Mastering Advanced Rhinoplasty

444
8
8.2.16  Case 16: Augmentation with Diced
Cartilage from the Previous Rib
Cartilage Graft
A 55-year-old male presented after five previous unsuccessful
rhinoplasties. The most recent failed surgery attempted to cor-
rect severe saddling with a solid rib graft but was complicated
by severe warping and graft distortion. Examination also
revealed a scarred and irregular nasal skin envelope. Surgical
exploration showed absent lateral crura and partial absence of
the intermediate crura. Explantation of the existing rib graft
produced a severely deformed and unusable specimen, neces-
sitating harvest of a new rib cartilage graft. Using fresh rib car-
tilage, batten grafts were created to reconstruct the overresected
nasal tip tripod, and the remaining cartilage was diced and
inserted into a sleeve of autologous temporalis fascia. Dorsal
augmentation with a large DC-F graft served to restore dorsal
contour and to minimize irregularities of the nasal skin enve-
lope. Three-year postoperative follow-up revealed satisfactory
nasal alignment and a good dorsal profile (. Fig. 8.21).
.
. Fig. 8.21  (a–b) Augmentation
with diced cartilage from the
previous rib cartilage graft. Batten
grafts for reconstruction of the
overresected LLCs. (c–e) Front
view, profile view, base view
pre-op/post-op
b
a

Chapter 8 · Secondary Augmentation of the Dorsum

445
8
d
c
.
. Fig. 8.21  (continued)
8.2 · Case Studies

446
8
e
.
. Fig. 8.21  (continued)

Chapter 8 · Secondary Augmentation of the Dorsum

447
8
8.2.17  Case 17: Augmentation with Diced
Cartilage from a Previous Rib
Cartilage Graft
A 58-year-old male was seen after unsuccessful saddle-nose
correction using a solid rib cartilage graft. Examination
revealed a scoliotic nose from a severely warped rib cartilage
graft and a twisted, slightly overprojected nasal tip with
grossly asymmetrical nostrils.
Reconstruction was begun by removing the warped
L-shaped rib cartilage graft. A double-layered conchal
­sandwich graft was then used as a columellar strut. The mis-
shapen lower lateral cartilages were suspended from this
strong central pillar, and a lateral crural overlap technique
was used on the left side, so simultaneously decrease of tip
projection and reshaping was achieved. On the right side an
upside-down-technique with an additional batten graft was
necessary to reconstruct a symetric framework. The dorsum
was then augmented using a DC-F graft created from recy-
cled rib cartilage wrapped in autologous temporalis fascia. A
straight and well-contoured nose was evident on 1-year
­follow-up (. Fig. 8.22).
8.2 · Case Studies

448
8
.
. Fig. 8.22  (a–f)
Augmentation with diced
cartilage from the previous rib
cartilage graft. (g–h) Front view,
profile view pre-op/post-op. (i–j)
Tip correction with lateral crural
overlap on the left side and
upside-down technique in
combination with onlay batten
graft on the right one. Base view
pre-op/post-op
a
b

Chapter 8 · Secondary Augmentation of the Dorsum

449
8
c
d
.
. Fig. 8.22  (continued)
8.2 · Case Studies

450
8
e
f
.
. Fig. 8.22  (continued)

Chapter 8 · Secondary Augmentation of the Dorsum

451
8
g
h
.
. Fig. 8.22  (continued)
8.2 · Case Studies

452
8
i
j
.
. Fig. 8.22  (continued)

Chapter 8 · Secondary Augmentation of the Dorsum

453
8
8.2.18  Case 18: Augmentation with Diced
Cartilage from the Previous Rib
Cartilage Graft
A 47-year-old male presented after multiple failed revision
rhinoplasties, including rib graft implantation. The cranial
end of the graft had warped and almost perforated the skin.
Surgical exploration was conducted using the external rhino-
plasty approach. After excision of extensive subcutaneous
scar tissue, concave deformities of both lateral crura were
exposed. The explanted rib cartilage also revealed numerous
foci of resorption. Tip support was reconstituted with a
double-­layered conchal sandwich graft followed by reshaping
the lateral crura with suture techniques. The dorsum was
then reconstructed using a DC-F graft created from recycled
rib cartilage. Multiple osteotomies, including parasagittal
medial, transverse, and low-to-low lateral osteotomies were
used to straighten the crooked bony pyramid (. Fig. 8.23).
a
b
.
. Fig. 8.23  (a–d)
Augmentation with diced
cartilage from the previous rib,
reconstruction of a straight
columella with double-layerd
conchal graft. (b–d) Front
view,profile view,base view
pre-op/post-op
8.2 · Case Studies

