expose the septum from the dorsum
to the maxillary crest and from the caudal margin back
to the anterior face of the sphenoid. As a result, structural
reorientation involving graft placement under direct visu­
alization and precise suture fixation is possible. In our
experience, placement of spreader grafts after dividing the
upper lateral cartilages through an external approach
results in far more predictable results than endonasal
placement. In addition, the lower third of the nose is seen
in broad relief and easily manipulated, providing the best
Figure 22-3  Patient with canted lower two thirds of nose. Although the nasal bones are situated in the midline, the nasal mid vault and lower third of
the nose are deviated to the patient’s right. Intraoperative assessment confirmed deviation at the bony–cartilaginous junction. An external rhinoplasty
approach with division of the upper lateral cartilages afforded excellent exposure of the structural deformity. A combination of anatomic realignment with
structural grafting and camouflage techniques were required to restore nasal function and achieve an aesthetic result.
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CHAPTER TWENTY-TWO  Evaluation and Correction of the Crooked Nose
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the radix to the supratip to avoid distortion that can occur
if a graft ends at the rhinion. In the uncommon case where
a patient is unwilling or unable to undergo costal cartilage
harvest, homologous irradiated rib graft is useful. It is
readily carved and compares favorably with the commer­
cially available alloplastic implants.
Numerous fixation techniques have been used to
secure dorsal grafts. Our preferred method is to suture the
caudal portions of the graft to the dorsal edges of the
upper lateral cartilages, as in an onlay spreader graft and
anchor the cephalic end to the bony dorsum with one or
two percutaneous Kirschner wires that are removed in 3
weeks as a minor office procedure that rarely requires
even local anesthesia. Lag screw fixation, although pre­
ferred by some, has been unsatisfactory for use due to the
tendency for the screw to extrude long term.
TECHNICAL ASPECTS OF SURGERY
Common steps in surgery of the crooked nose include
exposure of the nasal deformity, release of septal attach­
ments, hump reduction (often performed in an asymmet­
ric manner), straightening of the bony pyramid, and
correction of the deformity with structural and/or camou­
flage grafting. While various algorithms for treatment of
the crooked nose have been proposed,1,3 the complexity
and variability of the crooked nose render most such
approaches of more theoretical than practical value. Ulti­
mately, sound nasal analysis will dictate the sequence of
steps. Discussion of technical aspects of crooked nose
surgery begins with consideration of the crooked nasal
septum, which plays a pivotal role in pathogenesis of the
crooked nose deformity. A detailed discussion on manage­
ment of the upper, middle, and lower third of the nose
follows. Several instructive case studies are detailed in
the accompanying case examples shown in Figures 22-4
and 22-5.
Care must be taken during the surgical exposure to
preserve cartilaginous elements amid the disrupted,
scarred tissue planes. These characteristics necessitate
meticulous dissection during elevation of the skin–soft
tissue envelope in a sub–superficial musculoaponeurotic
system (SMAS) plane. Release of adhesions and structural
attachments optimizes exposure and relieves distortional
forces.
SEPTAL DEFORMITY IN THE CROOKED NOSE
The septum is the crux of the nasal osseocartilaginous
framework. Because the crooked nose is driven by a
crooked septum, failure to correct an underlying dorsal or
caudal septal deformity will inevitably result in migration
of the nose back to a crooked configuration. If the bony
and cartilaginous skeletons are shifted in opposite
disrupted by the open approach. An intercartilaginous
incision allows for camouflage techniques in the middle
third of the nose, as well as conservative hump reduction
and osteotomies, provided the nasal airway remains
widely patent. Grafts are placed immediately above peri­
chondrium or deep to periosteum to minimize the risk
of visible or palpable grafts. Although the delivery
approach has proven very useful in refinement of the
bulbous nasal tip, correction of tip asymmetries is less
reliable endonasally.
SELECTION OF GRAFT MATERIAL
Septal cartilage is the grafting material of choice because
of its versatility, ease of harvest, and minimal donor site
morbidity. When adequate septal cartilage is not availa­
ble, usually auricular cartilage or costal cartilage may be
used. Autologous tissues have long track records of success
and are associated with low risks of infection, extrusion,
and resorption. Conchal cartilage is best for alar batten
grafts and for filling small dorsal concavities, whereas
costal cartilage is often necessary for correction of a saddle
deformity or when previous surgery has reduced other
grafting options. Crushing cartilage significantly improves
camouflage and malleability but may predispose to resorp­
tion if chondrocyte viability is impaired by excessive
trauma. We rarely use calvarial or other bone grafts due
to the favorable attributes of cartilage, which include its
natural feel and facile harvest, carving, and fixation. Acel­
lular dermal matrix may be used selectively for camou­
flage of minor irregularities, although we prefer autologous
fascia, perichondrium, or fibroconnective tissue for this
purpose.
