Master Techniques in Rhinoplasty

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Once the tripod has been strengthened properly, the
nasal tip lobule can be addressed in a proper fashion. Tip
grafts should only be used with a stable nasal base. The
SSTE of mestizo patients tends to be heavier, and if a
stable base is not created, the underlying structures will
tend to collapse with time.
CONTOURING THE NASAL TIP
Tip defining techniques in mestizo patients are challeng­
ing. Alar cartilages tend to be weak and relatively wide
in patients with acute nasolabial angles, underprojected
tips, poor tip support, short caudal septums, and/or inad­
equate alar/columellar relationship.10,11 The graft ideally
should be harvested from septal cartilage and should be
a relatively straight piece of cartilage. It is placed overlap­
ping the caudal edge of the patient’s nasal septum and is
fixed securely with 3-0 Vicryl sutures superiorly and infe­
riorly at the level of the nasal spine. The feet of the medial
crura are then fixed to the caudal edge of this graft, and
its height is set depending on how much tip rotation and
projection the patient needs (Figure 32-5).
Figure 32-5  Approach to the nasal base. A, Patient with acute nasolabial angle, small nasal spine, and retrusive caudal edge of nasal septum; the nasal
tip has caudal orientation as well as poor projection and rotation. B–C, Surgical views detailing placement of caudal extension graft. D, Postsurgical result
after placement of caudal extension graft harvested from patient’s cartilaginous septum; nasolabial angle is less acute and tip has gained rotation and projec­
tion. (From Cobo R. Hispanic/Mestizo rhinoplasty. Fac Plast Surg Clin North Am 2010;18:173-188.)
A
B
D
C

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Roxana Cobo • William Numa
Cephalic trim of alar cartilages is only used when
necessary to avoid postsurgical alar pinching and internal
nasal valve collapse. If cephalic trimming is to be per­
formed, this is usually performed at the level of the ante­
rior lateral crura, taking care not to extend the excision
laterally to avoid supralar pinching or collapse of the
lateral nasal wall. When the scroll area is excised aggres­
sively, this can also create pinching and compromise the
internal nasal valve. Thus, cephalic trim is rarely per­
formed in these patients, and the bulbosity of the tip is
managed with suturing techniques that mainly affect the
horizontal component of the alar cartilage.
MANAGEMENT OF THE HORIZONTAL
COMPONENT
Suturing Techniques
Suturing techniques are the first steps in managing the
bulbous undefined nasal tips. Of the different surgical
options, the lateral crural steal is probably one of the most
useful techniques.4 Projection and rotation are obtained
by lengthening the medial crura at the expense of the
lateral crura. The vestibular skin is dissected to be able
to mobilize the cartilage freely. The new domes are defined
by placing independent 5-0 Prolene sutures lateral to the
original existing domes. These “newly created domes” are
then fixed in the midline with a continuous mattress 5-0
Prolene suture. This technique rotates the tip superiorly,
increases projection, and creates a more triangular base.
The use of a columellar strut with this type of suture
creates a very stable, triangular nasal tip complex (Figure
32-7).
Other suturing techniques commonly used are the
transdomal suture narrowing technique14 and the double-
dome unit technique.15 The transdomal suture narrowing
without providing any meaningful structural support.
Often, when these cartilages are sutured, they are so flimsy
that postsurgical pinching can be seen at the level of the
lobule. When managing the nasal tip, the alar cartilages
must be analyzed from its horizontal and its vertical com­
ponent. The vertical component is defined as the distance
from its caudal to its cephalic margin. The horizontal
component is defined as the distance of the alar cartilage
from the foot of its medial crura to its lateral crus (Figure
32-6).
When evaluating the vertical component of the tip
cartilages, one must define their width, curvature (flat,
convex, concave), and strength (flimsly or strong). The
horizontal component is used to determine the length of
the alar cartilages, the characteristics of the domal angle
(acute or obtuse), and the interdomal distance.
Surgical techniques can be divided into various
categories:
• Remodeling of the alar cartilages: cephalic trim or car­
tilage suturing techniques that help refine, project, and
rotate the nasal tip
• Division of the alar cartilages: division of the alar carti­
lages such as the lateral crural overlay method
• Grafts on nasal tip lobule: used to elongate, define,
project, and give additional support to the alar
cartilages
MANAGEMENT OF THE VERTICAL COMPONENT
A very common complaint of mestizo patients is that their
tip is wide and bulbous and undefined. An “easy” way of
dealing with this problem is to perform a cephalic trim of
the alar cartilages and suture the domes to decrease the
interdomal distance. If this is not done properly, it can
create numerous problems postsurgically for these patients.
Figure 32-6  Vertical and horizontal components. Vertical plane is defined as the distance from A to B: width and curvature (concave, convex, flat) are
primary considerations. The horizontal plane is defined as the distance from C to D. It is important to define the interdomal distance (distance from dome
to dome) and characterize the domal angle (acute or obtuse).
A
B
C
D
A
B
C
D
Interdomal
distance
Domal
angle
A - B: Vertical Plane
C - D: Horizontal Plane

CHAPTER THIRTY-TWO  Mestizo Rhinoplasty
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Figure 32-7  Lateral crural steal. A, Increase of the length of the medial crura by shortening the length of the lateral crura results in an increase in rota­
tion and projection of the nasal tip. B–D, Surgical case where a columellar strut has been sutured in place and lateral crural steal has been performed. There
has been an increase in tip rotation and projection at the expense of the lateral crura. (B–F, From Cobo R. Hispanic/Mestizo rhinoplasty. Fac Plast Surg Clin
North Am 2010;18:173-188.)
A
B
C
D
E
F

406
Roxana Cobo • William Numa
Figure 32-8  Transdomal suture narrowing technique. A continuous Prolene mattress suture is passed slightly lateral to the existing domes and knotted
in the midline. This maneuver brings the domes together in the midline creating an adequate interdomal distance. This creates a more triangular tip and
base. Tip projection is usually increased slightly or maintained.
Figure 32-9  Double-dome unit technique. This technique is used with tips that are very bulbous and undefined and with a very thick SSTE. Each dome
is defined and sutured independently. A third continuous horizontal mattress suture is passed slightly lateral to the newly defined domes and is sutured in
the midline. This creates a triangular nasal base and increases projection and rotation slightly.
technique is useful in nasal tips that are broad and trap­
ezoidal in shape. It helps improve tip support and enhances
tip projection. A 5-0 Prolene suture is passed through the
domes and is tied in the midline. This suture creates a
more triangular shape to the tip (Figure 32-8). The
double-dome suture technique not only increases tip pro­
jection and support but also can be a more aggressive
approach in lobular refinement. A 5-0 mattress suture is
used to “define” each dome independently, creating a
more acute interdomal angle. A third continuous suture is
then passed through the “newly defined domes,” securing
them at the midline. Both of these techniques create a
more triangular nasal lobule, increase tip projection, and
result in a narrower nasal tip (Figure 32-9).
Division of the Alar Cartilages
Many mestizo patients have acute nasolabial angles and
ptotic nasal tips with a long horizontal component of the
alar cartilages. In many of these patients, suturing tech­
niques are not sufficient to increase rotation; therefore,
more aggressive techniques such as division of the lateral
component of the alar cartilage are often required. The
lateral crural overlay technique is an excellent option to
increase rotation and to shorten an overlong nose without

CHAPTER THIRTY-TWO  Mestizo Rhinoplasty
407
Figure 32-10  Illustration of lateral crural overlay technique.
losing support.16 Alar cartilages are divided lateral to the
domes, and the cut segments are superimposed and
sutured using 5-0 Prolene or nylon mattress sutures. This
technique reconstructs the divided alar cartilage, thereby
creating a new intact strip with increased support at the
level of the overlapped lateral crura. The division should
be carried out symmetrically to avoid postsurgical tip
asymmetries. The domes are then defined with the sutur­
ing techniques mentioned earlier (Figure 32-10 and
32-11).
Grafts in the Nasal Tip
Tip grafts are used to improve definition and help increase
support and projection to many of the bulbous, undefined,
thick-skinned mestizo tips.12 These grafts should not be
used in excess and patients have to be chosen carefully
because they tend to become visible over time if one is not
careful to camouflage them adequately. Mestizo patients
generally want noses that do not appear big or overbuilt
but rather those that look narrower and more defined.
Often, the only way to achieve this result is by using grafts
to help build up the support structures that lie under a
very thick SSTE.
The shield graft is very useful to help define and
project a thick bulbous tip. It is ideally carved from septal
cartilage, although ear cartilage can also be used with
good results. Each shield graft is carved according to
the patient’s needs. Edges should be beveled and sutured
with 6-0 Prolene to the caudal margins of the medial/
intermediate crura–columellar strut complex. The leading
edge of the graft should always be at or just slightly above
the level of the existing domes regardless of the thickness
of the SSTE. This leading edge is then covered with
morselized cartilage or perichondrium to prevent visibility
in the future (Figure 32-12).
Alar rim grafts are very helpful in patients with weak
alar cartilages.10 In mestizo patients, after dome-binding
sutures and other suturing techniques are performed, it is
not infrequent to see a small concavity form in the lateral
crus of the alar cartilage that can later result in pinching
of the nasal tip and notching of the alar margin. This is
often due to the natural weakness of the lower lateral
cartilages in these patients. Alar rim grafts are placed in
a pocket at the caudal edge of the marginal incision. These
grafts help contour the alar margin and give the tip lobule
a more symmetrical appearance (Figure 32-13).
Frequently, after suturing techniques have been per­
formed, morselized cartilage is placed over the nasal tip
lobule. This cartilage helps hide any irregularities and
gives the tip a softer, more rounded look. Morselized car­
tilage can also be used to fill in any gaps in the middle
third of the nose.
Many other grafting options exist for the nasal tip (see
Table 32-3). Grafts should be placed carefully and ideally
sutured in place to avoid postsurgical shifting, which can
create noticeable asymmetries.
ALAR BASE REDUCTION
Alar base reduction can be used to decrease alar flare, alar
base width, or both. It is not a routine procedure in
mestizo patients and should be performed only at the end
of the operation if necessary. The medial incision is typi­
cally placed in a natural crease at the junction of the nasal
sill and ala. The lateral incision should not extend into
the alar facial groove as this could leave an unsightly scar
especially in patients with thick oily skin. Incisions are
closed using 6-0 Prolene or nylon sutures and sutures are
removed after 8 days (Figure 32-14).
POSTSURGICAL FOLLOW-UP
Postsurgical follow-up is absolutely necessary in mestizo
patients. Skin types vary but in general they tend to be
thicker and more oily. Patients should be warned that
edema of the nasal tip will be present for several months,

408
Roxana Cobo • William Numa
Figure 32-11  Patient photos of lateral crural overlay technique. A–B, This technique is useful in patients with a very long horizontal component of their
alar cartilages that creates long ptotic noses with an acute nasolabial angle. C, Alar cartilage is dissected from the vestibular skin. If necessary a very conserva­
tive cephalic trim of the lateral crura is performed leaving at least 9 to 10 mm of cartilage in its vertical component. The cartilage is transected 10 mm lateral
to the dome-defining point. D, Transected fragments are superimposed with the long medial segment placed on top of the short lateral segment. E, The
segments are fixed with 5-0 Prolene sutures. The edges are beveled and regularized. F, A new intact strengthened strip has been created. This rotates the
tip upward and shortens the long nose. (B–F, From Cobo R. Hispanic/Mestizo rhinoplasty. Fac Plast Surg Clin North Am 2010;18:173-188.)
A
B
C
D
E
F

CHAPTER THIRTY-TWO  Mestizo Rhinoplasty
409
Figure 32-12  Shield graft. A–C, The shield graft ideally should be
carved from cartilage obtained from the nasal septum but can also be
carved from auricular conchal cartilage. Dimensions can range from 7 to
10 mm in its leading edge, 8 to 15 mm in length, and 2 to 4 mm in
thickness, but it should be tailored depending on the patient’s individual
needs. D, It is sutured to the caudal margins of the medial/intermediate
crural–columellar strut complex with 6-0 Prolene, taking care to bevel its
edges fastidiously to avoid having it show postoperatively. E, The superior
edge of the shield graft is usually covered with morselized cartilage, peri­
chondrium, or temporalis fascia to avoid postsurgical visualization of the
edges. (C–E, From Cobo R. Hispanic/Mestizo rhinoplasty. Fac Plast Surg
Clin North Am 2010;18:173-188.)
A
Extended
shield graft
B
C
D
E
and because of the skin pigmentation, dark periorbital
circles can be accentuated and will be prominent for
several months after the surgery. It is important for these
patients to avoid sun exposure.
Persistent edema in the supratip region can be effec­
tively treated with 1 mg to 2 mg of triamcinolone aceto­
nide injections (Kenalog) subdermally. If necessary, these
injections can be started as early as 2 weeks postsurgery
and can be repeated every 6 weeks, taking care to tape
the nose following these injections. Care should be taken
not to inject too frequently as this can produce permanent
subcutaneous and cutaneous atrophy.
Following patients closely will help strengthen the
doctor-patient relationship. It will help patients under­
stand that time is their ally and that the postsurgical
results will not be appreciated for at least 6 to 12 months.
This is especially true in thick-skinned patients (Figures
32-15 and 32-16).