454
8
c
d
.
. Fig. 8.23  (continued)

Chapter 8 · Secondary Augmentation of the Dorsum

455
8
8.2.19  Case 19: Total Septal Reconstruction
with Concha Combined with DC-F
Graft from Rib Cartilage
An 18-year-old male presented with postsurgical columellar
retraction and a saddle-nose deformity following nasal sep-
toplasty. Examination also revealed a wide nose with a bony
rhinion hump. Surgical exploration revealed complete
absence of the anterior septum without evidence of septal
abscess or inflammation. Surgical overresection was thought
to be the most likely cause of the dorsal and columellar defor-
mities. Reconstruction was performed using only conchal
cartilage harvested from both ears, since the patient refused
rib graft harvest. A double-layered conchal sandwich graft
was first used to create a neoseptum and support the middle
vault and columella. The remaining cartilage was diced and
used as a DC-F graft for dorsal augmentation.
Although significant improvement was achieved, the
patient returned 2 years postoperatively seeking further dor-
sal augmentation with rib cartilage. Consequently, a second
DC-F graft was created from diced rib cartilage and autolo-
gous temporalis fascia. The new DC-F graft was then placed
on top of the previous graft, and improved profile aesthetics
resulted (. Fig. 8.24).
8.2 · Case Studies

456
8
.
. Fig. 8.24  (a–c) Total septal
reconstruction with concha
combined with DC-F graft from
rib cartilage. (d–f) Front view,
profile view, base view pre-op/
post-op. and after revision. (g) Ear
configuration after removal of the
whole concha
a
b

Chapter 8 · Secondary Augmentation of the Dorsum

457
8
c
d
.
. Fig. 8.24  (continued)
8.2 · Case Studies

458
8
e
f
1
2
3
.
. Fig. 8.24  (continued)

Chapter 8 · Secondary Augmentation of the Dorsum

459
8
g
.
. Fig. 8.24  (continued)
8.2 · Case Studies

460
8
8.2.20  Case 20: Removal of Silicone Implants
and Replacement of DC-F Graft
A 35-year-old female presented with a large silicone nasal
implant and impending extrusion at the nasal tip. Immediate
removal with simultaneous reconstruction with autologous
tissue was recommended and performed.
After lifting the nasal skin flap, the implant was identified
and removed, and the capsule was then incised and enlarged.
Tip support was reconstituted using a double-layered conchal
sandwich graft as a columellar strut. Deformed lower lateral car-
tilages were then suspended from the strut graft after perform-
ing a lateral crural “steal” procedure to increase tip projection.
Further projection and tip refinement were achieved with place-
ment of shield and cap grafts. The remaining conchal cartilage
was then diced and wrapped in autologous temporalis fascia to
create a DC-F graft for dorsal augmentation. The patient refused
harvest of rib cartilage for dorsal augmentation (. Fig. 8.25).
.
. Fig. 8.25  (a–b) Removal of
silicone implants and
replacement with DC-F graft.
(c–e) Front view, profile view,
base view pre-op/post-op
a
b

Chapter 8 · Secondary Augmentation of the Dorsum

461
8
c
d
.
. Fig. 8.25  (continued)
8.2 · Case Studies

462
8
e
.
. Fig. 8.25  (continued)