When costal cartilage is required, we prefer to use the
“floater” tenth rib as a dorsal onlay graft. Harvesting from
this site decreases pain, carving time and risks of flail
chest and pneumothorax. Harvesting additional cartilage
from other ribs may be necessary if additional grafting
material is needed. The floater rib has less curvature than
attached ribs and contains both bone and cartilage, thus
mimicking the structural elements to be replaced. The
bony portion of the graft is cantilevered on the rasped
bony foundation of the upper third of the nose to promote
a bony union. If cartilage is harvested from the seventh
or eighth ribs, the grafts should be taken from the center
of a relatively straight cartilage segment to decrease risk
of warping.
Dorsal costal cartilage grafts serve to provide suffi­
cient structure to recreate a straight dorsal line and simul­
taneously camouflage and modify irregularities. Costal
cartilage dorsal grafts are not immune to distortion during
or after surgery, and a few pearls may decrease the risk
of warping. Carving the graft symmetrically by trimming
from both lateral edges and placing a Kirschner wire in
the middle of the graft has been recommended. We rou­
tinely place the dorsal graft along the entire dorsum, from

286
Michael J. Brenner • Peter A. Hilger
that gentle sweeping with a Frazier suction is sufficient to
elevate the flap off the nasal septum.
An area requiring special attention during elevation
of mucoperichondrial flaps is the intersection of the nasal
septum with the vomerine-maxillary groove. At this loca­
tion, the septal perichondrium, maxillary periosteum, and
vomerine crest form a line of dense adhesions that must
be released. This adhesion is sometimes referred to as a
conflicting line (Figure 22-6). We prefer to elevate inferior
and superior tunnels separately and then use a hockey
stick–shaped dissector to lyse these fibrous attachments.
directions, addressing the deviation of the nasal bones
alone may actually worsen the septal component. Attach­
ments between the nasal septum and other nasal frame­
work transmit distortions of the septum to the external
nose (Table 22-1). The septal perichondrium has signifi­
cant tensile strength, so dissection deep to this layer pre­
vents tearing and perforation. In contrast, dissection
between the mucosa and perichondrium is associated with
decreased flap viability, bleeding, and tears. When the
correct plane of cleavage is identified with a Cottle eleva­
tor, the subsequent flap dissection proceeds easily, such
Figure 22-4  Crooked nose with I-shaped deformity. This patient had a history of nasal trauma 5 years earlier and complained of a crooked nose and
a fixed nasal obstruction, more severe on the right side. The osseocartilaginous vault is deviated to the patient’s left. Sky view emphasizes the preoperative
deviation to the patient’s left. Surgical management included medial and lateral osteotomies, unilateral spreader graft to right to correct for asymmetric
collapse, and use of a crushed cartilage graft to camouflage depression of the right nasal mid vault.
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CHAPTER TWENTY-TWO  Evaluation and Correction of the Crooked Nose
287
Deviated portions of the quadrangular cartilage may
then be addressed using a variety of techniques. Scoring,
crosshatching, gentle crushing, and morselization of septal
cartilage may be adequate to improve mild deviations
when used in conjunction with Mustarde-type mattress
stitches. Deviated cartilage may also be resected with
preservation of a 1.5-cm dorsal and caudal L-shaped strut
that spans from the rhinion to the posterior septal angle.
Failure to preserve this L-shaped strut predisposes to
saddle nose deformity, columellar retraction, and tip
ptosis. Some authors have gone so far as to describe this
This approach avoids violation of the intranasal mucosa
and unintended scarring. If the caudal anterior septum is
subluxed off the maxillary crest, a “swinging door”–type
approach may be used, wherein a small triangular wedge
of caudal septum near the posterior septal angle is judi­
ciously trimmed to bring the septum back into the midline
position.4,5 The septal base is then secured with suture to
the periosteum of the maxillary crest periosteum (Figure
22-7). Dissection then proceeds posteriorly and superiorly
to free the mucoperichondrium under the upper lateral
cartilages.
Figure 22-5  Crooked nose and thin skin. Successful correction of the crooked nose requires extra precision in patients that have thin nasal skin. In this
patient, dorsal hump reduction and medial and lateral osteotomies were followed by spreader grafts, alar rim grafting, and onlay crushed cartilage grafting.
Grafts that are placed immediately under the skin–soft tissue envelope are poorly concealed in patients with thin skin; thus, precise anatomic realignment
was necessary.
A
B

288
Michael J. Brenner • Peter A. Hilger
Table 22-1  Septal Deformity and Corresponding
External Deformity
Septal Deformity
Corresponding External Deformity
Dorsal septal
deviation
Asymmetric upper lateral
cartilages or mid vault
collapse
Caudal septal
subluxation
Medial crura and columella
displacement into nasal
airway
Anterior septal
angle distortion
Twisting of cartilaginous domes
and nasal tip asymmetry
Posterior septal
angle deflection
Columellar base asymmetry
and medial footplate
malposition
Figure 22-6  Lysis of the “conflicting line” during septoplasty. After the
superior mucoperichondrial and inferior mucoperiosteal tunnels have been
elevated, the fused connective tissue (conflicting line) between the vomer­
ine maxillary crest and cartilaginous septum is divided sharply to avoid
inadvertent fenestration of the flap during this portion of the dissection.