410
Roxana Cobo • William Numa
Figure 32-14  Alar base reduction. A, Reduction of alar flare: Reduction of the lateral portion of the alar base without resecting the nasal sill. B, Resection
of the more medial segment of the alar base will decrease the width of nasal sill or base with less reduction in alar flaring. C, Combined resection will decrease
alar flaring and the base width, giving the nostrils a more elongated look.
Figure 32-13  Alar rim grafts. A, Placement of alar rim grafts in a pocket that is made following the marginal incision. B, C, Preoperative and postopera­
tive basal view of patient with placement of shield graft and alar rim grafts.
A
B
C

Figure 32-15  Preoperative (A–D) and postoperative (E–H) patient photographs.
F
A
D
B
C
E
G
H

Figure 32-16  Preoperative (A–D) and postoperative (E–H) patient photographs.
A
B
C
D
E
F
G
H

CHAPTER THIRTY-TWO  Mestizo Rhinoplasty
413
6. Ospina W. América Mestiza—El país del Futuro. Bogotá,
Colombia: Villegas Editores; 2000:23–38.
7. Daniel RK. Hispanic rhinoplasty in the United States with
emphasis on the Mexican American nose. Plast Reconstr Surg.
2003;112:244–256.
8. Becker D, Pastorek NJ. The radix graft in cosmetic
rhinoplasty. Arch Fac Plast Surg. 2001;3:115–119.
9. Toriumi D. Management of the middle nasal vault in
rhinoplasty. Opin Tech Plast Reconstr Surg. 1995;21:16–30.
10. Toriumi DM. New concepts in nasal tip contouring. Arch Fac
Plast Surg. 2006;8:156–185.
11. Swartout B, Torimi DM. Rhinoplasty. Curr Opin Otolaryngol
Head Neck Surg. 2007;15:219–227.
12. Cobo R. Facial Aesthetic surgery with emphasis on
rhinoplasty in the Hispanic patient. Curr Opin Otolaryngol
Head Neck Surg. 2008;16:369–375.
13. Godin MS, Waldman SR, Johnson CM. Nasal augmentation
using Gore-Tex: A 10 year experience. Arch Fac Plast Surg.
1999;1:18–121.
14. Tardy ME, Cheng E. Transdomal suture refinement of the
nasal tip. Fac Plast Surg. 1987;4:317–326.
15. McCollough EG, English JL. A new twist in nasal tip surgery:
an alternative to the Goldman tip for the wide or bulbous
lobule. Arch Otolaryngol Head Neck Surg. 1985;111:
524–529.
16. Konior RJ, Kridel R. Controlled nasal tip positioning via the
open rhinoplasty approach. Fac Plast Surg Clin of North Am.
1993;1:53–62.
CONCLUSIONS
Surgical techniques in mestizo patients are oriented to
create definition and increase support, rotation, and pro­
jection without increasing size or volume dramatically.
Support structures are reinforced, suture techniques and/
or grafts are placed in a precise manner, and very little
tissue is resected. The objective is to obtain a balanced
nose that blends in with the patient’s features. The results
must withstand the natural healing process. If executed
correctly, this will in most cases give patients a nose that
is closer to their aesthetic ideal without changing their
ethnic features dramatically.
REFERENCES
1. Romo III T, Abraham MT. The ethnic nose. Fac Plast Surg.
2003;19(3):269–277.
2. Leach J. Aesthetics and the Hispanic rhinoplasty.
Laryngoscope. 2002;112.
3. Leong S, White P. A comparison of aesthetic proportions
between the healthy Caucasian nose and the aesthetic ideal.
J Plast Reconstr Aesthet Surg. 2006;59:248–252.
4. Cobo R. Mestizo rhinoplasty. Fac Plast Surg. 2003;119(3):
257–268.
5. Ortiz F, Olmedo A. Rhinoplasty on the mestizo nose. Clin
Plast Surg 1977;4(1).

415
C H A P T E R T H I R T Y - T H R E E 
Rhinoplasty in the Aging Patient
Ryan M. Greene • Dean M. Toriumi
Aesthetic and reconstructive rhinoplasty is commonly
acknowledged as the most demanding and difficult of
the plastic surgical procedures. Although many technical
advances have occurred throughout the past century, its
fundamental philosophy remains constant. This philoso­
phy involves significant planning and conservative surgi­
cal changes to achieve a natural-appearing result. Initially,
the operation generally involved a tissue reduction proce­
dure with excision of various nasal anatomic components.
More recently, rhinoplasty has evolved into a procedure
that involves tissue reorientation and augmentation, with
careful attention to long-term surgical outcome.
PERSONAL PHILOSOPHY
Rhinoplasty is a complex operation that requires precise
preoperative diagnosis to select the appropriate surgical
technique. Owing to variations in nasal anatomy and
aesthetic expectations, no single technique is appropriate
for all patients. Each rhinoplasty patient presents the
surgeon with a diversity of nasal anatomy, contours,
and proportions that require a series of organized
maneuvers tailored to the patient’s anatomic and func­
tional needs. The surgeon must also be skilled at manipu­
lating and controlling the dynamics of postoperative
healing to attain optimal long-term aesthetic results. A
necessary prerequisite is the skill to visualize the ultimate
long-term healed result while manipulating the nasal
structures.
ANATOMY
Aging of the nasal structures and external contour of the
nose is influenced by a variety of genetic and environmen­
tal factors. Additionally, the nasal shape changes over
time as well. In children, the nasal dorsum is typically
concave and assumes a more straight or convex shape
in early adult life. This convexity is further enhanced in
midlife by the development of a drooping, ptotic tip. In
addition to these changes to the appearance of the nose,
nasal function tends to deteriorate over time as the nasal
airway changes.
As patients age, the skin thins with loss of elasticity,
subcutaneous fat deposits resorb, and the underlying soft
tissues atrophy. With these changes, the underlying
support structures of the nose, such as the lower lateral
cartilages and nasal bones, become skeletonized or visible.
In addition, skin hydration is diminished, and the skin
becomes less pliable.1 This affects the skin’s ability to
contract and redrape after the cartilaginous and bony
structures of the nose are reduced.
The most significant changes over time occur in the
upper and lower lateral cartilages. These cartilages are
connected by a fibrous union at the cephalic margin of the
lateral crura, the scroll region.1 As the nose ages, the upper
and lower lateral cartilages begin to separate and frag­
ment.2,3 This may result in collapse of the internal nasal
valve and lateral wall. As one ages, the middle nasal vault
will tend to collapse as the upper lateral cartilages move
inferomedially. Loss of support of the medial crura and
stretching of the fibrous attachments from the posterior
septal angle and nasal spine to the medial crural foot­
plates result in their posterior movement and retraction
of the columella.3 These changes also occur by loss of the
fat pad below the medial crura and resorption of the
premaxilla.2 With loss of support of the medial crura and
separation of the lateral crura from the upper lateral
cartilages, the nasal tip may become ptotic, with an
appearance of increased length and a more acute naso­
labial angle.
With aging, the nasal bones may become brittle and
are more readily fractured.4 Care must be taken during
osteotomies to avoid excessive narrowing of the bony vault
or comminuted fractures of the nasal bones. Periosteal
elevation is not recommended in the aging patient and, if
used, should not extend to the point of the intended lateral
osteotomies, to avoid loss of periosteal support.4 Although
undesirable in the younger patient, greenstick fractures
can be effective in the older patient.4 Finally, dorsal hump
reduction must be executed with great precision to mini­
mize irregularities of the bony nasal vault as the skin over
the dorsum tends to be very thin.

416
Ryan M. Greene • Dean M. Toriumi
PREOPERATIVE ASSESSMENT
Preoperative assessment of the rhinoplasty patient includes
the assessment not only of the anatomic and functional
components but also the emotional and psychological
factors.5 As with all facial aesthetic surgery, it is important
for the physician to discuss motivation and aesthetic goals
of rhinoplasty surgery with the patient. It is critical to
elucidate what aesthetic changes the patient desires. Older
patients have developed a self-image over many years and
must be prepared for the planned surgical changes. Many
older patients do not want to look dramatically different,
and thus conservative changes are generally most appro­
priate. Patients who desire dramatic changes warrant
careful evaluation prior to consideration as surgical
candidates.
In this age group, a thorough preoperative medical
examination is mandatory. Many of these patients have
comorbid medical conditions. A careful medical history
and physical examination are critical prior to performing
this type of surgery. It is often a good idea to consult with
the patient’s primary care physician prior to scheduling
surgery. Many of these patients take medications that can
affect clotting; these medications should be stopped at
least 2 weeks before surgery.
SURGICAL TECHNIQUE
PREOPERATIVE CONSIDERATIONS
The surgical approaches to the nose include nondelivery
techniques (cartilage-splitting or retrograde approach),
delivery of bilateral chondrocutaneous flaps, and the
external rhinoplasty approach. Selection of the approach
should be based on both operative objectives and surgical
experience. When only conservative volume reduction of
the lateral crura and dorsal hump reduction are planned,
a nondelivery approach (cartilage-splitting or retrograde
approach) will suffice. However, when more complex
nasal tip work is required, delivery of bilateral chondro­
cutaneous flaps or the external rhinoplasty approach
should be used. The external approach is preferred when
complex tip grafting or middle nasal vault reconstruction
is planned. Regardless, the surgeon should select the least
invasive approach possible to avoid disruption of nasal
support mechanisms and maximize the functional and
aesthetic result.
External incisions can be used with greater frequency
in older patients because the skin is less likely to scar
unfavorably.6 Nasal skin in the aging patient also has
multiple rhytids that can aid in camouflage. Even though
it is rarely necessary, direct excision of skin from the nasal
dorsum or supratip can be performed to aid redraping
of the skin or elevating the severely ptotic nasal tip.7–9
Because of the thin skin found in the aging nose, even the
smallest irregularities or asymmetries can become notice­
able. As a result, debulking of underlying subcutaneous
fat and muscle tissue should not be performed. This sub­
cutaneous tissue should be preserved to maximize camou­
flage of the cartilage and bone. Tip grafts should also be
limited unless the patient has medium to thick skin.10 If
they are used, they should be carefully sculpted and cam­
ouflaged to avoid visible edges. With thin skin, a thin layer
of perichondrium or superficial temporal fascia can be
applied over the graft, with an understanding that it will
create temporary edema of the grafted area that should
resolve over 6 to 12 months.
When treating the aging nose, the nasal tip should be
managed first to set tip projection and rotation before
completing profile alignment. After setting appropriate tip
projection, dorsal hump reduction may not be needed.
Frequently, older patients will also benefit from augmen­
tation of the radix to create a straight profile. This strategy
of increasing tip projection and raising the radix allows
the surgeon to preserve a high dorsal profile while also
creating a favorable tip-supratip relationship (Figure
33-1). As mentioned earlier, only conservative changes
should be made in the nasal contour because older patients
tend to have a set self-image. The nose should also be in
harmony with the patient’s other facial features.
THE EXTERNAL APPROACH
The patient is first injected with 1% lidocaine with
1 : 100,000 epinephrine into the nasal tip, between and
around the domes, down the columella, along the site of
the marginal incision, and along the lateral wall of the
nose. Additional injections high on the nasal septum and
along the osteotomy sites are then placed. An inverted-V
columellar incision is then marked, midway between the
base of the nose and the top of the nostrils. A transcolu­
mellar incision is executed with a No. 11 blade. Care must
be taken to avoid damaging the caudal margin of the
medial crura. Marginal incisions are then made along the
caudal margin of the lateral crura, which are extended to
meet the columellar incision.
After completing the incisions, angled Converse scis­
sors are used to elevate the skin off the medial crura. Once
the columellar flap is elevated off the medial crura, dis­
section is advanced laterally to expose the lateral crura.
A thin layer of perichondrium is left on the surface of the
lower lateral cartilages. The anterior septal angle is identi­
fied, with exposure of the middle nasal vault in the midline.
Blunt dissection is continued to the rhinion, which may
be followed by subperiosteal dissection of the skin off the
nasal dorsum up to the nasion if profile alignment is nec­
essary. If a radix graft is planned, then a narrow pocket
should be dissected in the midline over the radix. This
narrow pocket will prevent shifting of a radix graft if radix
augmentation is necessary.

