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projection requires either an increase or decrease in the
distance the nasal tip extends from the vertical facial
plane. The Goode method and the 3:4:5 triangle are the
two most common ways of measuring projection.
THE GOODE METHOD
As described by Goode, nasal projection as measured from
the alar–facial crease should be 60% of nasal length. A
vertical axis is drawn from nasion to alar groove intersect­
ing a horizontal line from the alar groove to the tip. A
ratio can be expressed as ala-tip–nasion-tip equaling 0.55
to 0.60. This ratio correlates well with an aesthetically
balanced nasal projection (Figure 24-4).1
THE 3:4:5 TRIANGLE
Crumley and Lanser demonstrated a relationship between
nasal length and desired tip projection as forming a 3:4:5
right triangle. The vertical line is dropped from the nasion
and the hypotenuse is a line drawn from the nasion to the
tip. The ratio of the horizontal line (from vertical facial
plane to tip) to the nasal dorsal line (hypotenuse) should
be 3 : 5 or 0.60 (Figure 24-5).3 This is in accordance with
the measurements proposed by Goode.
NASAL TIP ROTATION
Simons describes rotation of the nasal tip as an arc with
the radius maintained.4 As the tip is rotated, there is some
illusion of increased projection, although none exists
NASAL PROFILE LENGTH
As measured from the nasion to the tip-defining point,
nasal length should approximate one-third of the height
of the face from hairline to menton (Figure 24-1).1
RADIX POSITION AND NASOFRONTAL ANGLE
The radix, or root, of the nose is a synonym for the nasion,
the gentle depression where the nose meets the forehead.
The angle that is formed by the forehead and nose is the
nasofrontal angle. It is usually between 115 and 130
degrees. Too shallow an angle creates a “Greek” nose,
with the forehead sloping directly into the nasal dorsum.
Another useful angle is the nasofacial angle. This angle is
formed between the dorsal line and a vertical line travers­
ing the nasion. Called the aesthetic profile angle by Jacques
Joseph (who actually had a device to measure it directly)
and renamed the nasofacial angle today, this angle ideally
measures from 30 to 35 degrees (Figure 24-2).2
More relevant is the relative height of the radix. The
ideal level lies at the upper eyelash line in women and
slightly higher in men. The height of the radix directly
affects nasal length: the higher the radix, the longer the
nose. Today (and throughout time) a long, elegant profile
is the aesthetic ideal. Adjusting the height of the radix is
an important step in achieving this ideal (Figure 24-3).
NASAL PROFILE PROJECTION
Projection of the tip is the actual measured distance
from the alar–facial plane to the tip. A change in nasal
Figure 24-1  Nasal length, as measured from the nasion to the tip-
defining point, should approximate the height of one-third of the face.
Figure 24-2  The aesthetic facial angle (as described by Joseph) is
formed by the intersection of a vertical line dropped from the glabella with
a line from the nasion to tip-defining point. Tip projection is optimal with an
angle of 30 degrees.

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NASOLABIAL ANGLE AND COLUMELLA
The nasolabial angle is the angle formed between the
columella and upper lip. Ideally, the nasolabial angle
is 90 to 95 degrees in men and 95 to 110 degrees in
women (Figure 24-7).5 It is affected by two major
(Figure 24-6). Tip rotation is defined as the tip angle from
the vertical alar crease through the tip. In women this
angle is approximately 105 degrees, and in men, it is 100
degrees. The degree of rotation may be affected by the
intrinsic properties of the nasal tip (lower lateral carti­
lages) or external properties (caudal septum).
Figure 24-3  A, Preoperative left oblique view illustrating a low radix, making the bridge appear short. Since the apparent nasal start point is at the hump
and the tip is dependent, the nose appears bottom-heavy. B, The 19-month postoperative left oblique view illustrating higher radix, with a longer, more
elegant profile. The nose is no longer bottom-heavy, so attention is directed to the eyes. Radix augmentation was achieved with diced cartilage wrapped
with temporalis fascia.
A
B
Figure 24-4  Goode’s method. Vertical axis is from nasion to the alar
groove. The horizontal line is from ala to the tip. Nasal projection should
be 60% of nasal length. This is expressed as a ratio with ala-tip–nasion-tip
equaling 0.55 to 0.60.
A
T
N
Figure 24-5  In the 3:4:5 triangle, the ratio of projection to length is
represented by the ratio 3 : 5. In accordance with Goode’s method, nasal
projection is 60% of nasal length.
4
3
5

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Minas Constantinides • Frank P. Fechner
for example) creates a more retracted, acute nasolabial
angle (Figure 24-9).
Columellar position may be classified as retracted,
neutral, or hanging. Ideally, 2 to 4 mm of columellar show
on lateral view is normal. A retracted columella occurs
with upwardly displaced medial crura. This may occur
from either a deficiency of the mid-portion of the caudal
septum alone or in conjunction with a cephalically rotated
tip. A hanging columella occurs either from an overdevel­
oped caudal septum pushing the medial crura inferiorly
(as in a tension nose), or from weak medial crural support
(typical of a full transfixion incision without subsequent
re-support of the medial crural complex) (Figure 24-10).
OVERALL FACIAL APPEARANCE
AND THE NOSE
Changes in the size of the nose immediately affect the
appearance of other parts of the face, namely the lips and
chin. On the contrary, alterations to the lips, chin, and
even neck may influence apparent nasal size. It is rela­
tively common to see a patient with a convex facial profile
where the nose receives overwhelming attention. The large
nose may appear more pronounced by limited forehead
projection, microgenia, and submental fullness. By
enhancing chin projection and neck definition, the overall
prominence of the nose is seemingly decreased. Through
these ancillary procedures, less dramatic nasal reduction
may be required for a balanced facial profile (Figure
parameters—the caudal septum as it meets the nasal spine
and the relative position of the columella. A prominent
caudal septum and/or nasal spine will push the upper
philtrum of the lip out, effacing the nasolabial angle and
making it more obtuse (Figure 24-8). A deficient caudal
septum at its posterior angle (as seen in platyrhine noses,
Figure 24-6  As described by Simons, as the nasal tip rotates through an arc, there is an apparent increase in nasal projection, although none exists.
A, “X” is the distance from the tragus to the nasal tip. The angle from the horizontal is 12.4 degrees. B, The distance from tragus to tip remains the same
while the angle from the horizontal significantly decreases to 6.1 degrees. The illusion is one of increased projection while all that has occurred is increased
rotation.
A
Distance “X”
12.4° from horizontal
Distance X
6.1° from horizontal
B
Figure 24-7  The nasolabial angle is formed between the columella and
upper lip. Ideally, the nasolabial angle is 90 to 95 degrees in men and 95
to 105 degrees in women.

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PHYSICAL EXAMINATION
The preoperative examination will prevent many unsatis­
factory results and establish a precise surgical plan. The
nose is considered within the overall facial anatomy.
Does the patient have rather bold facial features such
as high cheeks, strong jaw, and full lips, or rather a deli­
cate appearance? How do chin projection and the neck
definition fit into the overall facial profile with the nose?
How does the nose complement or detract from other
features? In particular, does it distract from the beauty of
the eyes?
24-11). Similarly, in this situation, reduction rhinoplasty
alone can help improve the facial balance and will make
the weak chin less apparent. Because we prefer to strive
for normal facial balance, we would recommend chin
enhancement in conjunction with reduction rhinoplasty.
Commonly, patients may not be aware of their microgenia
but rather focus exclusively on the nose. Computer pho­
toimaging can be extremely helpful in demonstrating the
advantage of a balanced facial profile. At the very least,
it uncovers the patient’s own aesthetic preferences and
ensures that both surgeon and patient share the same
aesthetic and surgical goals.
Figure 24-8  A, C, Preoperative right lateral views illustrating obtuse nasolabial angles due to excessively prominent posterior septal angle.
B, D, Postoperative right lateral views illustrating more acute nasolabial angles, creating more attractive lines between nose and upper lip.
A
B
C
D

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Next, the nose is analyzed in the frontal view where
straightness and width are assessed. This examination is
best subdivided in thirds starting from the top. The top
third is mostly represented by the bony nasal vault. Is the
width appropriate or too wide? Both dorsal width and
ventral width are considered. Dorsal width is the plateau
of the nasal bones; ventral width corresponds to the naso­
facial grooves. An upper third that is too narrow overall
The quality of the skin requires accurate assessment
when considering reducing a large nose. If the skin is rela­
tively thin and elastic, it may more readily follow struc­
tural changes made to the underlying bone and cartilage.
But when the skin is thick and stiff, it may not contract
readily around a smaller nasal skeleton, leading to poor
tip definition. In thick-skinned patients, an overzealous
reduction is ill advised.
Figure 24-9  A, Preoperative left lateral view illustrating acute, deep nasolabial angle from congenitally underdeveloped posterior septal angle and nasal
spine. B, One-year postoperative view illustrating improvement of appearance from both tip rotation and filling of nasolabial angle with cartilage grafts.
A
B
Figure 24-10  A, Preoperative right lateral view illustrating a hanging columella from weak medial crural strength. B, One-year postoperative view with
improved columellar strength and length after tongue-in-groove and tip-grafting techniques.
A
B

CHAPTER TWENTY-FOUR  The Large Nose
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the patient a predictive image of his or her nose after a
successful rhinoplasty. It is advisable for the surgeon to
demonstrate a conservative result rather than an overly
perfect one. Most patients understand that a computer-
generated image is not real life, but they still may expect
such a result. Computer imaging has proved useful to
determine the extent of nasal reduction. Commonly, a
patient bothered by his large nose will desire a nose that
objectively may be too small for his face, and beyond what
realistic surgery can achieve.
We image the nose in two views: the lateral and the
worst oblique. Invariably, one oblique view will look
better than the other; we choose the worst-looking one in
order to show greatest possible improvement. This often
corresponds to the side that the patient sees as his worst
side when taking photographs. Many patients request
frontal imaging, but this is often the most difficult view
to image accurately with the least distortion. If helpful,
base-view imaging can also be accurate and demonstrate
improvements in tip symmetry, base and lobular width,
and tip definition.
Imaging can also help solve certain planning dilem­
mas. If the radix is low, does the patient like the appear­
ance of the dorsal line with the radix low or high? How
much dorsal reduction looks good to the patient? Is a
straight dorsal line desired, or does the patient prefer a
supratip break? Does the middle third need to be substan­
tially widened or just subtly supported? How much tip
rotation looks best? Once the desired images are obtained,
we typically either print them for the patient to take
home, or burn them onto a CD as jpeg files. In patients
who are dissatisfied with their surgical outcome, we have
never found that it is because of the preoperative imaging.
is extremely rare in primary rhinoplasty but may be seen
in secondary cases. More commonplace is an upper third
in which one nasal bone has been depressed by injury
while the other has been elevated, creating a deviation to
one side.
The middle third is largely determined by the rela­
tionship of the upper lateral cartilages to caudal ends of
the nasal bones and the cartilaginous septum. Is it too
wide, normal, or collapsed? What is the side wall’s inter­
nal resilience? A collapsed or weak middle third may lead
to internal valve collapse after reduction rhinoplasty if
precautions are not taken.
The lobular lower third has to be assessed for tip
configuration, symmetry, length, projection, and width.
The need for alar base reductions can often be predicted
during the initial examination.
Last, the profile view is studied. Starting from the top,
the nasion, or radix, is evaluated. If too deep, it can be
augmented. If too shallow, it can be carved out. A deep
nasion commonly presents with a nasal hump. After filling
of the nasion, less of a dorsal reduction may be needed
for a straight profile of the upper two thirds.
COMPUTER PHOTOIMAGING
As with any cosmetic procedure, it is important to under­
stand goals, desires, and expectations of the rhinoplasty
patient. The patient needs to understand what he or she
can expect from the cosmetic nasal operation. The patient’s
satisfaction after the procedure will in part be determined
by the surgeon’s success in laying out these goals before­
hand. Photoimaging plays an adjunctive role in showing
Figure 24-11  A, Retruded chin with a prominent nose exaggerates overall facial imbalance. B, Chin implantation alone will partially restore facial balance,
even without rhinoplasty.
A
B

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hump and wide nasal bones. Sometimes, the bony pyramid
is shifted and requires straightening. The nasion may
benefit from alterations.
Radix: Classically, the ideal position of the radix is
at the level of the supratarsal crease when assessed in the
side view. Although this guideline is helpful, minor devia­
tions from the norm are common. Most commonly, the
radix has acceptable position and depth before rhino­
plasty and will not require alteration.
If the nasion is lacking depth, deepening can be
achieved en bloc with the hump reduction (see later). To
control the superior extent of the neoradix, a transcutane­
ous horizontal osteotomy with a 2-mm osteotome is
helpful. Additional radix deepening can be achieved with
radix rasps. The skin and soft tissue envelope of the radix
is thicker than that of the remaining nose. Contracture of
these soft tissues around a lowered radix is variable and
it will not always lead to a one-to-one radix reduction.
For the deep radix, augmentation is indicated. Plan­
ning this maneuver before surgery is important because
filling the deep radix is routinely performed after hump
reduction. If hump removal is performed to the level of
the radix, augmentation will not be possible or will lead
to undesirable results. The preferred grafting material for
nasion augmentation is autologous cartilage obtained
from the nasal septum. In the rare case when no nasal
septal cartilage is available (such as after a previous
septoplasty), cartilage obtained from the cartilaginous
nasal hump, cephalic trim, or ear concha can be used. The
graft can be layered and sutured together to fill the deep
nasal–frontal angle. The graft edges should be beveled or
crushed to prevent the visibility of the radix graft. If con­
cerns exist about postoperative graft shift or movement,
a temporary transcutaneous suture is used. An even more
novel radix graft may be created from temporalis fascia
wrapped around diced cartilage. This graft shows great
local stability, is moldable during early healing, and does
not lead to a visible edge as in some solid radix augmenta­
tion grafts (see Figure 24-3).6 The outcome of radix
augmentation is more predictable than the reduction
maneuver.
Bony hump: Reduction of a nasal hump is an integral
part of rhinoplasty for the large nose. Virtually all nasal
humps have a bony and a cartilaginous portion. Being
part of the middle third of the nose, the cartilaginous
hump is reduced sharply (see later) followed by bony
reduction achieved with an osteotome, rasp, or the com­
bination of both. Because most humps encountered in
large noses require reduction by 2 mm or more, we favor
the use of a flat osteotome (i.e., Rubin osteotome) first,
followed by further incremental reductions with nasal
rasps. The goal of hump removal is a straight nasal profile
avoiding a stigmatizing overreduction. Performing hump
reduction requires that the surgeon is able to follow the
osteotome’s path beneath the skin; even in the open
approach, visualization of the bone cuts is limited. Once
Photoimaging is an excellent communication and plan­
ning tool that is invaluable during rhinoplasty planning
for surgeon and patient alike.
ANESTHESIA
There are multiple anesthesia options available for a
reduction rhinoplasty operation. Most commonly, the rhi­
noplasty surgeon has his or her personal preferences based
on training and personal experience. Today, many sur­
geons prefer nasal surgery under general inhalation
anesthesia. Advantages include total analgesia, hypnosis,
and protection of the patient’s airway. Side effects like
intraoperative vasodilation and postoperative nausea and
vomiting can jeopardize the outcome of a rhinoplasty. In
addition, many patients perceive general anesthesia as
risky and invasive.
We prefer conscious sedation via the intravenous
route. Sometimes, local anesthesia with preoperative pre­
medication can provide an attractive alternative to deeper
modes of anesthesia. Independent of anesthesia mode, the
decongestion and anesthesia of the nose are achieved with
endonasal placement of 4% cocaine-soaked packs fol­
lowed by injection of 1% to 2% lidocaine with 1 : 100,000
epinephrine as regional and local blocks. Appropriate
management of the intraoperative blood pressure by an
experienced anesthesiologist will further minimize bleed­
ing. Placement of small tampons into the posterior nasal
passages and choanae will provide appropriate minimiza­
tion of posterior oozing into the pharynx. The tampon
strings are kept attached and brought out of the nostril to
prevent the tampon’s inadvertent aspiration.
SURGICAL TECHNIQUE
The sequence that rhinoplasty surgery is performed varies
from surgeon to surgeon. Some surgeons start creating the
new dorsal line of the nose starting from the top down,
with the nasal tip being addressed last. Alternatively, if
the open rhinoplasty approach is used, tip projection can
be set first and the upper third of the nose addressed at
the end. In endonasal rhinoplasty, this bottom-up sequence
is often not feasible given the difficulty of exposure after
dome binding and tip definition have been completed. To
facilitate a systematic discussion, we will address surgical
technique questions by the three segments of the nose:
upper, middle, and lower thirds.
UPPER THIRD OF THE NOSE
The upper nasal anatomy is determined by the bony nasal
vault, which includes the maxillary frontal processes and
the confluence of the nasal bones with the bony nasal
septum. The large nose usually presents with a bony nasal

