Mastering Advanced Rhinoplasty

495
9
a
b
c
.
. Fig. 9.14  (a–c) Correction of deviated and
narrow nasal bridge. Frontal view, profile view,
base view pre-op/post-op
9.2 · Case Studies: Primary Nasal Pyramid Correction

496
9
9.2.7 Case 7: Deviated Wide Nasal Bridge
A 17-year-old male presented with an S-shaped deviation of
the dorsum and an overly wide nasal pyramid. Severe defor-
mity of the nasal septum necessitated an extracorporeal sep-
toplasty to adequately straighten the nose. Spreader grafts
were attached to the neoseptum before reimplantation. The
tip was contoured using transdomal and spanning sutures,
followed by tip rotation with a tongue-in-groove technique
combined with a posterior sling suspension suture. Following
parasagittal medial osteotomies and percutaneous low-­to-­
low lateral and transverse osteotomies, the bony vault was
repositioned and stabilized in a straight and narrow configu-
ration (. Fig. 9.15).

Chapter 9 · Osteotomies in Primary Rhinoplasty

497
9
.
. Fig. 9.15  Correction of deviated wide
nasal dorsum with extracorporeal septl
reconstruction. (a) Explanted deformed sep-
tum causing the deviated nasal bridge. (b–d)
Frontal view, profile view, base view pre-op/
post-op
a
b
c
9.2 · Case Studies: Primary Nasal Pyramid Correction

498
9
d
.
. Fig. 9.15  (continued)

Chapter 9 · Osteotomies in Primary Rhinoplasty

499
9
9.2.8 Case 8: Deviated Nasal Bridge
A 52-year-old male presented with a severe S-shaped devia-
tion of the nose and an overprojected dorsum. From the
basal view, the tip was asymmetrical, and the anterior border
of the septum was shifted to the right side.
Using the open approach via an inverted-V transcolumel-
lar incision, the ULCs were separated (extramucosally) from
the septum, and parasagittal medial osteotomies were cre-
ated with a Lindemann burr to release the perpendicular
plate superiorly. Then both the upper and lower mucosal tun-
nels were dissected, revealing a severe septal deformity that
necessitated extracorporeal septal reconstruction. After frac-
turing the perpendicular plate posteriorly and unhinging the
septum from the maxillary crest inferiorly, the septal parti-
tion was removed en bloc. Only the bony cartilaginous
­junction was long enough to recreate a straight dorsum, and
consequently the septum was rotated 90°, and the cartilage
was scored and splinted using thinned perpendicular eth-
moid bone. The septal spur was then harvested and used to
fabricate spreader grafts, which were sewn to the new dorsal
border. Before reimplanting the newly straightened neosep-
tum, the deformed bony pyramid was mobilized using per-
cutaneous low-to-low lateral and transverse osteotomies. The
reimplanted neoseptum was then sutured to the nasal bones,
the ULCs, and the anterior nasal spine after creation of osse-
ous drill holes.
After trimming the cephalic portion of the LLCs and
inserting a columellar strut created from septal cartilage, the
tip was further contoured using spanning sutures combined
with a tip suspension suture with a posterior sling. Rim grafts
were then placed bilaterally, and for dorsal camouflage, three
layers of allogenic fascia lata were added to the nasal dorsum
(. Fig. 9.16).
9.2 · Case Studies: Primary Nasal Pyramid Correction

500
9
a
b
c
.
. Fig. 9.16  (a–c) Correction of deviated nasal
bridge. Frontal view, profile view, base view
pre-op/post-op

Chapter 9 · Osteotomies in Primary Rhinoplasty

501
9
9.2.9 Case 9: Asymmetrical Nasal Bridge
with Severe Septal Deviation
An 18-year-old female presented with bilateral nasal obstruc-
tion after severe childhood nasal trauma. Examination
revealed rightward deviation of the nose, a dorsal hump, and
previous fracture dislocation of the septum.
Using the external approach, the entire septum was dis-
sected and removed en bloc. A straight cartilage segment of
sufficient size was available to reconstruct the entire caudal
L-strut but not the entire dorsal L-strut. Consequently, the
dorsal L-strut was reconstructed by morselizing two
deformed pieces of cartilage and suturing them together. The
dorsal construct was then sutured to a double-layered piece
of flat cartilage. Bilateral spreader grafts were fashioned from
the cartilaginous spur and sutured to the neoseptum. Before
replacement of the neoseptum, parasagittal medial osteoto-
mies and percutaneous low-to-low lateral and transverse
osteotomies were used to mobilize the bony pyramid. The
neoseptum was then reimplanted in a more anterior position
with suture fixation to the ULCs and to the anterior nasal
spine via a drill hole. The medial crura were then sutured to
the anterior margin of the caudal septum. The tip was con-
toured with transdomal sutures and a double-layered tip
graft. Small cartilage chips were used to smooth the nasal
dorsum (. Fig. 9.17).
9.2 · Case Studies: Primary Nasal Pyramid Correction

502
9
.
. Fig. 9.17  (a–f) Asymmetrical
deviated nasal bridge. (a–c)
Extracorporeal
septal
recon-
struction. (d–f) Frontal view, pro-
file view, base view pre-op/
post-op
a
c
d
b

Chapter 9 · Osteotomies in Primary Rhinoplasty

503
9
e
f
.
. Fig. 9.17  (continued)
9.2 · Case Studies: Primary Nasal Pyramid Correction

504
9
9.2.10  Case 10: Inverted-V Deformity
A 30-year-old patient was seen after severe nasal trauma with
inverted-V deformity on the right side. After opening up the
nose, we found that this deformity had been created by a dis-
ruption and disconnection of the upper lateral cartilage from
the bony pyramid.
Next to osteotomies for narrowing and symmetrical
positioning of the nasal bones, unilateral spreader grafts
on the right side were placed to correct the inverted-V
deformity. To camouflage any irregularities of the dorsum,
a graft from the septum was placed as a dorsal onlay graft
(. Fig. 9.18).