CHAPTER THIRTY-THREE  Rhinoplasty in the Aging Patient
417
or avoided. The surgeon should be aware that the
septal cartilage may be partially calcified, which leaves
the surgeon with less cartilage for harvesting or grafting.
In some patients, it may be necessary to dissect
between the medial crura to access the caudal septum.
Patients with a deviated caudal septum may benefit from
this approach to allow correction of the deformity. Other
patients with poor tip support could benefit from stabili­
zation of the nasal base through this approach.
PTOTIC NASAL TIP
As the nose ages, the nasal tip frequently droops, creating
a ptotic nasal tip. This change in nasal contour gives
an elongated appearance. Patients that have shorter
medial crura are more likely to develop tip ptosis due to
lack of support. Patients with long medial crura that wrap
around the nasal spine and caudal septum are less likely
to develop tip ptosis (Figure 33-2). Severe ptosis of the
nasal tip can also result in nasal airway compromise
by altering the pathway of inspiratory air currents.3
Correction of the ptotic nasal tip generally involves
increasing nasal tip rotation and projection. As demon­
strated by the tripod concept described by Anderson,11
ptosis of the nasal tip can usually be corrected by sup­
porting the medial and intermediate crura or by shorten­
ing the lateral crura.
We typically use a graduated approach for correction
of the ptotic nasal tip by initially considering placing a
sutured-in-place columellar strut between the medial
SEPTAL SURGERY
When performing septal surgery in the older patient, dis­
section of the mucosal flaps should be limited because the
mucoperichondrium is thinner and drier. A substantial
L-shaped septal strut should be preserved to support the
lower two thirds of the nose. We prefer to leave at least a
2-cm anterior septal strut and 1.5-cm caudal strut for
support. Extra cartilage should be left at the osseocarti­
laginous junction to avoid loss of dorsal septal support. A
Killian incision is preferred because of its excellent expo­
sure without compromise of the support attachments
between the feet of the medial crura and the caudal
septum. A hemitransfixion incision can be used if expo­
sure of both sides of the caudal nasal septum is required.
The hemitransfixion or full transfixion incision can some­
times lead to a loss of support due to disruption of some
of the attachments between the medial crura and caudal
septum. When a decrease in tip projection is desired, a
full transfixion incision can be used to disrupt these
attachments.
When exposing the septal cartilage in the aging
patient, it is generally preferable to raise a mucoperichon­
drial flap on only one side of the septum, to preserve the
vascular supply of the contralateral side and minimize
chances of hematoma formation. After completion of the
septal surgery, a running 4-0 plain catgut mattress suture
is used to approximate the mucoperichondrial flaps
and prevent fluid collection and hematoma formation. By
limiting septal surgery, nasal packing can be minimized
Figure 33-1  A, Profile of an aging patient. Note the underprojection of the nasal tip. B, Placement of a caudal extension graft with septal cartilage
overlapping the existing nasal dorsum. C, Note the increased tip projection to create a straight dorsal profile.
A
B
C

418
Ryan M. Greene • Dean M. Toriumi
the medial crura. Once the incision is made, a precise
pocket is made between the medial crura for graft place­
ment and suture fixation.
In many patients, a columellar strut will not provide
sufficient support to the nasal base. These patients will
require more significant structural support. One option is
to suture the medial crura to the caudal septum. This
maneuver will shorten the nose and support the nasal
base. This technique should be used only when the caudal
septum is long and would otherwise require shortening.
Another option is to use a caudal extension graft. Such a
graft is typically overlapped and sutured to the existing
caudal septum. Then the medial crura are sutured to the
crura. We have found this to be particularly effective if
the dependent lobule is caused by buckling of the medial
or intermediate crura. A sutured-in-place columellar strut
both provides support and straightens buckled medial and
intermediate crura. A straight rectangular piece of septal
cartilage is placed in a precise pocket created between the
medial and intermediate crura.10 The columellar strut is
fixed into position using a 5-0 plain catgut suture on a
straight septal needle. The strut is easily applied using the
external rhinoplasty approach, which allows maximal
visualization, precise placement, and suture fixation of the
graft. These struts can also be applied using a small endo­
nasal incision placed just caudal to the caudal margin of
Figure 33-2  Relationship between medial crura and footplates to the caudal septum. A, Long strong medial crura extend to base of nose near posterior
septal angle and wrap around caudal septum. B, This relationship provides excellent nasal tip support. Short medial crura do not extend to the nasal base
and provide less tip support. C, Short caudal septum with separation of medial crura away from caudal septum results in loss of tip support.
A
B
C

CHAPTER THIRTY-THREE  Rhinoplasty in the Aging Patient
419
extends lateral to the anatomic dome. This suture narrows
the nasal tip by approximating the domes and creating a
more acute domal angle, in addition to increasing tip
projection and rotation. In some cases, the transdomal
suture can further compromise the nasal airway if the
lateral crura protrude into the airway. Such obstruction
can be avoided by using an alar batten graft or lateral
crural strut graft to lateralize the offending lateral segment
of the lateral crus. If the transdomal suture does not
correct the ptotic nasal tip, it may be necessary to perform
a more aggressive maneuver that shortens the lateral
crura.
The lateral crural overlay technique is a procedure
that increases tip rotation by shortening the lateral crura.
In this technique, the lateral crura are incised at the
midpoint, and the medial segment is dissected from
the underlying vestibular skin (Figure 33-4). The cut ends
of cartilage are then overlapped (3 mm or 4 mm) and
caudal margin of the caudal extension graft to stabilize
the nasal base and reposition the nasal tip. The caudal
extension graft must be in the midline and oriented to
increase tip rotation. Fixation of the medial crura to the
caudal septum or an extension graft provides increased
tip support (Figure 33-3). Such fixation creates moderate
rigidity of the nasal tip that can be discussed with the
patient preoperatively.
If stabilizing the nasal base does not adequately
correct the ptotic nasal tip, then additional surgical
maneuvers must be used to increase tip rotation. The
objective of these maneuvers is to rotate the nasal tip by
recruiting lateral crura medially. Placement of a transdomal
suture recruits lateral crura medially to increase tip pro­
jection and rotation.12,13 Without violating the underlying
vestibular skin, a 5-0 clear nylon suture is placed in a
horizontal mattress fashion across both domes. To recruit
the lateral crura medially, the lateral bite of the suture
Figure 33-3  Caudal extension graft. A, The caudal extension graft is shown intraoperatively. B, The graft then is shown sutured into place. Note the
harvesting site, maintaining the L-shaped support. C, The caudal view of the graft sutured into position. D, The superior view of the graft sutured into posi­
tion. Note how the caudal extension graft typically overlaps the existing caudal septum. It is critical that the caudal margin of the extension graft is in the
midline.
A
B
C
D

420
Ryan M. Greene • Dean M. Toriumi
A
B
C
D
E
F
Figure 33-4  Lateral crural overlay technique. A, The overly long lower lateral cartilages. B, The overly long lateral crura are seen intraoperatively.
C, D, The cartilages are marked for excision. E, Lateral crura overlap is depicted. F, An intraoperative photograph of cartilage dissected from underlying
vestibular skin.

CHAPTER THIRTY-THREE  Rhinoplasty in the Aging Patient
421
G
H
I
J
K
G, H, Lateral crura ends are resutured. I, Excessive caudal margins of the overlapped cartilage are trimmed. J, K, Lateral crura are
realigned, symmetrical, and stable.
Figure 33-4, cont’d

422
Ryan M. Greene • Dean M. Toriumi
NARROWED MIDDLE NASAL VAULT
In some older patients, an excessively narrow middle nasal
vault can result when weak upper lateral cartilages col­
lapse inferomedially. Severe collapse may also result in
collapse of the internal nasal valve. These patients experi­
ence improvement in their nasal airway obstruction while
performing the “Cottle maneuver” or with lateralization
of the lateral nasal wall with an instrument. To correct
this deformity, the surgeon can apply bilateral spreader
grafts between the dorsal (anterior) margin of the nasal
septum and the upper lateral cartilages.14–16 These grafts
are rectangular in shape and measure approximately 5 to
15 mm in length, 3 to 5 mm in width, and 1 to 2 mm in
thickness. The majority of spreader grafts extend from a
point just cephalic to the anterior septal angle to the
osseocartilaginous junction. In most older patients with a
functional deficit at the internal nasal valve or lateral wall,
spreader grafts will be insufficient, and alar batten grafts
should be used. These cartilage grafts are placed caudal
to the existing lateral crura to support the lateral wall.
Spreader grafts can be applied via an endonasal
approach into precise submucosal tunnels16 or may be
applied directly between the upper lateral cartilages and
the nasal septum via the external rhinoplasty approach.6,15
In the external rhinoplasty approach, the upper lateral
cartilages are freed from the nasal septum after the middle
nasal vault is exposed. The rectangular spreader grafts are
then applied between the upper lateral cartilages and
septum, and sutured into place with a 5-0 PDS mattress
suture. With incorporation of the upper lateral cartilages
in the suture, the middle nasal vault width is set and
inferomedial collapse of the upper lateral cartilages is
avoided. Patients with short nasal bones are at higher risk
of collapse and will need thicker and longer spreader
grafts. Careful attention must be given to the width of the
middle nasal vault to avoid creating excessive width with
the spreader grafts. If possible, the surgeon should try to
avoid dividing the upper lateral cartilages from the
septum, in order to preserve support in the older patient.
Thus, if dorsal hump reduction is not needed, the spreader
grafts may be placed into submucosal tunnels made via a
small intranasal incision, with preservation of the attach­
ment of the upper lateral cartilages to the septum.6,16
PROFILE ALIGNMENT AND NARROWING
THE NOSE
Successful management of the bony nasal vault involves
conservative dorsal hump reduction, preservation of a
high dorsal profile, and avoidance of dorsal irregularities.
Because the nasal bones in the aging patient can be thin
and brittle, careful manipulation of the bony vault must
be exercised in order to avoid comminuted fractures or
excessive narrowing of the bony vault. Typically, con­
servative dorsal hump reduction is performed after tip
resutured with two 5-0 clear nylon mattress sutures to
reconstitute the lateral crural segments into their short­
ened configuration. The degree of tip rotation is directly
proportional to the degree of overlap (shortening) of the
lateral crura. Symmetric alignment of the lateral crura
must be achieved to avoid tip or alar margin asymmetry
(Figure 33-5).
Another technique used in tip control involving
the lower lateral cartilages is the lateral crural wedge
technique (Figure 33-6). The wedge resection of the
lower laterals is made to rotate the tip cephalad. In most
cases, adequate correction of the ptotic nasal tip requires
the use of more than one of the aforementioned tech­
niques. An effective combination for correction of the
ptotic tip is a lateral crural overlay with a caudal exten­
sion graft.
Once the ptosis of the nasal tip has been corrected,
additional tip projection can be achieved by suturing a
shield-shaped cartilage tip graft into position. A tip graft
is sculpted from septal cartilage and sutured to the caudal
margin of the medial and intermediate crura with 6-0
PDS (polydioxanone) suture (Ethicon, Somerville, NJ).
The tip graft serves to provide additional tip projection,
hide tip asymmetries, improve the shape of the lobule,
and increase tip support.14 The use of tip grafts should be
limited in older patients, because maximal tip refinement
is generally unnecessary. In addition, the leading edge
of the tip graft will be more visible beneath the thinner
skin of these patients and should be limited to patients
with thicker skin. In thin-skinned patients, the leading
edge of the tip graft should be camouflaged with crushed
cartilage or soft tissue (perichondrium, fascia, etc.) (Figure
33-7).
Other nasal tip problems, such as an underprojected
or bulbous tip, can be managed by other techniques com­
monly used in younger patients. However, care must be
taken to preserve as much of the cartilaginous framework
as possible. Emphasis should be placed on repositioning
existing cartilage structures, rather than excising them.
The weaker cartilages of the aging nose are also more
prone to deformity (e.g., buckling, bossae) under the
forces of scar contracture. When performing volume
reduction of the lateral crura in the aging patient, resec­
tion should be primarily medial, leaving at least 8 to
10 mm of intact strip.
It is imperative that the surgeon anticipates the
effects of scar contracture on the reduced cartilages. It is
shortsighted to try to attain the ideal final result at the
time of surgery, which neglects the additional refinement
that occurs with resolution of edema and healing. There­
fore, the surgeon can anticipate additional tip refinement
that will result from postoperative forces of scar contrac­
ture. Finally, aesthetic changes should be conservative
because older patients are more set in their self-image,
as well as their perception of acceptable change in nasal
contour.

CHAPTER THIRTY-THREE  Rhinoplasty in the Aging Patient
423
Figure 33-5  Patient with ptotic nasal tip. The lateral crural overlay technique was used to shorten the lateral crura and rotate the nasal tip. Preoperative
(A, C, E, G) and postoperative (B, D, F, H) views.
A
B
C
D
E
F
G
H

424
Ryan M. Greene • Dean M. Toriumi
female patients, with a slightly higher location in male
patients.
For larger dorsal hump reductions, a Rubin osteotome
can be used, while smaller dorsal humps can be managed
with a fine rasp. With larger dorsal humps, wide under­
mining of the overlying skin–soft tissue envelope is neces­
sary to accommodate for reduced skin elasticity and less
rapid shrinkage and redraping. Because the thin skin of
older patients shows even the smallest dorsal irregularity,
special care must be taken to ensure a smooth dorsum.
position is set. In patients with a deep nasofrontal angle,
small crushed-cartilage radix grafts can be placed above
a dorsal hump to create a straight profile (Figure 33-8).
In many cases, dorsal hump reduction can be avoided if
the profile can be corrected with the use of a radix graft
in combination with an increase in tip projection and
rotation. The surgeon should consider a radix graft in
patients who demonstrate a deep nasofrontal angle with
a low nasal starting point. The nasal starting point should
be located at the level of the superior palpebral fold in
Figure 33-6  Lateral crural wedge technique. A, Overly long lateral crura contribute to the ptotic nasal tip. B, The planned wedge is outlined on the
lateral crura. C, The lateral crura wedge is excised. D, Lateral crura are resutured, thus rotating the tip cephalad.
A
B
C
D