Chapter 8 · Secondary Augmentation of the Dorsum

463
8
8.2.21  Case 21: Removal of Silicone Implants
and Replacement of DC-F Graft
A 35-year-old female presented seeking revision rhinoplasty
after six previous rhinoplasties elsewhere. Examination
revealed a malpositioned dorsal silicone implant placed dur-
ing the most recent surgery. A bulky and wide supratip and a
retracted left soft triangle were also observed. Because of
severe septal deviation, airway obstruction was also present
bilaterally.
Surgical exploration revealed a postsurgical deformity of
both lower lateral cartilages resulting from previous overre-
section. Insufficient treatment of the intermediate crura was
also seen. Despite multiple prior surgeries and a history of
nasal dysfunction, no attempt had been made to correct the
severe septal deformity.
We began reconstruction by resecting the deformed cen-
tral septum, shortening the caudal L-strut, and suturing the
caudal septum to the anterior nasal spine using a transverse
drill hole. In order to increase nasal length, the right conchal
cartilage was harvested to create a double-layered sandwich
graft, which was inserted between the medial crura.
Deformity of the intermediate crura was eliminated using a
lateral crural overlap technique. This enabled the deformed
segments to be sutured to the lateral crura. Batten grafts were
then used to further strengthen and straighten the surgically
overresected lateral crura. Additional cartilage was harvested
from the tenth rib. Rib cartilage was used to fabricate the two
batten grafts as well as two alar rim grafts, two spreader
grafts, and enough residual cartilage to create a large DC-F
graft from autologous deep temporalis fascia for dorsal aug-
mentation (. Fig. 8.26).
a
b
.
. Fig. 8.26  (a–c) Removal of silicone implants and replacement with DC-F graft, reconstruction of the overresesected lateral crura. (d–f) Front
view, profile view, base view pre-op/post-op
8.2 · Case Studies

464
8
c
d
.
. Fig. 8.26  (continued)

Chapter 8 · Secondary Augmentation of the Dorsum

465
8
f
e
.
. Fig. 8.26  (continued)
8.2 · Case Studies

466
8
8.2.22  Case 22: Removal of Synthetic Implant
and Replacement of DC-F Graft
A 38-year-old female presented with a severe polly-beak
deformity after previous rhinoplasty 20 years earlier. Using
the open approach, surgical exploration revealed augmen-
tation of the overresected dorsum with an unidentifiable
synthetic implant. The tip was badly scarred, and thick non-
resorbable suture material had been used for tip contour-
ing. The right LLC was malpositioned, and the cephalic
border was overresected. After removing the dorsal implant,
the dorsum was underprojected with numerous contour
irregularities. The caudal septum was weak and deformed
but also overprojected. After lowering the anterior septal
angle, the caudal septum was sutured to the ANS via osse-
ous drill holes. The right concha cavum and cymba were
then harvested, and the cymba was used to create a double-
layered sandwich graft that was sutured while stabilizing
the cartilage segments with an Aiach-Gubisch clamp
(Medicon, Inc., Setauket, New York). The conchal cavum
was used to augment the caudal septum, and the sandwich
graft was then placed in front of the caudal septum; the
medial crura were sutured to the graft. The malpositioned
right LLC was transposed caudally and fixed in a symmetri-
cal position. The LLCs were then contoured with spanning
sutures combined with a tip suspension suture and poste-
rior sling. After narrowing the nasal pyramid with parasag-
ittal medial osteotomies created with the Lindemann burr
and percutaneous low-to-low lateral and transverse osteot-
omies, the dorsum was reconstructed with a DC-F graft
fashioned from allogenic fascia lata and finely diced rib car-
tilage (. Fig. 8.27).
.
. Fig. 8.27  (a–e)
Reconstruction of the anterior
septum with double layered
conchal graft, dorsal
reconstruction with DC-F graft
and tip configuration with
suture techniques. (f–h) Front
view, profile view, base view
pre-op/post-op
b
a

Chapter 8 · Secondary Augmentation of the Dorsum

467
8
d
c
e
.
. Fig. 8.27  (continued)
8.2 · Case Studies

468
8
f
g
.
. Fig. 8.27  (continued)

Chapter 8 · Secondary Augmentation of the Dorsum

469
8
.
. Fig. 8.27  (continued)
h
8.2 · Case Studies

470
8
8.2.23  Case 23: Enlarging the Shrunken Skin
Envelope by Continuous Manual
Stretching as Prerequisite
for a Successful Augmentation
with Solid Rib Graft
A 51-year-old male presented with an overly short saddle
nose resulting from childhood trauma and septal abscess for-
mation. The patient had also undergone several unsuccessful
attempts at surgical restoration.
Previous surgery failed because of an overly tight skin
envelope that prevented successful skeletal expansion. Our
past experience with tissue expanders has been ­disappointing;
therefore, we sought another means of enlarging the soft-tis-
sue envelope. One option was a paramedian forehead flap,
but the deficit was not large enough to justify such an aggres-
sive procedure. Consequently, we instructed the patient to
begin cutaneous stretching exercises for at least 30 min each
day, tensioning the dorsal skin and columella in a caudal
direction. After 6 months of therapy, soft-tissue elasticity had
improved dramatically, allowing for placement of a two-piece
L-shaped (solid) rib graft. To achieve a straight nasal profile,
the dorsal rib graft had to be contoured to account for vari-
ous irregularities in skin thickness. One-year follow-up
revealed good nasal length and improved dorsal projection
(. Fig. 8.28).
.
. Fig. 8.28  (a–e)
Reconstruction with solid rib
graft. One-year follow-up
revealed good nasal length and
improved dorsal projection
a
b