Elevation of
mucoperichondrium
Sharp incision
at “transition point”
Perichondrium
Periosteum
Figure 22-7  Correction of caudal septal deflection with a “swinging door” technique. The initial septal deformity (left) may be corrected through a variety
of techniques depending on severity of the deformity. For minor distortions, it may suffice to swing the caudal septum to the opposite side. Alternatively,
the caudal septum may be conservatively trimmed and placed back on maxillary crest. For more severe cases, it may be necessary to incise, score, or trim
the septum and then stabilize the septum with septal batten or shim spreader grafts.
Before
Swinging
door
Trimmed
Maxillary
crest
Small
wedges
removed
Batten graft
secured with
mattress
sutures
Scored
concave
side
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C

CHAPTER TWENTY-TWO  Evaluation and Correction of the Crooked Nose
289
used depending on the specific deformity present. Rarely,
repositioning of the bony vault will achieve simultaneous
correction of lower two thirds of the nose by virtue of
attachments of the upper lateral cartilages to the dis­
placed nasal bones, although a septal deformity must not
been overlooked.
Dorsal Hump Reduction
In the crooked nose, it is common for the posterior portion
of the septum to be straighter than the dorsum. As a
result, dorsal hump reduction alone may markedly dimin­
ish the extent of deformity. When performing resection of
a dorsal hump, the Rubin osteotome is advanced at an
incline that will preserve equal height on either side of the
nose. As shown in Figure 22-9, his technique prevents
crucial L-shaped strut as “sacrosanct,”6 with the caveat
that this L-shaped strut can be removed and recon­
structed. When performing the septoplasty through an
open approach, the supporting attachments of the
L-shaped strut are disrupted and must be reconstituted
with a columellar strut or other structural support.
When the caudal and dorsal septal components are
both severely deviated, it may be necessary to perform an
extracorporeal septoplasty, in which the septum is removed
and replaced after being rotated 180 degrees. This tech­
nique exploits the tendency of the posterior septum to be
closer to the midline position than the anterior septum.
Whenever possible, a small strut of cartilage in the key­
stone area is preserved as a fixation point for the reim­
planted septum. Disruption of this area increases the risk
of irregularity over the rhinion, which has thin skin and
may show notching. In cases where the septum does not
provide adequate salvageable grafting material, the
deformed septum may be removed and the L-shaped strut
replaced with a strut made from costal cartilage.
After completion of the septoplasty, bilateral muco­
perichondrial flaps are secured over the nasal septum with
a quilting mattress stitch. An often overlooked technical
pearl is elevation of the lower third of the nose during flap
resuspension. This maneuver is performed by having an
assistant apply steady traction to a suture that has been
passed through the domes of the alar cartilages. Doing so
ensures smooth redraping of the flap, which otherwise
falls and bunches at the caudal portion of the septum.
While neglect of this detail seldom has immediate reper­
cussions, over time the contractile forces acting on the
distorted nasal lining will predispose to nasal collapse as
the lining pulls against the newly reconstructed
framework.
When the septum tends to warp we may place a
vomer or perpendicular plate of the ethmoid “shim
spreader graft.” With this technique, a bony graft measur­
ing 2
1
12
12
×
 cm is harvested. Multiple 1-mm holes are
then drilled through it. The graft is then secured to the
concave side of the septum flush with the dorsal edge.
Suture fixation of the graft to the septum allows the graft
to function as a rigid, permanent intranasal stent.
UPPER THIRD/BONY PYRAMID OF
THE CROOKED NOSE
Overview
Deformity of the bony nasal pyramid is often a major
component of the crooked dorsum. A severely deviated
bony dorsum may be addressed early in the operation to
provide a stable foundation for the lower two thirds of the
nose. The surgeon should perform osteotomies only after
careful analysis of the dimensions of each side of the nasal
pyramid. Various permutations of medial, intermediate,
and lateral osteotomies, illustrated in Figure 22-8, are
Figure 22-8  Medial, lateral, and intermediate osteotomies. The medial
osteotomy preferably fades laterally as it proceeds cephalad, and it is not
always necessary if a hump reduction is performed. Intermediate osteoto­
mies are used selectively due to risk of comminution. Intermediate osteoto­
mies must be performed prior to lateral osteotomies. The lateral osteotomy
is usually performed in a high–low–high pathway through the ascending
process of the maxilla.
Medial
osteotomy
pathway
Lateral
osteotomy
pathway
Intermediate
osteotomy
pathway
Figure 22-9  Angled hump reduction. In the case of a deviated nose,
an angled hump reduction with preservation of mucoperichondrium is
necessary to achieve nasal sidewalls of equal length. Removal of the hump
in a beveled manner equalizes the lateral walls such that the distance “X”
from point A to point B (right side) is equal to the distance “X′” from point
A′ to B′ (left side). After hump reduction, the nose is restored to the midline
with septoplasty and osteotomy.