CHAPTER THIRTY-THREE  Rhinoplasty in the Aging Patient
425
Internal or external nasal valve collapse can be surgi­
cally corrected by applying bilateral alar batten grafts at
the site of maximal lateral nasal wall collapse or near the
nostril margin, respectively.15,17,18 Alar batten grafts can
be fashioned from curved cartilage of the nasal septum or
of the cavum or cymba conchae of the ear. The concave
surface of the batten graft is oriented medially to support
the collapsing segment of the nostril (external valve col­
lapse) or lateral nasal wall (internal valve collapse). To
correct external valve collapse, the grafts are typically
placed just caudal to the lateral crura and extend from
the pyriform aperture to the lateral aspect of the lateral
crura (Figure 33-9). For internal valve collapse, the grafts
are placed at the point of maximal lateral nasal wall col­
lapse, usually at the point of the supra-alar groove. As
with spreader grafts, these grafts can be applied through
either an endonasal incision or via the external rhino­
plasty approach. Once the graft is in position, there should
be an immediate improvement in support of the alar side
walls as well as diminution of alar collapse during inspira­
tion through the nose. We use splints in the nasal vestibule
to support the alar battens and to help them heal in a
lateral position.
Following profile alignment, lateral osteotomies can be
performed using the smallest osteotome possible to mini­
mize trauma and bleeding. Often, a 2- or 3-mm straight
osteotome can be used to fracture the thin bone.6,16 In
most aging patients, medial osteotomies can be avoided
as the bones are readily fractured.
EXTERNAL NASAL VALVE COLLAPSE
Older patients often present to the surgeon with com­
plaints of nasal airway obstruction located primarily at
the entrance to the nose (nostril margin). The nostrils may
collapse on moderate to deep inspiration, with inadequate
support of the lateral nasal wall and alae secondary to
weak lower lateral cartilages. In some cases, the lateral
crura are in a cephalic position and provide little support
to the alar side walls.15,17,18 This deficiency has been
described as “external nasal valve collapse” and can be
diagnosed by observing alar collapse on deep inspiration.
These patients will characteristically experience improved
nasal airflow if the alae are supported during nasal
breathing.
Figure 33-7  A, B, Tip graft camouflaged with a crushed cartilage graft behind the leading edge of the tip graft. C, Tip graft from the anterior view sutured
in position.
A
B
C

426
Ryan M. Greene • Dean M. Toriumi
A
B
C
D
E
F
Figure 33-8  Patient with dorsal hump and deep radix. Double-layer radix graft placed into narrow pocket over nasofrontal angle to augment the radix
and help create a straight dorsal profile. Preoperative (A, C, E, G) and postoperative (B, D, F, H) views.
ACUTE NASOLABIAL ANGLE
OR RETRACTED COLUMELLA
Owing to posterior positioning of the feet of the medial
crura, the older patient frequently has an acute nasolabial
angle. Correction of this deformity adds support to the
medial crural component of the tripod complex and
improves the aesthetic appearance on lateral view. For
minor augmentation, 1- to 2-mm pieces of cartilage can
be placed into a small pocket between the feet of the
medial crura. This serves to support the lower lateral
cartilages, preserve tip projection, and correct an acute
nasolabial angle. With more significant deficiency of the
medial crura, more aggressive maneuvers may be neces­
sary. A sutured-in-place columellar strut may be suffi­
cient. In most patients, however, a caudal extension graft
will be necessary to support the nasal base and open the
nasolabial angle.
The caudal extension graft is set in the midline and
sutured between the medial crura. This maneuver moves

CHAPTER THIRTY-THREE  Rhinoplasty in the Aging Patient
427
the upper lip posture during smiling. This technique may
be coupled with a tip graft to optimize the overall appear­
ance of the lower third of the nose (Figure 33-11).
Many older patients present with a hanging columella
deformity caused by loss of support or stretching of fibrous
connections between the caudal septum and medial crura.
Correction of this deformity may entail trimming of the
caudal margin of the nasal septum or medial crura. This
can also include excision of excess vestibular skin between
the caudal septum and medial crura as well. If the caudal
nasal septum is trimmed, there may be a loss of nasal tip
support. A better option to correct the hanging columella
is set-back of the medial crura on the overly long caudal
septum. After dissecting between the medial crura, the
medial crura can be sutured to the caudal septum with
5-0 clear nylon suture to set tip projection and alar–
columellar relationship.
POSTOPERATIVE CARE
Careful postoperative care is critical to achieve an optimal
result following rhinoplasty. In addition, patients should
be monitored closely during the immediate postoperative
period to ensure adequate oxygenation and hemostasis. To
avoid life-threatening complications, the cardiac and pul­
monary status of the patient should also be monitored.
Finally, if nasal packing is used, it should be removed
within 24 hours after surgery, with subsequent examina­
tion of the septal flaps to evaluate for a septal hematoma.
Columellar sutures should be removed on the seventh
postoperative day. Postoperative edema that develops in
the medial crura caudally and corrects the acute nasola­
bial angle or retracted columella.19 A straight piece of
septal cartilage is sutured to the stable caudal septum with
5-0 clear nylon mattress sutures (Figure 33-10). This
allows extension of the graft into a pocket between the
medial crura. The graft is then sutured between the medial
crura with 5-0 clear nylon sutures. During this maneuver,
care must be taken to set the proper tip projection, rota­
tion, and columellar show. A more rigid nasal tip with
less recoil results due to fixation of the medial crura to
the caudal extension graft. If this grafting technique is
planned, this rigidity and lack of recoil should be explained
to the patient prior to the procedure. In addition, this graft
may alter the length of the upper lip, which could change
Figure 33-9  Alar batten graft applied into pocket caudal to existing
lateral crura to support lateral wall.
G
H
Figure 33-8, cont’d

428
Ryan M. Greene • Dean M. Toriumi
occur in approximately 10% of cases.20 This figure may
actually be much higher if sequelae such as persistent
swelling, ecchymoses, and skin discoloration are consid­
ered. Postoperative sequelae and complications of rhino­
plasty generally fall into five major categories: infection,
trauma, necrosis, functional problems, and iatrogenic
difficulties.5
Rhinoplasty is considered by many to be the most
difficult facial plastic operation, largely due to the intri­
cate and highly variable anatomy. In addition, any surgi­
cal modification is likely to change over the lifetime of
the patient, secondary to postoperative scar contracture
and healing. For these reasons, primary rhinoplasty is
often associated with a suboptimal outcome. It has been
estimated that 8% to 15% of primary rhinoplasty
patients eventually undergo revision surgery.21 There are
a number of nasal deformities that can result from primary
the supratip region can be treated with taping of the
supratip. On rare occasions, subdermal injections (0.1 to
0.2 ml) of triamcinolone acetonide (Kenalog, 10 mg/ml;
Westwood-Squibb, Buffalo, NY) can be placed into the
supratip. Such injections should only be used in patients
with thick skin. These injections may be administered 2
weeks after surgery, with no more than one injection per
month. Dermal atrophy may result from either intrader­
mal injections or frequent injections of higher concentra­
tions of Kenalog.
COMPLICATIONS
Because rhinoplasty is considered to be an elective surgery,
complications in the postoperative period can be particu­
larly distressing. It has been estimated that complications
Figure 33-10  A, Short caudal septum. B, Caudal septal extension graft sutured in position. The graft is harvested with a standard septoplasty. C, Intra­
operative photograph showing the graft sutured in place.
A
B
C

CHAPTER THIRTY-THREE  Rhinoplasty in the Aging Patient
429
Figure 33-11  Patient with thick skin and bulbous nasal tip. In this patient, a tip graft was applied to increase tip projection. A caudal extension graft was
used to support the nasal base. Preoperative (A, C, E, G) and postoperative (B, D, F, H) views.
A
B
C
D
E
F
G
H

430
Ryan M. Greene • Dean M. Toriumi
6. Toriumi DM. Surgical correction of the aging nose. Facial
Plast Surg. 1996;12:205–214.
7. Larrabee WF. Rhinoplasty in the aging patient. In: Krause CJ,
Pastorek N, Mangat DS, eds. Aesthetic Facial Surgery.
Philadelphia: JB Lippincott; 1991:361–384.
8. Johnson CM, Anderson JR. Nose lift operation: An adjunct to
aging face surgery. Arch Otolaryngol. 1978;104:1–6.
9. Kabaker SS. An adjunctive technique to rhinoplasty of the
aging nose. Head Neck Surg. 1980;2:276–281.
10. Toriumi DM, Johnson CM. Open structure rhinoplasty:
Featured technical points and long-term follow-up. Facial
Plast Surg Clin North Am. 1993;1:1–22.
11. Anderson JR. Surgery of the nasal base. Arch Otolaryngol.
1984;110:349–358.
12. Tardy ME, Cheng E. Transdomal suture refinement of the
nasal tip. Facial Plast Surg. 1987;4:317–326.
13. Toriumi DM, Tardy ME. Cartilage suturing techniques for
correction of nasal tip deformities. Op Tech Otolaryngol Head
Neck Surg. 1995;6:265–273.
14. Johnson CM, Toriumi DM. Open Structure Rhinoplasty.
Philadelphia: WB Saunders; 1990.
15. Toriumi DM. Management of the middle nasal vault in
rhinoplasty. Opin Tech Plast Reconstr Surg. 1995;2:16-30.
16. Sheen JH. Spreader graft: A method of reconstructing the roof
of the middle nasal vault following rhinoplasty. Plast Reconstr
Surg. 1984;73:230–237.
17. Tardy ME, Garner ET. Inspiratory nasal obstruction
secondary to alar and nasal valve collapse. Op Tech
Otolaryngol Head Neck Surg. 1990;1:215–217.
18. Constantian MB. The incompetent external nasal valve:
Pathophysiology and treatment in primary and secondary
rhinoplasty. Plast Reconstr Surg. 1994;93:919–931.
19. Toriumi DM. Caudal extension graft for correction of the
retracted columella. Opin Tech Otolaryngol Head Neck Surg.
1995;6:311–318.
20. Weimert TA, Yoder MG. Antibiotics and nasal surgery.
Laryngoscope. 1980;90:667–672.
21. Byrd HS, Hobar PC. Rhinoplasty: A practical guide for
surgical planning. Plast Reconstr Surg. 1993;91:642–656.
rhinoplasty, including middle vault collapse, supra-alar
pinching, and pollybeak deformity. Every surgeon should
become familiar with these deformities.
FUTURE CONSIDERATIONS
The aging nose presents many unique challenges that
must be considered to achieve a desirable result. In addi­
tion to addressing aesthetic changes, proper preoperative
diagnosis is critical to identify all existing functional defi­
cits. In this age group, aesthetic changes should be con­
servative, with extensive discussion prior to surgery.
Because there is decreased structural support in the older
patient, excision of supportive cartilaginous and bony
structures should be minimized. Additional support should
instead be provided with structural grafts to stabilize the
nose and increase the likelihood of a favorable functional
and aesthetic outcome.
REFERENCES
1. Janeke JB, Wright WK. Studies on the support of the nasal
tip. Arch Otolaryngol. 1971;93:458–464.
2. Krmpotic-Nemanic J, Kostovic I, Rudan P, et al.
Morphological and histological changes responsible for the
droop of the nasal tip in advanced age. Acta Otolaryngol.
1971;71:278–281.
3. Patterson CN. The aging nose: Characteristics and correction.
Otolaryngol Clin North Am. 1980;13:275–288.
4. Tardy ME. Rhinoplasty in midlife. Otolaryngol Clin North
Am. 1980;13:289–303.
5. Holt GR, Garner ET, McLarey D. Postoperative sequelae and
complications of rhinoplasty. Otolaryngol Clin North Am.
1987;20:853–876.

431
C H A P T E R T H I R T Y - F O U R 
Cleft Lip Rhinoplasty
Jonathan M. Sykes
The cleft lip nasal deformity is a complex, three-
dimensional problem that challenges any rhinoplasty
surgeon. The extent of the nasal deformity is related to
the severity of the original cleft malformation and ranges
from mild to severe.1
The secondary cleft nasal deformity is related to
several factors: (1) the original deformity, (2) any interim
surgery performed on the nose, lip, and alveolus, and
(3) growth pattern of the nose and midface. The decision
to perform nasal surgery is determined by the amount of
functional breathing issues and aesthetic concerns of the
patient. This chapter describes the nasal deformities asso­
ciated with congenital clefting and outlines the timing and
techniques used to correct these deformities.
ANATOMY OF THE CLEFT
NASAL DEFORMITY
The nasal deformities associated with congenital unilat­
eral cleft lips have been well described and are consis­
tent.2,3 The extent of the typical nasal deformity is related
to the degree of deficiency of alar base support on the cleft
side. The typical characteristics of the unilateral cleft lip
nose are described in Table 34-1.4
The hallmark of the unilateral cleft lip nasal deform­
ity is a three-dimensional asymmetry of the nasal tip and
alar base4 (Figure 34-1). The columella and caudal nasal
septum always deviate to the noncleft side, secondary to
an asymmetric, unopposed pull of the orbicularis oris
muscle. The cleft alar base is asymmetric and the cleft ala
is displaced laterally, inferiorly, and posteriorly to its non­
cleft counterpart.5 The nasal tip is also asymmetric, with
the cleft side lower lateral cartilage (LLC) having a shorter
medial crus and longer lateral crus than the LLC on the
noncleft side (Figure 34-2). The weakened and malposi­
tioned cleft side LLC produces a nostril that is wide and
horizontally oriented.
The nasal septum in the unilateral cleft lip nose is
deviated caudally to the noncleft side, and is bowed pos­
teriorly to the cleft side6 (Figure 34-3). In a study of 140
nasal septums in patients with unilateral lip clefting,
Crockett and Bumstead7 found that the bony septum was
deviated into the cleft airway in 80% of these patients.
Interestingly, most patients with clefting do not complain
of nasal obstruction despite having significant deviation
and abnormality of the nasal airway. In all likelihood,
this tolerance of major abnormalities of the nasal septum
can be attributed to the fact that cleft patients become
accustomed to their nasal airway anatomy and associated
impaired nasal breathing from a very young age.
The etiology of the asymmetry of the cleft alar base
is a lack of skeletal support on the cleft side alar base.5
Deformities of the bony skeleton near the pyriform aper­
ture result in inadequate support of the alar base both
medially (at the columella) and laterally (at the alar-facial
groove). The lack of medial and lateral support causes
introversion of the nasal ala and webbing of the nasal
vestibule.8 The contour of the lateral crus of the LLC is
often concave, secondary to the lack of medial and lateral
support.9 Introversion of the cleft ala is defined as a pos­
terior and inferior malposition of the cephalic border of
the lateral crus of the LLC. The combination of the lack
of skeletal support and the malposition of the cleft LLC
causes weakness of the external nasal valve, often further
compromising nasal airflow in the cleft patient.
The middle third of the nose in the unilateral cleft lip
nasal deformity is also characterized by weakness of the
upper lateral cartilages (ULCs) and malposition of these
cartilages.6 Again, this weakness results from inadequate
skeletal support and is often manifest by concave ULC.
This weakness typically affects the internal nasal valve on
the cleft side.
BILATERAL CLEFT NASAL DEFORMITY
The bilateral cleft lip nasal deformity is also caused by a
lack of skeletal support. The bilateral cleft lip nose is
usually not grossly asymmetric. Of course, if a marked
difference exists on the two sides of the lip, there can be
gross asymmetry of the cleft nasal tip and alar base in the
bilateral cleft lip patient.
The bilateral cleft lip nose is characterized by a lack
of skin and cartilaginous support in the nasal tip.10 The
columella in bilateral deformities is typically short and
there is inadequate projection of the nasal tip. The extent