CHAPTER TWENTY-FOUR  The Large Nose
307
third width, opening of the internal nasal valve, and cam­
ouflaging or straightening of a curved dorsal septum.
Spreader grafts can be layered for additional width and
should be flush with the height of the septum after being
secured in place with 4-0 PDS sutures. They are easier
placed using the open approach. Endonasally, spreader
grafts can also be placed into tight-fitting pockets between
dorsal septal mucoperichondrium and septal cartilage
without suturing (Figure 24-12).
LOWER THIRD OF THE NOSE
The nasal tip of the large nose commonly is overprojected
and bulbous. In addition to deprojection and tip defini­
tion, goals of nasal tip improvements also commonly
involve adjustments to tip rotation. Balanced relationships
of columella to alar margins should be ensured but rarely
require additional maneuvers in the large nose. Finally,
appropriate alar width is ensured.
PROJECTION
Large noses are usually overprojected. Whenever the nasal
tip is altered, special consideration has to be paid to tip
support. Although various major and minor tip support
structures have been identified, their individual impor­
tance varies from patient to patient.
Patients with a tension tip deformity have an over­
projected nose secondary to an overdeveloped quadran­
gular cartilage, both dorsally and caudally. In a tension
nose, the anterior septal angle represents the highest point
of the nasal tip. Indeed, the height of the septum is the
main tip-support mechanism in this case. When it is
reduced as part of the hump treatment to a level below
the domes, it alone will lead to effective deprojection. In
addition, separating the medial crura from and shortening
the caudal septum will further weaken tip support. Indeed,
excessive loss of projection is a danger in these noses.8
Often, the tension nose presents with a prominent pos­
terior septal angle and/or nasal spine. Resection of this
can improve definition of the lip–columella transition.
When the lower lateral cartilages are strong and
prominent, tip deprojection and appropriate adjustment
of rotation will need to be managed by alterations to this
cartilage pair. Deprojection can be achieved by reducing
the length and strength of the lower lateral cartilage.
According to Anderson’s tripod concept,9 shortening the
medial crura (i.e., resection or weakening of the foot­
plates) will deproject the tip and decrease rotation. More
commonly, we use the versatile lobule division followed
by suture overlay of the lower lateral cartilages. The
extent of overlay will determine deprojection and tip
rotation. The location of lobule division (lateral, interme­
diate, or medial crus) will further influence rotation
(Figures 24-13 and 24-14).10
the osteotomy is completed and the reduction has been
assessed, further bone reduction and smoothening are per­
formed with nasal rasps. We prefer coarse and fine pull-
action rasps used sequentially. Bone debris is aspirated
and a smooth contour is ensured.
Nasal osteotomies: Usually performed at the com­
pletion of the rhinoplasty procedure, nasal osteotomies
will narrow the upper nose. Because the nasal pyramid
will appear wide after hump reduction, osteotomies play
a vital role in reduction rhinoplasty by closing the “open
roof” and producing an elegant nasal shape. Our most
common osteotomy technique includes the high–to–low–
to–high lateral bone cut followed by a possible medial
osteotomy through an endonasal incision. Subperiosteal
tunnels are developed to minimize postoperative bruising
by periosteal rents and vessel injury. A curved, guarded
3-mm osteotome is used to create a continuous lateral
osteotomy. Alternatively, a 2-mm straight unguarded oste­
otome may be used to create perforating osteotomies
through an intranasal technique. Digital pressure applied
to the nasal bones leads to the desired infracture of the
bony segment. For a bone that does not produce the
desired narrowing, we reconfirm that a complete lateral
osteotomy was performed or outfracture the bony plate
followed by a repeated infracture. Rarely, a 2-mm percu­
taneous osteotomy may be required to complete the oste­
otomy. Important in performing lateral nasal osteotomies
is to stay rather posterior within the nasal process of the
maxilla and not come too anterior lest the osteotomy be
visible.7
MIDDLE THIRD OF THE NOSE
Aside from reduction of the cartilaginous hump, the
middle third of the nose commonly requires limited work
in management of the large nose. It rather follows some­
what passively changes produced by managing the upper
and lower thirds.
Hump reduction: The cartilaginous dorsal hump is
produced by the dorsal septal cartilage and its confluence
with the upper lateral cartilages. Most of the hump is
produced by the quadrangular cartilage; therefore, dorsal
reduction of the septum after its separation from the
upper lateral cartilages in the open rhinoplasty approach
will produce effective hump removal. The integrity of the
confluence is reestablished with 4-0 PDS sutures. Using
the endonasal technique, separation of the upper lateral
cartilages is not routinely performed. The horizontal
aspect of the upper lateral cartilages is usually removed
en bloc together with the dorsal septum. Entering the
nasal cavity during hump reduction should be avoided.
Spreader grafts: Spreader grafts are routinely fash­
ioned from autologous septal cartilage and placed between
dorsal septum and upper lateral cartilages. They can serve
four main goals: supporting weak upper lateral cartilages
to maintain dorsal width, widening of the dorsal middle

308
Minas Constantinides • Frank P. Fechner
ROTATION
Conservative cephalic trims of the lateral crura usually
represent the first step in tip modification. At least 7 mm
of cartilage width should be maintained at the widest
point. This maneuver by itself will lead to moderate tip
definition and minimal tip rotation. Tip rotation can be
further changed by strategic adjustment of the caudal
septum: if a triangle of cartilage with its base at the dorsal
septum is excised, the tip will rotate up; if the triangle
base is posterior, caudal rotation will be the consequence
due to weakening of the medial crural footplate attach­
ments. Most commonly in the large nose, we prefer to alter
rotation and projection simultaneously by lobule division
techniques. After dividing the lateral crus and shortening
the cartilage strip through overlap and suturing, rotation
and deprojection will result. If the medial crus is divided,
caudal rotation and deprojection will be controlled by the
extent of crural overlay. Division of the intermediate crus
leads to only small rotational changes and primarily
decreases projection. A similar impact can be achieved by
simultaneously dividing and shortening both the medial
and lateral crura. The advantages of the lobule division
technique include complete control of projection and defi­
nition while recreating a double-layer strong continuous
cartilaginous strip. The domes are usually not divided to
minimize risks for bossae and tip asymmetries.
TIP DEFINITION
Many large noses will present with a wide, bulbous, or
boxy tip, making tip sculpting techniques imperative.
After conservative cephalic trims have been performed
and tip projection and rotation have been set, double-
dome binding sutures are commonly used. These horizon­
tal mattress sutures of 4-0 or 5-0 Prolene set the domes
to the most desirable position. In thin-skinned patients,
care is taken to ensure that the lateral crus lateral to the
suture is not indented to guard against surface shadows,
telltale signs of rhinoplasty (see Figure 24-15). Tip grafts
are rarely necessary in the large nose. Final definition of
the tip will in part be determined by the skin thickness.
ALAR BASE REDUCTION
Although the need for alar base reduction is usually deter­
mined preoperatively, this step is always performed at the
end of the procedure. Because alar base reductions are
virtually impossible to reverse, a conservative approach is
best. If in doubt, it can also be performed as an office
procedure once the first stages of healing are completed.
Alar base reduction is useful in narrowing the alar width
and/or decreasing nostril flare, which may increase with
tip deprojection.
Figure 24-12  A, Right oblique preoperative view illustrating large nose with large bony and cartilaginous hump in a tension nose. B, One year postop­
erative view. Bony and cartilaginous hump reduction and lateral osteotomies were accompanied by spreader grafts to stabilize the upper lateral
cartilages.
A
B

CHAPTER TWENTY-FOUR  The Large Nose
309
Figure 24-13  A, Schematic base view of the overprojected nose. B, The tip scissors have cut through the alar cartilage, dividing it at the angle, or the
junction of the medial and intermediate crura. C, A horizontal mattress suture has been placed after the intermediate crus has been overlapped over the
medial crus. Typically, 6-0 nylon is used. D, Base view shows the achieved deprojection.
A
B
C
D
The alar base is best reduced by creating a medial
advancement rotation flap of the ala. A portion of the
nostril sill can be excised, and then an incision carried
laterally just above the alar–facial groove. The ala can
then be rotated into the defect left on the sill. If flare is
present, an additional excision of the caudal cut edge of
the ala can be performed prior to closure.11
COMPLICATIONS SPECIFIC TO
THE LARGE NOSE
Although general complications in rhinoplasty will be dis­
cussed extensively in other chapters of this book, there are
specific complications of reducing the large nose that
warrant discussing here.
UPPER THIRD COMPLICATIONS
Complications of the upper third are complications involv­
ing osteotomies. The most common is the open roof
deformity, occurring most frequently after large hump
reductions with a Ruben osteotome. When a high nasal
dorsum is reduced, a gap is created between the nasal
bones. If lateral osteotomies are insufficient to close the
gap, a visible and palpable ridge will result where the
overlying soft tissue is unsupported. If such a gap is noticed
in the operating room, repeating the lateral osteotomy

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Minas Constantinides • Frank P. Fechner
Figure 24-15  A, Preoperative base view with wide domal angle and convex lateral crura in thin-skinned patient. B, One-year postoperative base view
after dome-binding and interdomal sutures. The domal angle is reduced but the crura lateral to the domes are flat, not concave, creating a strong, natural-
appearing tip.
A
B
Figure 24-14  A, Preoperative left lateral view illustrating an overprojected, over-rotated tip after primary rhinoplasty, creating a nose that is too short.
B, The 20-month postoperative view after vertical lobule division, creating a less-projected, less-rotated tip and a longer, balanced profile.
A
B
lower and performing complete medial osteotomies will
often close the gap. If not, then the gap may be filled with
either crushed cartilage or cephalic trim cartilage.
Such large gaps in the bones may also be accompa­
nied by inadvertent resection of the mucosa beneath the
bones, creating a fistula between the skin flap and the
nasal cavity. Packing this area off with crushed cartilage
or soft tissue will allow the underlying mucosal edges to
seal themselves off from the nasal superstructure.
If the nasal bones are overly narrowed because of
nasal bone collapse after osteotomies, then a pinched and
abnormal upper vault will result. One effective way to
stabilize the collapsing bone is to place a long spreader
graft beneath it. If this is not feasible, then packing the
bone up temporarily may suffice. One effective material
is oxidized cellulose gauze (Surgicel, Ethicon, Somerville,
NJ) moistened with antibiotic ointment.
Overly lowering the dorsum with a Ruben osteotome
occasionally occurs to even the experienced surgeon.
Indeed, one technique is to resect the bony dorsum, rasp
the deep surface, and then replace the dorsal segment.
Such a technique is more technically challenging than
sequential dorsal lowering with rasps but is a valuable
option in the event of overaggressive en bloc resection of
the dorsum (Figure 24-16).
Overaggressive deepening of the radix with osteoto­
mies can also yield surprises. Tardy described a technique
by which an osteotomy is first made into the frontal bone
in the midline to the radix, and then the dorsal osteotomy
is carried up to meet.12 With this procedure, care must be

CHAPTER TWENTY-FOUR  The Large Nose
311
Figure 24-16  A, Preoperative right profile view illustrating high bony profile with supratip saddle due to trauma. B, Postoperative view. During the dorsal
reduction with a Ruben osteotome, too much lowering was achieved. On the table, the excised dorsum was rasped on its undersurface and then replaced.
The result illustrates an acceptable dorsal contour. Note that tip deprojection without rotation was achieved by vertical lobule division with overlap at the
angle, the junction of the intermediate with the medial crus.
A
B
taken not to carry the osteotomy too acutely into a
well-pneumatized frontal bone lest the frontal sinus be
encountered.
MIDDLE THIRD COMPLICATIONS
Upper lateral cartilage destabilization leading to contour
deformity, the most severe being the inverted-V deformity,
is commonly seen with large nose rhinoplasty. Strong sta­
bilization of the upper lateral cartilages with spreader
grafts is almost always required after large dorsal reduc­
tions. Both this deformity, and nasal bone deformities dis­
cussed earlier, are amenable to correction with injectable
fillers to mask the shadowing created by the instability.
LOWER THIRD COMPLICATIONS
In tension noses, inadequately stabilizing the medial crura
will result in delayed postoperative tip ptosis with a result­
ant pollybeak. Overreducing tip projection in thick-
skinned patients will result in loss of tip definition and a
worse aesthetic outcome. Both of these problems are
avoided when the medial crura are well stabilized and
supported. Commonly, a columellar strut graft is used for
this. However, in many tips even this is not adequate, and
the more secure tongue-in-groove technique yields stronger
support for a more predictable tip position.13
CONCLUSIONS
Although operating on the large nose is simply performing
more reduction than a typical reduction rhinoplasty, there
are unique challenges presented by this type of rhino­
plasty. Communicating and making clear what surgery
can and cannot do is aided by computer photoimaging.
Surgical techniques that ensure stability and predictabil­
ity are more likely to result in achieving the expected
result. In the end, by creating a more balanced nose, the
focus of the observer will revert to the eyes and improve
how the whole face looks. Ultimately, this goal is what
leads to the highest degree of patient satisfaction.
REFERENCES
1. Powell N, Humphreys B. Proportions of the aesthetic face.
New York: Thieme-Stratton; 1984.
2. Joseph J. Rhinoplasty and facial plastic surgery with a
supplement on mammaplasty, English translation by Stanley
Milstein. Phoenix: Columella Press; 1987.
3. Crumley RL, Lanser M. Quantitative analysis of nasal tip
projection. Laryngoscope. 1988;98(2):202–208.
4. Simons RL. Nasal tip projection, ptosis and supratip
thickening. J Ear Nose Throat. 1982;61(8):452–455.
5. Pearlman SJ. Surgical treatment of the nasolabial angle in
balanced rhinoplasty. Fac Plast Surg. 2006;22(1):28–35.

312
Minas Constantinides • Frank P. Fechner
6. Daniel RK, Calvert JC. Diced cartilage in rhinoplasty surgery.
Plast Reconstr Surg. 2004;113:2156.
7. Kortbus MJ, Ham J, Fechner F, Constantinides M.
Quantitative analysis of lateral osteotomies in rhinoplasty.
Arch Fac Plast Surg. 2006;8:369–373.
8. Constantinides M, Levine J. Managing the tension nose. Fac
Plast Surg Clin North Am. 2000;8(4):479–486.
9. Anderson JR. A reasoned approach to nasal base surgery.
Arch Otolaryngol Head Neck Surg. 1984;110:349–358.
10. Constantinides M, Liu E, Miller PJ, Adamson PA. Vertical
lobule division in open rhinoplasty: Maintaining an intact
strip. Arch Fac Plast Surg. 2001;3:258–263.
11. Bennet GH, Lessow A, Song P, Constantinides M. The
long-term effects of alar base reduction. Arch Fac Plast Surg.
2005;7(2):94–97.
12. Tardy ME. Rhinoplasty: The art and the science.
Philadelphia: WB Saunders; 1997:313–318.
13. Kridel RW, Scott BA, Foda HM. The tongue-in-groove
technique in septorhinoplasty: A 10 year experience. Arch Fac
Plast Surg. 1999;1(4):246–256.

313
C H A P T E R T W E N T Y - F I V E 
The Underprojected Nose
and Ptotic Tip
Vito C. Quatela • James M. Pearson
Surgery of the lower third of the nose represents one of
the most challenging aspects of rhinoplasty. The nasal tip
is a three-dimensional structure described in terms of
projection, rotation, length, and shape. Each of these com­
ponents must be considered to achieve an aesthetically
pleasing result, which depends upon symmetry and pro­
portion in relation to the rest of the nose and surrounding
facial features.
The nasal tip is a dynamic structure, hinged by the
upper lateral cartilages and by the recurvature of the
lower lateral cartilages. Major and minor tip support
mechanisms play a central role in tip stability and posi­
tioning. The nasal surgeon should be keenly aware of
tip anatomy and also have a solid understanding of tip
dynamics and factors that contribute to tip rotation and
projection. He or she should appreciate the range of tech­
niques available to affect tip position and possess the
foresight to judge which techniques would be most advan­
tageously applied to each case.
ANATOMY
The nasal tip is comprised of the paired lower lateral
cartilages, or alar cartilages, which may be each divided
into three crura: medial, middle, and lateral. Regarding
terminology, the terms medial segment of the lower lateral
cartilage and medial crus are synonymous. Likewise, the
lateral crus is also called the lateral segment of the lower
lateral cartilage. These terms are used interchangeably
throughout the literature and in this chapter. The domal
junction denotes the border between the lateral and middle
crura, while the columellar junction separates the middle
and medial crura. The dome itself is formed by the domal
segment of the middle crus, which is situated adjacent and
anterior to the lobular segment of the middle crus1 (Figures
25-1 and 25-2).
A key component of nasal tip anatomy lies in the
scrolled attachment of the cephalic margins of the lower
lateral cartilages to the caudal margin of the upper lateral
cartilages. This region is often affected during rhinoplasty,
which results in weakening of this major source of tip
support.
TIP UNDERPROJECTION AND
UNDERROTATION/PTOSIS
Nasal tip projection is defined as the horizontal distance
from the alar crease of the facial plane to the nasal tip on
lateral view, or the posterior-to-anterior distance that the
nasal tip extends in front of the facial plane as seen on
basal view.2 The analysis of tip projection may be under­
taken using several different techniques.
One of the most commonly used measurements is the
Goode method, which defines ideal tip projection as a
ratio of the distance from the nasion to the tip-defining
points. Using the Goode method, this ideal ratio of tip
projection to nasal length is 0.55 to 0.6 : 13 (Figure 25-3,
A). With Simons method, tip projection (defined as the
distance between subnasale to the tip-defining point)
should equal the height of the upper lip (subnasale to the
vermillion border) (Figure 25-3, B). Crumley and Lanser
described a right triangle with dimensions corresponding
to nasal proportions; ideally projection : height : length is
equal to 3 : 4 : 5. In other words, ideal tip projection is 75%
of the nasal height, measured using a vertical line from
the nasion to the nasal base (Figure 25-3, C). Powell and
Humphries defined the ideal relationship between tip pro­
jection and nasal height as a 2.8 : 1 ratio (Figure 25-3, D).
Byrd and Hobar proposed that ideal projection is two
thirds of the ideal nasal length, which is itself ideally two
thirds of the midfacial height.3
Nasal tip rotation is defined as movement of the
nasal tip along an arc with constant distance from the
facial plane4 (Figure 25-4). A ptotic nasal tip may be
otherwise described as underrotated. Thus, the terms
ptotic and underrotated as applied to the nasal tip are
used interchangeably.
Points of reference used when measuring tip rotation
include the upper lip and the Frankfort horizontal plane.
When the upper lip is referenced, the nasolabial angle is

314
Vito C. Quatela • James M. Pearson
horizontal plane, and then the columella is brought into
balance with the ala.6 The ideal angle varies with gender;
for women an angle between 10 and 30 degrees is favored,
whereas for men an angle between 0 and 15 degrees is
considered ideal.
The amount of rotation and projection demonstrated
by a nose should be interpreted in relation to the
overall nasal appearance. Individual nasal characteristics,
the angle between the line of the nasal columella and the
line of the upper lip.5 The authors’ preferred method is
based upon the Frankfort horizontal plane and the long
axis of the nostril (Figure 25-5). The long axis of the
nostril is ideally oriented parallel to the columella (Figure
25-6), but often discrepancy exists between the two.
When addressed surgically, the long axis of the nostril is
first rotated to an angle favorable to the Frankfort
Figure 25-1  Anatomy of the nose. The nasal tip is a dynamic structure, hinged by the upper lateral cartilages and by the recurvature of the lower lateral
cartilages. (Johnson Jr CM, Toriumi DM. Open Structure Rhinoplasty. Philadelphia: WB Saunders; 1990.)