A
A´
X
B
X´
B´

290
Michael J. Brenner • Peter A. Hilger
are often used. “Inside-out” osteotomies can prove
extremely helpful in minimizing periosteal injury if mul­
tiple osteotomies are necessary. With this method, postage
stamp–type perforations of the nasal bone are created
endonasally, and the intervening bone bridges are frac­
tured with minimal periosteal disruption.8,9 This approach
is ideal for correction of traumatic medial displacement
of a nasal bone. An alternative approach involves access­
ing the pyriform aperture through a sublabial approach
just over the canine fossa. The risk of comminution of the
nasal side wall is greatest when medial, intermediate, and
lateral osteotomies are performed.
Medial osteotomies are performed prior to lateral
osteotomies in order not to destabilize the nasal pyramid.
Medial osteotomies are directed obliquely at approxi­
mately 25 degrees off midline and fade laterally along
their course. This path avoids the “rocker defor­mity” in
which the osteotomy is inadvertently carried into the
frontal bone resulting in a mobile fragment that rocks in
the cephalocaudal dimension (percutaneous osteotomy
across the nasal bridge will correct this deformity). Medial
osteotomies may be unnecessary if an open roof deformity
results from dorsal hump reduction or when the nasal
bones are symmetric and the deviated pyramid can be
corrected with lateral osteotomies alone. Incomplete oste­
otomies are to be avoided, as these “green-stick” fractures
may predispose to bony irregularities and unpredictable
healing. The intermediate osteotomy is useful for restoring
a collapsed lateral wall to a neutral position or reducing
the outward bowing of an overly convex lateral wall.
Intermediate osteotomies are performed after medial oste­
otomies to avoid performing osteotomy on mobile bone
segments.
Lateral osteotomies are most commonly performed in
a high–low–high pattern. This particular trajectory confers
several advantages for most patients:
1. Initiating the osteotomy high on the pyriform
aperture avoids disruption of the inferior turbinate
and preserves nasal airway patency by maintaining a
ledge of bone at Webster’s triangle (the base of the
pyriform aperture).
2. Proceeding low along the mid-dorsum achieves
aesthetic narrowing of the ascending process of the
maxilla and masks the osteotomy site beneath the
thicker soft tissues in the nasofacial sulcus.
3. Returning to a high position prevents excessive
narrowing of the root of the nose.
When the nasal base is broad, the osteotomy may be
performed in a low–low–high path, so long as this can be
performed without impairing the airway. A unilateral
osteotomy is especially useful in the midline nose with a
convex side wall. This convexity may create the illusion
of deviation where none exists; therefore, a unilateral oste­
otomy corrects the perceived irregularity.
overresection of the more vertical component. If a dorsal
hump reduction is deferred until after the septoplasty,
particular care is taken to ensure that an adequate septal
L-shaped strut remains, lest the hump reduction have the
unintended consequence of compromising dorsal support.
This error will undermine reconstructive efforts and pre­
dispose to saddle nose deformity. In the patient with a
reasonably straight dorsum, short nasal bones, and long
upper lateral cartilages, the resected dorsal hump may be
sculpted and repositioned on the dorsum as an onlay
graft, thereby obviating the need for osteotomies.7 This
useful approach simultaneously achieves reduction of the
dorsal hump, correction of the open roof deformity, pres­
ervation of the middle vault, and restoration of natural
dorsal contour.
Osteotomies
Osteotomies are inherently destabilizing, and foremost
consideration must be given to avoiding unintended com­
plications when undertaking these maneuvers. One of the
most common errors is inadequate preservation of maxil­
lary periosteum. As shown in Figure 22-10, the perios­
teum maintains the integrity of the nose after medial and
lateral osteotomies. It protects from nasal collapse and
comminution. Precise use of a sharp osteotome minimizes
periosteal shearing and postoperative edema. When per­
forming sliding (continuous) endonasal osteotomies, use
of a smaller osteotome or directing the guard downward
minimizes trauma. Interrupted percutaneous osteotomies
Figure 22-10  Demonstration of the importance of preservation of peri­
osteum. The periosteum is crucial in maintaining support and preventing
nasal collapse after osteotomies. On the left side, the periosteum has been
kept in continuity allowing for aesthetic narrowing with preservation of
structural support. On the right side, the periosteum has been inadvertently
sheared during osteotomy. As a result, there is soft tissue collapse and
compromise of nasal airway patency due to telescoping of the bones and
excessive medial displacement of the anterior bony framework.