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Jonathan M. Sykes
The medial crura of the LLCs are short, and the
lateral crura are both long in bilateral clefts (Figure 34-5).
This results in underprojection of the nasal tip, and dis­
placement of the alar bases in a posterior, lateral, and
inferior location when compared to noncleft patients. If
one side of the lip is more involved than the other side,
the short columella is typically deviated toward the less
involved side, pulling the tip toward that direction. The
nostrils in bilateral cleft lip patients are more horizontal
than those in noncleft patients. The nasal septum is
usually midline, being deviated caudally to the less
involved side if asymmetry exists. The middle nasal third
exhibits poor cartilaginous support, compromising the
internal nasal valve and affecting functional nasal
breathing.
Table 34-1  Characteristics of Unilateral Cleft Lip
Nasal Deformity
Nasal tip
Medial crus of lower lateral cartilage shorter on cleft side
Lateral crus of lower lateral cartilage longer on cleft side
(total length of lower lateral cartilage is same)
Lateral crus of lower lateral cartilage may be caudally
displaced and may produce hooding of alar rim
Alar dome on cleft side is flat and displaced laterally
Columella
Short on cleft side
Base directed to noncleft side (secondary to contraction
of orbicularis oris muscle)
Nostril
Horizontal orientation on cleft side
Alar base
Displaced laterally, posteriorly, and inferiorly
Nasal floor
Usually absent
Nasal septum
Caudal deflection to the noncleft side and posterior
deviation to the cleft side
Figure 34-1  Intraoperative base view of a patient with a right complete
cleft lip and cleft palate with significant cleft nasal deformity. This view shows
the obvious alar base asymmetry and the caudal septum deviated to the
noncleft side.
Figure 34-2  A, B, Schematic diagram and intraoperative photograph of a left complete cleft nasal deformity. On the cleft side, the medial crus is shorter
and the lateral crus longer than the noncleft side counterpart.
B
A
of columellar shortening is related to the size, shape, and
position of the prolabium and to the severity of the cleft
deformity (Figure 34-4). An abnormal junction between
the columella and the central aspect of the upper lip is
usually present. Characteristics of the bilateral cleft lip
nasal deformity are listed in Table 34-2.

CHAPTER THIRTY-FOUR  Cleft Lip Rhinoplasty
433
Figure 34-3  A, Schematic diagram of a left cleft nasal deformity showing the architecture of the caudal septum deviated to the noncleft side. B, Intra­
operative photograph of this complete cleft lip and nasal deformity.
B
A
Figure 34-4  A, Basal view of a patient with incomplete bilateral cleft lip with good projection. B, Patient with severe bilateral complete lip and palate
deformity showing obvious lack of columellar length and lack of normal tip projection.
A
B
TIMING OF CLEFT NASAL REPAIR
Cleft nasal reconstruction can be divided into primary and
secondary repairs.1 Primary rhinoplasty refers to nasal
surgery performed at the time of the initial cleft lip repair.
Secondary rhinoplasty refers to any cleft nasal surgery
performed after the initial cleft lip repair. Secondary cleft
rhinoplasty may be further subdivided into intermediate
repairs, usually performed during childhood, and defini­
tive repairs, occurring at the time of full nasal growth.
The decision to perform surgery on patients with cleft
deformities is the product of many factors. These include
the fact that the child with a nasal malformation is exposed
to ridicule during childhood. This philosophy is counter­
pointed by the surgeon’s knowledge that nasal and mid­
facial growth is not completed until the mid-to-late teen
years. Early surgical intervention is thought to interfere
with subsequent nasal growth. The philosophy that early
nasal surgery affects subsequent nasal growth is sup­
ported by the experimental work of Sarnat and Wexler11
and Bernstein,12 who demonstrated nasal growth inhibi­
tion in animals after aggressive resection of the nasal
septum and overlying mucoperichondrium.
Although traditional philosophy avoids aggressive
early nasal surgery fearing nasal growth inhibition, there
is a growing trend toward primary cleft nasal repair.5,13 In
many centers, rhinoplasty at the time of initial cleft repair
is the accepted surgical treatment. This philosophy recog­
nizes that maximizing nasal tip projection and nasal and
alar base symmetry during lip repair allows the nose to
grow in a symmetric fashion. For this reason, most con­
temporary cleft surgeons perform primary nasal repair on
the tip and alar base.

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Jonathan M. Sykes
years, and definitive rhinoplasty after full facial growth
has been reached. Nonsurgical repositioning of alveolar
segments serves to lessen tension across the lip wound,
improve nasal tip symmetry in wide unilateral clefts, and
elongate the columella and expand the nasal soft tissues
in bilateral clefts.14 There have been many reports of
presurgical devices designed to decrease the cleft gap and
minimize the eventual lip and nasal deformity.15,16 Pre­
surgical nasoalveolar molding (PNAM) uses an intraoral
alveolar molding device with nasal molding prongs17
(Figure 34-6). Successful use of any presurgical ortho­
pedic devices requires a team approach—a dedicated
orthodontist, a flexible and patient surgeon, and an
involved, responsive, cooperative, and compliant family
Figure 34-5  A, B, Schematic diagram and photograph of a patient with bilateral complete cleft lip deformity. The medial crus of each side of the nose
is shorter and the lateral crus longer than in unaffected alar cartilage.
B
A
Figure 34-6  Photograph of a presurgical nasoalveolar molding device
(PNAM).
Table 34-2  Characteristics of Bilateral Cleft Lip
Nasal Deformity
Nasal Tip
Medial crura of LLC short bilaterally
Lateral crura of LLC long bilaterally
Lateral crura displaced caudally
Alar domes poorly defined and widely separated,
producing an amorphous tip
Columella
Short
Base is wide
Nostril
Horizontal orientation bilaterally
Alar base
Displaced laterally, posteriorly, and inferiorly
Nasal floor
Usually absent bilaterally
Nasal septum
In a complete bilateral cleft lip and palate, the septum is
midline; however, if cleft on one side is incomplete,
the septum deviates toward the less affected side.
PRESURGICAL MANAGEMENT OF THE
CLEFT NASAL DEFORMITY
The traditional approach to management includes a single
stage lip repair at 3 months of age, palatoplasty at approx­
imately 1 year of age, alveolar bone grafting at 9 to 11

CHAPTER THIRTY-FOUR  Cleft Lip Rhinoplasty
435
The other component of primary rhinoplasty involves
nasal tip plasty. The cutaneous attachments of the LLCs
are separated. This is accomplished by creating medial
and lateral tunnels using the incisions of the standard
rotation–advancements lip repair19 (Figures 34-9 and
34-10). Dissection on the undersurface of the LLC
(between the cartilage and vestibular skin) is not per­
formed. The medial and lateral tunnels are then
connected.
After the lip is sutured closed and the alar base is
repositioned, the LLC is molded into its new shape. This
can be accomplished with interdomal sutures or with the
application of nasal bolsters. The purpose of these maneu­
vers is to recreate the dome of the LLC into a more medial,
projected position. Essentially, a “steal” from lateral crus
to medial crus is performed to increase nasal tip projection
and improve tip symmetry.20 Complete release of the skin
overlying the LLC prevents tethering and irregularities of
the nasal tip. If a tip bolster is used, the suture is passed
through a subcutaneous tunnel and tension is placed on
the LLC, creating blanching of the nasal tip skin (Figure
34-11). Bolsters are typically removed at seven to ten
days. Lastly, silastic nasal conformers are placed into the
nostrils to help shape the LLC and reshape the nostril
configuration (Figure 34-12). The conformers are left in
place for 4 to 6 weeks, if tolerated by both the patient and
family.
SECONDARY CLEFT NASAL
RECONSTRUCTION
The cleft nasal deformity that is present during teenage
years is a product of many factors including (1) the extent
of the original nasal deformity, (2) the patient’s growth,
and (3) any intervening surgery and related scarring.
Figure 34-8  A, B, Schematic diagram and intraoperative photograph
showing internal alotomy separating the cleft side nasal base from pyriform
aperture.
Figure 34-7  Patient with complete unilateral cleft lip and palate with the
PNAM device in place.
(Figure 34-7). If properly performed, PNAM can provide
soft tissue expansion and mold the nasal infrastructure,
thereby decreasing the nasal deformity.
PRIMARY CLEFT RHINOPLASTY
The goals of primary rhinoplasty are to maximize sym­
metry of the nasal tip and alar base. In that the base of
the nose in the unilateral deformity involves gross asym­
metries of both the skeleton and soft tissues, the soft tissue
attachments of the alar base must be completely freed
from the skeletal base (pyriform aperture).5 This allows
repositioning of the nasal and alar base in a more sym­
metric fashion.13,18
Dissection of the cleft alar base from the pyriform
aperture involves an internal alotomy (Figure 34-8). Sep­
aration of the soft tissue attachments begins with an inci­
sion at the anterior portion of the inferior turbinate on the
cleft side. After the cleft alar base is entirely separated
from its skeletal attachments, the floor of the nose is
approximated and the alar base is medialized, thereby
creating improved three-dimensional symmetry.

Figure 34-10  A, B, Schematic diagram and intraoperative photograph showing the medial dissection separating the medial crus of the lower lateral
cartilage from the overlying skin.
A
B
Figure 34-11  A, Intraoperative photograph of a patient with left complete cleft lip and palate prior to lip repair and nasal tip rhinoplasty. B, Intraoperative
photograph after the completion of surgery with repair of the cleft lip and nasal tip rhinoplasty. Nasal conformers are in place as well as tip bolsters.
A
B
Figure 34-9  A, B, Schematic diagram and intraoperative photograph of the lateral nasal dissection separating the lateral crus of the lower lateral cartilage
from the overlying skin.
B
A

CHAPTER THIRTY-FOUR  Cleft Lip Rhinoplasty
437
approach is used by some surgeons, the open or external
approach provides additional exposure to diagnose
deformities and perform various techniques to correct
complex nasal deformities.
The incisions used to open the nose vary, but a com­
bination of bilateral marginal incisions with an inverted-V
mid-columellar incision is typically used.22 However, if
additional skin is needed in the columella, modification of
the typical external columellar incision can be used. In the
unilateral cleft nasal deformity, an asymmetric V-to-Y on
the cleft side can be designed to increase columellar soft
tissue (and length). If significant columellar deficiency is
present in the bilateral cleft nose, a midline V-to-Y upper
lip incision can be used, recruiting skin from the upper
lip into the columella. An alternative incision choice is to
use upper lip forked flaps23 (Figure 34-13). These flaps
have the advantage of narrowing the central segment
while lengthening the columella. The sliding chondrocu­
taneous flap, first described by Vassarionov and modified
by Wang, has been designed to advance both skin and
cartilage into the columella and nasal tip while revising
the cleft lip scar.21
SEPTAL RECONSTRUCTION
The cleft lip nose is usually associated with significant
septal deformity. In the unilateral cleft nose, the pyriform
aperture is very asymmetric and usually has a bony defi­
ciency on the cleft side. This bony asymmetry, coupled
with an unopposed pull of the orbicularis oris muscle
results in a caudal nasal septum significantly deviated to
the noncleft side. In the bilateral deformity, bony defi­
ciency on both sides of the pyriform aperture causes a
wide and poorly supported caudal nasal septum. This
results in a wide and weakly supported caudal septal
deformity.
Figure 34-12  Close-up view of Silastic nasal conformers used at the
conclusion of cleft repair.
Figure 34-13  A, Bilateral forked flaps used to narrow philtral width in a bilateral cleft lip in lengthening the columella. B, Postoperative photograph of
the same patient with fork flaps sutured into position lengthening the columella.
A
B
Therefore, the facial plastic surgeon must understand the
anatomy of the standard nasal deformity associated with
lip clefting, and be prepared for individual variations that
can occur with intervening surgeries.
The timing of definitive cleft septorhinoplasty should
account for several factors. These include midface and
nasal growth, specific psychological patient desires, and
any concomitant associated functional issues.21 In general,
nasal reconstruction in cleft patients is not performed
prior to full nasal growth, which is approximately 16 years
of age in females and 18 years of age in males. If signifi­
cant dentofacial deformity exists, orthognathic surgery is
usually performed prior to undertaking any nasal surgery.
INCISIONS
The approach used to perform cleft nasal reconstruction
varies with the deformity. Although the endonasal