Chapter 8 · Secondary Augmentation of the Dorsum

471
8
.
. Fig. 8.28  (continued)
d
c
8.2 · Case Studies

472
8
Suggested Reading
Calvert JW, Kwon E. Techniques for diced cartilage with deep temporalis
fascia graft. Facial Plast Surg Clin N Am. 2015;23(1):73–80.
Calvert JW, Brenner K, Da Costa-Iyer M, Evans GR, Daniel RK. Histological
analysis of human diced cartilage grafts. Plast Reconstr Surg.
2006;118(1):230–6.
Calvert JW, Patel AC, Daniel RK.  Reconstructive rhinoplasty: operative
revision of patients with previous autologeous costal cartilage grafts.
Plast Reconstr Surg. 2014;133(5):1087–96.
Daniel RK.  Diced cartilage grafts in rhinoplasty surgery: current tech-
niques and applications. Plast Reconstr Surg. 2008;122:1883.
Daniel RK, Calvert JW. Diced cartilage grafts in rhinoplasty surgery. Plast
Reconstr Surg. 2004;7(113):2156–71.
Daniel RK, Sajadian A. Secondary rhinoplasty: management of the over-
resected dorsum. Facial Plast Surg. 2012;28(4):417–26.
Davis RE, Wayne I. Rhinoplasty and the nasal SMAS. Arch Facial Plast Surg.
2004;6(2):124–32.
Eitschberger E. Histological findings following cartilage transposition in exper-
imental animal septoplasties (author’s transl). HNO. 1980;28:158–60.
Article in German.
.
. Fig. 8.28  (continued)
e

Chapter 8 · Secondary Augmentation of the Dorsum

473
III
Nasal Pyramid
Contents
Chapter 9
Osteotomies in Primary Rhinoplasty – 475
Chapter 10
Osteotomies in Secondary Rhinoplasty – 507

475
9
Osteotomies in Primary
Rhinoplasty
9.1
Surgical Principles – 476
9.2
Case Studies: Primary Nasal Pyramid Correction – 481
9.2.1
Case 1: Wide Nasal Bridge – 481
9.2.2
Case 2: Wide Nasal Bridge – 484
9.2.3
Case 3: Wide Nasal Bridge Complicated by Fracture
of the Septal Frame – 487
9.2.4
Case 4: Wide Nasal Bridge with Functional Problems – 489
9.2.5
Case 5: Narrow Nasal Bridge – 492
9.2.6
Case 6: Narrow Nasal Bridge with Overprojected Dorsum – 494
9.2.7
Case 7: Deviated Wide Nasal Bridge – 496
9.2.8
Case 8: Deviated Nasal Bridge – 499
9.2.9
Case 9: Asymmetrical Nasal Bridge with Severe Septal Deviation – 501
9.2.10
Case 10: Inverted-V Deformity – 504

Suggested Reading – 506
© Springer International Publishing AG 2018
W. Gubisch, Mastering Advanced Rhinoplasty,