Periosteum
disrupted
Periosteum
preserved
Soft tissue
collapse
Sheared
periosteum
Internal nasal
valve collapse

CHAPTER TWENTY-TWO  Evaluation and Correction of the Crooked Nose
291
during the acute phase of healing. Scar formation pro­
vides permanent stabilization. Side wall spreading/flaring
sutures are a type of mattress suture that elevate a col­
lapsed upper lateral cartilage by fixation to the nasal bone
periosteum. Clocking sutures may be placed between the
septum and upper lateral cartilages to unfurl the twisted
dorsal septum. Septocolumellar sutures secure a scored or
weakened caudal septum to a rigid columellar strut.12
With each of these approaches, the sutures reorient the
cartilaginous portion of the framework in the desired
direction. Camouflaging onlay grafts will help to mask
minor, residual asymmetries.
LOWER THIRD OF THE CROOKED NOSE
Although tip refinement can be performed through an
endonasal approach, the external approach affords the
best opportunity for success in addressing a severely devi­
ated or twisted nasal tip. Prior to refining the tip, a dis­
placed caudal septum should be secured in the midline so
as to provide a stable foundation, and any resection should
be performed conservatively. The nasal tip is straightened
and sculpted with grafting or suture-based techniques,
and tip support mechanisms are reconstituted. The 5-0
polydioxanone (PDS) suture affords sufficient durability
to maintain position and is subsequently resorbed, thereby
avoiding a persistent nidus for chronic inflammation.
Grafts are placed in precise pockets or fixated with sutures.
NASAL STABILIZATION
Rhinoplasty is an inherently destabilizing procedure, and
the nose is fragile in the immediate postoperative period.
Although a structural approach emphasizes preservation
or reconstitution of nasal support structures, internal and
external stabilization is often helpful. Septal splints,
secured with a nylon stitch, flank the septum, help to
stabilize the midline, and prevent formation of synechiae
during the first postoperative week. If there is concern that
a nasal side wall is unstable, an intranasal stent is secured
in position with sutures that pass up through the skin of
the lateral nose and are tied to a soft dressing. Taping of
the nasal dorsum and placement of a nasal cast obliterates
dead space, stabilizes the nose, and prevents inadvertent
injury during the initial phase of healing. Because dissec­
tion is performed in avascular planes, bleeding should be
minimal and internal nasal packing is not needed.
SUMMARY
Surgical correction of the crooked nose is deceptively
complex. A detailed understanding of its pathogenesis
facilitates proper diagnosis and treatment. Systematic
identification of the structures responsible for the devia­
tion is a prerequisite for correction. Usually a combination
MIDDLE THIRD OF THE CROOKED NOSE
Straightening the crooked middle third of the nose involves
treatment of complex functional and aesthetic deformi­
ties. Usually, an underlying septal deviation is present.
Unfortunately, the commonly used techniques of septal
scoring, partial resection, shaving, crushing, and cross-
hatching all weaken the cartilage. In addition, the patency
of the mid vault is often compromised by collapse or
depression in the crooked nose. Preexisting nasal airway
problem may be further exacerbated by osteotomies that
narrow the mid vault region. For these reasons, spreader
grafts or broad sandwiching stent grafts play a major role
in reconstruction of the crooked mid vault.
Spreader grafts, originally described by Sheen,10 stent
the airway open while also addressing the aesthetic prob­
lems of a pinched or twisted middle third of the nose and
open roof deformity. These grafts are secured in a submu­
coperichondrial plane, flanking the septum. They embrace
the L-shaped septal strut to restore rigidity to otherwise
flaccid septal cartilage. These grafts also increase the
angle of the internal valve angle, improve airway patency,
and maintain a straight dorsum. Although septal cartilage
is preferred, ethmoid bone, other autologous cartilage, or
an alloplastic implant may be used. Recently, there has
been interest in extended spreader grafts made from high
density porous polyethylene (MEDPOR). This alloplast
allows fibrous ingrowth and resists resorption, thereby
stabilizing the upper lateral cartilages and straightening
the septum. Although experience is limited, these rigid
grafts can provide mid vault and tip support.
A number of variations on spreader grafts have found
application in treatment of the asymmetric mid vault
associated with the crooked nose. A planoconvex spreader
graft, which is flat on one side and rounded or beveled on
the other surface, may be placed in between the upper
lateral cartilage and septum. The flat side of the graft
faces outward such that the convex surface of the graft
fills the concavity created by curvature of the dorsal
septum.11 A side wall spreading suture can be used to
elevate a depressed upper lateral cartilage. The triangular
spreader graft, unilateral spreading graft, or asymmetric
spreaders are refinements of the classic spreader tech­
nique. Alternatively, a septal extension graft secured to
the convex surface of the septum may be paired with a
spreader graft on the contralateral concave side. To cam­
ouflage mild deviations, a concave region of the dorsal
septum may be augmented with crushed cartilage and the
contralateral convexity shaved.
Suture-based techniques are useful adjuncts to struc­
tural grafting and camouflaging defects of the nasal
middle vault. For example, a differential suturing tech­
nique may be applied to the upper lateral cartilages and
spreader graft–septum complex. As a general rule, we do
not rely on sutures for permanent fixation; instead, sutures
are used to align raw surfaces in a particular configuration

292
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Surg. 1984;73:230–239.