Chapter 9 · Osteotomies in Primary Rhinoplasty

505
9
a
b
c
.
. Fig. 9.18  Correction of (a–c) Inverted-V deformity.
Frontal view, profile view, base view pre-op/post-op
9.2 · Case Studies: Primary Nasal Pyramid Correction

506
9
Suggested Reading
Bloom JD, Immermann SB, Constantinidis M. Osteotomies in the crooked
nose. Facial Plast Surg. 2011;27(5):456–66.
Daniel RK. Mastering rhinoplasty. Heidelberg: Springer; 2010.
Davis RE, Raval J.  Powered instrumentation for nasal bone reduction:
advantages and indications. Arch Facial Plast Surg. 2003;5(5):384–91.
Guyuron B. Rhinoplasty. New York: Elsevier; 2012.
Harris MO, Baker SR. Management of the wide nasal dorsum. Arch Plast
Surg. 2004;6:41–8.
Sullivan PK, Harshbarger RJ, Oneal RM. Osteotomies. In: Gunter JP, Rohrich
RJ, Adams WP, editors. Dallas rhinoplasty, vol. 1. St. Louis: Quality
Medical Publishing; 2002. p. 595–614.

Chapter 9 · Osteotomies in Primary Rhinoplasty

507
© Springer International Publishing AG 2018
W. Gubisch, Mastering Advanced Rhinoplasty,
10
Osteotomies in Secondary
Rhinoplasty
10.1
Surgical Principles of Osteotomies in
Secondary Rhinoplasty – 508
10.2
Case Studies: Secondary Nasal Pyramid Correction – 509
10.2.1
Case 1: Wide Nasal Bridge – 509
10.2.2
Case 2: Wide Nasal Bridge – 511
10.2.3
Case 3: Asymmetrical Wide Nasal Bridge – 513
10.2.4
Case 4: Deviated Nasal Pyramid Combined with Inverted-V
Deformity – 516
10.2.5
Case 5: Deviated Nasal Pyramid – 519
10.2.6
Case 6: Wide Bony Pyramid – 522
10.2.7
Case 7: Crooked Nose with Asymmetrical and Deviated Nasal
Pyramid – 525
10.2.8
Case 8: Narrow Nasal Pyramid with Inverted-V Deformity – 528

Suggested Reading – 530

508
10
10.1 Surgical Principles of Osteotomies
in Secondary Rhinoplasty
The principles of nasal pyramid correction in secondary
rhinoplasties are identical to the ones in primary rhino-
plasties.
The most common reasons for revisions are remaining
deviations or asymmetries of the bony pyramid caused by
the primary rhinoplasty. These often result from incom-
plete osteotomies or inadequate postoperative fixations.
We think that the postoperative fixation by any kind of
cast for only 1 week is often not sufficient.
Therefore, we always change the patient’s cast after 1 week,
and often there is the opportunity to correct minor deviations
during this time. A cast is applied for a second week, and in
patients with a very wide nasal pyramid, we continue to do this
for a third week to keep the bony pyramid narrow.
In terms of incomplete osteotomies, the revision has to
perform what did not work during the primary procedure.
With the technique of external osteotomies, this works nicely.
Another common failure patients complain about is
visible stair-step deformities at the lateral nasal wall.
These mostly result from a displacement of the osteoto-
mies. If these are performed just at the junction from the
nasal bone to the maxilla, the bone transection will always
be too high. This happens more often when using the low-
to-high lateral osteotomy than in a low-to-low technique;
we prefer the latter.
The neglect of the use of spreader flaps or spreader grafts
can be responsible for an unpleasant outcome of the primary
procedure. Therefore, it is essential to use one of these two
techniques in all rhinoplasties in which the dorsum has been
lowered. This also helps to prevent the occurrence of inverted-
­V deformities.

Chapter 10 · Osteotomies in Secondary Rhinoplasty

509
10
10.2 
  Case Studies: Secondary Nasal
Pyramid Correction
10.2.1  Case 1: Wide Nasal Bridge
A 25-year- old patient presented after three previous rhino-
plasties with a wide nasal pyramid and irregularities of the
dorsum after grafting with conchal cartilage.
After opening the nose, the anterior septum was found to be
overresected. Therefore, a large columellar strut, taken from the
septum, was put in a pocket in front of the anterior septal border,
and the medial crura were affixed to it. After smoothing the dor-
sum, paramedian osteotomies were performed with a
Lindemann fraise, and then low-to-low lateral and transverse
osteotomies were performed transcutaneously. As a result of this
mobilization, a satisfactory narrowing of the pyramid was pos-
sible. The dorsum was covered with two layers of allogenic fascia
(Tutogen). The tip was narrowed by transdomal sutures, and a
cap graft from fascia was put on the tip. By using fascia any vis-
ibility of the graft was avoided (. Fig. 10.1).
10.2 · Case Studies: Secondary Nasal Pyramid Correction