CHAPTER TWENTY-FIVE  The Underprojected Nose and Ptotic Tip
315
Figure 25-2  Anatomy of the lower lateral cartilage.
Lateral crura
Domal Junction
Domal segment
Lobular segment
Middle crura
Columella junction
Medial crura
Footplate segment
Columella segment
Figure 25-3  A, The Goode method
defines ideal nasal tip projection as a ratio of
0.55 to 0.6 of the distance from the nasion
to the tip-defining points. B, With Simons
method, tip projection (Sn–Tp) should
equal the height of the upper lip (Sn–Vs).
C, Crumley and Lanser described a right trian­
gle with dimensions corresponding to nasal
proportions; ideally projection : height : length
is equal to 3 : 4 : 5. D, Powell and Humphries
defined the ideal relationship between tip
projection and nasal height as a 2.8 : 1 ratio.
(Y-Tp) / (N-Tp)= 0.55 - 0.60
N
Y
Tp
A
(Sn-Tp) = (Sn-Vs) = 1:1
(Y-Tp):(Y-N):(N-Tp)= 3:4:5
(N-X) / (X-Tp) = 2.8
Tp
Sn
Vs
N
Y
Tp
N
X
Tp
B
C
D
including rotation, projection, length, and height, do not
exist in a vacuum and should not be evaluated in isolation.
Their relevance derives from their contribution to the
overall aesthetic balance and proportion of the nose and
face. Similarly, illusion plays an important role in nasal
appearance. For example, a ptotic nasal tip will appear to
be elongated due to the loss of a distinct supratip break.
Similarly, excessive dorsal height or a dorsal hump may
cause an otherwise well-projected nose to appear to be
underprojected as well as elongated. Other facial features
contribute to nasal illusions as well; a retrodisplaced pogo­
nion or an anteriorly sloping forehead lends to the illusion
of an overprojected nose. These concepts were introduced
and are discussed more completely in Chapter 3 of this
text.

316
Vito C. Quatela • James M. Pearson
Figure 25-4  Nasal tip rotation is defined as movement of the nasal tip
along an arc with constant distance from the facial plane.
Figure 25-5  The degree of tip rotation is measured with reference to the Frankfort plane and the long axis of the nostril.
Frankfort
plane
20°
Figure 25-6  The long axis of the nostril is ideally oriented parallel to
the columella.
2-4 mm

CHAPTER TWENTY-FIVE  The Underprojected Nose and Ptotic Tip
317
TIP SUPPORT
The structure and position of the nasal tip depend not just
on the sum of its constituent parts but also on the support
conferred by the upper lateral cartilages, nasal septum,
and skin–soft tissue envelope (SSTE). Additionally, the
combined effects of age, underlying medical conditions,
trauma, and surgical interventions factor prominently in
the ultimate appearance of the nasal tip.
To achieve the desired changes to the structure of the
nasal tip, the surgeon must understand the factors con­
tributing to tip support and dynamics. Nasal tip support
derives from the inherent strength of the lower lateral
cartilages, the nasal septum, and the various ligaments
and fibrous connections between the alar cartilages and
adjacent structures. By convention, support mechanisms
are divided into major and minor groups. The three major
tip support mechanisms include the size, shape, and resil­
ience of the medial and lateral crura of the lower lateral
cartilages, the attachment of the medial crural footplate
to the caudal septum, and the scrolled attachment of
the cephalic margins of the lower lateral cartilages to the
caudal margin of the upper lateral cartilages. The minor
tip supports generally include the dorsal septum, inter­
domal ligaments, membranous septum, anterior nasal
spine, attachment of the lower lateral cartilages to the
SSTE, the thickness of the SSTE, and the lateral crural
attachment to the pyriform aperture (Table 25-1).
The interdomal ligament acts to support the nasal tip
as a fibrous connection between both domes and the ante­
rior septal angle. The contribution of this ligament is
somewhat controversial in that some authors consider the
interdomal ligament to be a fourth major tip support
mechanism, whereas others consider it to be a minor one.
The tripod model proposed by Jack Anderson pro­
vides a mechanical model with which to understand the
relationship between projection and rotation. Importantly,
it can be used to predict the effects that alar cartilage–
modifying maneuvers are likely to have on both tip
projection and rotation.
Table 25-1  Nasal Tip Support Mechanisms
Major Group
Minor Group
• Strength and shape of
lateral crura
• Strength, shape, length
of medial crura
• Upper lateral union to
lower lateral
• Medial crural-septal
fibrous union
• Interdomal
ligamentous sling
• Cartilaginous septal
dorsum
• Lateral crura-pyriform
aperture
• Skin thickness and its
attachment to cartilage
• Nasal spine
The tripod concept postulates that nasal tip projection
and rotation may be understood by considering the nasal
tip as a tripod composed of the conjoined medial crura of
the lower lateral cartilage as one leg and the two lateral
crura as each remaining leg (Figure 25-7, A). By changing
the length of one component of the tripod, a correspond­
ing change in nasal tip projection and rotation can be
anticipated. For example, shortening the two lateral crura
would be expected to increase tip rotation along with
slight deprojection (Figure 25-7, B). Likewise, lengthen­
ing the conjoined medial crura alone would increase both
projection and rotation (Figure 25-7, C).
CAUSES OF TIP PTOSIS AND
UNDERPROJECTION
Any condition that weakens the tip support mechanisms
just delineated may lead to tip ptosis and underprojection.
The range of possible etiologies includes congenital weak­
ness of the nasal cartilages or other tip support mecha­
nisms, infection, trauma, and iatrogenic damage.
For each patient, the etiology of ptosis and under­
projection should be investigated to elucidate the con­
tributing factors. To ensure success, the surgical plan must
address the specific issues pertinent to each case.
Iatrogenic causes of tip ptosis and underprojection are
common. Patients with a history of prior septorhinoplasty
are at risk for developing tip sequelae due to surgical
disruption of tip support mechanisms. Additionally, the
effects of scar contracture of the disrupted SSTE further
contributes over time to postoperative tip ptosis and
deprojection.
Practically every maneuver associated with the
endonasal approach compromises tip support mecha­
nisms, including the intercartilaginous incision and the
alar cephalic trim. A cadaveric study using objective
measurements found that the intercartilaginous incisions
and cartilage delivery techniques inherent to the endona­
sal approach caused a 35% loss of tip support.7 Alar
cartilage–splitting techniques and aggressive cartilage
resection further compromise nasal structure and support
mechanisms.
There is controversy as to the relative destructuring
effects of the endonasal approach versus the nasal decor­
tication undertaken with the open approach. The authors’
opinion is that although the open approach to rhinoplasty
is referred to as simply another approach, in reality it is
another operation entirely. The open approach necessi­
tates rebuilding injured tip support that is compromised
as part of the decortication.
In the operated nose, ptosis and underprojection are
typically not apparent in the early postoperative period.
However, with passing time, the effects of scar contracture
and gravity often create conditions that cannot be with­
stood by the diminished structure of the operated nose.

318
Vito C. Quatela • James M. Pearson
Figure 25-7  A, Tripod theory. The upper tripod legs are formed by the lateral crural complex and the lower tripod leg is formed by the conjoined
medial crura. B, Here, shortening of the upper legs leads to movement of the tip of the tripod upward and slightly posteriorly, effectively increasing nasal
tip rotation without a significant effect on tip projection. C, Lengthening the lower tripod leg increases both tip rotation and projection.
Central limb
of tripod
Conjoined
medial crura
A
B
C
Likewise, the effects of skin envelope contracture are only
seen over time and through hindsight the need for more
structure is elucidated.
METHODS OF REPAIR
The authors prefer the open approach to the nose if any
tip work is required, as is the case in the great majority
of our nasal cases. Methods of repair may be divided
into alar cartilage–modifying techniques and adjunctive
maneuvers.8
Alar cartilage–modifying techniques to address tip
underrotation and underprojection include placement of
a columellar strut, tip grafting, lateral crural steal, lateral
crural overlay, and the tongue-in-groove techniques.
Adjunctive maneuvers include establishing proper dorsal
height, addressing alar–columellar discrepancy, premaxil­
lary grafting, alar cephalic trim, resection of an overdevel­
oped scroll region, and debulking the SSTE. Each of these
options will be described next.
The surgical techniques described in this chapter may
be used either independently or in combination depending
on the findings and contributing factors present in each
case, as well as on the degree of rotation or projection
intended.
GRAFTING MATERIALS
Throughout the course of a rhinoplasty, often cartilagi­
nous grafting material is needed to provide the structural
support required to affect desired changes. The preferred
grafting materials are septal cartilage followed by auricu­
lar cartilage, then costal cartilage. In the unoperated nose,
sufficient septal cartilage is usually available to enable its
use in most cases. In revision cases, the surgeon should
investigate the status of the septal cartilage, while retain­
ing a backup plan should insufficient septal cartilage be
found at the time of surgery. A paucity of remaining septal
cartilage requires that the surgeon find another source. As
a matter of course, revision cases should be counseled
about and consented for auricular and costal cartilage
harvest in the event the need arises for alternative sources
of cartilaginous grafting material.
When septal cartilage is found to be inadequate, auric­
ular cartilage should be sought. A cartilage incision is made
along the inner rim of the antihelical fold, while preserving

CHAPTER TWENTY-FIVE  The Underprojected Nose and Ptotic Tip
319
a strip of intact cartilage between the cymba concha supe­
riorly and the concha cavum inferiorly, which the authors
prefer to harvest separately. Preservation of this auricular
cartilage strut enables the healing auricle to resist contrac­
tion and deformation during healing, thus preserving the
anteroposterior dimension of the conchal bowl.
The concha cavum is the preferred auricular substrate
for tip grafting if septal cartilage is unavailable, while the
cymba concha is the favored source of alar grafting mate­
rial. When used for a columellar strut, the concha cavum
or concha cymba is reinforced by folding it upon itself,
with concave surfaces facing each other, and sutured
together using multiple 5-0 nylon sutures in a horizontal
mattress fashion.
COLUMELLAR STRUT
The columellar strut graft, along with septocolumellar
fixation, provides the foundation upon which to build and
refine the nose. This maneuver is the first tip-modifying
step performed as part of the authors’ preferred open
technique. The structural integrity of the tripod segment
formed by the conjoined medial crura is often compro­
mised in noses undergoing rhinoplasty. That compromise
may be due to congenitally weak crura or secondary to
traumatic or iatrogenic damage to tip support mecha­
nisms. Regardless of the etiology, the effects of diminished
integrity of this inferior tripod segment cause the nose to
collapse toward the face, effectively deprojecting and
counterrotating the nasal tip.
A sturdy fragment of cartilage is desirable for colu­
mellar strut grafting. A favorable piece of septal cartilage
can usually be harvested from along the floor of the nose
where the cartilaginous septum joins the maxillary crest
(Figure 25-8). After harvesting it, the graft is further
trimmed to the appropriate size and shape using a No. 15
blade and a cutting block. A graft measuring 20 mm in
length and 3 to 5 mm in width is typically adequate.
In the authors’ preferred rhinoplasty sequence, septo­
plasty and harvest of septal cartilage are performed first,
followed by opening the nose and dorsal reduction if
indicated. Next, placement of spreader grafts is under­
taken before the tip is addressed. Once the columellar
strut graft is prepared, a pocket is dissected between the
limbs of the medial crura in the direction of the nasal
spine, while carefully preserving a layer of soft tissue
overlying the nasal spine (Figure 25-9). The columellar
strut is then implanted into this pocket, to a depth that
preserves a soft tissue cushion between the deep aspect of
the strut and the nasal spine. The columellar strut is then
sutured to the medial crura using multiple 4-0 plain gut
sutures in horizontal mattress fashion (Figure 25-10).
Symmetric fixation of the medial crura to the strut graft
is necessary to maintain symmetry between the left and
right alar domes.
Figure 25-8  Columellar strut: a sturdy strut is harvested from along the
inferior border of nasal septal cartilage.
Columellar
strut
Figure 25-9  Placement of the columellar strut in a pocket dissected
between the medial crura.
The columellar strut adds substantially to the
stability of the nasal base. In a study that used objective
measurements of nasal support in patients undergoing
rhinoplasty, placement of a columellar strut alone
increased nasal tip support 40% over baseline in the
vector of the columella.7

320
Vito C. Quatela • James M. Pearson
end should be thinned adequately to allow it to take on a
gentle anterosuperior curvature. Prior to making final
adjustments, the SSTE can be redraped over the domal–
tip graft complex and temporarily sutured at the colu­
mella to allow the surgeon to visualize the tip graft’s effect
on nasal tip contour and projection as well as to check for
visible irregularities. If the SSTE is thin, the surgeon may
choose to apply a crushed cartilage onlay graft to camou­
flage any visible edges. The tip graft is performed last in
the sequence of tip-modification maneuvers.
LATERAL CRURAL STEAL TECHNIQUE
If increased tip rotation and projection are desired, the
lateral crural steal technique may be employed. This
maneuver entails placing an interdomal mattress suture
in such a way as to advance the lateral crura onto the
medial crura10,12 (Figure 25-12). Two technical points
warrant description. First, the vestibular skin must be
dissected from the undersurface of the domal portion of
the alar cartilages bilaterally. Otherwise, the mattress
suture will traverse the musosa and remain exposed within
Once the columellar strut is secured, the surgeon can
then closely evaluate the contribution of the lateral crura
to tip rotation. Considering again the tripod model, dis­
proportionately long lateral crura will tend to have a
counterrotating effect on the nasal tip. At this juncture,
the surgeon may wish to consider using one of two
cartilage-modifying techniques described for this purpose:
the lateral crural steal or the lateral crural overlay. Both
maneuvers increase tip rotation. The choice as to which
technique to employ depends on the existing tip projec­
tion, and the surgeon’s decision based on this to modify
tip projection. Both of these techniques are described in
greater detail later.
NASAL TIP GRAFT
Tip grafting is a powerful tool that can provide additional
structural support as well as projection to the nasal tip.
The tip graft was developed to provide a stable and
durable tip support that appeared natural over time.9 The
graft is fashioned from autogenous cartilage, preferably
septal cartilage, and is secured at the caudal margin of
the medial crura. It should extend from the proximal end
of the conjoined medial crura to just beyond the domes.
The tip graft can provide a small increase in tip projection
as well as a refined tip contour that accentuates favorable
nasal light reflexes.
The shape of the graft is roughly hexagonal, with the
projecting end wider than the proximal end (Figure
25-11). It is carved intentionally longer than required and
fixated to the caudal border of the medial crura using 6-0
nylon sutures. Once in place, its shape and size are refined
using a No. 15 blade to shave the cartilage to the exact
specifications indicated. Circumferential beveling should
be performed to minimize visible edges. The projecting
Figure 25-11  The shape of the tip graft is roughly hexagonal, with the
projecting end wider than the proximal end. It is fixated to the caudal border
of the medial crura using 6-0 nylon sutures.
Figure 25-10  The columellar strut is inserted into a pocket dissected
between the medial crura, to a depth that preserves a soft tissue cushion
between the deep aspect of the strut and the nasal spine. The columellar
strut is sutured to the medial crura using multiple 4-0 plain gut sutures in
horizontal mattress fashion. (Adapted from Johnson et al.6)

CHAPTER TWENTY-FIVE  The Underprojected Nose and Ptotic Tip
321
crural overlap effectively shortens the upper tripod limbs,
resulting in decreasing projection along with increasing
rotation. If less deprojection or maintenance of projection
is desired, less lateral crural overlap is used. As previously
described for the lateral crural steal, the vestibular skin
must be dissected from the undersurface of the domal and
mid-body segments of the alar cartilages bilaterally as
described earlier.
TONGUE-IN-GROOVE TECHNIQUE
The tongue-in-groove technique is another method of
increasing tip rotation and controlling tip projection. The
technique consists of advancing the medial crura cepha­
loposteriorly onto the caudal septum into a surgically
created pocket between the crura.2 The amount of tip
rotation may be adjusted based upon the degree of supe­
rior advancement of the medial crura onto the septum.
Similarly, tip projection may be decreased by positioning
the medial crura posteriorly onto the septum.
This technique should only be used in patients
who have a redundancy of the caudal septum that would
otherwise require trimming.11 Ideal patients for applica­
tion of this technique include those with either a short
upper lip or with columellar show, as this maneuver
improves both conditions. When the tongue-in-groove
technique is used, columellar strut placement is typically
not required because the caudal septum takes the place
of the columellar strut in stabilizing the medial crura and
the base of the nose.
Performance of the tongue-in-groove maneuver
begins with a transfixion incision made at the caudal
border of the cartilaginous nasal septum. Caudal to that
incision, a pocket is dissected between the medial crura
of the lower lateral cartilages. Next, the medial crura are
advanced cephalically and posteriorly onto the exposed
caudal nasal septum. The amount of advancement in each
direction is dictated by the intended degree of rotation
and/or deprojection. Once the desired position of the
lower lateral crura is achieved, fixation is accomplished
using horizontal mattress sutures through the ipsilateral
medial crura–caudal septum–contralateral medial crural
complex (Figure 25-14).
the nasal airway. Such exposure increases the risk of
postoperative infection, ulceration, or otherwise delayed
healing. Second, the columellar strut may extend beyond
the level of the native domes. If that is the case, the
mattress suture should traverse the strut as well, at the
intended height of the new tip. If the columellar strut still
extends beyond the augmented domes, it is trimmed at
that time to be 1 mm below the intended level of tip
projection as established by the tip graft.
LATERAL CRURAL OVERLAY TECHNIQUE
If increased tip rotation along with decreased projection
or maintenance of projection is desirable, the lateral
crural overlay technique may be used (Figure 25-13).
This maneuver involves dividing the lateral crura at its
midsection and overlapping the proximal ends over the
distal ends, then suturing the overlapped ends together
using horizontal mattress sutures.10 The degree of overlap
is modified to impart the desired amount of tip deprojec­
tion and rotation. With regard to the tripod theory, lateral
Figure 25-12  Schematic diagram of the lateral crural steal technique. The lateral crura are advanced medially onto the medial crura.
B
A
C
Figure 25-13  Schematic diagram of the lateral crural overlay technique.
The middle section of the lateral crus is divided, and the margins are over­
lapped. (Adapted from Konior.13)