11. Toriumi DM, Ries WR. Innovative surgical management of the
crooked nose. Fac Plast Surg Clin North Am. 1993;1:63–78.
12. Pontius AT, Leach JL Jr. New techniques for management of
the crooked nose. Arch Fac Plast Surg. 2004;6:263–266.
of structural reorientation and camouflaging techniques is
required. In our experience, the presence of nasal obstruc­
tion, marked septal deformity, and tip asymmetry all
favor an external approach to correcting the crooked nose.
Preservation and reconstitution of nasal support mecha­
nisms remain paramount.
REFERENCES
1. Byrd HS, Salomon J, Flood J. Correction of the crooked nose.
Plast Reconstr Surg. 1998;102:2148–2157
2. Rhee SC, Kim YK, Cha JH, et al. Septal fracture in simple
nasal bone fracture. Plast Reconstr Surg. 2004;113:45–52.
3. Hsiao YC, Kao CH, Wang HW, Moe KS. A surgical algorithm
using open rhinoplasty for correction of traumatic twisted
nose. Aesthet Plast Surg. 2007;31:250–258.
4. Metzenbaum M. Replacement of the lower end of the
dislocated septal cartilage versus submucous resection of the
dislocated end of the septal cartilages. Arch Otolaryngol.
1929;9:282.

293
C H A P T E R T W E N T Y - T H R E E 
Saddle Nose Deformity
Kevin Brenner • Jay Calvert
A saddle nose deformity derives its name from the appear­
ance of the nose on lateral view as the dorsal curve resem­
bles the depression in a horse’s saddle. The gross deficiency
that exists in the dorsum of the nose, no matter the etiol­
ogy, creates an obvious and progressive scooped-out
deformity. When viewed frontally, an illusory excessive
width exists across the bridge. The first paper written on
the treatment of saddle nose deformity was John Orlando
Roe’s original article in 1887, “The deformity termed
‘Pug-Nose’ and its correction by a simple operation.”1 The
first attempt at correction of saddle nose deformity
occurred when Robert F. Weir implanted the breastbone
of a duck into the shrunken nose of a syphilitic patient in
1892.2 In 1896, Israel was the first to use a human bone
graft to the nose.3 Many authors have published articles
detailing the etiology, classification, and treatment of this
deformity.1–28 Most recently, Daniel and Brenner published
a classification of saddle nose deformity with a focus on
septal saddling. In this article, the authors describe their
approach to the treatment of these deformities as they
address each component separately.
DEFINITION
The term “saddle nose deformity” is a pathologic entity
resulting from loss of dorsal height, caused by a substan­
tial decrease in the cartilaginous vault and/or bony vault.
It may include any of a variety of features: (1) middle
vault and dorsal depression, (2) loss of tip support and
definition, (3) columellar retrusion, (4) shortened vertical
length, (4) tip overrotation, and (5) retrusion of the nasal
spine and caudal septum. Regardless of the etiology, the
central underlying defect is lost integrity of the bony and
cartilaginous dorsum resulting in a short nose with com­
promised support.
Saddle nose deformity can occur following a variety
of nasal pathologic conditions. The majority of saddle
nose deformities are acquired (secondary to trauma, septal
hematoma, septorhinoplasty to correct traumatic injuries,
cocaine abuse, infection, and cosmetic septorhinoplasty),
but congenital causes do exist (i.e., Binder syndrome).
Although it is difficult to assess the true prevalence of
nasal saddling in any given population, certain groups of
patients seem to be particularly prone. Facial trauma
victims, cocaine abusers, and patients who have under­
gone previous septorhinoplasty, particularly following
traumatic injury, seem to be at highest risk.
CLASSIFICATION
No matter which classification system is followed, nasal
saddling exists along a spectrum. Tardy has described a
three “M” category classification system: minimal, moder­
ate, and major. Minimal saddling demonstrates modest
tip–supratip differential with a supratip depression greater
than the ideal 1 to 2 mm. The bony nasal hump is mildly
accentuated, the nose is wide, and minimal columellar
retraction exists. Moderate saddling shows depression sec­
ondary to lost dorsal height in the quadrangular cartilage.
Columellar retraction results in an acute nasolabial angle.
Major saddling is a more severe deformity often secondary
to massive blunt frontal trauma, resulting in a twisted
nose with severe septal deviation. Vartanian categorized
saddling into four types, based on the degree of existing
anatomic deficit. Type 1 describes minor supratip or
dorsal nasal depression with preservation of lower third
projection. Type 2 has moderate to severe dorsal depres­
sion with a prominent lower third. Type 3 has moderate
to severe dorsal depression and lower third deficits result­
ing in loss of tip support. Type 4 refers to a pan-nasal
defect with severe middle nasal dorsal deficiency, in com­
bination with deficits of the upper and lower thirds.