438
Jonathan M. Sykes
asymmetric position. The alar base width on the cleft side
is often narrower than the noncleft side and malpositioned
in either a superior or an inferior position versus the unaf­
fected alar base.
An additional deformity that often presents with the
secondary cleft defect is a lack of normal configuration of
the affected nasal sill. During initial lip closure, the floor
of the nose is reconstructed. A very small deformity (mal­
position) of the nasal sill (0.5 to 1 mm) at the time of lip
closure usually creates a very noticeable deformity in the
adult nose. At the time of definitive nasal reconstruction,
the nasal sill and anterior floor should be closed in as
symmetric a position to the noncleft side as possible. This
often requires incision of the nasal sill and layered repair
of the nasal floor. The cleft alar base is then repositioned
in a symmetric fashion.
LOWER NASAL THIRD
After stabilizing the caudal nasal septum and providing
three-dimensional alar base symmetry, the external rhino­
plasty is performed. The lower third of the nose requires
support and symmetry. Support and symmetry can be
established by stabilizing the nasal tip complex to the
nasal septum. This can be accomplished by (1) a tongue-
in-groove technique, (2) extended spreader grafts, (3) a
septal extension graft, or (4) a columellar strut to create
three-dimensional symmetry.
After stabilizing the medial crura to the nasal septum,
vertical division of the LLC can be performed lateral
to the nasal dome. This allows an increase in nasal tip
Nasal reconstruction begins with septal reconstruc­
tion and repositioning. If the caudal septum is dislocated,
it must be freed from its bony and soft tissue attachments,
and repositioned into the midline6 (Figure 34-14). This
often requires resection of a small amount of inferior
cartilage from the maxilla and suture repositioning of the
caudal septum. The caudal septum is usually sutured to
the nasal spine with 4-0 monofilament long-acting absorb­
able suture. If the septum requires further stabilization or
straightening, a caudal septal extension graft can be used.
This provides support to the base of the nose, and can be
a pillar upon which to suture and stabilize the nasal tip.
The posterior septal deformity should also be cor­
rected to maximize the nasal airway and to obtain carti­
lage grafts. In the unilateral cleft nose, the posterior
septum is usually deflected significantly to the cleft side.
The septum is usually approached through an open sep­
toplasty, by separating the LLCs. This allows correction
of both the caudal and posterior deformities and gives
access to obtain cartilage for graft material.
TREATMENT OF THE ASYMMETRIC
ALAR BASE
The alar base on the cleft side is usually malpositioned.
In the original congenital malformation, the position of
the affected alar base is posterior, lateral, and inferior to
the unaffected side. Once the lip is repaired, however, the
alar base is repositioned. This new position may be sym­
metric with the noncleft side, but usually is in a new
Figure 34-14  A, Deviated nasal septum in a patient with right cleft lip prior to reconstruction and repositioning. B, Intraoperative photograph of the
patient after reconstruction of the nasal septum and suture repositioning to the nasal spine.
A
B

CHAPTER THIRTY-FOUR  Cleft Lip Rhinoplasty
439
Various techniques exists to treat the LLC concavity.
These include suture techniques, underlay alar strut
grafts, onlay grafts, and autocartilage flaps.27 Addition­
ally, the lateral crus can be dissected from the underlying
vestibular skin, removed, flipped, and resutured in a
convex fashion (Figure 34-16). Alar strut grafts are placed
between the existing concave-outward LLC and the
underlying vestibular skin (Figure 34-17). This graft
strengthens the lateral crus of the LLC and flattens the
concave LLC.
Suture techniques such as horizontal mattress sutures
also strengthen and flatten the lateral crus of the LLC.
Last, the cephalic margin of the LLC can be made into
an advancement flap. This cartilage flap can be advanced
to support the remaining LLC. Each of these techniques
Figure 34-15  Intraoperative photograph of an open septorhinoplasty
with middle third spreader grafts sutured into position.
Figure 34-16  Schematic diagram of a concave lateral crus of lower lateral cartilage, flipping of this cartilage, and resuturing.
projection. Reconstitution of the divided nasal tip carti­
lages is then performed with a 5-0 monofilament long-
acting absorbable suture. Camouflage of nasal tip
asymmetries is then accomplished with a shield-style
nasal tip graft.24 The tip graft is sutured into position
with 6-0 monofilament permanent suture. In cleft nasal
deformities, tip grafts provide support, an increase in
nasal projection, and camouflage for tip asymmetries.
Vertical dome division both narrows the nasal tip and
provides elevation of the cleft side LLC. If there is residual
alar hooding of the cleft side LLC after completing divi­
sion of the LLC, the LLC can be sutured superiorly to
elevate the cleft side alar rim. The LLC may be sutured
to the ipsilateral ULC for superior repositioning.
MIDDLE THIRD OF THE CLEFT NOSE
The middle third of the nose in cleft patients often is
weak, resulting in both aesthetic and functional issues.
Concavity of the cleft side ULC often results in internal
nasal valve dysfunction.25 This weakness can be treated
with onlay grafts, spreader grafts, autogenous spreader
flaps, or flaring sutures (Figure 34-15). Unilateral, or
asymmetric spreader grafts, placed between the ULC and
the nasal septum, often improve nasal function and help
to straighten the deviated nose.
TREATMENT OF THE ALAR RIM (LATERAL
CRUS OF THE LLC)
The cleft side LLC is poorly supported with lack of normal
skeletal support medially and laterally. This lack of
support usually causes malposition of the cleft alar rim.
The cleft side lateral crus of the LLC is concave and
results in an introverted alar contour.26

440
Jonathan M. Sykes
Figure 34-18  A, B, Preoperative and postoperative
frontal photograph of a patient with complete left cleft lip
and palate status post open septorhinoplasty. C, D, Preop­
erative and postoperative lateral photographs of the same
patient who underwent open septorhinoplasty with lateral
crural repositioning.
A
B
C
D
Figure 34-17  Intraoperative photograph of an open rhinoplasty with an
alar strut graft sutured to the under surface of the lateral crus of the lower
lateral cartilage.
supports the lateral crus of the LLC and strengthens the
external nasal valve (Figures 34-18 and 34-19).
TREATMENT OF DENTOFACIAL
DEFORMITIES
The incidence of dentofacial deformities in cleft patients
is well known. The skeletal deformity includes maxillary
hypoplasia. This affects maxillary growth in both antero­
posterior and transverse dimensions.28 Ross has shown
that the development of maxillary hypoplasia is related to
the type and timing of the palatoplasty procedure.29 Max­
illary hypoplasia results can result in class III malocclu­
sion and significant midfacial skeletal deficiency (Figure
34-20).

CHAPTER THIRTY-FOUR  Cleft Lip Rhinoplasty
441
Le Fort midface osteotomy of the maxilla, is performed
(Figures 34-21 and 34-22).
SUMMARY
Reconstruction of cleft lip nose is extremely challenging.
The congenital malformation involves all tissue layers,
from the skeletal platform to the external nasal skin.
Primary rhinoplasty is useful to maximize nasal symmetry
and minimize psychological ridicule for the child.
This also allows the nose to grow in a symmetric
fashion. Definitive rhinoplasty is performed using an
The dentofacial deformities associated with the treat­
ment of cleft malformations result in poor support of the
nasal base. To reconstruct the face of many cleft patients
in an optimal fashion, both orthognathic surgery and
rhinoplasty are required. If the dentofacial deformity is
significant enough to necessitate orthognathic surgery, the
skeletal surgery is usually completed prior to undertaking
rhinoplasty.30 Although some surgeons advocate simulta­
neous orthognathic surgery and rhinoplasty, staged
surgery provides the most precise facial reconstruction
and allows safe handling of the endotracheal tube. In
severe Class III malocclusion with associated skeletal
deformity, distraction osteogenesis, rather than traditional
Figure 34-19  A, B, Preoperative and postoperative
frontal photographs of a patient with bilateral cleft lip and
palate after two procedures. The first procedure was a Le
Fort I maxillary osteotomy with advancement and the
second procedure, open septorhinoplasty with an autol­
ogous costal cartilage graft. C, D, Preoperative and post­
operative photographs of the same patient before Le Fort
I maxillary osteotomy and open septorhinoplasty after
both of these procedures.
A
B
C
D

442
Jonathan M. Sykes
Figure 34-20  A–C, Frontal, left lateral, and basal view of a patient with
left complete cleft lip and palate and significant nasal deformity. The patient
has a significant skeletal disproportion with Class III malocclusion. On intraoral
examination, the patient has 15 mm of underjet.
A
B
C
Figure 34-21  A, B, Frontal and close-up lateral photographs of the patient after a Le Fort I maxillary osteotomy and placement of a distraction osteo­
genesis device.
A
B

CHAPTER THIRTY-FOUR  Cleft Lip Rhinoplasty
443
A
B
C
D
Figure 34-22  A–H, Preoperative and postoperative right and left lateral, right oblique, and basal views of the patient after distraction osteogenesis with
and 16-mm maxillary advancement and open septorhinoplasty with autologous rib cartilage grafts.

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Jonathan M. Sykes
5. Sykes JM, Senders CW. Surgical treatment of the unilateral
cleft nasal deformity at the time of lip repair. Fac Plast Surg
Clin North Am. 1995;3:69–77.
6. Jablon JH, Sykes JM. Nasal airway problems in the cleft lip
population. Fac Plast Surg Clin North AM. 1999;7:391–403.
7. Crockett D, Bumstead R. Nasal airway, otologic and
audiologic problems associated with cleft lip and palate. In:
Bardack J, Morris HL, editors. Multidisciplinary management
of cleft lip and palate. Philadelphia: WB Saunders; 1990.
8. Stenstrom SJ. The alar cartilage and the nasal deformity in
unilateral cleft lip. Plast Reconstr Surg. 1966;38:223–231.
9. Avery JK. The unilateral deformity. In: Millard RD, editor.
Cleft craft: the evolution of its surgery. Boston: Little, Brown;
1975.
10. Cronin TD. The bilateral cleft lip with bilateral cleft of the
primary palate. In: Converse JM, editor. Reconstructive plastic
surgery. Philadelphia, WB Saunders; 1964.
11. Sarnat BG, Wexler MR. Growth of the face and jaws after
resection of the septal cartilage in the rabbit. Am J Anat.
1996;118:755–767.
external rhinoplasty approach with structural grafting.
Structural grafting is used to maximize function, struc­
ture, support and symmetry.
REFERENCES
1. Sykes JM, Senders CW. Surgery of the cleft lip and nasal
deformity. Oper Tech Otolaryngol Head Neck Surg.
1990;1:219–224.
2. Blair VP. Nasal deformities associated with congenital cleft of
the lip. JAMA. 1925;84:185–187.
3. Huffman WC, Lierle DM. Studies on the pathologic anatomy
of the unilateral hare-lip nose. Plast Reconstr Surg.
1949;4:225–234.
4. Sykes JM, Senders CW. Pathologic anatomy of cleft lip, palate
and nasal deformity. In: Meyers AD, editor. Biological basis of
facial plastic surgery. New York: Thieme; 1993.
E
F
G
H
Figure 34-22, cont’d

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445
20. Ness JA, Sykes JM. Basics of Millard rotation-advancement
technique for repair of the unilateral cleft lip deformity. Fac
Plast Surg. 1993;9:167–176.
21. Wang TD. Secondary rhinoplasty in unilateral cleft nasal
deformity. Fac Plast Surg. 2007;23:123–127.
22. Sykes JM, Senders CW, Wang TD, Cook TA. Use of the open
approach for repair of secondary cleft lip-nasal deformities.
Fac Plast Surg. 1993;1:111–126.
23. Millard DR Jr. Columella lengthening by a forked flap. Plast
Reconstr Surg. 1958;22:545.
24. Toriumi DM, Johnson CM. Open structure rhinoplasty. Fac
Plast Surg Clin North Am. 1993;1:1–22.
25. Park SS. Treatment of the internal nasal valve. Fac Plast
Surg. 1999;7:333–345.
26. Park BY, Lew DH, Lee YH. A comparative study of the
lateral crus of alar cartilage in unilateral cleft lip nasal
deformity. Plast Reconstr Surg. 1998;101:905–919.
27. Chand MS, Toriumi DM. Treatment of the external nasal
valve. Fac Plast Surg. 1999;7:347–355.
28. Sykes JM, Rotas N. Orthognathic surgery in the cleft lip and
palate patient. In: Larrabee WF, Thomas JR, editors. Facial
plastic surgery clinics of North America. Philadelphia: WB
Saunders; 1996.
29. Ross RB. Treatment variables affecting facial growth in
complete unilateral cleft lip and palate. Part 7. An overview
of treatment and facial growth. Cleft Palate J. 1987;24:71.
30. Herber CS, Lehman JA Jr. Orthognathic surgery in the cleft
lip and palate patient. Clin Plast Surg. 1993;20(4):755-768.
12. Bernstein L. Early submucous resection of nasal septal
cartilage: a pilot study in canine pups. Arch Otolaryngol.
1973;97:272–285.
13. McComb HK, Coghlan BA. Primary repair of the unilateral
cleft lip nose: completion of a longitudinal study. Cleft Palate
Craniofac J. 1996;33:23–31.
14. Grayson BH, Santiago PE, Beecht LE, Cutting CB.
Presurgical nasoalveolar molding in infants with cleft lip and
palate. Cleft Palate Craniofac J. 1999;36:486–498.
15. Liou EJW, Subramanian M, Chen PKT, Huang CS. The
progressive changes of nasal symmetry and growth after
nasoalveolar molding: a three-year follow-up study. Plast
Reconstr Surg. 2004;114:858–864.
16. Maull D, Grayson B, Cutting C, et al. Long-term effects of
nasoalveolar molding on three-dimensional nasal shape in
unilateral clefts. Cleft Palate Craniofac J. 1999;36:391–
397.
17. Grayson B, Cutting C. Presurgical nasoalveolar orthopedic
molding in primary correction of the nose, lip, and alveolus of
infants born with unilateral and bilateral clefts. Cleft Palate
Craniofac J. 2001;35:193–198.
18. Mulliken JB, Martinez-Perez D. The principle of rotation
advancement for the repair of unilateral complete cleft lip
and nasal deformity: technical variations and analysis of
results. Plast Reconstr Surg. 1999;104:1247–1249.
19. TerKonda RP, Sykes JM. Controversies and advances in
unilateral cleft lip repair. Curr Opin Otolaryngol Head Neck
Surg. 1997;5:223–227.