322
Vito C. Quatela • James M. Pearson
ADJUNCTIVE TECHNIQUES AND
OTHER CONSIDERATIONS
ESTABLISHING PROPER DORSAL HEIGHT
The establishment of proper dorsal height should be
accomplished prior to undertaking attempts at tip modi­
fication, as improper dorsal height fosters an illusion of
tip malposition. For example, an overly high dorsum
appears as a dorsal convexity on lateral view. This convex­
ity creates the illusion of underprojection in an otherwise
well-projected tip. The dorsum should follow a smooth,
straight contour from the radix to the supratip break.
Once dorsal height is established, the surgeon will more
readily appreciate which adjustments, if any, may be indi­
cated to the nasal tip position to achieve the desired result.
ALAR–COLUMELLAR DISCREPANCY
Excessive caudal projection of the septal quadrangular
cartilage may contribute to alar–columellar discrepancy
or “columellar show” resulting in apparent underrotation
of the nasal tip (Figure 25-15). Similarly, excessive caudal
projection of the medial crural cartilages may contribute
to the same problem. When present, resection of the
caudal septum or caudal margin of the medial crura may
be indicated. The offending cartilage should be trimmed
as needed to reduce columellar show to within the favo­
rable 2- to 4-mm range and to reestablish harmony
between the long axis of the nostril and the columella.
Alternatively, the tongue-in-groove technique, described
previously, may be applied to address alar–columellar
discrepancy. This subject will be covered at length in a
separate chapter.
Following suture fixation, excess caudal septum may
still project beyond the medial crura–septum complex.
Once the surgeon is satisfied with the new tip position,
any excess caudal septum may be conservatively trimmed.
Following this maneuver, redundant membranous septum
may be present intranasally. This excess soft tissue should
be grasped with forceps and gently retracted caudally,
then trimmed and sutured such that the caudal portion
of the membranous septum approximates with the
transfixion incision. Not excising the redundant soft
tissue in this region may predispose the patient to nasal
airway obstruction due to membranous septum bunching
postoperatively.
In addition to its usefulness for increasing tip rotation
and controlling tip projection, the tongue-in-groove
method may also be applied to improve columellar show
and to aid in the correction of cadual septal deviation.2
Advocates of this technique note the predictability of
the final tip position in comparison to other cartilage-
modifying techniques, which may be subject to changes
with contracture during healing. Depending on the degree
of rotation desired, additional maneuvers may be required
to supplement the tongue-in-groove. In a series of 203
rhinoplasty patients who underwent the tongue-in-groove
technique, 14 patients also required the employment of
the lateral crural overlay to further increase rotation or to
deproject the tip.2
With the tongue-in-groove technique, the effect on
nasal tip projection and rotation is not necessarily pre­
dicted by the tripod model because the tripod concept
describes only the changes brought about by lengthening
or shortening the tripod limbs. With the tongue-in-groove,
it is not the length but rather the position of lower tripod
limb that is modified with respect to the septum and the
upper limbs.
Figure 25-14  Schematic diagram of the tongue-in-groove technique. The medial crura are advanced cephalically and posteriorly onto the exposed
nasal septum. The complex is suture fixated in the desired orientation.
A
B
C

CHAPTER TWENTY-FIVE  The Underprojected Nose and Ptotic Tip
323
address this finding is the premaxillary graft. A graft of
septal or auricular cartilage is placed in a surgical pocket
created at the base of the columella, beneath the feet of
medial crura and overlying the central premaxilla.9 This
maneuver moves the lower limb of the nasal tripod ante­
riorly, effectively raising the height of the base of that
tripod limb and contributing to tip projection (see Figure
25-7 C). Additionally, a premaxillary plumping graft can
also be used to open (i.e., make more obtuse) an overly
acute nasolabial angle. Bruised autologous cartilage can
be placed just inferiorly to the soft tissue of the nasolabial
angle, where it can add to the illusion of tip rotation.
ALAR CEPHALIC TRIM
Excessively wide lateral crura may contribute to tip ptosis.
A simple alar cephalic trim of cartilage creates an area of
dead space that, with scar contracture, rotates the tip
upward to a more favorable position. The surgeon should
be careful to preserve at least 8 mm of lateral crural width
to ensure structural integrity of the lower lateral cartilage.
Overresection of the lateral crura may result in weakened
cartilages, which are predisposed to buckling with scar
contracture, leading to bossae formation.
OVERDEVELOPED SCROLL REGION
The scroll is the region of overlapping attachment of the
caudal border of the upper lateral cartilage to the cephalic
border of the lower lateral cartilage. Overdevelopment
of the scroll region can also contribute to tip ptosis. If
indicated, conservative resection of the scroll can effec­
tively shorten the length of the lateral crura (lateral
tripod limbs) and consequently aid in rotating a ptotic tip
(Figure 25-16).
PREMAXILLARY GRAFTING
Inadequate tip projection may arise from a lack of ade­
quate support at the base of the lower tripod limb, where
the medial crural footplates lie adjacent to the premaxilla.
In that situation, the lower limb of the tripod is weakened
and apparently foreshortened. A useful technique to
Figure 25-15  Excessive caudal projection of the septal quadrangular
cartilage may contribute to “columellar show” resulting in apparent under­
rotation of the nasal tip. Resection of the caudal septum may be indicated
to increase tip rotation.
Figure 25-16  Conservative resection of an overdeveloped scroll can effectively shorten the length of the lateral crura (lateral tripod limbs) and conse­
quently aid in derotating a ptotic tip.

324
Vito C. Quatela • James M. Pearson
the inherent inelasticity of a thickened SSTE may prevent
the overlying envelope from conforming to the underlying
structure, thereby blunting and taking away from the
definition of the nasal tip, despite an ideally defined
underlying structure. Conservatively thinning the under­
surface of the SSTE should be undertaken when indi­
cated to minimize these effects. During healing, periodic
treatments
with
subcutaneous
long-acting
steroid
SKIN–SOFT TISSUE ENVELOPE
In every rhinoplasty, the thickness of the nasal SSTE
must be considered. In some cases, the SSTE may have
a major influence on the appearance of the nasal tip. In
other cases, it may have only a minor contribution. A
thick SSTE provides additional mass, which may contrib­
ute to forces favoring tip counterrotation. Additionally,
Figure 25-17  Preoperative and 1-year postoperative photographs of three patients who underwent open septorhinoplasty, which included correction
of tip underprojection and underrotation in each case.

CHAPTER TWENTY-FIVE  The Underprojected Nose and Ptotic Tip
325
ent procedures, as described. Further modifications can
be made using adjunctive techniques as indicated.
Successful surgery of the nasal tip demands a thor­
ough knowledge of anatomy, tip support mechanism,
dynamics, and techniques. Factors contributing to tip
rotation and projection are unique to each nose. A surgical
plan should be tailored to the particular needs presented
by each patient.
The techniques described herein are not intended to
be an exhaustive review of the surgical options available
to address the array of nasal tip characteristics that may
be encountered. Instead, this chapter provides an over­
view of versatile and proven techniques that may be
applied to the majority of cases and that have been found
to effect predictable and lasting results.
The challenge presented to the nasal surgeon by tip
rhinoplasty is to integrate a keen appreciation for nasal
aesthetics with an intimate knowledge of tip anatomy and
dynamics, the diagnostic insight to elucidate the etiology
of tip malposition, and the surgical skill to apply a variety
of techniques as needed to achieve a desired result.
REFERENCES
1. Daniel RK. The nasal tip: anatomy and aesthetics. Plast
Reconstr Surg. 1992;89(2):216–224.
2. Kridel RWH, Scott BA, Foda HMT. The tongue-in-groove
technique in septorhinoplasty. Arch Fac Plast Surg. 1999;1:
246–256.
3. Toriumi DM. Rhinoplasty. In: Park SS, et al., eds. Facial
plastic surgery: The essential guide. New York: Thieme; 2005;
223–253.
4. Simons RL. Nasal tip projection, ptosis, and suptratip
thickening. J Ears Nose Throat. 1982;61(8):452–455.
5. Orten SS, Hilger PA. Facial analysis of the rhinoplasty
patient. In: Papel ID, et al., eds. Facial plastic and
reconstructive surgery. New York: Thieme; 2002;361–368.
6. Johnson Jr CM, Toriumi DM. Open structure rhinoplasty.
Philadelphia: WB Saunders; 1990.
7. Beaty MM, Dyer WK, Shawl MWW. The quantification of
surgical changes in nasal tip support. Arch Fac Plast Surg.
2002;4:82–91.
8. Foda HM. Management of the droopy tip: A comparison of
three alar cartilage-modifying techniques. Plast Reconstr
Surg. 2003;112(5):1408–1417; discussion 1418–1421.
9. Pastorek N, Ham J. The underprojecting nasal tip: An
endonasal approach. Fac Plast Surg Clin North Am. 2004;
12(1):93–106.
10. Foda HMT, Kridel RWH. Lateral crural steal and lateral
crural overlay. Arch Otolaryngol Head Neck Surg. 1999;125:
1365–1370.
11. Toriumi DM. New concepts in nasal tip contouring. Arch Fac
Plast Surg. 2006;8:156–185.
12. Kridel RWH, Konior RJ, Shumrick KA, Wright WK. Advances
in nasal tip surgery: The lateral crural steal. Arch Otolaryngol
Head Neck Surg. 1989;115:1206–1212.
13. Konior RJ. The droopy nasal tip. Fac Plast Surg Clin North
Am. 2006;(14):291–299.
(triamcin­olone acetonide 10 mg/mL) can aid in reducing
edema and scar contracture of the tip.6
Once the tip work is completed, osteotomies are per­
formed as needed. If septal work or cartilage harvest was
performed, a 4-0 plain gut suture on a Keith needle is
used to approximate the septal mucoperichondrial flaps.
Splints made from Silastic sheeting are applied to each
side of the nasal septum and sutured in place using a 2-0
silk suture anteriorly. The columellar skin incision is
closed using 6-0 nylon sutures. The marginal incision is
closed using 5-0 plain gut sutures. Polysporin-coated
Telfa rolled onto itself is used to lightly pack the nasal
cavity.
POSTOPERATIVE CARE
The patient is discharged home with a prescription for
broad-spectrum antibiotics for a few days. The nasal
packing is removed the following morning, and the patient
is instructed to begin using saline nasal spray several
times daily. The columellar sutures are removed on post­
operative day 3 or 4, and the incision site is dressed with
paper tape. If used, the Silastic splints are removed on
postoperative day 7. If subtle irregularities or excessive
edema are present, nasal exercises are started at this time.
The patient is instructed to avoid exertion and aerobic
exercise until the end of the third postoperative week. By
the end of the fourth week, if excessive or asymmetric
edema or scar tissue formation is present, subcutaneous
injections of long-acting steroid (triamcinolone acetonide)
are initiated typically in the supratip or side wall regions
as indicated.
SUMMARY
The need to modify the underprojected and underotated
nasal tip arises regularly in patients seeking rhinoplasty.
In fact, the majority of all cases involve some degree of
such modification (Figure 25-17). Tip underrotation was
observed in 72% of patients in a report of 500 consecutive
rhinoplasty cases.8 Of those, 85% required application of
a cartilage-modifying technique to rotate the tip. The
remaining 15% were surgically treated with adjunctive
maneuvers alone, including cephalic trim of the lateral
crura, excision of the overdeveloped scroll region, or low­
ering the height of the anterior septal angle.
The nasal surgeon has at his or her disposal several
proven methods for addressing tip projection and rotation.
A method of repair should be chosen based on the desires
and needs of the patient and the anatomy of the nose in
question. A case may call for increasing projection alone,
increasing rotation alone, or increasing both projection
and rotation. Different presentations may require differ­

327
C H A P T E R T W E N T Y - S I X 
Thin Skin Rhinoplasty:
Aesthetic Considerations
and Surgical Approach
Michael J. Brenner • Peter A. Hilger
Thin nasal skin readily reveals imperfections of the under­
lying osseocartilaginous framework and has profound
implications for the surgical planning and execution of
rhinoplasty. Thin skin may be a normal variant or the
result of prior surgery, trauma, or disease. The relative
inattention to this subject in the literature is striking,
particularly when one considers the small tolerance for
error that exists when working with thin skin. One pos­
sible explanation is the misconception that relatively few
techniques are available to improve surgical results in this
difficult group. Another explanation for this conspicuous
omission is the prevailing notion that the character of thin
skin is largely immutable.1 This chapter addresses these
concerns and introduces a variety of techniques that we
have found beneficial in patients with thin nasal skin.
In this discussion, “thin skin” and “thin nasal skin”
more properly refer to a thin nasal skin–soft tissue enve­
lope (SSTE). When anatomic reference to the skin of the
nose in isolation is intended, we refer specifically to the
epidermis, dermis, or cutaneous layer. We have chosen
this potentially confusing terminology because most clini­
cians tacitly include the four layers of tissue between the
skin and osseocartilaginous framework when they speak
of patients with thin skin. Furthermore, this approach
allows us to consider in our discussion of thin skin both
patients with naturally fine skin as well as patients who
have undergone prior rhinoplasty and have thin SSTEs
with a parchment-like character. Several of the technical
considerations in these two groups are similar. The aging
nose, discussed in a separate chapter, also exhibits thin­
ning of the SSTE and is briefly addressed in this
discussion.
ANATOMY OF THE SKIN-SOFT
TISSUE ENVELOPE
The anatomy of the SSTE and its relation to the nasal
framework is of great interest to the rhinoplasty surgeon
working with thin nasal skin. The thickness of the SSTE
varies, being thickest over the radix and supratip area and
thinnest at the rhinion. There are four layers of tissue that
reside between the skin and osseocartilaginous frame­
work: the superficial fatty panniculus, the fibromuscular
layer, the deep fatty layer, and the perichondrium or peri­
osteum.2 The fibromuscular layer contains the nasal
superficial musculoaponeurotic system (SMAS), which is
in continuity with facial SMAS, platysma, and galea. This
layer provides structure and is flush to the underlying
vascular supply of the SSTE. In the patient with thin nasal
skin, extra care is taken to preserve the vascular supply
of the SSTE by elevating a flap immediately superficial to
the perichondrium.
The facial muscles exert dynamic forces on the nose
that are often pronounced in patients with thin skin. The
nasal muscles are innervated by the zygomatic branch of
the facial nerve and have been divided into four groups:
elevator, depressor, compressor, and minor dilator muscles.
The elevator muscles, including the procerus, levator labii
superioris alaeque nasi, and anomalous nasi, shorten the
nose and dilate the nostrils. The depressor muscles,
including the depressor septi and alar portion of the
nasalis, lengthen the nose and dilate the nostrils. The
compressor muscles, including the transverse portion of
the nasalis and compressor narium minor, lengthen the
nose and contract the nostrils. Last, the minor dilator
muscle is the dilator naris anterior. These muscles have
functional and aesthetic relevance to thin skin rhinoplasty,
with their role in surgical treatment sometimes described
as “dynamic rhinoplasty.” Understanding these muscle
actions allows for improved control of dorsum–tip–labial
relationships.
TYPES OF THIN SKIN
NATURALLY THIN SKIN
In patients who have not undergone prior nasal surgery,
the thickness of the supratip soft tissue is dictated by the