Daniel recently expanded on these earlier classifica­
tion systems, attempting to integrate the external appear­
ance of the nose, the degree of compromise of septal
support, and selection of surgical treatment into what is
referred to as septal saddle nose. Septal support is deter­
mined by pressing the nasal tip inward—if the tip remains
supported, then septal support is adequate; if the tip
compresses against the premaxilla, then the support is
inadequate. This classification system thus consists of a
subset within the broader saddle nose classification
systems and is defined by the combination of a dorsal
depression and inadequate septal support:

294
Kevin Brenner • Jay Calvert
TREATMENT
The surgical correction of saddle nose deformity should
be approached and planned in the same intricate manner
as any major nasal reconstruction case. Burget and
Mennick have worked extensively to develop an algorith­
mic approach to rebuilding complex nasal defects.18 Pre­
operative deficiencies in bony and cartilaginous support,
internal nasal lining, and external coverage must all be
determined. Less severe deformities, where supporting
structures remain strong, can be simply treated with
dorsal onlay grafts. When upper lateral cartilage weak­
ness exists, middle vault integrity must be reestablished.
Spreader grafts help restore the internal nasal valve
(Figures 23-1 and 23-2); severe upper lateral cartilage
collapse may require replacement Batten grafts. Obviously
every patient will be unique in all of these categories,
dictating a slightly different plan for each operation. The
basic components to consider follow:
1. Reestablishing support:  When the quadrangular
cartilage is no longer able to support the nasal roof,
it must be either buttressed or, better yet, replaced.
Autologous rib cartilage is the ideal material for this
purpose since it is abundant in supply and
extremely strong in form.
Type 0 (Pseudosaddle)
These patients present with depression of the cartilaginous vault
following a prior rhinoplasty and is invariably due to over­
resection of the cartilaginous vault, a relative depression of
the cartilaginous dorsum due to a prominence of the bony
vault, or a combination of the two. The etiology is not due
to lost septal support but rather to aggressive dorsal changes.
Septal support is excellent and there is a negative septal
support test.
Type I (Minor—Cosmetic Concealment)
These cases have excessive supratip depression and columellar
retraction but normal septal support. Cosmetic concealment
is possible provided the septal compromise is static and not
progressive.
Type II (Moderate—Cartilage Vault Restoration)
The dominant factor is compromise of septal support, which
leads directly to cartilaginous vault collapse, columellar
retraction, and loss of tip support.
Type III (Major—Composite Reconstruction)
In major cases, there is a total absence of septal support for the
cartilaginous vault, columellar, nasal tip, and external valves.
Flattening of the nose is obvious in all views.
Type IV (Severe—Structural Reconstruction)
These cases represent the end stage of septal collapse. They are
compounded by bony vault disruption and severe contracture
of the nasal lining often associated with major septal perfora­
tions. Septal collapse has occurred resulting in cartilage vault
depression and columellar shortening. The nasal tip has lost
its projection and the nostrils are broad. There is no support
to the vestibular and nostril valves with dramatic compromise
of the external airway. The nasal loblule is often rotated
upward. The nose is short in absolute terms and further
emphasized by an acute nasolabial angle. Depression of the
bony vault is a major factor that may limit support for the
reconstruction.
TYPE V (Catastrophic—Nasal Reconstruction)
The majority of these cases have progressed from reconstructive
aesthetic rhinoplasty to aesthetic reconstruction of the nose
and its adjacent tissues. Many will require forehead flaps for
either lining or skin coverage. Equally significant, the bony
deformity extends farther into the facial skeleton, warranting
some type of degloving approach and extensive bone grafting
and/or plating. These cases are best referred to surgeons who
have a high degree of special expertise.
Figure 23-1  Standard placement of bilateral spreader grafts.
Figure 23-2  Securing spreader grafts. Left, Three-layer mattress suture
technique. Right, Five-layer “figure-of-eight” technique that includes the
upper lateral cartilage for security and narrowing.

CHAPTER TWENTY-THREE  Saddle Nose Deformity
295
DISCUSSION
There appears to be a progression in difficulty with these
cases as follows: (1) postseptoplasty, (2) posttraumatic,
(3) secondary rhinoplasty, (4) secondary saddle defor­
mity, and (5) the cocaine nose. The patient who saddles
following a septoplasty has essentially normal tissue
throughout the nose except for the compromised septum.
Once the septum is restored, the tip and bony vault can
be modified as desired using standard techniques. The
question is whether to perform cosmetic concealment,
structural restoration, or both.