476
9
9.1
Surgical Principles
Surgical alteration of the bony pyramid is often anxiety-­
provoking for the prospective rhinoplasty patient. Just talk-
ing about “breaking” the bone in the middle of the face
creates fear and apprehension. However, contemporary tech-
niques, combined with sophisticated cutting instruments,
intraoperative ice-water cooling, and postoperative mechan-
ical cooling devices to minimize swelling and bruising, have
greatly improved surgery of the bony vault. Yet despite tech-
nical advances, the most important factor is still a well-­
conceived and individualized treatment plan executed with
meticulous precision and extreme care.
Our treatment philosophy seeks to create bone fragments
that are as large as possible and to mobilize them completely
so that it becomes much easier to mold a new bony pyramid.
Typically this is done using parasagittal medial osteotomies,
percutaneous transverse osteotomies, and percutaneous low-­
to-­low lateral osteotomies (. Fig. 9.1). By using a 2- or 3-mm
osteotomies and the percutaneous technique for the transverse
and lateral ­osteotomies, the blunt force energy is applied at right
angles to the bone for more precise bone cut placement, and by
using a ­mallet made from Teflon, the blunt force energy is dis-
sipated like a shock absorber for less tissue trauma. Using this
approach, we feel that we can avoid many of the complications
resulting from unwanted bony comminution or misplaced
bone cuts. We also use a single-access incision for each percu-
taneous osteotomy (. Fig. 9.2). For the lateral osteotomy, the
skin incision is placed at the junction of the caudal and medial
thirds, and for the transverse osteotomy, the incision is placed
at the junction of the central and middle thirds (. Fig. 9.3).
After inserting the osteotome, we also score the periosteum
along the fracture line to displace blood vessels and minimize
bleeding and to get a glas cutter effect (. Fig. 9.4). Finally, in
our practice we have not observed medial displacement of the
inferior turbinate head with the low-to-low lateral osteotomy,
and therefore we are not using a high-to-low-to-low technique
for preserving Webster’s triangle.
.
. Fig. 9.1  Options for osteotomy configurations. Straight osteotomy
lines produced by parasagittal medial, transverse, and percutaneous
low-to-low lateral osteotomies. Curved osteotomy lines produced by
conventional high-to-low-to-high lateral and medial oblique osteoto-
mies
.
. Fig. 9.2  Stab incision for percutaneous transverse osteotomy

Chapter 9 · Osteotomies in Primary Rhinoplasty

477
9
.
. Fig. 9.3  Percutaneous trans-
verse and low-to-low lateral
osteotomy. Lindemann fraise for
parasagittal medial osteotomies.
Making the percutaneous stab
incision for the transverse and
lateral osteotomies
.
. Fig. 9.4  Pushing away the vessels by scratching on the bone. Place-
ment of the percutaneous access incisions
9.1 · Surgical Principles

478
9
When performing the parasagittal medial osteotomy
(which is always performed first), we are occasionally con-
fronted with the challenge of achieving straight and symmetri-
cal osteotomy lines when the bony vault is asymmetrical
(. Fig. 9.5). When a large hump is first removed, a large open
roof is produced, and medial osteotomies are unnecessary. But
in cases with a small dorsal hump and thick dorsal bone, or in
those without a dorsal hump, creation of symmetrical medial
osteotomies is best achieved using the Lindemann fraise
(. Fig.  9.6). Using a power-driven Lindemann fraise, the
­parasagittal cuts are performed from the inside out and extend
cephalically near the intercanthal line. In addition to parallel
and straight bone cuts, the Lindemann osteotomies also remove
the excess bone (. Fig. 9.5) that prevents adequate narrowing of
the bony vault. Low-to-low lateral osteotomies are performed
next, and the procedure is then completed with transverse oste-
otomies to fully mobilize the bone fragments. Only in few cases
do we perform an oblique osteotomy, which can also be per-
formed with a Lindemann fraise (. Fig. 9.7). Ice-water irriga-
tion is then used to prevent bleeding and reduce swelling.
.
. Fig. 9.5  Intraoperative photograph showing enlarged open roof and excised unequal bone fragments after parasagittal medial osteotomy
with a 5-mm chisel

Chapter 9 · Osteotomies in Primary Rhinoplasty

479
9
.
. Fig. 9.6  Paramedian osteot-
omy with a Lindemann fraise
.
. Fig. 9.7  Oblique osteotomy with a Lindemann fraise
9.1 · Surgical Principles

480
9
We apply ice water for some minutes, which helps to
reduce bleeding and swelling. These techniques help to
­mobilize the nasal pyramid best, and from our point of view,
this is the prerequisite for straightening or narrowing any
disfiguration of the nasal pyramid.
Complete mobilization of the bony vault is a prerequisite
for straightening and/or narrowing a misshapen bony nasal
pyramid. However, aggressive skeletal mobilization also
necessitates prolonged external splinting for a favorable sur-
gical outcome. For most noses, 2  weeks of postoperative
splinting is adequate, but for a very wide bony vault, we pre-
fer 3 weeks of immobilization using a plaster of Paris splint
extending onto the forehead and reinforced by a circular
bandage to minimize movement from the mimetic muscula-
ture. Removal of the splint after 2 weeks in these cases may
result in recurrence of a wide nose (. Fig. 9.8).
.
. Fig. 9.8  Plaster of Paris splint extending onto the forehead and
reinforced by a circular bandage