328
Michael J. Brenner • Peter A. Hilger
characteristics of the skin and contribute to thinning and
premature aging of the skin. Corticosteroid excess, as may
occur with diseases of the adrenal cortex, pituitary neo­
plasms, and exogenous corticosteroid use are additional
factors associated with thinning, weakening, and delayed
healing of the skin. Ehlers-Danlos syndrome and osteo­
genesis imperfecta, which are associated with defective
collagen synthesis, result in abnormally thin skin with
decreased tensile strength, as part of their clinical behav­
ior. While the techniques presented herein for thin skin
are highly versatile, the dynamics of healing in aging and
disease are beyond the scope of this chapter.
PHILOSOPHICAL CONSIDERATIONS
RELATED TO THIN SKIN
SMALL MARGIN OF ERROR
Identification of thin skin during the preoperative assess­
ment is crucial in planning rhinoplasty so that the patient
can be counseled appropriately and the surgical plan
adapted to the special needs of thin skin. The potential
margin for error is narrower in patients with thin nasal
skin. While thin skin confers an excellent opportunity for
achieving refinement of the nasal tip, subtle irregularities
will be more difficult to conceal. Some patients have very
strong or prominent cartilages whose entire cartilage
outline is discernible.
THE SHRINK WRAP EFFECT
The “shrink wrap” effect that occurs after rhinoplasty is
more profound in patients with thin skin. In contrast to
thick skin, which limits the degree of resection that can
be performed, thin skin allows for a greater degree of
overall reduction and creation of a smaller nasal contour.
On the other hand, such patients are at greater risk for
disfigurement by the contractile forces of healing. During
the postoperative course, patient with tight skin will notice
that the nasal covering becomes even more constricted.
The surgical plan must acknowledge that the toll of the
“shrink wrap” effect may progress well beyond the first
couple of postoperative years.
IMPLICATIONS OF THIN SKIN ARE DIFFERENT
FOR EACH THIRD OF THE NOSE
The healing process in patients with thin skin exerts char­
acteristic effects on each portion of the nose. Over the
bony pyramid, thin skin predisposes to palpable and
sometimes visible osteotomy sites. Small spicules of bone,
minor bony irregularities, or asymmetric bone regrowth
are poorly concealed. The late narrowing of the nasal
midvault seen with typical reductive rhinoplasty is accen­
tuated in these patients. In addition, imprecise correction
density of sebaceous glands in the epithelium and the
suppleness of the subcutaneous tissues. Patients with
“thick skin,” discussed in detail in Chapter 27 in the text,
usually have sebaceous skin with dense underlying soft
tissues that obscure nasal framework and resist surgical
refinement. Patients with naturally fine skin have the
opposite problem—skin that reveals too much—and
subtle imperfections will “shine through” the delicate veil
of the thin nasal covering. In such cases, absence of the
usual buffer of skin and soft tissue will often draw atten­
tion to the contours of the underlying cartilaginous and
bony nasal anatomy in an unflattering manner. Thin skin
may occur irrespective of age, gender, or ethnicity;
however, the prototypical thin-skinned patient in the
senior author’s practice is a young woman in her 30s,
often of Nordic descent, with fair skin, blonde or red hair,
and blue eyes (Fitzpatrick Type I or II).
PARCHMENT THIN SKIN
Thin skin is also seen in association with prior rhino­
plasty.3 The prototypical patient in this setting is a female
with medium to medium-thin facial skin who relates a
history of progressive changes to the character of the skin
subsequent to one or more prior rhinoplasties. Examina­
tion of the skin and its underlying soft tissue elements
demonstrates atrophic changes in association with scar­
ring. Actinic changes or talangiectasias are usually present,
often over the rhinion, and there is poor elasticity to the
nasal covering. This skin is sometimes described as “parch­
ment thin skin,” a reflection of its fragile quality and its
thin, almost translucent appearance.
In the previously operated nose, thin skin may be
adherent to the underlying framework. As a result, the
underlying cartilaginous and skeletal irregularities stand
out in relief. Parchment preparation, which historically
involved the stretching, scraping, and drying of skin under
tension to create a stiff, translucent material, has much in
common with the pathogenesis of iatrogenic thin skin in
postrhinoplasty patients. Thinness of the SSTE—often
unrecognized at time of original surgery—predisposes to
development of this complication, but parchment thin
skin usually indicates transection or injury of the nasal
SMAS during dissection. This transgression permanently
compromises skin quality and increases risk of alar retrac­
tion due to exaggerated scarification. Steroid injection
compounds the problem.
AGING AND DISEASE-RELATED THIN SKIN
Last, normal aging and several disease entities cause
thinning of the skin. These causes have an underlying
physiology that differs from both innately thin nasal skin
and from acquired parchment thin skin. Aging is associ­
ated with reduction of the skin’s strength, thickness, and
elasticity. Actinic changes and solar damage also alter the

CHAPTER TWENTY-SIX  Thin Skin Rhinoplasty: Aesthetic Considerations and Surgical Approach
329
of the open roof deformity and other irregular contours
become progressively more conspicuous as the skin seats
down tightly over the framework. Thin skin in this area
resists attempts by the surgeon to camouflage significant
structural abnormalities with onlay grafts. The thin skin
over the rhinion is most prone to alterations in color,
texture, and tone. Prior to surgery, many patients have
actinic changes; these patients need to be counseled
regarding the risk for development of telangiectasias. The
skin may become shiny as it becomes taut. The lower third
of the nose is particularly prone to deforming forces of the
healing SSTE.
TECHNICAL CONSIDERATIONS
OVERVIEW
The presence of thin skin has implications for all major
aspects of rhinoplasty. Thin skin necessitates extra care in
the elevation and protection of the SSTE; it requires spe­
cific strategies for structural correction and camouflage of
the osseocartilaginous framework, and it calls for special
measures for prevention and treatment of bossae and
other contour irregularities. Skin color changes can be
minimized or treated, and this will be discussed later in
this chapter. Crushed cartilage may be combined with a
variety of other soft tissue grafting materials. Certain
adjunctive techniques are beneficial for fine tuning after
thin skin rhinoplasty, although injection of either fillers or
steroids is best performed conservatively or avoided alto­
gether. Each of these technical points is covered in the
discussion that follows.
ELEVATION AND PROTECTION OF THE SSTE
In patients with thin nasal skin, it is important to elevate
the SSTE in as thick a flap as possible. The plane of dis­
section is immediately superficial to the perichondrium
over the upper and lower lateral cartilages and subperi­
osteal over the bony dorsum. If no bony dorsal surgery is
required, elevation over the dorsum is avoided because
such unnecessary dissection may provoke the unwanted
shrink-wrap effect. Thick skin is comparatively forgiving
of imprecise dissection, whereas failure to respect the vas­
cular supply of the SSTE in the patient with thin skin
results in excessive postoperative edema and a parchment-
like character to the skin. Furthermore, transsection of
the SMAS disrupts the anatomic barrier between the skin
and structural framework, allowing adhesions to form
between the framework and dermis. This impropriety can
permanently compromise skin quality and also increases
the risk of retraction and dimpling due to exaggerated
scarification.
In cases of parchment thin skin, where the quality of
the SSTE is compromised, we routinely place an implant
that increases the thickness of the soft tissue between the
skin envelope and the framework. When performing a
secondary rhinoplasty, we will often harvest not only the
conchal cartilage but also postauricular fibroconnective
tissue, which is obtained from the conchal mastoid sulcus
and over the mastoid process as shown in Figure 26-1.
This tissue is flattened in a tympanoplasty press, creating
a pliable sheet of soft connective tissue that can be placed
over the nasal framework. This graft can be heavily com­
pressed, but it is kept hydrated to improve viability. In
our hands, this technique not only thickens the SSTE but
may actually improve the quality of the scarified SSTE,
making it more supple and natural appearing. Temporalis
fascia is also useful for this purpose. Perichondrium pro­
vides a nice soft tissue cushion and is readily available if
one is harvesting a rib graft. Acellular dermal matrix is
an alternative,4 but it does thin progressively over time,
and in many cases virtually disappears.
STRATEGIES FOR CAMOUFLAGE,
AUGMENTATION, AND
STRUCTURAL CORRECTION
Most of the soft tissue grafts used as a buffering between
the nasal covering and the framework serve the dual func­
tion of camouflage and protection of the SSTE. Tempora­
lis fascia is effective for smoothing contour irregularities.
When used alone, it does not add significant bulk. Due to
its thick, fibrous consistency, the temporalis fascia pro­
vides excellent tissue cover. Fibroconnective tissue, peri­
chondrium, and crushed cartilage are also useful for this
purpose. Temporalis fascia and fibroconnective tissue may
both be harvested with minimal concern for the donor site
and, unlike crushed cartilage, are usually available in
ample supply even in the case of revision surgery.
When performing surgery on the upper third of the
nose in patients with thin skin, several technical pearls
should be kept in mind. First, it is important to use a very
fine rasp to smooth out any subtle irregularities. Although
rather coarse rasps are used frequently in rhinoplasty, thin
skin is unforgiving and requires a painstaking approach.
It is especially important to vigorously irrigate out any
debris that remains after dorsal reduction or osteotomies.
Retained small particles of bone or cartilage can act as a
nidus for inflammatory response and lead to unsightly
postoperative irregularities that show through the skin.5
In a primary rhinoplasty, by far, our preferred graft
material is crushed septal cartilage. A thin sheet of septal
cartilage is reserved for a dorsal onlay graft that will
extend from the radix to the supratip. The edge of the
cartilage is beveled and placed in a cartilage crusher that
has smooth surfaces and that will not macerate the graft.
The cartilage is carefully crushed to create a pliable yet
intact graft that is slightly larger than the original sheet
of cartilage. At this point, the dorsum should already
have been lowered approximately 0.5 mm below the

330
Michael J. Brenner • Peter A. Hilger
For major anatomic deformities, definitive structural
grafting is indicated. Whereas crushed cartilage may
conceal a multitude of imperfections in patients with
thicker skin, thin skin rhinoplasty mandates precise struc­
tural alignment and contouring to avoid visible or palpa­
ble deformity. The previously discussed camouflage
techniques should be applied over a carefully contoured
framework. Grafts and implants are beveled and posi­
tioned precisely. Peripheral crushing of cartilage grafts
may further assist with their camouflage. Sometimes, two
different grafts confer similar functional benefits, but one
is superior from an aesthetic standpoint. For example,
strong alar batten grafts are excellent for resisting the
weight of thick, heavy skin that would otherwise collapse
the nasal valve, but such an approach yields an unaccept­
able aesthetic result with thin skin. Placement of lateral
crural strut grafts, in contrast, is more appropriate for
patients with thin skin, as in the patient shown in Figure
26-3. Lateral crural strut grafts will improve the nasal
airway without untoward effects on the external appear­
ance of the nose, since they are concealed underneath the
alar cartilages.
desired profile to allow for the height added by the
graft. The graft is then placed over the dorsum using
bayonet forceps and may be secured in place, if desired.
As with the patient shown in Figure 26-2, this technique
is almost routinely used in a prophylactic fashion, and the
objective is to provide a smooth structural interface with
the SSTE.
When a smooth sheet of cartilage is not available for
minor augmentation, one may consider wrapping diced
auricular cartilage in fascia6 or in Surgicel, as described
in the “Turkish Delight” procedure.7 When used in closed
rhinoplasty, these rolled grafts have a tendency to drift
from their intended position. Therefore, minimizing dis­
section plays an important role in providing a more precise
pocket. With an external approach, such movement is of
lesser concern since direct fixation with suture is possible.
We avoid the use of Gore-Tex in revision rhinoplasty,
particularly when the nasal vault has been reconstructed
with spreader grafts or other techniques that require sepa­
ration of the upper lateral cartilages from the septum. We
have noted persisting erythema of the nasal skin when
using Gore-Tex in these cases as a cushioning agent.
Figure 26-1  Harvest of temporalis fascia and fibroconnective tissue. The postauricular approach used for harvest of conchal cartilage is easily adapted
for harvest of either postauricular fibroconnective tissue or deep temporalis fascia.
Cartilage
Postauricular
incision
Postauricular
fibroconnective
tissue
Temporalis
muscle and
fascia
Cartilage
A
B

CHAPTER TWENTY-SIX  Thin Skin Rhinoplasty: Aesthetic Considerations and Surgical Approach
331
from months to years after rhinoplasty.11 The classic triad
of risk factors for bossae includes thin nasal skin, inter­
lobular bifidity, and strong alar cartilages.9,11 The pres­
ence of thin skin not only contributes to the pathogenesis
of bossa formation (due to the “shrink wrap” effect) but
also increases the likelihood that revision surgery will be
necessary for their correction, since bossae range in sever­
ity and thicker skin may conceal subtler deformities.
Some authors have suggested that early and late
bossae arise through distinct mechanisms.11 According to
PREVENTION AND TREATMENT OF BOSSAE IN
PATIENTS WITH THIN SKIN
Bossae are the most common postrhinoplasty deformity of
the lower third of the nose and are one of the more
common indications for revision rhinoplasty.8–11 Patients
with thin skin have a substantially increased risk for for­
mation of bossae and other related deformities of the nasal
tip. Bossae, illustrated in Figure 26-4, are knoblike pro­
tuberances of the alar cartilages that typically develop
Figure 26-2  Use of crushed cartilage as a prophylactic measure in the patient with thin skin. This patient wished correction of a broad, overprojecting
nose with dorsal convexity. Dorsal hump reduction was followed by laterally fading medial osteotomies and internal lateral osteotomies to close the open
roof. A tongue-in-groove relationship was established between the medial crura. A crushed cartilage radix graft was followed by onlay of dorsal crushed
cartilage to ensure smooth contour.
A
B

332
Michael J. Brenner • Peter A. Hilger
Figure 26-3  Lateral crural strut grafts in a patient
with prominent nasal cartilages and thin skin. In this
patient, lateral crural strut grafts were placed along the
undersurface of the alar cartilages. These grafts are
inconspicuous and preferable to more visible alar
batten grafts. The lateral crural struts smoothed alar
contour, corrected recurvature, and improved nasal
patency. After hump reduction, the use of asymmetric
spreader grafts, larger on right than left, closed the
open roof and achieved aesthetic widening of the mid­
vault with correction of deviation of the cartilaginous
vault. A radix graft assisted in achieving a smooth
dorsal contour, and crushed cartilage was used as
softening agent over the infratip lobule and nasal
dorsum.
A
B
Figure 26-4  Bossa formation. A bossa is a knob-like prominence affect­
ing the nasal tip that may develop after rhinoplasty. They may be unilateral
or bilateral and often involve weakening of the lower lateral cartilages such
that forces of scar contracture buckle the lateral crus resulting in distortion
of the dome and alar rim.
Bossae
defect
this theory, early bossae result from inadequately cor­
rected or iatrogenic asymmetries that become evident
early in the postoperative course, as postsurgical edema
resolves. In this situation, thin skin acts almost like a
veneer that fails to buffer and may even accentuate asym­
metries. Late bossae are the product of progressive scar
contracture and fibrosis acting upon an attenuated carti­
laginous scaffold. Here, the thin nasal covering, with its
exaggerated contractile characteristics, not only heralds
the development of the deformity but actively mediates
the knuckling and contortion of the alar cartilages. Late
bossae are often associated with alar retraction and other
deformities, such as collapse of the alar rim.
Fortunately, if thin skin is identified at the outset,
several useful approaches are available for prevention and
treatment. Technical oversights that may predispose to

CHAPTER TWENTY-SIX  Thin Skin Rhinoplasty: Aesthetic Considerations and Surgical Approach
333
perichondrium, over the nasal tip may decrease the risk
of this complication.9 Any weak areas that may buckle
under the influence of contractural forces should be rein­
forced to decrease the likelihood of complication. Vertical
dome division is to be avoided in patients with thin skin.
The surgical approach to correction of bossae in
patients with thin skin emphasizes the same concepts that
assist in prevention: reconstitution of the dome, strength­
ening of alar cartilages, and correction and camouflage
of irregularities (Figure 26-5). As Daniel has emphasized,
of cardinal importance is the question, “Is this a minor
bump, or is it a major tip deformity?8” Bossae represent
late bossae formation are failure to reconstitute the domal
unit with suture in a symmetric fashion; weakening of the
cephalic margins of the lower lateral cartilages by crush­
ing, scoring or overresection; and creation of sharp or
irregular edges with resection. Conservative resection is
advised, as the desired contour alteration can often be
achieved with nondestructive techniques, such as suture
sculpting. Beveling of cartilage is preferable to more
traumatic methods. Use of a columellar strut or other
structural grafting affords stability to the tip that may
decrease the risk of bossa formation. In addition, placing
crushed cartilage grafts or other softening agents, such as
Figure 26-5  Correction of nasal tip bossae. This patient with very thin skin developed progressive bossae formation a decade after previous rhinoplasty.
Bossae were exposed through an external approach. The tip was retrodisplaced through conservative shave of the medial crural footplates and a
total transfixion incision. The use of postauricular fibroconnective tissue as softening agent was instrumental in restoring a smooth, natural contour to the
nasal tip.
A
B

334
Michael J. Brenner • Peter A. Hilger
REFINEMENTS AND ADJUNCTIVE TECHNIQUES
Certain adjunctive techniques may be of benefit after
rhinoplasty in patients with thin skin. If the patient devel­
ops a very small cartilaginous area that is palpable through
the skin, and the irregularity is caused by small cartilage
excess, we would consider using a 16-gauge needle that
we pass through the skin and then morsalize the small
irregularity in situ. For the patients who develop erythema
of their skin following rhinoplasty, we recommend pulse
dye laser therapy. Careful avoidance of sun exposure and
use of sun block will decrease the incidence and severity
of this complication (Figure 26-6). It may also be advis­
able for patients to avoid use of isotretinoin, as its effects
on collagen production and degradation influence the
a range of deformities, and the extent of deformity may
not be entirely evident before surgery. While some deform­
ities may be improved with conservative trimming through
an endonasal approach, others may be addressed with
cartilage overlapping techniques. Severe deformities often
necessitate structural grafting for tip reconstruction that
may best be performed through an external approach. An
often overlooked technical pearl is generous undermining
of the vestibular skin. Failure to do so will leave the car­
tilage in its distorted mold, thereby causing the frame­
work to fall back into a buckled configuration. In addition,
with more severe deformities, the contraction of the bossa
also causes collapse of the remaining lateral crus with
resultant accentuation of the bossa and medialization of
the alar rim.
Figure 26-6  Maintenance of skin quality in a
patient with fair, thin skin. Excessive freckling and
change to skin color and texture were avoided by
raising a thick skin flap, using crushed cartilage, and
sunscreen use postoperatively. Correction of a
ptotic, overprojected tip and dorsal convexity was
achieved with a combination of conservative resec­
tion, structural grafting, and use of radix graft and
crushed cartilage.
A
B