Posttraumatic noses can be divided into primary and
secondary cases. The nose that sustains severe septal
trauma with saddling often requires a total septoplasty
with restoration of the L-shape strut. In contrast, the
posttraumatic nose that has had surgery with subsequent
saddling may now include a septal perforation, significant
resections, and additional scarring. The secondary rhino­
plasty nose can have saddling due to overresection, loss
of septal support, or both. Simple tip compression will
help in defining the need for structural support versus
aesthetic correction. The most difficult cases are patients
with failed prior attempts at correcting their saddle
deformity and cocaine noses. In addition to the challenges
of support and aesthetics, one must contend with lining
contracture, which often requires extensive composite
grafts. The classical method of mobilizing the lining sleeve
is often limited as it does not add to the destroyed tissue—
hence, the need to add composite grafts of conchal carti­
lage and skin, which can resist the contractile forces.
As the deformities become more complex, the need
for restoration of structure and support becomes critical
for the shape of the nose and opening of the airway. The
greater the problem, the less septal cartilage is usually
available and the less adequate conchal cartilage becomes.
Costal cartilage is virtually the only material with suffi­
cient strength and volume to achieve the reconstructive
goals. Cadaver cartilage is not an acceptable alternative
unless the patient is medically unfit to withstand rib
2.  Addressing the airway:  As the degree of saddling
becomes more severe, there appears to be an
increasing need for restoration of both the internal
and external nasal valves. Spreader grafts must be
used as part of the reconstruction, frequently in
concert with the septal support and/or replacement
grafts. When external valve collapse occurs or the
upper lateral cartilages are no longer sufficient,
batten grafts should be used to reestablish the
requisite support. With severe scarring, as occurs in
the multiply operated patient and the advanced
cocaine nose, large batten grafts from the eighth
costal cartilage frequently work the best. For
patients with compromised nasal lining and alar
retraction, skin–cartilage ear composite grafts work
well to augment the lining and prevent recurrent
retraction. In severe cases, the addition of alar rim
grafts may be necessary.
3. The nasal tip:  Support is essential. With the
exception of septal replacement grafts, the
columellar strut is the most important determinant
of long-term tip support and projection (Figure
23-3). In saddle noses, the scarring is severe and
ear cartilage clearly lacks the requisite strength to
resist the inevitable contractile forces of the skin
envelope. A large post of costal cartilage works
extremely well as a columellar strut. For the best
aesthetic reconstruction, it is wise to place this graft
as a stand-alone graft instead of incorporating it or
attaching it to the septal replacement graft. Once
the support is reestablished, then the tip structure
can be defined by either suturing the existing alar
cartilages or replacing them with tip grafts.
4. The dorsum:  The dorsum must be considered as a
separate component. We have found that
reestablishing the dorsal line is difficult with carved
cartilage grafts. The authors almost exclusively use
deep temporal fascia grafts alone or in combination
with diced cartilage as minor dorsal camouflage
grafts or major augmentation grafts.
Figure 23-3  Total nasal reconstruction can require a dorsal replacement graft integrated with a septal replacement strut graft. Additional shield tip graft
is shown. Some patients require an additional columellar strut independent of the septal strut.

296
Kevin Brenner • Jay Calvert
complex if performed en bloc has a minimal margin of
error (Figure 23-4). Composite reconstruction was
designed to overcome many of these problems by splitting
the operation into two separate components: a rigid deep
foundation layer and a more superficial aesthetic layer.
The deep foundation layer replicates the structural support
provided by the septum/cartilaginous vault. The superfi­
cial aesthetic layer allows maximum flexibility in achiev­
ing the desired tip and dorsal contour. Fascia-wrapped
diced cartilage grafts have become extremely useful for
this purpose. The addition of a distinctly independent
columellar strut allows one to push down the columellar
labial angle, achieve additional nasal length, and project
the nasal tip above the dorsal line.
cartilage harvest or has been shown to have extensive
ossification of their costal cartilage rendering it useless.
In our opinion, these complex cases deserve the best
possible results, and patients will ultimately be better off
if the surgeon elects to not compromise their choice of
graft material in an effort to save the patient a short costal
scar. In our experience, cadaver cartilage absorbs over
time.
The goal in composite reconstruction is to restore the
cartilaginous support to the nose. The problem is that
large costal cartilage grafts carved to restore the dorsum
are time consuming, frequently warp, and can provide a
less-than-ideal dorsal appearance unless executed per­
fectly. Further, reconstruction of the columellar–tip
Figure 23-4  Pre- and postoperative photos of a patient with saddle nose repair.
A
B
C
D

CHAPTER TWENTY-THREE  Saddle Nose Deformity
297
E
F
Figure 23-4, cont’d.
SUMMARY
Saddle nose deformity is perhaps one of the most chal­
lenging problem in all of rhinoplasty surgery. It requires
correction of both form and function while providing the
least amount of tissue to work with. The authors have
found that composite reconstruction, using autogenous
tissues, can provide excellent results for these very difficult
problems.
Ultimately, autogenous rib reconstruction becomes
the only option and it serves as both structural framework
and aesthetic contour. One important question is, What is
the reconstructive surgeon’s obligation—to provide rigid
support to the nose or simple cosmetic camouflage? It is
our belief that the surgeon should re-create a strong sup­
portive nose using the patient’s own tissues that will last
a lifetime.
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