510
10
a
b
c
.
. Fig. 10.1  (a–c) Correction of wide nasal bridge.
Frontal view, profile view, base view pre-op/post-op

Chapter 10 · Osteotomies in Secondary Rhinoplasty

511
10
10.2.2  Case 2: Wide Nasal Bridge
A 29-year-old patient was seen after two previous rhinoplas-
ties. In addition to a loss of support from overresection of the
septum and incomplete lowering of the dorsum, the nasal
pyramid was also overly wide. The reason for the deformity
of the nasal pyramid was the extremely thick bone, which
required four chisels to cut the strong hump. Initially a
­parasagittal medial osteotomy with a Lindemann fraise was
performed after lowering the dorsum, followed by low-to-
low lateral and transverse osteotomies transcutaneously to
mobilize the pyramid and narrow it. A cast was put on for
3 weeks to guarantee the narrowing of the bones. The missing
support was achieved by a strong sandwich graft from the
concha. The tip was narrowed by transdomal sutures and
contoured by spanning sutures (. Fig. 10.2).
a
b
c
.
. Fig. 10.2  (a–e) Wide nasal bridge.
(a) Chisels destroyed by strong bony
hump. (b) Strong bony hump. (c–e)
Front view, profile view, base view
pre-op/post-op
10.2 · Case Studies: Secondary Nasal Pyramid Correction

512
10
e
d
.
. Fig.10.2  (continued)

Chapter 10 · Osteotomies in Secondary Rhinoplasty

513
10
10.2.3  Case 3: Asymmetrical Wide Nasal
Bridge
A 51-year-old patient presented after two rhinoplasties,
which were followed by nasal trauma. His complaints cen-
tered on the deviated nose, an open roof, and a wide tip with
asymmetrical nostrils. The facial skeleton was asymmetrical.
The pyramid was straightened and narrowed after
parasagittal medial osteotomy and low-to-low lateral
­osteotomy combined with a transverse osteotomy per-
formed transcutaneously. The dorsum was camouflaged
by two layers of alloplastic fascia. Narrowing the tip by
transdomal sutures was not effective because of the thick
cartilage. Therefore, both domes were divided and then
sutured together. A shield graft from the tragus was
applied. The residual parts of the tragus were used to graft
the supratip area (. Fig. 10.3).
10.2 · Case Studies: Secondary Nasal Pyramid Correction

514
10
.
. Fig. 10.3  (a–e) Correction
of asymmetrical wide nasal
bridge. (a) Removal of bony
spiculae with a chisel. (b)
Removal of bony spiculae wth a
side-cutting burr. (c–e) Front
view, profile view, base view
pre-op/post-op
a
b
c

Chapter 10 · Osteotomies in Secondary Rhinoplasty

515
10
d
e
.
. Fig.10.3  (continued)
10.2 · Case Studies: Secondary Nasal Pyramid Correction

516
10
10.2.4  Case 4: Deviated Nasal Pyramid
Combined with Inverted-V Deformity
A 20-year-old patient presented after previous rhinoplasty
with a severely deviated septum resulting in a severely devi-
ated nose. The anterior septal border subluxated to the right
and blocked the right nostril. The reason for the poor result
from the previous operation was the fact that the anterior
border was deformed and totally unstable.
Therefore, we performed an extracorporeal septal recon-
struction, resected the deformed anterior part, and recreated
a neoseptum with a straight anterior border and a straight
dorsum, strengthened and supported by two spreader grafts.
This spreader grafts also helped to overcome the inverted-V
deformity. After paramedian, low-to-low lateral, and trans-
verse osteotomies, the nasal pyramid could be narrowed and
straightened, but the prerequisite for a straight nose was the
straight neoseptum, which we had replanted after radical
mobilization of the nasal pyramid and fixed to the upper lat-
eral cartilages and the nasal bones after drilling holes there.
The neoseptum was also fixed through a drill hole to the
anterior nasal spine. The spine was very wide but dislocated
to the right; we partially resected it so that the residual spine
stood in the midline. The tip was contoured by transdomal
and spanning sutures, and the position was secured by a tip
suspension suture with a posterior sling.
After 1 year postsurgery, excess of the vestibular skin that
was not totally smoothed out could still be seen on the right
side, leaving a little irregularity. This was created by the
extreme subluxation of the septum. The patient did not want
further revision because the result was perfect for her
(. Fig. 10.4).

Chapter 10 · Osteotomies in Secondary Rhinoplasty

517
10
.
. Fig. 10.4  (a–d) Correction of deviated
nasal pyramid combined with inverted-V
deformity. (a) Extracorporeal septal
reconstruction. (b–d) Front view, profile
view, base view pre-op/post-op
a
b
10.2 · Case Studies: Secondary Nasal Pyramid Correction

518
10
c
d
.
. Fig.10.4  (continued)