CHAPTER TWENTY-SIX  Thin Skin Rhinoplasty: Aesthetic Considerations and Surgical Approach
335
REFERENCES
1. Sheen J. Special problems: Thick skin, thin skin. In: Aesthetic
rhinoplasty. St Louis:1987;1032–1043.
2. Letourneau A, Daniel RK. The superficial musculoaponeurotic
system of the nose. Plast Reconstr Surg. 1988;82:48–57.
3. Baker TM, Courtiss EH. Temporalis fascia grafts in open
secondary rhinoplasty. Plast Reconstr Surg.
1994;93:802–810.
4. Gryskiewicz JM. Waste not, want not: The use of AlloDerm in
secondary rhinoplasty. Plast Reconstr Surg.
2005;116:1999–2004.
5. Parkes ML, Kanodia R, Machida BK, et al. Revision
rhinoplasty. An analysis of aesthetic deformities. Arch
Otolaryngol Head Neck Surg. 1992;118:695–701.
6. Kelly MH, Bulstrode NW, Waterhouse N, et al. Versatility of
diced cartilage-fascia grafts in dorsal nasal augmentation.
Plast Reconstr Surg. 2007;120:1654–1659.
7. Erol OO. The Turkish Delight: A pliable graft for rhinoplasty.
Plast Reconstr Surg. 2000;105:2229–2241.
8. Daniel R. Nasal bossae. Arch Fac Plast Surg.
2003;5:424–426.
9. Gillman GS, Simons RL, Lee DJ, et al. Nasal tip bossae in
rhinoplasty. Etiology, predisposing factors, and management
techniques. Arch Fac Plast Surg. 1999;1:83–89.
10. Goodwin WJJ, Schmidt JF. Iatrogenic nasal tip bossae.
Etiology, prevention, and treatment. Arch Otolaryngol Head
Neck Surg. 1987;113:737–739.
11. Kridel RW, Yoon PJ, Koch RJ, et al. Prevention and correction
of nasal tip bossae in rhinoplasty. Arch Fac Plast Surg.
2003;5:416–422.
12. Allen BC, Rhee JS. Complications associated with isotretinoin
use after rhinoplasty. Aesthet Plast Surg. 2005;29:102–106.
character of nasal skin and may increase the risk of late
deformities.12 Nasal exercises, involving manual massage
to smooth areas of irregularity, may help settle areas of
induration and liberate overly adherent skin from the
underlying structural framework.
Some “minimally invasive” procedures, frequently
thought to be innocuous, should be performed with the
utmost caution in patients with thin skin. Most grafts will
thin to some extent with passage of time, and we are
inclined to observe small prominences initially. We are
extremely cautious with injectable steroids or any other
method to decrease soft tissue volume, even if there is
initially a subtle contour irregularity from the cushioning
technique. Use of fillers is generally ill-advised in patients
with thin skin, particularly in the setting of revision rhi­
noplasty. Many patients will exhibit a bluish discoloration
of the overlying skin prior to extrusion of the agent.
Patients may pursue such treatments, wishing to avoid
surgery, but the transient nature of the improvement and
the often disappointing aesthetic result make these treat­
ments generally unattractive options.
CONCLUSION
An understanding of thin nasal skin and its significance
in nasal surgery is of great importance to the rhinoplasty
surgeon. The predilection of thin skin to contract and
to give rise to secondary deformities is an integral aspect
of this subject. Identification of the thin skin preopera­
tively is crucial for surgical planning and prevention of
disfigurement.

337
C H A P T E R T W E N T Y - S E V E N 
The Thick-Skinned
Rhinoplasty Patient
Richard E. Davis
When it comes to the subject of rhinoplasty, many authors
trivialize or overlook the role of nasal skin in cosmetic
nasal surgery. Instead, interest is directed at the nasal
skeleton and the various methods of modifying the under­
lying skeletal framework. Although skeletal modification
is fundamental to a successful rhinoplasty, the nasal skin
and its associated soft tissue components, often called the
skin–soft tissue envelope (SSTE), also play a critical role
in the surgical outcome. Indeed, for a small subset of
rhinoplasty patients, soft tissues may prove the limiting
factor in creating a more beautiful nose. At the very least,
it is the nasal SSTE that transforms the unfamiliar shape
of the raw nasal skeleton into the refined and elegant outer
contour of an attractive human nose. Moreover, this trans­
formation is far from simplistic. Owing to site-specific
variations in skin thickness within the nose, the skin’s
contribution to nasal topography is nonlinear and
indirect, making cosmetic nasal surgery a translational
activity—exponentially more challenging than directly
sculpting an object’s surface contour. Furthermore,
because the SSTE is susceptible to the capricious effects
of contracture, fibrosis, and edema, unforeseen skin
changes can alter the intended nasal contour and compro­
mise the otherwise well-executed operation. In rare but
extreme cases, soft tissue healing aberrations may become
so severe as to negate the skeletal modifications entirely,
resulting in even greater cosmetic deformity. Hence, to
ignore the importance of the SSTE in cosmetic nasal
surgery is to disregard a critical component of the surgical
outcome.
VARIATIONS IN SKIN TYPE
While skin of any type can potentially spoil the rhino­
plasty outcome, it is generally skin types on the extreme
limits of thickness that are the most challenging for the
cosmetic nasal surgeon. In patients with extremely thin
nasal skin, the atretic covering offers scant camouflage or
concealment, and the surgeon must render a flawless
underlying skeletal contour to prevent visible imper­
fections in the surface topography. Moreover, both
telangiectasias and dyschromias are easily provoked with
surgical dissection of thin nasal skin. On the other hand,
delicate skin is generally much less prone to edema or
excessive fibrosis, and skin incisions tend to heal favorably
in thin-skinned individuals. In fact, the thin-skinned rhi­
noplasty patient will often experience a shorter-than-aver­
age length of recovery with far less soft tissue distortion.
In contrast to the thin-skinned nose, extremely thick
nasal skin conceals all but the most conspicuous imper­
fections of the underlying nasal skeleton. However, the
advantages of ultra-thick skin end there. In fact, excessive
skin thickness is often regarded as one of the most formi­
dable, and sometimes insurmountable, obstacles in cos­
metic rhinoplasty. The reasons for this sinister distinction
are numerous, and the hazards of thick nasal skin have
prompted many surgeons to avoid treating this challeng­
ing patient population altogether. However, as ethnic
diversity continues to increase throughout the United
States, thick-skinned patients have become an increas­
ingly prevalent segment of the rhinoplasty consumer
demographic. Moreover, the growing popularity of cos­
metic nasal surgery in places like South America and Asia,
where thick nasal skin is common, ensures that thick-
skinned patients will become more prevalent worldwide.
Without question, the thick-skinned rhinoplasty patient
will be seen with greater frequency in the future, and
demands for effective ethnically appropriate outcomes
will increase accordingly.1
ANATOMY OF NASAL SKIN
Histologic analysis of nasal skin reveals most of the same
components and structures found elsewhere in the integu­
ment. However, several important differences are worth
noting. Without question, the most profound difference is
a discrete fibromuscular tissue layer that separates the
nasal skin from the underlying skeletal framework.
Comprised largely of skeletal muscle, this fibromuscular
layer is functionally and anatomically analogous to
the superficial musculoaponeurotic system (SMAS) seen
elsewhere in the face.2 Dubbed the “nasal SMAS,” this

338
Richard E. Davis
markedly thickened fibromuscular tissues with compara­
tively few areas of thin, pliable soft tissue covering.
PHYSICAL LIMITATIONS OF
THE THICK-SKINNED NOSE
As a consequence of its physical bulk and added weight,
thick nasal skin poses a formidable challenge for the rhi­
noplasty surgeon. Perhaps the foremost challenge is the
loss of surface definition created by masking of the under­
lying skeletal framework. Because thick nasal skin more
effectively obscures topographic features of the underlying
nasal skeleton, the delicate surface undulations which
characterize a well-defined and attractive nose are lost.
Moreover, a weak and underprojected nasal framework
only serves to exacerbate the loss of surface highlights.
In addition to skeletal masking, ultra-thick nasal skin
also burdens the cartilage framework with added weight
relative to a thin nasal covering. Surgical modifications
that undermine structural support are ill-advised, espe­
cially in thick-skinned noses, since progressive skeletal
collapse and nasal deformity often ensue. Instead, cos­
metic modifications must be accompanied by structural
reinforcement to ensure both an attractive outer contour
and a skeletal framework that can permanently support
fibromuscular layer also varies in thickness according to
the individual skin type. In the thin-skinned nose, pores
are small and both the dermis and the nasal SMAS are
thin and delicate. In contrast, large pores and modest
dermal thickening are often observed in thick-skinned
noses. However, robust hypertrophic thickening of the
nasal SMAS layer is considered to be the underlying cause
of the thick-skinned nose.3 In fact, hypertrophy of the
nasal SMAS can more than double the thickness of normal
nasal skin. Fortunately, the nasal SMAS is also a discrete
tissue layer that can be excised with relative ease—a key
feature in surgical management of the ultra thick-skinned
nose.
Although dermal thickening and muscle hypertrophy
are frequently observed in the thick-skinned nose,
these characteristics are seldom distributed evenly (Figure
27-1). For example, hypertrophy of the nasal SMAS is
typically most prominent in the nasal tip and immediate
surroundings. In contrast, very little muscle hypertrophy
is observed at the rhinion or columella, even in patients
with ultra-thick skin. In the same way, fat is also more
abundant in the thick-skinned nose. However, fat makes
little contribution to overall flap thickness except in the
nasal root and supratip regions. In conclusion, all noses
have site-specific variations in flap thickness, but thick-
skinned noses tend to have more fat, a thicker dermis, and
Figure 27-1  Schematic comparison of nasal skin thickness in the thick-skinned platyrrhine nose (A) and in the mesorrhine nose with intermediate skin
thickness (B). In both types of nasal morphology, skin is thickest at the nasion and supratip. However, in the platyrrhine nose (A), the cartilage framework
is typically weak and underprojected, with broad, soft alar cartilages that are covered by a comparatively thick skin–soft tissue envelope. In contrast, the
mesorrhine nose (B) is characterized by a strong, well-projected skeletal framework and a more delicate skin–soft tissue envelope, giving rise to a more
attractive outer contour.
A
B

CHAPTER TWENTY-SEVEN  The Thick-Skinned Rhinoplasty Patient
339
nifedipine, may be useful in treating postoperative vaso­
spasm,4 but surgical intervention may be needed to reduce
skin tension and restore perfusion when conservative
measures prove ineffective.
Whereas the cosmetic merits of a rigid skeletal frame­
work and a taut, tightly adherent skin envelope are irrefu­
table, optimization of surface definition will sometimes
require a nose that is aesthetically too large for the face.
Although this dilemma has no easy answers, an artfully
proportioned and well-defined, if slightly oversized, nose
is generally preferable to a smaller, yet amorphous one.
In every case, a careful preoperative assessment of skin
elasticity, coupled with a frank discussion regarding the
limitations of thick skin, is imperative to establish appro­
priate cosmetic expectations.
Ironically, even though good skeletal support is para­
mount in the thick-skinned nose, most individuals with
overly thick nasal skin also possess soft and exceedingly
weak nasal cartilage. This is best exemplified in the plat­
yrrhine nasal morphology known for its broad flat nasal
contour. In addition to its hallmark shape, the platyrrhine
nose is also characterized by thick inelastic nasal skin, soft
underprojected tip cartilages, and a small underdeveloped
nasal septum (see Figure 27-1). In fact, the distinctive
architecture of the platyrrhine nose is widely regarded as
one of the most difficult technical challenges in cosmetic
nasal surgery. Paradoxically, the unfavorable combination
of thick skin and weak cartilage is compounded by the
need to substantially increase nasal tip projection in most
platyrrhine noses. While the platyrrhine nose is arguably
among the most challenging of all anatomic configura­
tions, it is also among the most common nasal morpholo­
gies worldwide.
ADVERSE HEALING CHARACTERISTICS OF
THICK NASAL SKIN
Although the physical properties of bulky inelastic skin
often complicate its surgical manipulation, it is the adverse
healing characteristics of thick skin that most profoundly
distinguish it from other skin types. Although all surgi­
cally manipulated nasal skin exhibits a characteristic
cycle of inflammation, repair, and recovery; thick nasal
skin is far more prone to excessive inflammation, pro­
longed tissue distortion, and abnormal recovery. Unlike
thin nasal skin which exhibits only modest edema and
minimal fibrosis, in virtually all thick-skinned individu­
als, robust edema gives rise to unwanted cosmetic distor­
tion and prolonged recovery. In the thin-skinned individual,
rapid restoration of the lymphatic and capillary circula­
tion leads to prompt reduction of lymphedema and soften­
ing of the firm and swollen nasal soft tissues. Often this
process is complete in as little as 3 to 6 months. This in
turn gives rise to a thin, delicate, and more tightly adher­
ent skin envelope, producing a more attractive and better
the added burden of bulky nasal skin. Indeed, without a
sturdy and structurally secure cartilage framework, a
stable and more refined nasal contour is virtually impos­
sible. Although rigid skeletal support does not by itself
ensure a more beautiful nose, a strong nose with ample
structural support is the first and foremost requirement
for cosmetic enhancement in the thick-skinned patient.
In addition to safeguarding against structural col­
lapse, a well-proportioned and rigid skeletal framework
also facilitates stretching of the nasal skin to further refine
the surface contour. Stretching the nasal tip skin over a
stiff and slightly longer skeletal framework improves
surface definition by tightening, and thus thinning, the
bulky skin envelope. Although increases in nasal length
or tip projection can potentially improve surface high­
lights, cosmetic gains require not only a sturdy skeletal
framework, but also a readily distensible skin envelope.
Indeed, without adequate skin elasticity, forceful attempts
to tighten the skin envelope may produce unsightly
skeletal distortion and/or excessive skin tension. In the
thick-skinned nose with dermal thickening, the resulting
inelasticity often restricts skin stretching and prohibits
optimal contour refinement. In extreme cases, severely
inelastic skin may even prevent desired increases in tip
projection or nasal length. However, not all thick-skinned
patients suffer from inelasticity. In some thick-skinned
patients, the skin remains highly distensible despite its
thickness, and substantial thinning can be achieved with
negligible increases in skin tension. Therefore, skin elas­
ticity does not always correlate with skin thickness, and
a careful preoperative assessment of skin distensibility is
mandatory for all thick-skinned patients, particularly
since skin elasticity is a key determinant of surgical
success. Likewise, because nasal skin may become leath­
ery and inelastic following previous nasal surgery, the
assessment of skin elasticity is also vitally important in
the revision rhinoplasty patient.
Although a taut skin envelope is an important tool in
the treatment of the thick-skinned nose, it is not without
potential risk. Excessive skin tension may restrict cutane­
ous perfusion resulting in circulatory compromise or even
pressure necrosis when nasal skin is stretched too tightly.
The risk of skin injury is increased by preexisting factors
that impair nutrient blood flow, such as tobacco use,
microvascular disease, or cocaine-induced vascular com­
promise. Additional factors that may compromise per­
fusion include excessive use of electrocautery, reckless or
extensive tissue dissection, and overly tight compression
dressings. Regardless of the situation, nutrient blood flow
must be safeguarded by ensuring sustained capillary refill,
particularly upon application of a tight compression
dressing. Visible signs of vascular insufficiency, such as
blanching, loss of capillary refill, or severe venous conges­
tion, should prompt immediate intervention directed
at the restoration of nutrient blood flow. Topical vaso­
dilators, such as nitroglycerin paste or topically applied