447
C H A P T E R T H I R T Y - F I V E 
Nasal Airway Obstruction
Kimberly Lee • Babak Azizzadeh • Babak Larian
The nasal airway is of paramount importance to the
astute rhinoplasty surgeon. Often, great aesthetic results
are combined with poor functional outcomes, leading to
dissatisfaction and the need for further intervention.1,2
This problem is curtailed by careful consideration and
analysis of the function of the nose as well as its aes­
thetic value. Even well-experienced surgeons face this
problem in a significant number of patients. In the hands
of the less-experienced surgeon eager to only please the
patient’s aesthetic needs, this may be a more common
issue. This is complicated by the fact that minor intra­
nasal pathologic conditions that were not clinically sig­
nificant preoperatively may become distressing and a
focal point of complaints in the postoperative setting. As
such, surgeons must diagnose both cosmetic and func­
tional issues well in advance so as to ensure a favorable
outcome.
NASAL ANATOMY AND FUNCTION
One may assume the anatomy of this area to be simple,
but there are some nuances that explain our less than
satisfactory outcomes or complications.
SEPTUM
The septum is composed of several components, both
bony and cartilaginous. Maxillary, palatine, vomerine,
and ethmoid bones contribute to the bony septum.
However, the anterior nasal septum is cartilaginous, which
allows for the most protruding portion of the nose to be
flexible. The cartilaginous septum is attached superiorly
to the perpendicular plate of the ethmoid, the bony groove
on the undersurface of the nasal bones, and the upper
lateral cartilages; these structures are held together by the
continuity of the perichondrium and periosteum. Anteri­
orly fibrous attachments to the medial crura of the lower
lateral cartilages determine the integrity of the tip. Infe­
riorly, the cartilaginous and bony septum lie in the bony
groove of the maxillary crest via dense fibrous connective
tissue. Embryologically, the cartilaginous septum develops
from the perpendicular plate of the ethmoid, yet it remains
nonossified. As such, the overlying perichondrium is
contiguous with the periosteum of the perpendicular plate.
While the vomer has a different embryologic origin and
maintains its own periosteum, it is separated at the transi­
tion point with the septum of ethmoid bone origin. This
seemingly innocuous fact is an important one in that
elevation of the mucoperichondrium at the juncture of the
perpendicular plate of ethmoid is rarely met with resis­
tance or perforation. The majority of perforations occur
at the junction of the cartilage to the vomer due to the
noncontinuous covering.
The flow of air in the nasal passage follows the basic
tenets of physics and Ohm’s law, whereby gases move
when there is a pressure gradient, and this flow can be
hampered by friction. In laminar flow in a passageway,
the fluid in the center has the greatest motion while that
which is in contact with the sidewalls is hampered and
moves slowly. Turbulent flow results from random, non­
linear motion. In the nasal cavity, laminar flow is of utmost
importance because it allows for appropriate humidifica­
tion and proper mucociliary flow of mucus, while turbu­
lence creates more friction and impairs both functions.
The septum helps ensure a laminar flow pattern.
TURBINATES
The three paired turbinates are located on the lateral nasal
wall. The superior and middle turbinates arise from the
ethmoid bone, whereas the inferior turbinates are made
of independent bony structure. Covered by both respira­
tory and olfactory epithelium, the superior turbinate is
located high in the nasal vault and usually arises from the
cribriform plate of the ethmoid bone. The middle tur­
binate has a less consistent site of origin and could arise
from the cribriform plate, the lamina papyracea, or the
uncinate process in some cases.
The inferior turbinate bone arises on the inferior
portion of the lateral nasal walls. The bone itself is pen­
etrated heavily by vascular channels, which supply the
overlying respiratory epithelium. The lacrimal duct drains
into the nose just lateral to the inferior-anterior portion
of the inferior turbinate.
The anterior tip of the turbinates not only directs the
air along the passageway to the nasopharynx in a laminar
fashion but also acts to deflect some of the air upward

448
Kimberly Lee • Babak Azizzadeh • Babak Larian
Inspire). If complete nasal deviation is noted, coexistent
pathology needs to be ruled out with computed
tomography.
Once adequate examination and workup have been
completed and the appropriate diagnosis has been made,
attention is then directed to treating the underlying etiol­
ogy for the patient’s nasal airway obstruction. Allergic
rhinitis, chronic rhinosinusitis, and turbinate hypertrophy
must be initially treated medically. Assuming that all
other diagnoses have been ruled out and the patient is
diagnosed with only septal deviation as the cause of the
nasal aiway obstruction, the decision to perform a septo­
plasty is entertained. However, the contribution of the
nasal turbinates should not be overlooked.
Prior to performing surgery, a thorough history needs
to be taken, specifically addressing any coagulopathies,
medication allergies, or coexisting medical conditions that
can be medically optimized preoperatively. Additionally,
patients with nasal polyps may be administered preopera­
tive steroids to facilitate intraoperative bleeding and any
associated asthma.
SURGICAL TECHNIQUE
The facial skin is prepared with povidine-iodine or chlor­
hexidine solution and draped to expose the face. Cotton
pledgets soaked with neosynephrine and cocaine are
inserted into the nares bilaterally to help achieve vasocon­
striction. Using a small syringe and 27-gauge needle, 1%
lidocaine with 1 : 100,000 epinephrine is injected to locally
anesthetize the region. Local anesthesia is infiltrated
externally if the patient is undergoing simultaneous rhi­
noplasty or internal/external valve reconstruction. The
anesthetic is injected into the intercartilaginous region to
block the external nasal nerve bilaterally, the edge of the
piriform aperture to get the branches of the infrorbital
nerve to the nasal ala, and the junction of the caudal
septum and columella. Intranasally, it is injected between
the perichondrium and the septal cartilage and between
the mucoperiosteum and the bone to help achieve anesthe­
sia, hydrodissect the surgical plane, and increase the soft
tissue bulk to avoid inadvertent perforation of the muco­
perichondrial flap. The inferior turbinates are also anes­
thetized bilaterally as needed. In the event of a severely
deviated septum that precludes injection of the local anes­
thetic, a long nasal speculum is placed into the narrowed
nasal cavity and deflected toward the contralateral side to
allow for improved exposure.
In performing a septoplasty, there are two incisions
that are typically used—hemitransfixion or Killian—and
a decision as to which one to use is made by the surgeon
(Figure 35-1). This decision is based on several factors.
The hemitransfixion incision allows adequate exposure to
address the septal deviation in both anterior and posterior
regions. Furthermore, it allows placement of endonasal
towards the olfactory mucosa, thus facilitating olfaction.
The nasal cycle, a periodic alternating engorgement and
enlargement of the inferior turbinates on one side accom­
panied by contralateral turbinate shrinkage, occurs in
about 85% of people. The cycle takes anywhere between
3 to 4 hours to complete, and the total airflow throughout
the cycle remain constant. Often, in the postoperative
setting, patients complain of alternating nasal obstruc­
tion, which is in effect a heightened awareness of the cycle
due to surgery and resultant hypersensitivity.
NASAL AIRWAY OBSTRUCTION
There are several components that contribute to nasal
airway obstruction. In the pediatric population, congeni­
tal anatomic contributions are significant, with adenoid
hypertrophy and choanal atresia being the most common.
For the adult population, in addition to anatomic consid­
erations, such as septal deviation, septal spurs, and tur­
binate hypertrophy, the differential diagnoses of tumors
and polyps need to be entertained and excluded. A list of
nasal airway obstruction components is given in Table
35-1.
PREOPERATIVE ASSESSMENT
Using a headlight, nasal speculum, and an optional endo­
scope, the surgeon needs to perform diagnostic endoscopy
of the nasal vault and nasopharynx. This allows full eval­
uation of these regions and exclusion of any nonanatomic
causes of nasal airway obstruction. Specifically, it allows
diagnosis of any visible polyps or malignancies. If puru­
lent discharge or middle meatus obstruction is identified,
sinusitis is likely and appropriate treatment with antibiot­
ics is indicated. If an allergic component is considered,
nasal steroid sprays, nonsedating antihistamines, and
decongestants are first-line treatment. Allergy testing and
desensitization should also be considered. Rhinitis medi­
camentosum must be ruled out and treated in individuals
who chronically use oxymetazoline (Afrin), phenylephrine
(Neo-Synephrine), and/or xylometazoline (Otrivin or
Table 35-1  Components of Nasal Airway Obstruction
Septum
Polyps
Maxillary crest
Tumors
Turbinates
Narrowed pyriform aperture
External nasal valve
Stenosis
Internal nasal valve
Choanal atresia
Allergic rhinitis
Adenoid hypertrophy

CHAPTER THIRTY-FIVE  Nasal Airway Obstruction
449
Accurate identification of the septal cartilage is the
most critical aspect of the septoplasty because it will allow
for adequate exposure of the septum and for hemostasis
during the procedure. Using a Cottle elevator, the overly­
ing mucoperichondrium is elevated and dissected off of
the underlying cartilage. Adequate exposure of the septal
cartilage will yield a bluish-grayish color and a gritty
texture. Only after accurate identification can the remain­
ing mucoperichondrial layer be elevated posteriorly to the
vomer under direct visualization with adequate light and
suction.
A septal floor can be encountered inferiorly near the
nasal floor during elevation of the mucoperichondrial
flaps, and extreme caution is indicated to avoid perfora­
tion. The mucosa is usually adhered to the subluxed car­
tilage, and careful elevation of the mucosa needs to be
performed using a Freer or Cottle elevator. The spur
should not be removed until there is adequate exposure
and detachment from the overlying mucosa (see Figure
35-1A-C).
After adequate elevation of the mucoperichondrium,
the septal cartilaginous incision can be made with a
D-knife, Cottle elevator, or No. 15 blade scalpel, leaving
at least a 1-cm caudal and dorsal strut of cartilage to
prevent postoperative loss of tip support. This incision
needs to be performed carefully to prevent cutting through
the contralateral mucoperichondrium, which would lead
to a through-and-through perforation. Once the septal
cartilage is incised, the contralateral mucoperichondrium
is elevated in a similar fashion in the plane between the
cartilage and mucoperichondrium. Upon satisfactory
completion of bilateral mucoperichondrial elevation, a
nasal speculum is placed to straddle the septal cartilage.
Meticulous analysis of the nasal septum is critical.
Only when all of the components contributing to the nasal
airway obstruction are addressed will the patient have
satisfactory results and clinical relief of the nasal airway
obstruction. Several options exist if the mid-portion of the
septal cartilage is found to be the culprit of the deviation.
The septum can be removed (submucous resection) using
a Ballenger swivel knife or D-knife, straightened manually
by morselizing or scoring, or removed and replaced
between the septal mucosa flaps (Figure 35-2). If a sub­
mucous resection is undertaken, a 1- to 2-cm L-strut of
cartilage must be preserved in both the dorsal and caudal
aspect of the septum to avoid saddle nose deformity as
well as loss of tip support. Deviated septal cartilage outside
the support structure of the L-strut can be resected in
small pieces, preserving as much cartilage in place as
possible.
Cartilage-sparing techniques are often preferred to
submucous resection, although in many instances, the
cartilage will be removed for use during the rhinoplasty
portion of the procedure. Although moderately deformed
septal cartilage cannot be repositioned without removal of
some cartilage in most circumstances, there are some
spreader grafts by having access to the entire length of the
upper lateral cartilage. The hemitransfixion incision is
placed in the most caudal aspect of the cartilaginous
septum.
The Killian incision is placed approximately 1 cm
posterior to the location of the hemitransfixion incision.
This is often the preferred incision if the septal deviation
that needs to be addressed is predominantly posterior as
it inherently leaves adequate caudal support. Surgeon
preference will play a major role in deciding which inci­
sion is performed. In either technique, the surgeon should
leave 1 to 2 cm of cartilaginous strut on the caudal and
dorsal aspect of the septum to prevent postoperative loss
of tip support that can lead to an aesthetically dis­
pleasing pollybeak deformity.
Figure 35-1  A, The septum is deviated off the maxillary crest. B, Bilateral
mucoperichondrial flaps have been elevated. C, Maxillary crest and inferior
aspect of septum can be resected to centralize the septum. D, In septo­
plasty, there is a choice of two incisions that are performed: hemitransfixion
or Killian. The hemitransfixion incision allows the surgeon adequate expo­
sure to address septal deviation in both anterior and posterior regions. It is
placed in the caudal cartilaginous septum extending from the dorsalmost
to the caudalmost region. The Killian incision is similar except that it is placed
posterior to the location of the hemitransfixion incision. This is often the
preferred incision if the septal deviation that needs to be addressed is pos­
terior. In either technique, the surgeon should leave at least a 1-cm strut
on the caudal aspect to prevent postoperative loss of tip support.
A
B
C
Killian
incision
Hemitransfixion
incision
D