Chapter 10 · Osteotomies in Secondary Rhinoplasty

519
10
10.2.5  Case 5: Deviated Nasal Pyramid
A 28-year-old female was seen after three previous rhino-
plasties. She complained about a deviation of the bony pyra-
mid and asymmetry of the columella base as well as a
subluxation of the anterior septum to the left, with a consecu-
tive asymmetry of the external nasal valve. She could not
breathe properly, and the Cottle test result was positive. After
insertion of a glass spreader and opening of the inner valve,
her breathing became normal.
From the outer aspect, there was also a malformation of
the right lower lateral cartilage.
Using an open approach with an inverted-V transec-
tion, the anterior nasal spine was found to be slightly dis-
located, but the damage was so small that there was no
reason to fracture it and to bring it in the midline. To fix
the anterior ­border of the septum properly in the midline,
we applied a four-hole microplate, which was fixed with
two microscrews; after trimming, we fixed the anterior
border to it. Thus, the septum was in the midline. We put
in a columellar strut and fixed the medial crura to it. The
narrowed inner valve was widened by putting in spreader
grafts on both sides. The deviated bony pyramid was
straightened by paramedian, external low-to-low lateral,
and transverse osteotomies. To overcome the severe con-
cavity of the lower lateral crus on the right side, we used a
fold-under flap technique. On the left side, there was only
a minor concavity that could be corrected with horizontal
mattress sutures. For stabilization, we placed a batten graft
under the left lateral crus. To give the ala a better contour,
we put in a rim graft and covered the whole dorsum with
two layers of alloplastic fascia (. Fig. 10.5).
10.2 · Case Studies: Secondary Nasal Pyramid Correction

520
10
.
. Fig. 10.5  (a–e) Correction of
deviated nasal pyramid and
concave LLCs. (a–b) Fold-under
flap on the right side, horizontal
mattress suture and batten graft
on the left side, spreader grafts
on both sides of the septum.
(c–e) Front view, profile view,
base view pre-op/post-op
a
b
c

Chapter 10 · Osteotomies in Secondary Rhinoplasty

521
10
e
d
.
. Fig.10.5  (continued)
10.2 · Case Studies: Secondary Nasal Pyramid Correction

522
10
10.2.6  Case 6: Wide Bony Pyramid
A 23-year-old male presented for revision surgery after a
severe nasal trauma in childhood. The patient complained
that he was unable to comfortably wear his eyeglasses as a
result of his nasal bridge deformity. Examination revealed a
very large nasal pyramid with an overprojected dorsum and
a retracted columella. Endonasal inspection revealed a severe
residual septal deformity.
Using the open rhinoplasty approach, the upper lateral
cartilages (ULCs) were first divided from the dorsal septum.
However, elevation of the septal flaps was challenging because
of heavy scarring and partial reduplication of the residual sep-
tal bone and cartilage fragments. Lowering the dorsum with a
chisel was avoided because the nasal bones were exceptionally
brittle and easily disrupted. Therefore, we used a powered
cylindrical drill to remove the bony hump and to successfully
create a smooth bony contour. Parasagittal medial osteoto-
mies were then created with a Lindemann burr, and the
­perpendicular plate was fractured posteriorly using a 5-mm
chisel and firm (transverse) digital pressure applied along the
desired fracture line. The residual parts of the septum were
then removed and fixed to a PDS foil scaffold. The neoseptum
was reimplanted after mobilizing and narrowing the nasal
bones with transcutaneous low-to-low lateral and transverse
osteotomies. The neoseptum was sutured to the ULCs and to
the nasal bones and the anterior nasal spine (ANS) after the
creation of osseous drill holes. The ANS was also modified
with the Lindemann burr to create a sagittally oriented groove
for better stabilization of the caudal neoseptum. For recon-
struction of the retracted columella and correction of the
overly acute nasolabial angle, a double-layered conchal sand-
wich graft was also fixed to the caudal neoseptum. The very
wide and bulky tip was narrowed using transdomal sutures
combined with spanning sutures and a tip suspension suture
with a posterior sling. The reconstruction was concluded with
placement of four layers of allogenic fascia lata (Tutoplast) as
a full-length dorsal onlay graft (. Fig. 10.6).

Chapter 10 · Osteotomies in Secondary Rhinoplasty

523
10
.
. Fig. 10.6  (a–e) Correction of
wide bony pyramid. (a)
Extracorporeal septal
reconstruction: explanted septum
with PDS-foils for reconstruction
of the internal nasal valve. (b)
Sandwich graft from the concha
used as septal extension graft.
(c–e) Front view, profile view,
base view pre-op/post-op
a
c
b
10.2 · Case Studies: Secondary Nasal Pyramid Correction

524
10
.
. Fig.10.6  (continued)
d
e

Chapter 10 · Osteotomies in Secondary Rhinoplasty

525
10
10.2.7  Case 7: Crooked Nose
with Asymmetrical and Deviated
Nasal Pyramid
A 38-year-old male presented after three previous nasal sur-
geries with an overly wide and deviated nasal pyramid and an
inverted-V deformity. The profile revealed an overprojected
tip, saddling of the cartilaginous dorsum, and a bony dorsal
hump. The base view revealed a very unnatural pointed tip
with asymmetrical nostrils.
Using the open rhinoplasty approach, dissection of the
tip revealed a severe asymmetry of the lower lateral carti-
lage (LLC). Despite the use of an open approach with previ-
ous surgery, this deformity had been unrecognized and/or
untreated. Next, the septum was dissected, and the residual
components were removed. After thinning the bony septal
components with a powered cylindrical drill bit, a straight
neoseptum was created by splinting the cartilaginous seg-
ments using the thinned ethmoid plate as a splinting graft.
The bony dorsum was then smoothed using the powered
cylindrical drill bit to create a smooth and even contour
dorsal profile. After parasagittal medial osteotomies and
percutaneous low-to-low lateral and transverse osteoto-
mies, the wide and deviated nasal pyramid was successfully
straightened and narrowed. The neoseptum was then reim-
planted in a more anterior position so that the medial crura
could be fixed to the anterior border of the septum using
the tongue-­in-­groove technique. The neoseptum itself was
fixed to the ULCs and to the nasal bones and ANS after cre-
ating osseous drill holes with the Lindemann burr. For
sculpting the tip and correcting the tip asymmetry, a unilat-
eral lateral crural overlay technique (lateral sliding tech-
nique) was performed on the right side. Transdomal sutures
and spanning sutures were then applied to narrow the tip
cartilages. After redraping the skin flap, the middle vault
saddle deformity was corrected by reimplanting pieces of
allogenic fascia that were removed during dissection of the
dorsum (. Fig. 10.7).
10.2 · Case Studies: Secondary Nasal Pyramid Correction