340
Richard E. Davis
inflammatory response, such as catgut or Vicryl are
avoided whenever possible, and tissue trauma is mini­
mized with judicious use of electrocautery and tissue
retraction. Prior to surgery, nasal soft tissues are also vaso­
constricted with topical decongestants and infiltrated with
adrenaline to minimize the extravasation of blood and
fluid. Ancillary supportive measures, such as controlled
hypotension, corticosteroids, icepacks, upright position­
ing, compressive bandaging, and emesis prevention,
further help to prevent unwanted fluid extravasation.
Despite prudent measures to contain surgical inflam­
mation, in a small number of thick-skinned patients, a
vigorous and sustained inflammatory response may still
develop. In the worst case scenario, the outcome is severe
cosmetic distortion, often accompanied by nasal airway
obstruction. While there is no conclusive means of iden­
tifying susceptible patients, the incidence is much higher
in patients with darker skin tones, thick sebaceous skin,
and a history of hypertrophic scars or keloid formation.
Postoperative steroid treatment may negate the inflamma­
tory response, but early intervention is essential, since it
is often difficult or even impossible to reexpand the thick­
ened and scarred soft tissue envelope.
SKELETAL AUGMENTATION
In addition to the mandatory adjunctive measures for
controlling surgical inflammation discussed above,
perhaps the single most important element in the thick-
skinned rhinoplasty is secure structural support. Without
question, achieving good surface definition is far more
likely when thick skin has been stretched to its full capac­
ity over a stable and shapely nasal framework. While this
goal requires both a healthy cutaneous blood supply and
rigid skeletal tissues, the cutaneous blood supply is largely
predetermined, and only skeletal rigidity can be improved
to any significant extent. However, a skeletal framework
of sufficient rigidity is not easily achieved in the patient
with naturally weak nasal cartilage. Not only must the
framework bear the additional weight of thick skin, it
must also provide sufficient strength to stretch the inelas­
tic tissues and to resist the formidable deformational
forces of postoperative swelling and contracture. Ironi­
cally, the thick-skinned nose, particularly the platyrrhine
morphology, is often structurally deficient to begin with,
and thick-skinned noses often lack cartilage of sufficient
quantity or quality to create a secure skeletal framework.
Consequently, autologous rib cartilage and/or conchal
cartilage grafts are frequently needed to augment skeletal
support and enhance nasal contour in the thick-skinned
individual.
While the specifics of skeletal augmentation and
structural fortification are beyond the scope of this
chapter, a host of established and effective grafting
defined nasal contour. In contrast, for the thick-skinned
individual, capillary and lymphatic channels are slow to
recanalize and recovery is protracted, sometimes requiring
as long as 18 to 24 months for complete recuperation.
Soft-tissue edema temporarily obscures surface highlights
and skeletal modifications often appear overly conserva­
tive or even imperceptible. In severe cases, swelling may
never fully resolve as prolonged lymphedema may trigger
subcutaneous fibrosis and permanent increases in skin
thickness. Exogenous influences, such as sunburn, acne,
allergic rhinitis, tobacco use, vigorous exercise, or pro­
longed dependent posture, may also exacerbate swelling
and increase the risk of unwanted fibrosis, particularly
in previously operated noses or noses undergoing exten­
sive surgical dissection. For these challenging patients,
subcutaneous fibrosis may occasionally prove difficult to
control and may actually result in a larger and less attrac­
tive nose, particularly when the nasal skeleton has been
aggressively reduced in size and/or when preventative
measures have been neglected. Hence, the need to curtail
runaway inflammation is paramount in the thick-skinned
patient.
In addition to unwanted fibrotic thickening of the
skin envelope, thick-skinned patients, like all rhinoplasty
patients, are also susceptible to contracture of the nasal
soft tissues. In extreme cases, contracture and adhesions
triggered by subcutaneous fibrosis can severely distort the
underlying nasal framework giving rise to progressive
misalignment and unsightly nasal deformity. Patients with
naturally weak or surgically compromised skeletal tissues
are particularly prone to this undesirable wound-healing
phenomenon, again underscoring the importance of secure
skeletal support in the thick-skinned nose. Although the
cosmetic ideal may dictate a reduction in nasal size, soft
tissue complications such as fibrosis or contracture are far
more common following aggressive size reductions. Thus,
in the oversized thick-skinned nose, it is often prudent to
sacrifice diminutive size in exchange for improved overall
shape and enhanced definition.
PERIOPERATIVE MANAGEMENT
While surgical swelling is undesirable in all patients, it is
often far more detrimental in the thick-skinned rhino­
plasty patient. To minimize the threat of unfavorable
wound healing, all reasonable efforts should be taken to
prevent and/or contain surgical swelling and inflamma­
tion. Without question, this is best accomplished through
a multifaceted approach. First, favorable anatomic
dissection planes are exploited using delicate surgical dis­
section combined with meticulous soft tissue technique.
This limits disruption of the lymphatic and capillary
networks while minimizing the release of harmful inflam­
matory mediators. Suture materials prone to a robust

CHAPTER TWENTY-SEVEN  The Thick-Skinned Rhinoplasty Patient
341
techniques are now available to ensure a structurally
secure and rigid nasal framework. Although skeletal
reconstruction is sometimes a formidable task, particu­
larly in the previously operated nose, modern structural
rhinoplasty techniques have proved invaluable in the
thick-skinned patient. In fact, owing to the reliability of
these techniques, it is most often the lack of skin disten­
sibility, rather than structural instability, that is the limit­
ing factor in cosmetic enhancement of the thick-skinned
nose.
Despite structural fortification of the thick-skinned
nose with autologous cartilage, a satisfactory cosmetic
outcome is not a foregone conclusion. In every nose, the
tug-of-war between skeletal rigidity and soft tissue com­
pliance is governed by a host of independent variables.
The collective impact of soft tissue influences, such as
elasticity, fibrosis, contracture, vascularity, immune func­
tion, and inflammation, serve to create either a hostile or
favorable environment for the transplanted cartilage.
Cartilage characteristics, such as size, shape, ischemic
tolerance, susceptibility to warping, and fixation tech­
nique, also combine to influence the end result. Which
forces will ultimately prevail is impossible to predict
with absolute certainty, and favorable prognostic indica­
tors are not a guarantee of success. However, when the
complexion is smooth and healthy, when the skeletal
tissues are abundant and firm, and when the soft tissue
inflammatory reaction is modest, sound surgical principles
are usually rewarded with a noticeably more attractive
nasal contour.
Just as enlarging the skeletal framework will theoreti­
cally enhance nasal contour, so too, shrinking the skeletal
framework may have the opposite effect. Perhaps the
most difficult patient in rhinoplasty is the thick-skinned
individual with a massively oversized nose. Although
reduction rhinoplasty is needed to enhance facial aesthet­
ics, the loss of skeletal volume creates copious dead space,
often giving rise to edema, fibrosis, and additional thick­
ening of the already thick skin. Instead of a tightly adher­
ent skin envelope with enhanced contour and improved
definition, the thick-skinned nose may appear amorphous,
unstructured, and decidedly less attractive, despite its
smaller size. Moreover, the capacity of nasal skin to shrink
also declines with age, and is particularly poor in the older
adult with inelastic skin. Because a less attractive nose is
a very real possibility in this circumstance, it is often best
to forego elective cosmetic rhinoplasty in this small subset
of thick-skinned patients.
NASAL SKIN “DEFATTING”
While a sturdy and well-proportioned nasal framework
remains the cornerstone of effective rhinoplasty, surgical
thinning of the SSTE is a potentially safe and effective
means of achieving additional definition and contour
refinement in the ultra thick-skinned nose. Although
nasal “defatting” has been advocated for decades, this
term has been used to denote a group of dissimilar surgi­
cal techniques that are often risky and potentially harmful.
Techniques that seek to promote skin flap shrinkage, such
as dermal cross-hatching or CO2 laser treatment of the
flap undersurface, are ill advised since dermal thickening
and decreased elasticity often result. Injuries to the sub­
dermal plexus may also result from these techniques,
potentially leading to vascular insufficiency and skin
necrosis, particularly when combined with aggressive
skeletal augmentation and/or comorbidities such as
tobacco use. In contrast, careful excision of the fibromus­
cular tissue layer can provide a safe and effective surgical
adjunct to cosmetic rhinoplasty in select thick-skinned
individuals. In addition to restoring the skin envelope to
a more favorable thickness, nasal SMAS excision may
also improve skin distensibility to further improve surface
highlights.
SMAS DEBULKING TECHNIQUE
Using the exposure afforded by the external rhinoplasty
approach, the fibromuscular SMAS layer is accessed for
surgical debulking. Following standard skin incisions, the
nasal framework is degloved in the subperichondrial
plane using mostly blunt (cotton swab) dissection to mini­
mize disruption of the capillary and lymphatic networks.
Once elevated, the full depth of the SSTE can be evalu­
ated, and the contribution of the fibromuscular tissue
layer can be assessed (Figure 27-2, A). In patients with
ultra-thick nasal skin (usually 5-mm total thickness or
more), the fibromuscular SMAS layer can be safely excised
in areas where improved surface definition is desired—
usually the tip, supratip, and infratip lobule. In order to
maintain a uniform flap thickness and avoid injury to
the subdermal plexus, the fibromuscular SMAS layer is
excised en bloc using a combination of blunt and sharp
dissection5 (Figure 27-2, B–D). With careful and direct
dissection of the SMAS layer, the subdermal plexus is left
largely undisturbed, and the nutrient blood supply to the
nasal skin is protected, a vitally important step if aggres­
sive skin stretching is also planned. Special care is exer­
cised near the alar groove where the predominant blood
supply enters the subdermal plexus6 (Figure 27-3). In
addition to creating a uniform flap thickness, en bloc exci­
sion yields a slab of malleable graft material that can be
used for augmentation of the radix or other deficient sites.
While this procedure can sometimes be performed in revi­
sion rhinoplasty patients, previous surgical disruption of
the soft tissues may make navigation far more challeng­
ing. Possible complications, such as inadvertent skin per­
foration or ischemic skin necrosis, are rare, but occur with

Figure 27-2  A–D, Intraoperative views showing en bloc excision of fibromuscular (nasal SMAS) tissue layer with preservation of underlying subdermal
fat. E, F, Skeletal augmentation with septocolumellar extension graft.
A
D
E
F
B
C
Figure 27-3  Schematic illustration of predominant arterial blood supply to the nasal tip skin from the front (A) and lateral (B) perspectives. The nasal tip
skin is perfused by a rich interconnecting vascular arcade derived from both the internal and external carotid systems. The proximal nose is supplied by
terminal branches of the internal carotid artery: the angular artery (AA) and the dorsal nasal artery (DN). However, the nasal tip is supplied predominantly
by the external carotid system via the lateral nasal artery (LN). As a terminal branch of the facial artery, the lateral nasal artery courses 2 to 3 mm above the
alar groove and should be preserved during dissection to avoid compromise of nutrient blood flow.
Dorsal nasal artery
Angular artery
Lateral
nasal artery
A
B

CHAPTER TWENTY-SEVEN  The Thick-Skinned Rhinoplasty Patient
343
greater frequency in the severely fibrotic revision rhino­
plasty patient, especially those with preexisting comor­
bidities such as nicotine use.
COMPRESSION DRESSING
Immediately following surgical intervention the focus
shifts to postoperative supportive care. For the thick-
skinned rhinoplasty patient, supportive care can “make
or break” the surgical outcome. Intraoperatively, support­
ive care begins with a firm yet gentle, cinch-type compres­
sion dressing. Binding the nose securely with hypoallergenic
tape and a nasal splint limits nasal edema, minimizes
dead space, and tamponades small vessel bleeding.
Although an overly tight bandage potentially risks soft
tissue ischemia, a gentle compression dressing restricts
postoperative swelling and is an important tool in postop­
erative edema management. Capillary refill is monitored
closely in the first 12 to 24 hours after dressing placement
to ensure that nutrient blood flow remains intact, and
ancillary supportive measures such as ice, elevation, rest,
antiemetics, and blood pressure control are instituted to
minimize swelling. While 6 to 7 days of gentle compres­
sion are generally most effective, the dressing is sometimes
removed sooner in cases of vascular insufficiency or
contact dermatitis.
POSTOPERATIVE STEROID TREATMENT
In general, all thick-skinned individuals should be con­
sidered at risk for dead-space fibrosis and cutaneous
thickening regardless of nasal size. In addition to a well-
designed compression dressing and aggressive periopera­
tive edema management, long-term avoidance of sunburn,
excessive salt intake, prolonged recumbent posture,
and strenuous activity will help to facilitate shrinkage of
the swollen skin envelope. In the event that supportive
measures are unsuccessful, adjunctive treatment measures
may also prove beneficial. Such treatments include
massage, stenting, compressive taping, topical steroid
administration, and steroid injection. Of these, by far the
most effective, yet also the most risky, is injection with
triamcinolone acetonide suspension. This long-acting syn­
thetic glucocorticoid acts to reduce edema and prevent
fibrosis when injected into the subcutaneous nasal tissues.
Commonly known by the brand name Kenalog (Bristol-
Myers Squibb, Princeton, NJ), this powerful anti-
inflammatory drug may also predispose to local tissue
atrophy, such as dermal thinning, fat necrosis, or cartilage
graft resorption. Triamcinolone may also predispose to
localized infection or telangiectasias, and side effects are
more common when used at full strength or frequent
intervals. Fortunately, adverse reactions are usually
avoided with a low starting concentration of 5 to 10 mg/
ml, restricting the total dose to less than 5 mg, and gradu­
ally titrating to the desired effect. Treatment is best post­
poned in the first 2 to 3 months following surgery to
prevent cartilage atrophy unless severe fibrosis or bony
callus is evident. Prior to injection, triamcinolone aceto­
nide is diluted in lidocaine containing epinephrine to
minimize tissue spread and reduce injection site discom­
fort. Initial treatment results are usually evident within 3
to 4 weeks, but repeated monthly injections are often
necessary before sustained clinical improvement is
achieved. Although triamcinolone injection is a useful
adjunct in the actively healing nose, it has little benefit in
the fully healed nose—emphasizing the importance of
timely intervention.
SUMMARY
The thick-skinned nose has long proved a difficult chal­
lenge for the cosmetic nasal surgeon. The challenge is
even greater when thick skin is accompanied by a weak,
underprojected cartilage framework. Although cosmetic
expectations must be tempered, surgery in the thick-
skinned patient often results in substantial cosmetic
improvement when sound surgical principles are observed.
The combination of a reinforced and well-proportioned
nasal framework, coupled with a carefully thinned and
taught nasal skin envelope, is often rewarded with
surprisingly good cosmetic results in the favorable patient
(Figure 27-4).

344
Richard E. Davis
Figure 27-4  A–C, Preoperative views of thick-skinned platyrrhine nose prior to cosmetic rhinoplasty. D–F, Postoperative views after rib graft skeletal
augmentation and nasal SMAS excision.
A
B
C
D
E
F

CHAPTER TWENTY-SEVEN  The Thick-Skinned Rhinoplasty Patient
345
4. Davis RE, Wachholz J, Jassir D, et al. Comparison of topical
anti-ischemic agents in the salvage of failing random-pattern
skin flaps in rat. Arch Fac Plast Surg. 1999;1(1):27–32.
5. Davis RE, Wayne I. Rhinoplasty and the nasal SMAS
augmentation graft: advantages and indications. Arch Fac
Plast Surg. 2004;6:124–132.
6. Rohrich RJ, Gunter JP, Friedman RM. Nasal tip blood supply:
an anatomic study validating the safety of the transcollumellar
incision in rhinoplasty. Plast Reconstr Surg. 1995;95:795–799.
REFERENCES
1. Davis RE. Rhinoplasty and concepts of facial beauty. Fac Plast
Surg. 2006;22(3):198–203.
2. Letourneau A, Daniel RK. The superficial musculoaponeurotic
system of the nose. Plast Reconstr Surg. 1988;82:48–57.
3. Garramone Jr RR, Sullivan PK, Devaney K. Bulbous nasal tip:
an anatomical and histological evaluation. Ann Plast Surg.
1995;34:288–291.

347
C H A P T E R T W E N T Y - E I G H T 
Short Nose
Michael M. Kim • Tom D. Wang
Lengthening the short nose is one of the most difficult
challenges in rhinoplasty. Etiologies for the development
of a short nose include congenital, traumatic, iatrogenic
(previous surgery), infectious, and granulomatous factors.
Regardless of the cause, short nose correction requires the
surgeon to precisely identify anatomical abnormalities
and deficiencies and to perform an array of technically
precise and difficult operative techniques.
THE SHORT NOSE DEFINED
There is no strict definition of what makes a nose “short,”
but multiple surrogate measurements exist. These propor­
tions and measurements enable the surgeon to ascertain
an “ideal” nasal length and shape that are harmonious
with the rest of the face. The face in its vertical dimension
may be divided into thirds, with the nose—measured from
the glabella to the subnasale—comprising the middle
third of the face. In a similar fashion, ideal nasal length
measured from the radix to the subnasale should approxi­
mate 47% of the distance measured from the radix to the
menton.2
Ideal nasal length can also be extrapolated through
the use of various formulas devised to determine ideal
nasal tip projection. Goode determined that the ideal ratio
between nasal tip projection and length ranged from 0.55
to 0.6 : 1. The pitfall of using this ratio to extrapolate ideal
nasal length is that one must assume ideal tip projection,
a condition that is not universally met. In fact, many short
noses feature poorly supported, underprojected tips.
Tip rotation is another determining factor in produc­
ing a short or short-appearing nose. Rotation is deter­
mined by the nasolabial angle or the angle between a line
drawn from the subnasale along the columella and a line
drawn from the subnasale down to the upper lip vermil­
lion. Nasolabial angles are gender-specific in that an ideal
male nasolabial angle ranges from 90 to 105 degrees,
while the ideal female angle ranges from 95 to 115 degrees.
Nasolabial angles greater than these ideal ranges are
considered overrotated and can produce a “snub-nose” or
“pig snout” appearance.
Additional factors that contribute to a short-appearing
nose are a dorsal concavity, a long upper lip, an overpro­
jected tip, and a low and deep nasion or nasal starting
point.3 In Caucasian patients, the nasal starting point
should be at the level of the superior palpebral fissure,
while in other ethnic populations, such as Asians, a lower
starting point at a mid-pupillary level may be more
appropriate.
A thorough understanding of ideal nasal proportions
enables the surgeon to identify patient-specific anatomic
deficiencies. As such, various operative maneuvers and
techniques have been devised to lengthen a short nose into
a more ideal shape.
A SHORT HISTORY OF SHORT NOSE
CORRECTION TECHNIQUES
Jackson and Reid4 and Millard1 used full-thickness exter­
nal incisions in the supratip area referred to as a “guil­
lotine chop.” The tip was then released inferiorly, creating
a defect of the skin–soft tissue envelope (SSTE). This
cutaneous defect was then replaced with tissue provided
by a paramedian forehead flap. The placement of carti­
lage grafts was staged and done only when extra support
was deemed necessary.
Dingman and Walter5 emphasized the augmentation
of inner lining through the use of composite grafts. Bilat­
eral, curved conchal cartilage composite grafts were
placed within bilateral intercartilaginous incisions. The
septal portions of the flaps were sewn together such that
the two grafts were “gull wing”–like in appearance. The
juxtaposition of the septal portion of the grafts essentially
created a four-layer composite graft. If the SSTE was
deficient, cutaneous releasing incisions in conjunction
with forehead flap reconstruction were used.
Kamer’s technique also featured the use of composite
grafts in short nose correction.6 He described the inferior
“The very short nose is an atrociously eye-catching deformity, which attracts
ridicule and revulsion … a plastic surgeon’s nightmare.”
—D. Ralph Millard, Jr. M.D.1