Chapter 9 · Osteotomies in Primary Rhinoplasty

481
9
9.2
Case Studies: Primary Nasal Pyramid
Correction
9.2.1 Case 1: Wide Nasal Bridge
A 20-year-old female presented with a low and very wide
nasal dorsum and a wide and bulky nasal tip. Endonasal
examination also revealed a severe deformity of the anterior
septum.
An extracorporeal septoplasty was needed to thin the
widened bony septum and to reconstruct the anterior seg-
ment. After thinning the bony septum, a large piece of quad-
rangular cartilage was added to serve as a new caudal septum,
and spreader grafts were added for support. The bony vault
was then narrowed using parasagittal medial osteotomies
created with the Lindemann fraise, including removal of a
strip of bone followed by percutaneous low-to-low lateral
and transverse osteotomies. Using the low-to-low lateral
osteotomy also helped to increase dorsal height.
The wide nasal tip was contoured by resecting the cephalic
margin of the overly stiff lower later cartilages (LLCs) and by
using both transdomal and spanning sutures. The septi
depressor muscle was partially resected, allowing the colu-
mellar pedestal to be narrowed with transfixion sutures.
Further contouring was achieved with alar rim graft place-
ment and with morselized cartilage grafts to augment both
­soft-­tissue facets. A tip suspension suture was also used to
maintain tip position (. Fig. 9.9).
9.2 · Case Studies: Primary Nasal Pyramid Correction

482
9
a
b
.
. Fig. 9.9  (a–d) Correction of
wide nasal bridge including. (a)
Extracorporeal septal reconstruc-
tion. (b–d) Frontal view, profile
view, base view pre-op/post-op

Chapter 9 · Osteotomies in Primary Rhinoplasty

483
9
c
d
.
. Fig. 9.9  (continued)
9.2 · Case Studies: Primary Nasal Pyramid Correction

484
9
9.2.2 Case 2: Wide Nasal Bridge
A 19-year-old female presented with an ultrawide and slightly
overprojected nasal dorsum, a low radix, a wide columellar
pedestal, and a wide and bulky nasal tip.
Intraoperatively, a large fat pad between the medial
crura was resected. The ULCs were divided from the sep-
tum, and the cartilaginous hump was then resected. The
bony hump was lowered with a carbide rasp, and para-
sagittal medial osteotomies were created with an ultra-
wide Lindemann fraise to create a very wide osteotomy
line. Percutaneous low-­to-­low and transverse osteoto-
mies were then used to narrow the bony nasal vault.
The overprojecting ULCs were then used to create
spreader flaps.
The septi depressor muscle was partially resected, and the
resected cartilaginous hump was used as a columellar strut
graft. Tip contouring was accomplished by resecting the
cephalic margin of both LLCs and by using transdomal, span-
ning, and suspension sutures. The resected cephalic margins
were then used as alar rim grafts. Because tip projection
increased with the aforementioned changes, a push-­down tech-
nique was used to offset the increase in projection. The nasion
was then augmented with three layers of allogenic fascia lata,
while the dorsum was augmented with only a single layer. An
external nasal cast was placed for 3 weeks (. Fig. 9.10).

Chapter 9 · Osteotomies in Primary Rhinoplasty

485
9
.
. Fig. 9.10  (a–d) Wide nasal bridge. (a)
Removing intercrural fat pad. (b–d) Frontal
view, profile view, base view pre-op/post-
op
a
b
c
9.2 · Case Studies: Primary Nasal Pyramid Correction

486
9
d
.
. Fig. 9.10  (continued)