526
10
.
. Fig. 10.7  (a–e) Correction of a
crooked nose with asymmetrical
and deviated nasal pyramid.
(a) Severe asymetry of the LLCs. (b)
Symetrical contour of the LLCs by
suture techniques. (c–e) Front
view, profile view, base view
pre-op/post-op
a
c
d
b

Chapter 10 · Osteotomies in Secondary Rhinoplasty

527
10
e
.
. Fig.10.7  (continued)
10.2 · Case Studies: Secondary Nasal Pyramid Correction

528
10
10.2.8  Case 8: Narrow Nasal Pyramid
with Inverted-V Deformity
A 39-year-old female presented after previous rhinoplasty
with an unsatisfactory functional and cosmetic outcome. An
overly narrow dorsum with collapsed internal nasal valves
resulted in bilateral nasal airway obstruction. A C-shaped
dorsal curvature and an overresected dorsum with an
inverted-V deformity also led to a cosmetic deformity of the
nasal bridge. Additionally, an overrotated, deviated, and boxy
nasal tip with retracted soft-tissue facets and an oblique colu-
mella was observed.
Using the open rhinoplasty approach, exploration con-
firmed the clinical findings: the dorsum was extremely narrow
with collapse of both internal nasal valves, and both LLCs
exhibited buckling at the transition of the medial and interme-
diate crura. After separating the ULCs from the dorsal septum,
parasagittal medial osteotomies were created using a powered
Lindemann fraise. The bony pyramid was then mobilized
using percutaneous low-to-low lateral and transverse osteoto-
mies. Rib cartilage was then harvested and 2.0-mm wide carti-
lage strips were fabricated for use as extended spreader grafts.
Extended spreader grafts served to simultaneously straighten
the dorsum, widen the internal valves, and eliminate the
inverted-V deformity. The overprojected and overrotated tip
was then deprojected and counterrotated using the medial
crural overlay technique. This also permitted simultaneous
correction of the buckled medial crura. The overresected lat-
eral crura were then strengthened using lateral crural strut
grafts fashioned from rib cartilage, and transdomal sutures
were used to contour the nasal tip. Because of thin overlying
skin, the tip framework was also covered with a shield graft
fashioned from allogenic fascia lata. The columellar incision
was then closed with 6-0 permanent sutures, whereas all other
sutures were performed with resorbable suture material. The
residual rib cartilage was diced to a very fine consistency and
used as free diced cartilage (FDC) to augment and smooth the
dorsum and soft-­tissue triangles (. Fig. 10.8).

Chapter 10 · Osteotomies in Secondary Rhinoplasty

529
10
a
b
c
.
. Fig. 10.8  (a–c) Correction of a narrow nasal
pyramid with inverted-V deformity. Front view, profile
view, base view pre-op/post-op
10.2 · Case Studies: Secondary Nasal Pyramid Correction

530
10
Suggested Reading
Ballert JA, Park SS. Functional rhinoplasty: treatment of the dysfunctional
nasal sidewall. Facial Plast Surg. 2006;22(1):49–54.
Becker DG, Bloom J. Five techniques that I cannot live without in revision
rhinoplasty. Facial Plast Surg. 2008;24(3):358–64.
Sheen JH. Spreader graft: a method of reconstructing the roof of the middle
nasal vault following rhinoplasty. Plast Reconstr Surg. 1984;73(2):230–9.

Chapter 10 · Osteotomies in Secondary Rhinoplasty

531
IV
Tip
Contents
Chapter 11
Tip Refinement in Primary Rhinoplasty – 533
Chapter 12
Tip Refinement in Secondary Rhinoplasty – 635