450
Kimberly Lee • Babak Azizzadeh • Babak Larian
Using an osteotome or rongeur, the surgeon can resect
the bony portion along the maxillary crest. It is important
to avoid pulling when removing cartilage or bone. Instead,
Takahashi forceps can be used to safely remove tissue.
When the forceps have engaged the tissue completely, a
twisting motion can free the tissue before gently removing
it from the nasal cavity. Pulling on tissue that is not com­
pletely detached from the surrounding structures may
increase the risk of damage to the cribriform plate, since
a large portion of septal tissue is connected to the ethmoid
structures.
After correction of the bony deviation, the cartilagi­
nous septum can be replaced on the trough of the maxil­
lary crest and aligned perpendicularly, without deviating
into either nasal airway. Sometimes, an anchoring suture,
passed through the posterior septal angle and nasal spine,
is necessary for stabilization of the cartilaginous septum
in the midline.
CARTILAGINOUS INCISIONS OR SCORING
OF CARTILAGE
Cartilage-scoring technique weakens the tensile strength
of the cartilage and, after postoperative splinting, encour­
ages it to scar into a straighter conformation.
A mucoperichondrial flap can be elevated on the
concave side to place full-thickness incisions into the
septum. The incisions can be made in either a checker­
board grid or horizontal-line pattern. Alternatively, one
can remove small wedges of cartilage from the convex
surface of the cartilage.
situations where it can be spared. One such situation is
septal buckling, which can easily be overlooked without
careful attention. Often, despite adequate submucous
resection of the septal cartilage, septal buckling remains
due to memory, maxillary crest abnormalities, and septal
spurs. In these situations, either unilateral or bilateral
septal stenting splints can be placed on the side of the
septum with horizontal mattresses sutures. This allows
support for the septum while straightening it and the
septal splints can be removed after 1 to 3 weeks.
In many patients, the septum can be found to be devi­
ated to the side, and on closer examination, the caudal
septum is actually subluxed off of the maxillary crest. Two
options exist for the surgeon in this situation. The swing­
ing door technique can be used to remove the inferior
portion of the septal cartilage followed by suturing the
caudal septum in the midline position. Frequently, during
the septoplasty, further inspection of the septum reveals
that the caudal septum is actually displaced off of the
maxillary crest, causing septal deviation and asymmetric
nasal airflow. This situation can be easily resolved by
excising the redundant and displaced septal cartilage
along the nasal floor so that the caudal septum is free.
This sufficiently allows positioning of the cartilaginous
septum to the midline position.
The other option is to resect the caudal septal carti­
lage and reconstruct the tip with columellar strut grafts
to provide stability and prevent postoperative pollybeak
deformity. This can be prevented if the surgeon reserves
a 1- to 2-cm L-strut on the caudal and dorsal aspects,
which is paramount in resecting septal cartilage and
bone.
Figure 35-2  In cases where the mid-portion or superior aspect of the septum are severely deviated, the septum can be removed (submucous resec­
tion), straightened, rotated, and replaced back in place.
A
B
A
B

CHAPTER THIRTY-FIVE  Nasal Airway Obstruction
451
common cause of nasal airway obstruction in the 20- to
60-year-old age range is chronic turbinate hypertrophy
that can be secondary to anatomy, vasomotor, endocrine,
allergic, or environmental rhinitis. Rhinitis medicamento­
sum must be ruled out and treated in individuals who
chronically use Afrin, Neo-Synephrine, and/or Otrivin or
Inspire. As medical management is often unsuccessful,
surgical turbinate reduction is often used.
Inferior turbinate hypertrophy leading to nasal airway
obstruction is often broken down into two categories: (1)
enlarged turbinate bone with normal mucosa from either
developmental or traumatic causes and (2) thickened
turbinate mucosa from inflammation, allergy, endocrine
factors, or drug-induced rhinitis. However, the most
common etiology is compensatory hypertrophy of the tur­
binate mucosa secondary to significant septal deviation.
Turbinates form the lateral border of the internal
nasal valve, thus exerting most of their obstructive effect
anteriorly. Inferior turbinate hypertrophy can cause sig­
nificant nasal airway obstruction, as it is the most distal
region of airflow in the nose. There have been multiple
techniques to address turbinate hypertrophy. Submucous
resection is the most effective method, especially if bony
hypertrophy significantly contributes to the problem.
Using this method, the overlying inferior turbinate mucosa
is incised and a Cottle elevator is used to free up the
underlying bone from the overlying mucosa. Once this is
adequately performed, the bony portion is removed and
the incision is reapproximated. Other methods include
microdebrider submucous resection, radiofrequency abla­
tion (Coblation; ArthroCare, Austin, TX), and cauteriza­
tion of the inferior turbinate mucosa adjacent to the bony
portion. The main goal of achieving improvement in nasal
airway obstruction occurs via volume reduction to prevent
obstruction of the airflow through the nostrils. Mucosa-
sparing techniques lead to faster healing and less crusting,
in addition to preventing empty nose syndrome.
INTERNAL NASAL VALVE
The nasal valves are responsible for creating the narrowest
region in the nares and, subsequently, the airflow is tur­
bulent in these regions. The external nasal valve is bounded
by mobile alar side walls. The internal nasal valve cor­
responds to the middle nasal vault externally and is situ­
ated between the septum, caudal upper lateral cartilages,
and inferior turbinates, creating an approximately 10- to
15-degree angle. Despite a successful aesthestic rhino­
plasty, if proper attention is not made to nasal functional­
ity, significant problems can arise. Therefore, when
performing a rhinoplasty, attention should be directed to
avoiding overzealous dorsal reduction and cephalic resec­
tion. Patients with short nasal bones, preexisting nar­
rowed internal nasal valves, and/or aggressive dorsal
hump reductions are at a high risk of developing
One technique involves incising the septal cartilage
and scoring or removing thin wedges of septal cartilage
from the convex side of the deviated septum to allow flex­
ibility of the septum to encourage midline repositioning.
Another technique employed is morselization, which
involves elevating the mucoperichondrium bilaterally and
crushing the cartilage using Adson forceps or specially
designed morselization instruments in an effort to desta­
bilize the septal cartilage so that it will be straightened.
While theoretically the concept is enticing, unfortunately,
the extent of cartilage weakening is unpredictable. There­
fore, the results are variable, and consequently, unreliable.
The risk of losing dorsal support further contributes to
the infrequent use of this particular technique.
Caudal septum: if caused by subluxation off the max­
illary crest, use swinging door technique. Otherwise, resect
and reconstruct with columellar strut grafts.
If turbinate reduction is not deemed necessary, the
operation can conclude with closure of the mucoperichon­
drium and placement of quilting suture and/or nasal
stents. However, if endoscopic sinus surgery, polypectomy,
or rhinoplasty is to be performed in the same sitting, the
septoplasty is used first and those procedures can be used
prior to closing the Killian or hemitransfixion incision for
maximum visualization. The septal mucosa is inspected
so that any opposing perforations can be closed to prevent
any through-and-through defects. This can be accom­
plished using a 4-0 chromic suture in a purse-string
fashion. Isolated perforations limited to only one side do
not need to be sutured and can be thought to serve as a
drainage route for any potential postoperative hematomas
that may accumulate. With a 3-0 chromic suture on a
Keith needle, a quilting stitch is placed through both sides
of the mucosal flaps to adhere the flaps to the underlying
cartilage and prevent postoperative hematoma formation
followed by closure of the Killian or hemitransfixion inci­
sion. Septal splint placement is optional and depends
on the surgeon’s preference. Some find it advantageous
because it eliminates the need for packing and prevents
synechiae or hematoma formation. If splints are used, a
stitch is usually loosely placed to secure them to each
other in front of the columella and prevent inadvertent
displacement posteriorly into the airway. Removal of the
splints occurs approximately 1 to 3 weeks postoperatively.
Others use antibiotic-impregnated nasal packing com­
bined with oral antibiotics or mattress sutures. Patients
with nasal packing must be placed on oral antibiotics to
avoid toxic shock syndrome related to staphylococcal
infection.
TURBINATE REDUCTION
The subjective sensation of nasal airway obstruction has
led surgeons to focus attention to the contributing role of
the inferior turbinates. It has been noted that the most

452
Kimberly Lee • Babak Azizzadeh • Babak Larian
caudal-lateral portion of the upper lateral cartilage is
visualized. A 5-0 clear nylon horizontal mattress stitch
placed in this region of the upper lateral cartilage across
the nasal dorsum is anchored to the contralateral upper
lateral cartilage. As the suture is tied, the upper lateral
cartilages contract dorsally, and any previously placed
spreader grafts and the nasal dorsum serves as a fulcrum.
These sutures directly increase the internal valve angle,
which can be visualized as the suture is tied. Occasionally,
the flaring suture alone can significantly improve nasal
airway obstruction caused by internal valve collapse,
usually in situations where the middle nasal vault is
destabilized.
Other techniques include onlay grafts, autospreader
grafts, butterfly grafts, and the orbital suspension sutur­
ing method. Butterfly grafts can be used to help improve
significant internal nasal valve dysfunction. Using an
intercartilaginous incision, previously harvested conchal
cartilage grafts fashioned into butterfly grafts are placed
in the supratip region and sutured to the caudal edge of
the upper lateral cartilages. Although not commonly used
for primary surgical intervention, orbital suspension tech­
nique can be used in patients who have had unsuccessful
middle nasal vault reconstruction. This method suspends
a collapsed nasal valve to the orbital rim.
EXTERNAL NASAL VALVES
External nasal valves can also contribute to decreased
nasal airflow by collapsing the nasal alae with negative
pressure with inspiratory airflow. Multiple factors can also
contribute to the lack of support in the external nasal
valve, including iatrogenic, traumatic, congenital, and
senescent causes. To stabilize the external nasal valve, the
most common surgical methods of repair include lateral
crural strut or batten grafts (Figure 35-4).
Batten grafts are typically placed on top of existing
cartilage in the alar region. Alar batten grafts are used
to fortify weakened or absent lower lateral cartilages
or nasal sidewalls. Septal, conchal, or rib cartilage serve
as excellent sources of graft material. These batten
grafts are fashioned and then anchored using 5-0 chromic
sutures to the nasal mucosa to reinforce those areas of
the side wall or the alar lobule that collapse with
inspiration. These grafts do not typically change the
resting position of the valve. In thin-skinned patients,
it is especially important to thin the grafts and to bevel
the edges to prevent external visualization of the
graft. Alar batten grafts are sewn in place to act as a
reinforcement against dynamic collapse in the area of
the lateral crura. Lateral crural strut grafts can also be
used to prevent and treat external nasal valve collapse.
Lateral crural strut grafts refer to cartilaginous reinforce­
ment that is placed deep to the exisiting alar cartilage.
post­operative internal nasal valve collapse. Prophylactic
nasal valve reconstruction is necessary to avoid significant
postoperative functional and aesthetic deformity in the
middle nasal vault. Additionally, lateral osteotomies can
result in narrowing of the nose resulting in inadequate
airflow and clinical awareness of nasal airway obstruction.
Furthermore, the location of the intercartilaginous inci­
sion should be carefully placed to avoid postoperative
cicatrical web formation and stenosis.
The internal nasal valve is the narrowest region of
airflow, and it is often necessary to surgically address this
region to improve nasal airway obstruction. This can be
performed using a variety of techniques (Figure 35-3). A
common technique is to use spreader grafts fashioned
from septal or rib cartilage. While conchal cartilage can
also be used to create spreader grafts, this is less desired
as it is likely to have more curvature and less fortitude.
Spreader grafts can be placed endonasally or via and
external rhinoplasty approach. They are typically placed
in between the septum and the upper lateral cartilages.
The grafts can be unilateral, bilateral, identical, or asym­
metric depending on the problem at hand.
In addition to spreader grafts, flaring sutures can
be used to directly improve the internal nasal valve
angle. Using the external rhinoplasty approach, the
Figure 35-3  The internal nasal valve is the narrowest region of airflow,
and it is often necessary to surgically address this region to improve nasal
airway obstruction. This can be performed using a variety of techniques. A
common technique is to use spreader grafts fashioned from septal or costal
cartilage. While conchal cartilage can also be used to create spreader grafts,
this is less desired as it is more likely to have slight curvature. Two identical
thin pieces are fashioned from the cartilage and placed on each side of the
remaining septal cartilage strut to widen the region of the internal nasal
valve. To maintain their position adjacent to the strut, sutures are placed to
anchor the spreader grafts in the location desired for maximal effect. Flaring
sutures can also be used to further improve the internal nasal valve.
Intercartilaginous
incision

CHAPTER THIRTY-FIVE  Nasal Airway Obstruction
453
REFERENCES
1. Goode RL. Diagnosis and treatment of turbinate dysfunction.
A self-instructional package. Alexandria, CA: American
Academy of Otolaryngology–Head and Neck Surgery; 1977.
2. Schlosser RJ, Park SS. Surgery for the dysfunctional nasal
valve: cadaveric analysis and clinical outcomes. Arch Fac Plast
Surg. 1999;1:105–110.
CONCLUSION
Successful treatment of nasal airway obstruction depends
largely on careful analysis of the underlying anatomy and
structure, while scrutinizing the correct diagnosis preop­
eratively, intraoperatively, and postoperatively. As many
causes for nasal airway obstruction exist, the surgeon
needs to properly address all possibilities at the time
of surgery and use appropriate surgical planning and
intervention.
Figure 35-4  A, B, Lateral crural strut grafts are placed deep to lateral crura. C, D, Alar batten grafts are placed over the lateral crura.
A
B
C
D