Chapter 9 · Osteotomies in Primary Rhinoplasty

487
9
9.2.3 Case 3: Wide Nasal Bridge Complicated
by Fracture of the Septal Frame
A 25-year-old female presented with an extremely wide and
overprojected dorsum and a wide and underprojected nasal
tip. Thin overlying skin also revealed lots of skeletal irregu-
larities, and the endonasal examination revealed a deformed
anterior septum.
Using the external rhinoplasty approach to expose the
anterior nasal septum, an attempt to straighten the deviated
anterior septum in situ by scoring the deviated cartilage, and
splinting with ethmoid bone was complicated by bony frac-
ture separation of the septal partition during ethmoid bone
harvest. Consequently, since the septal partition was inad-
vertently mobilized like an extracorporeal septoplasty, it was
removed, splinted with thinned septal cartilage, and rein-
serted. Percutaneous transverse and lateral osteotomies were
then performed to narrow the extremely wide bony vault.
However, in order to achieve adequate narrowing, parasagit-
tal medial osteotomies were first created using a large
Lindemann burr to generate an unusually wide bony open
roof. Following fixation of the neoseptum, the upper lateral
cartilages (ULCs) were invaginated to form spreader flaps for
additional stability, and a columellar strut was added for tip
support. Tip narrowing was then accomplished using both
transdomal and spanning sutures. The dorsum was then
camouflaged with finely diced cartilage and a single layer of
cadaveric fascia lata. In order to achieve consistent position-
ing of the nasal bones during healing, a plaster of Paris cast
was maintained for three consecutive weeks (. Fig. 9.11).
9.2 · Case Studies: Primary Nasal Pyramid Correction

488
9
a
b
c
.
. Fig. 9.11  (a–c) Wide nasal bridge. Frontal view,
profile view, base view pre-op/post-op

Chapter 9 · Osteotomies in Primary Rhinoplasty

489
9
9.2.4 Case 4: Wide Nasal Bridge
with Functional Problems
A 26-year-old female presented with a very wide nasal bridge
that prevented a comfortable fit for her eyeglasses.
Examination of the profile revealed an overprojected tip and
cartilaginous dorsum.
Using the external rhinoplasty approach, a lateral cru-
ral overlay technique of 5 mm (lateral sliding technique)
was used for tip deprojection. After dissecting mucosa
from beneath the ULC/septal junction and dividing the
ULCs from the septum, parasagittal medial osteotomies
were created using a large Lindemann burr in order to cre-
ate a wide open roof for aggressive bone narrowing and to
align the osteotomy cuts in a precise and symmetrical
fashion. Percutaneous low-to-low (continuous) lateral and
transverse osteotomies were then performed to narrow
the bony nasal pyramid. Overprojected ULCs resulted
from the cartilaginous hump and the aggressive bony nar-
rowing. The ­overprojected ULCs were invaginated and
used as spreader flaps to stabilize the middle vault. The
low bony dorsum was then augmented with morselized
septal cartilage covered with three layers of allogenic fas-
cia lata (. Fig. 9.12).
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9
.
. Fig. 9.12  (a–d) Wide nasal bridge.
(a) Tip deprojection with lateral sliding
(lateral crural overlap) technique. (b–d)
Frontal view, profile view, base view pre-
op/post-op
a
b
c

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491
9
d
.
. Fig. 9.12  (continued)
9.2 · Case Studies: Primary Nasal Pyramid Correction

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9
9.2.5 Case 5: Narrow Nasal Bridge
A 24-year-old female presented for treatment of a dorsal
hump. From the frontal view, the dorsum was very narrow,
and compared with the dorsal width, the tip appeared too
wide.
Using the external approach, a fold-under flap tech-
nique was used to strengthen both lateral crura. Spanning
sutures were then used to refine the newly strengthened
LLCs. After separating the ULCs from the dorsal septum,
the cartilaginous hump was resected, and the bony hump
was lowered using the rasp. Spreader flaps that extended
into the keystone area were then created from the overpro-
jected ULCs after they were released from beneath the
nasal bones. This served to adequately widen the overly
narrow dorsum. Low-to-high lateral osteotomies were
then used to narrow the base of the bony vault. The colu-
mellar pedestal was narrowed by subtotal resection of the
septi depressor muscle followed by transfixion suture
placement (. Fig. 9.13).
.
. Fig. 9.13  (a–d) Widen a nar-
row dorsum using spreader flaps.
(a) Fixation of the invaginated
ULC
to
the
dorsal
septum
(spreader flaps), fold-under flaps
for stabilisation of the LLCs. (b–d)
Frontal view, profile view, base
view pre-op/post-op
a
b

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9
d
c
.
. Fig. 9.13  (continued)
9.2 · Case Studies: Primary Nasal Pyramid Correction