533
© Springer International Publishing AG 2018
W. Gubisch, Mastering Advanced Rhinoplasty,
11
Tip Refinement in Primary
Rhinoplasty
11.1
Surgical Principles – 535
11.1.1
Nasal Tip Contour – 536
11.1.2
Projection of the Tip – 542
11.1.3
Rotation of the Tip – 549
11.2
Case Studies: Contour – 555
11.2.1
Case 1: Debulking of the Tip – 555
11.2.2
Case 2: Debulking of the Tip – 557
11.2.3
Case 3: Augmentation of the Soft Triangle – 562
11.2.4
Case 4: Contouring by Suture Technique – 564
11.2.5
Case 5: Contouring by Suture Technique After Lateral
Crural Overlay – 570
11.2.6
Case 6: Contouring by Lateral Crural Steal and Transposition – 573
11.2.7
Case 7: Contouring in a Thick LLC by Dome Division Technique – 575
11.2.8
Case 8: Contouring in a Thick LLC by Dome Division Technique – 577
11.2.9
Case 9: Technique: Contouring in a Thin-Skinned Patient
with Suture Technique and Additional Camouflaging
with Allogenic Fascia Lata and Foot Plate Resection – 579
11.3
Case Studies: Projection – 582
11.3.1
Case 10: Deprojection and Lengthening of the Nose
by Modified Lateral Sliding (Overlay) Technique – 582
11.3.2
Case 11: Deprojection by Medial Sliding – 584
11.3.3
Case 12: Deprojection by Medial and Lateral Sliding – 586
11.3.4
Case 13: Deprojection – 591
11.3.5
Case 14: Technique: Reduction Rhinoplasty with Tip
Deprojection and Correction of Concave Lateral Crura
Using the Lateral Crural (Sliding) Overlap Technique – 594
11.3.6
Case 15: Increasing the Projection by Grafting – 598
11.3.7
Case 16: Increasing the Projection – 600
11.3.8
Case 17: Increasing the Projection by Grafting – 604

11.4
Case Studies: Rotation – 606
11.4.1
Case 18: Lengthening: Derotation by Columellar Strut Combined
with Extended Spreader Grafts – 606
11.4.2
Case 19: Lengthening: Derotation by Septal Extension Graft – 607
11.4.3
Case 20: Shortening: Cranial Rotation by Tongue-in-Groove
Technique – 610
11.4.4
Case 21: Shortening: Cranial Rotation by Modified
Tongue-in-Groove Technique – 612
11.4.5
Case 22: Shortening: Cranial Rotation by Suspension
with Anterior Sling Plasty – 613
11.4.6
Case 23: Shortening: Cranial Rotation by Suspension
with Anterior Sling Plasty – 617
11.4.7
Case 24: Shortening: Cranial Rotation by Suspension
with Posterior Sling Plasty – 621
11.4.8
Case 25: Identical to Case 2 in Primary Dorsum:
Tip Correction with Fold-Under Flap Technique, Transdomal
Suture, Spanning Suture, and Tip Suspension
with Posterior Sling – 622
11.4.9
Case 26: Shortening: Cranial Rotation by External Nose Lift – 626
11.4.10 Case 27: Shortening: Cranial Rotation by Dome Division
Combined with Internal Nose Lift – 628
11.4.11 Case 28: Tip Correction by Columellar Strut
(Sandwich Graft), Lateral Crural Steal Technique, Mattress
Sutures Plus Double Layered Onlay Graft in Combination
with Premaxillary Augmentation (DC-F Graft) – 630

Suggested Reading – 634

535
11
11.1 Surgical Principles
Alterations of nasal tip contour are perhaps the most chal-
lenging aspect of cosmetic rhinoplasty. And because tip con-
tour must harmonize with the surrounding facial features in
a natural but pleasing manner, some degree of surgical tip
refinement is a goal of nearly every cosmetic rhinoplasty.
However, in addition to constituting a major determinant of
facial beauty, the tip is also an integral component of the
human nasal airway. Hence, surgical alterations to the nasal
tip framework must be circumspect in order to prevent
impairment of nasal airway function. Naturally weak tip car-
tilages are at increased risk of collapse with surgical manipu-
lation, and cartilage size may not always correspond to
cartilage strength.
In addition to surgical technique, various architectural
and biomechanical properties govern the outcome of tip
rhinoplasty. Rollin K.  Daniel differentiates between the
three intrinsic factors of volume, definition, and width and
the three extrinsic factors of position, rotation, and projec-
tion—all critical determinants of tip aesthetics. Yet, from
an analytical and utilitarian standpoint, the characteristics
of contour, rotation, and projection are perhaps the most
useful.
Although surgical changes in contour, rotation, and pro-
jection of the nasal tip framework are prerequisites for a sat-
isfactory cosmetic transformation, architectural changes can
be profoundly altered by the characteristics of the overlying
skin/soft-tissue envelope. Noses with ultrathick tip skin have
greater bulk, weight, and volume (. Fig.  11.1), which can
obscure skeletal definition, promote unwanted tip ptosis, and
resist tip narrowing. On the other hand, mild to moderate
deformities of the underlying tip framework can be dimin-
ished or even totally concealed by thick nasal skin. Conversely,
ultrathin nasal skin offers better surface definition, less bulk,
and greater ease of tip narrowing, but thin skin provides little
or no camouflage of underlying skeletal imperfections, and
shrink-wrap contracture is typically more severe in thin-
skinned noses. And although surgical changes to the skeletal
framework are still paramount, the prudent surgeon will rec-
ognize the limitations of unfavorable skin types and counsel
patients accordingly.
In addition to the impact of the overlying skin/soft-tissue
envelope on tip aesthetics, changes in the surrounding nasal
anatomy may also have an impact on nasal tip aesthetics.
Since the nose represents a complex three-dimensional
structure, surgical changes in one area may have a secondary
anatomic and/or visual impact on another. For example,
reducing dorsal height gives the illusion of nasal lengthening,
and a slight increase in tip rotation may be needed to offset
this phenomenon. Conversely, augmentation of a low radix
may create the illusion of a counterrotated tip owing to
cephalic repositioning of the nasal starting point. Since the
final cosmetic outcome is determined by the impact of direct
skeletal alterations coupled with influences of both the skin
envelope and illusory changes, the combined impact of these
factors must be carefully considered during preoperative
planning and analysis.
.
. Fig. 11.1  Debulking of the
tip
11.1 · Surgical Principles