348
Michael M. Kim • Tom D. Wang
reconstructions of the cartilage framework designed to
resist the contractile forces associated with healing.
Increased nasal length can be achieved by anchoring
grafts to the existing septal cartilage. An example is the
caudal septal extension graft. These extension grafts can
be fashioned into a wedge shape such that the wider end
is placed anteriorly. This placement serves to counter rotate
the nasal tip and add absolute length to the nose.10 Due
to this graft’s unilateral nature, it is preferably sutured to
the nondeviated side to achieve balance (Figure 28-1).
Alternatively, extended spreader grafts—which extend
past the anterior septal angle—may be used for increased
length in conjunction with an extended columellar strut.
Fixation of these two structures can create a longer and
more stable cartilaginous L-strut. The dorsal portion of the
strut, which is composed of the paired extended spreader
grafts, is suture-fixated to the existing dorsal septum and
the paired upper lateral cartilages. The caudal portion of
the L-strut is then either placed to reside within a columel­
lar pocket or anchored to the nasal spine. Once the L-strut
is in place, then the medial crura of the lower lateral car­
tilages are sutured to the columellar strut in a tongue-and-
groove manner. Placement of the lower lateral cartilages
can be tailored to reside in a less rotated position.
Multiple versions of this L-strut have been described
with relatively minor differences.11,12 However, one special
case deserves mention. In cases where saddle deformity is
concomitantly present, a canoe-shaped cartilage graft
crafted from autologous costal cartilage can be used for
both dorsal augmentation and lengthening. Fixation of
this graft can be achieved by cutting a notch in the caudal
end of the graft and interdigitating a columellar strut
graft. The result is an L-strut with the benefit of having
the additional dorsal bulk required to augment the saddle-
nose deformity.13
Despite the interest in open structure techniques,
many simple, less aggressive maneuvers are available to
lengthen the short nose. Because nasal length is measured
from the tip-defining points to the nasal starting point, it
would follow that placing the nasal starting point in a more
cephalic position and the tip-defining points in a more
caudal position would provide additional length. The
former can be achieved by placing radix grafts in patients
who have a low and deep radix. This is done while keeping
in mind that the ideal nasal starting point in Caucasians is
approximately at the level of the superior palpebral fissure,
while certain ethnic populations, such as Asians, feature
ideal nasal starting points at the mid-pupillary level.
At the tip of the nose, grafts can be placed to move
the tip-defining points to a more inferior position while
simultaneously providing apparent counter rotation. On
occasion, stacking multiple layers of tip grafts may be
necessary to achieve the desired amount of correction.
Additional derotation can be achieved by a conservative
wedge-shaped resection of the membranous septum with
the wider portion of wedge resection positioned anteriorly.
The clear benefit of these less aggressive techniques is that
release of the bilateral mucoperichondrial flaps through
the use of staggered septal incisions. The mucoperichon­
drial void created within the inferiormost incision was
filled with a composite cartilage graft, while the superior­
most void was left to heal by secondary intention. As with
Dingman’s technique, the grafts were not fixated to the
underlying cartilaginous substructure.
In 1987, Giammanco described the use of a pedicled
chondromucosal flap in short nose correction.7 This flap
emanated from the dorsal septal cartilage and was rotated
to reside along the caudal edge of the septal cartilage. This
maneuver, in conjunction with bilateral composite grafts
placed between the upper and lower lateral cartilages,
served to lengthen the nose by creating additional septal
extension.
Gruber’s preferred technique featured the release of
the lower lateral cartilages from the upper lateral carti­
lages.8 Depending on the amount of release and correction
necessary, intervening auricular composite grafts (with
the skin side replacing a vestibular defect) may be used
as an interposition graft. Subsequent placement of a
batten graft secured to the caudal septal cartilage served
to brace the tip into its new, lower position.
Through an endonasal delivery approach, Gunter and
Rohrich9 performed a similar tip release maneuver between
the upper and lower cartilages. In addition, they resected
a small wedge-shaped portion of the posterior septal
angle. Therefore, the nose gained absolute length via the
tip release maneuver while apparent length was afforded
by the posterior septal angle excision. Both maneuvers
serve to counter rotate—and consequently lengthen—the
nose. Additional apparent lengthening through modest
deprojection is afforded by the transfixion portion of the
incision. They described this technique as a “less aggres­
sive” approach to lengthening that would obviate the need
for flaps, grafts, and implants, while acknowledging that
that this operation was mostly suitable for minor to mod­
erately short noses.
MODERN LENGTHENING TECHNIQUES
Many different nasal lengthening techniques have been
described. As is the case with many surgical challenges,
the fact that many operative techniques exist illustrates
that there is not one single ideal technique. However,
despite their differences, most modern and successful
short nose operations often exhibit the following: (1)
extensive undermining of the SSTE, (2) release, mobiliza­
tion, or replacement of the inner lining, and, most impor­
tantly, (3) the construction of a stable cartilaginous or
bony framework that can resist the relentless forces of
contraction exhibited by the healing nose.3
Recent descriptions of nasal lengthening techniques
build upon the work of the aforementioned pioneers.
Currently, many of these surgical descriptions emphasize
open structure techniques and increasingly stable

CHAPTER TWENTY-EIGHT  Short Nose
349
of using auricular cartilage include minimal donor site
morbidity, minimal resorption, the possibility of simulta­
neous harvest, and the possibility of composite grafting.
However, auricular cartilage often lacks the rigidity to
provide meaningful strength and support for structural
purposes, but can be useful in fashioning tip grafts. Septal
cartilage may have adequate strength and stability, but it
is often absent or insufficient secondary to harvest from a
prior operation. If present, septal cartilage can be used
to fashion tip grafts, columellar struts, and/or spreader
grafts. Autologous costal cartilage has the advantage of
potentially providing abundant amounts of rigid grafting
material. Some potential disadvantages include donor site
pain, scarring, and the possibility of pneumothorax and
graft warping. However, with technical refinements, many
of the potential complications related to rib cartilage
harvest have been minimized. The use of homologous,
irradiated cadaveric costal cartilage in lengthening is less
ideal in light of its relatively higher resorption rates.14
Alloplastic materials such as expanded polytetrafluor­
oethylene (Gore-Tex; Implantech Associates, Ventura,
CA) and porous polyethylene (Medpor; Porex Surgical,
Newnan, GA) can also be used in the short nose. Layered
Gore-Tex sheets or blocks can augment dorsal and radix
deficiencies, while the structural rigidity of Medpor allows
for its use as a stable columellar strut or caudal septal
extension grafts. Although alloplastic materials are easy
to work with and obviate the need for a separate donor
site, their increased rates of infection and extrusion rela­
tive to autologous materials have limited their popularity
within the United States.
PREOPERATIVE CONSIDERATIONS
The importance of the preoperative history and physical
cannot be overemphasized. Notably, the patient’s past
medical and surgical history may impact the surgeon’s
ability to achieve optimal results. Previous rhinoplasty or
nasal procedures can make surgical correction extremely
challenging as many of the problems associated with the
postrhinoplasty short nose stem from the overzealous
resection of cartilage and support structures. For instance,
the removal or overresection of lateral crura can cause
overrotation of the nasal tip as predicted by the “tripod”
concept described by Anderson.15 Similarly, overresection
of a prominent nasal dorsum may cause iatrogenic sad­
dling, another feature contributing to a short nose. These
factors, in addition to changes to the SSTE after nasal
surgery, can make revision short nose surgery technically
demanding.
A thorough examination of the nose facilitates the
identification of patient-specific anatomic deficiencies.
Assessment of the degree of tip support should be per­
formed as these elements may require replacement or
strengthening during the upcoming surgery. An intranasal
examination should ascertain the presence or absence of
Figure 28-1  A caudal septal extension graft harvested from septal car­
tilage. The wedge shape allows for counter rotation and consequent length­
ening of the nasal tip.
tip support structures are maintained and thus do not
need replacement or reconstitution.
GRAFTING MATERIALS
With the techniques described here, abundant grafting
material is often required. Autologous sources of cartilage
include auricular, septal, and costal cartilage. Advantages

350
Michael M. Kim • Tom D. Wang
a three-point retraction technique. At this point of the
procedure, the surgeon may encounter previously placed
grafts, especially in the case of revision surgery. These
grafts should be removed and may be potentially reused if
appropriate.
Continued elevation of the SSTE in a subnasal super­
ficial musculoaponeurotic system plane (SMAS) is carried
up to the rhinion. At that juncture, elevation of the enve­
lope in a subperiosteal plane is achieved with a Joseph
elevator. Excessive lateral and cephalic extension should
be avoided. On occasion, only a small precise pocket
should be elevated to accommodate radix or dorsal
only grafts, minimizing the possibility of postoperative
migration.
In cases where minimal lengthening is needed, this
amount of dissection may be sufficient as the placement
of radix grafts, dorsal only grafts, and tip grafts may be
done with little difficulty and without disrupting poten­
tially intact tip support elements. Septal cartilage can be
harvested through a Killian incision or hemitransfixion
incision. At least 1 cm of septal cartilage along the dorsal
and caudal portions of the cartilage is retained to preserve
an important support structure.
Auricular cartilage can be harvested from the conchal
bowl through an anterior or posterior approach based on
surgeon’s preference. Our preference is to harvest through
an anterior approach due to the ease of harvest and the
virtually inconspicuous nature of the antihelical scar.
Additional local anesthesia mixture is infiltrated under the
anterior and posterior skin attached to the conchal bowl.
This hydrodissection is avoided in cases where a compos­
ite graft is required. An anterior skin incision along the
antihelical fold is made and extended superiorly and infe­
riorly to reside within the periphery of the concha. The
skin is then elevated off of the conchal cartilage. Tip grafts
are preferably shaped like an isosceles triangle and there­
fore the anterior portion, or base of the triangle, should
be thickest as it is transplanted in an anterior position to
help with derotation. Therefore, the base of the triangle
is preferentially harvested closest to external auditory
canal as this is the thickest portion of conchal cartilage.
Other portions of the conchal cartilage may be harvested
for grafting as well, but retention of a “shoulder” of
cartilage medial to the antihelical fold will minimize the
potential postoperative appearance of palpable and visible
cut edges of cartilage. Closure is achieved with a running,
locking 6-0 fast absorbing gut with subsequent placement
of anterior and posterior Telfa bolsters secured in a
through-and-through manner with 4-0 nylon suture.
In noses requiring more aggressive modification, both
domes are grasped with Brown-Adson forceps and the
intervening interdomal ligaments are separated. The ante­
rior septal angle is identified and bilateral mucoperichon­
drial flaps are raised through an open septoplasty approach.
Septal cartilage, if present, can be harvested for grafting
material, and deviations of septal cartilage and bone can
internal lining as a paucity of septal mucosa (e.g., septal
perforation) and vestibular skin may require replacement
or at least wide elevation and release. Last, the mobility
and quality of the SSTE deserve close evaluation. Toriumi
et al.13 caution others with regard to the presence of a
significantly immobile and scarred envelope as this may
limit the amount of nasal lengthening possible. In those
patients, they advocate a preoperative program of vigor­
ous massage to aid in stretching and loosening the SSTE.13
Standard, seven-view preoperative studio-quality
photographs should be taken to compare the patient’s
nasal shape to previously mentioned ideals. Some practi­
tioners perform computer imaging to predict or estimate
nasal changes following surgical correction. Discussion of
these images with the patient may be helpful to explain
the surgery and set expectations so long as conservative
computer modifications are made. If one is to use
computer-altered imaging, it is important to show realistic
modifications because changes are infinitely easier to
perform at the computer table than in the operating room.
The patient’s anatomy will guide the surgeon with
regard to what techniques or combination of techniques
will be required. However, an algorithm devised by Naficy
and Baker attempts to simplify this process.3 The crucial
decision-point in their short nose algorithm concerns the
status of tip rotation. If the nasal tip is overrotated,
maneuvers such as the “flying buttress graft” or L-strut,
interposition grafts between the upper and lower lateral
cartilages, wedge-shaped caudal septal extension grafts,
and layered tip grafts may be appropriate. On the other
hand, if the tip is underrotated or has normal rotation,
techniques such as radix grafting, full-length tip grafts,
and rectangular caudal septal extension grafts may be
used when appropriate. Regardless of the system used by
the surgeon, treatment must be individualized based on
correcting each patient’s specific deficiencies.
OUR TECHNIQUE IN DETAIL
After general anesthesia is induced, the patient is intu­
bated and turned toward the surgeons. Two cotton pledg­
ets soaked in 4% cocaine are placed within each side of
the nose. A 1 : 1 local anesthesia mixture consisting of 1%
lidocaine with 1 : 100,000 of epinephrine and 0.5% bupi­
vacaine with 1 : 100,000 of epinephrine is infiltrated under
the SSTE, nasal base, and bilateral septal mucoperichon­
drial flaps. The patient is then prepped and draped in a
sterile fashion. Bilateral marginal incisions and an
inverted-V trans­columellar incision are made with a No.
15 scalpel. The columellar skin is carefully elevated by
scissor dissection without damaging the intimately associ­
ated medial crura of the lower lateral cartilages. Often the
paired columellar arteries must be cauterized for optimal
hemostasis. Elevation of the SSTE from the remaining
portions of the lower lateral cartilages is done via

CHAPTER TWENTY-EIGHT  Short Nose
351
be addressed simultaneously. Great care should be taken
during this portion of the procedure, especially in the case
of revision surgery, as the risk of perforation between two
directly apposed mucoperichondrial flaps is very high.
Often the paired upper lateral cartilages need to be
separated from the midline septal cartilage so as to further
identify the status of the septum and for additional inner
lining release. This maneuver also facilitates the place­
ment of extended spreader grafts, a prerequisite if a
“flying buttress” L-strut is to be constructed. The place­
ment of extended spreader grafts is particularly helpful in
those noses with a pinched middle-third or an inverted-V
deformity. The caudal portion of the L-strut can be fash­
ioned by a columellar strut graft placed in a precise pocket
along the columella and between the medial crura of the
lower lateral cartilages. The columellar graft interdigitates
between the paired, caudal portions of the extended colu­
mellar grafts and is fixed into position with 6-0 Prolene
suture. Subsequently, the paired medial crura are fixed to
the intervening columellar strut in a tongue-and-groove
manner with 4-0 plain gut on a Keith needle. This rela­
tionship may be altered to provide additional counter
rotation if required.
If the middle third is of adequate width, a caudal
septal extension graft can be attached to the existing
caudal septum with 6-0 Prolene mattress sutures. Because
many short noses are overrotated, a wedge-shaped graft
with the wide side anterior can confer counterrotation.
Once again, the paired medial crura are fixed to the caudal
septal extension graft in a tongue-and-groove manner.
The use of caudal septal extension grafts is our preference
when a large increase in nasal length is required as it is
relatively simple to perform with potentially more predict­
able long-term results.
When concomitant saddling is present in addition to
deficient nasal length, augmentation may be achieved
through a variety of methods including costal cartilage
grafting or the placement of alloplastic materials. If costal
cartilage harvest is chosen, it can be performed with
minimal associated complications or morbidity and has
the added benefit of potentially serving as the dorsal
portion of an L-strut if fixed to a columellar strut.
Once stability of the cartilaginous framework is
ensured, nonstructural elements such as radix grafts and
tip grafts can be placed. Layered tip grafts can be con­
structed to have more mass anteriorly and serve to counter
rotate the nose and place the tip-defining points in a more
caudal position.
While placing multiple grafts, the SSTE should be
serially redraped over the modified cartilaginous scaffold,
because the restricted mobility of a scarred SSTE may
limit the amount of correction possible. The use of a single
monocryl or Vicryl stitch in the center of the transcolumel­
lar incision may be helpful in relieving tension from
the redraped SSTE. Subsequent 6-0 fast-absorbing gut
is used to close the remaining portions of the
transcolumellar incision, while 5-0 chromic gut suture
reapproximates the bilateral marginal incisions. The
paired mucoperichondrial flaps are put in direct apposi­
tion with 4-0 Vicryl rapide in a running, quilting fashion.
At the conclusion of the procedure, skin adhesive fol­
lowed by paper tape is placed on the dorsum so as to exert
slight compression over the supratip area and provide
modest cephalic support to the tip. A thermoplastic nasal
splint is applied and tape is then placed over the splint.
Bacitracin-coated Telfa packs are placed in the nose and
are removed after 30 minutes while the patient is in the
recovery room. Patients are typically seen on postopera­
tive days 1 and 7.
ILLUSTRATIVE CASES
CASE 1
Patient 1 is a 32-year-old African American woman who
had undergone four previous rhinoplasties. Her nose
exhibited a widened dorsum, overrotated tip, and inade­
quate nasal length (Figure 28-2). Due to her previous
rhinoplasty procedures, septal cartilage was unavailable
for grafting.
The patient’s nose was opened with bilateral marginal
incisions and a transcolumellar incision. After elevation of
the SSTE, the presence of bilateral spreader grafts was
noted. Because she had excessive width in the middle
third, the spreader grafts were removed. Subsequently,
lateral osteotomies were performed to provide additional
narrowing.
Auricular cartilage was harvested from the patient’s
left ear through an anterior approach. The donor site inci­
sion was closed and bolstered in front and back. Three
layers of conchal cartilage were stacked and placed as a
tip graft to affect a decreased nasolabial angle (Figure
28-3). The nose was closed in a standard fashion.
CASE 2
A 27-year-old man presented with a congenitally short,
upturned nose. The tip was overrotated with excess nostril
show and inadequate nasal length (Figure 28-4).
After the SSTE was elevated, bilateral dome division
was performed via wedge resections with subsequent resu­
turing to affect additional caudal inclination of the lateral
crura. The lower lateral cartilages were separated and
septal cartilage was harvested through an open approach.
A columellar strut graft was created from the septal
cartilage and placed in a precise columellar pocket. The
lower lateral cartilages were then sutured to the columel­
lar strut in a tongue-and-groove fashion.
A “reverse” wedge of membranous septum was
resected and the nasal spine was reduced. Both maneuvers
combined to decrease the nasolabial angle. Last, auricular
cartilage was harvested for a multilayered tip graft.