536
11
11.1.1 Nasal Tip Contour
Nasal tip contour depends mainly on the three intrinsic fac-
tors of volume, definition, and width. The surgical options
available to change tip contour include excisional techniques,
suture techniques, or combined techniques. Because exci-
sional techniques are irreversible and destructive, they have
become increasingly less popular. Alternatively, suture tech-
niques that are potentially reversible and conserve intrinsic
skeletal support are quickly becoming the workhorse of con-
temporary rhinoplasty.
The goal of tip refinement surgery is a slender and attrac-
tive lobule while avoiding an overly pointed, “uni-tip” defor-
mity. In most noses, this requires two distinct cartilaginous
domes separated anteriorly by a small amount of soft tissue
to create a gentle rounding of the most projecting tip seg-
ment as seen from the basal view. Domal width can be
reduced with “intradomal” or “dome-unit” mattress sutures
to narrow domal angulation. However, care must be taken to
avoid overtightening of the suture, which can lead to collapse
of the lateral crus and lobular pinching. Similarly, “trans-
domal” mattress sutures can be used to bring individual
domes into closer proximity and to improve domal symme-
try, but care must be taken to place the suture posteriorly so
as to allow a slight divergence of the domes anteriorly
(. Fig.  11.2), thereby preventing unsightly pinching of the
infratip lobule. Divergence of the domal folds can also be
established using a shield graft to maintain a slight flaring of
the intermediate crura (. Fig. 11.3). In many instances, the
use of transdomal sutures may obviate the need for intra-
domal tip sutures, since domal narrowing often occurs as the
domes are sutured in closer proximity. In some cases, exces-
sive subcutaneous soft tissue can obscure tip definition to the
point that surgical debulking of the subcutaneous soft tissues
is necessary for optimal surface contour enhancement of the
tip (. Fig. 11.1). Although volume reduction can be accom-
plished with trimming of the cephalic margin, cephalic resec-
tion should be performed judiciously because overresection
of the lateral crura is one of the most common causes of post-
surgical tip deformity. The cephalic resection should be per-
formed medial to the junction of the intermediate and lateral
crus to prevent collapse and/or retraction of the lateral seg-
ment. Conservative resection is advised in all cases, but par-
ticularly with weak tip cartilages. Following resection, weak
lateral crura should be stabilized using ancillary techniques
such as onlay batten grafts, lateral crural strut grafts, or fold-­
under flaps. The last one is our preferred technique
(. Fig. 11.4). However, exceptionally thick and stiff cartilage
necessitates a combination of excisional and suture tech-
niques (. Fig. 11.5), since suture techniques alone are seldom
adequate.
Tip definition is defined by Rollin K. Daniel as the visibil-
ity or distinctive setting apart from the dome defining point
from the rest of the ala. Tip definition can be enhanced using
tip suture techniques to sculpt the tip cartilages or by placing
a shield graft to increase tip projection (. Fig. 11.3). Good tip
definition is always a goal of tip rhinoplasty. However,
­aesthetic preferences vary, and we strive to create a more or
less straight alar margin between the tip lobule and the lateral
ala as seen on basal view (. Fig. 11.6). Alar rim grafts, placed
into skin pockets dissected along the nostril rims via the
marginal incision (. Fig. 11.7), are used liberally to prevent
notching of the nostril rim (the so-called seagull deformity)
and/or retraction of the alar rim. When the need for alar rim
grafts becomes evident after skin closure, we insert the graft
via an external skin incision placed within the alar crease
(. Fig. 11.6). Graft length is variable, but when necessary, the
graft may extend all the way into the soft-tissue triangle to
prevent deformation of the entire alar rim (. Fig. 11.7).
To correct excessive tip volume and bulbosity, conserva-
tive resection of the lateral crus at the cephalic margin is a
standard part of our refinement technique. However, we per-
form the traditional cephalic resection only in thick crural
cartilages. In thin or medium-thickness cartilage, we retain
the cephalic margin as a fold-under flap to flatten and
strengthen the lateral crus (. Fig. 11.4). This is done by first
dissecting the vestibular skin off the undersurface of the lat-
eral crus and then incising the cephalic segment from above.
The excised segment is then folded under as an underlay-
ment graft such that the concave surfaces are placed face-to-­
face. The fold-under graft is then sutured with 6-0 PDS
sutures. Alternatively, to correct concavity of the lateral crus,
we suture the cephalic margin as a fold-over flap to bend the
lateral crus in the opposite direction (. Fig. 11.8). In both
cases, the retained cephalic margin serves to correct contour
deformities while simultaneously strengthening the lateral
crus against collapse. In this manner, we can later apply span-
ning sutures to control flaring without fear of deforming the
lateral crura.
Another method for strengthening the lateral crus is hor-
izontal mattress sutures (. Fig. 11.9). Using horizontal mat-
tress sutures to flatten the lateral crus simultaneously serves
to increase crural rigidity to allow placement of spanning
sutures with less risk of crural deformity (. Fig. 11.10).

Chapter 11 · Tip Refinement in Primary Rhinoplasty

537
11
a
b
.
. Fig. 11.2  (a, b) Suture
technique, preparing the
transdomal suture
.
. Fig. 11.3  Shield graft
11.1 · Surgical Principles

538
11
.
. Fig. 11.4  Combined suture/
cutting technique fold-under flap
technique (lateral crural
underlay)
.
. Fig. 11.5  Preparing ala spannning sutures

Chapter 11 · Tip Refinement in Primary Rhinoplasty

539
11
a
b
.
. Fig. 11.7  (a, b) Rim grafts
a
b
.
. Fig. 11.6  (a, b) Rim grafts
11.1 · Surgical Principles

540
11
a
b
c
.
. Fig. 11.8  (a–c) Lateral crural overlay technique

Chapter 11 · Tip Refinement in Primary Rhinoplasty

541
11
.
. Fig. 11.9  Horizontal
mattress suture
.
. Fig. 11.10  Spanning sutures combined with tip suspension suture
and posterior sling
11.1 · Surgical Principles

542
11
11.1.2 Projection of the Tip
Tip projection is an important parameter defined as the dis-
tance the nose protrudes from the face. Abnormalities in tip
projection include both overprojection and underprojection.
Typically in the overprojected tip, the patient complains
about a big nose. However, when analyzing a large nose, it is
important to differentiate between an overprojected dorsum
(nasal hump), an overprojected tip (Pinocchio nose), or both
an overprojected dorsum and an overprojected tip (rhino-
megaly). In cases of rhinomegaly where the overprojected tip
is not recognized and treated appropriately, even after a suc-
cessful dorsal realignment the nose will appear to “jump off
the face” because of the persistent and now even more obvi-
ous overprojected nasal tip. Although an isolated overpro-
jected tip is easily recognized, a normally projected tip with
an adjacent saddle-nose collapse may also give the (false)
impression of an overprojected tip. Therefore, care must also
be taken to differentiate between these two similar looking
but distinctly different contour deformities.
Early techniques for treatment of the overprojected tip
relied upon segmental excision of the nasal domes without
suture reapproximation of the alar cartilages to restore skel-
etal continuity. The result was often tip ptosis and polly-beak
formation and/or a pinched tip. However, safer and more
effective alternatives, such as the sliding techniques, are now
available. A variety of sliding techniques have been described,
including alar dome reduction (Hamra), alar cartilage over-
lap (Adamson), lateral crural overlap (Kridel/Foda), or alar
cartilage setback (Foda). All of these techniques rely upon
altering the relative length of the medial and lateral crura,
and sliding techniques can be used both medially
(. Fig. 11.11) and laterally (. Fig. 11.12). Medial sliding tech-
niques decrease tip projection while simultaneously decreas-
ing tip rotation (tip counterrotation). In contrast, lateral
sliding techniques decrease tip projection while simultane-
ously increasing tip rotation. By performing both medial and
lateral sliding techniques simultaneously, opposing changes
in tip rotation can be offset to prevent changes in tip rotation
if desired. Alternatively, the balance can also be manipulated
to achieve subtle changes in tip rotation and/or tip alignment
when necessary. The overall impact of adjusting medial or
lateral crural length can be easily understood using the “tri-
pod” model of tip dynamics as originally described by
Anderson.
Medial sliding techniques are also indicated for correct-
ing deformities involving the junction of the medial and
intermediate crura. Often a medial sliding technique is indi-
cated for correction of asymmetrical buckling at the junction
of the medial and intermediate crus, but counterrotation is
contraindicated. In this scenario, the buckled cartilage is
divided, and the cartilages are overlapped to eliminate the
buckling. However, to eliminate counterrotation, the upper
segment is rotated cephalically, creating a partial overlap and
a protruding upper segment that must be excised
(. Fig. 11.13).
Another means of achieving tip deprojection is the push-­
down technique (. Fig.  11.14). The push-down technique
involves repositioning the medial crura inferiorly in closer
proximity to the premaxilla. This works best in noses with a
protruding caudal septum, since the medial crura can be
sutured to the caudal septum for fixation. Depending upon
the natural length of the medial crura, the push-down tech-
nique can dramatically reduce tip projection without tran-
secting the tip cartilages. As adjunct to tip deprojection,
excess skin can be excised from the columella (. Fig. 11.15).
Typically, this is performed at the transcolumellar incision in
order to avoid an additional scar.
A variety of techniques are also available for increasing
tip projection. In the wide tip, a small amount of increased
tip projection is achieved simply with intradomal suture
placement (. Fig.  11.16). Columellar strut placement will
increase tip projection per se only minimally, but it does
serve to stabilize weak and underprojected tip cartilages.
And for many techniques that increase tip projection, a colu-
mellar strut is essential. One such technique is the lateral cru-
ral steal procedure. This technique recruits cartilage from the
lateral crus to elongate the medial crus and thus to increase
tip projection. This is accomplished by folding the lateral
crus at a point lateral to the existing nasal dome in order to
create a new, more projected nasal dome (. Fig.  11.17).
However, a columellar strut or equivalent graft is needed to
strengthen the medial crura and support the newly projected
domes.
Other means of increasing tip projection are augmenta-
tion grafts such as cap grafts (. Fig.  11.18), onlay grafts
(. Fig.  11.19), or even a nonintegrated shield graft
(. Fig. 11.3). However, these grafts are all associated with
the potential risk of graft visibility from gradual thinning
and/or contracture of the overlying skin. Moreover,
unsightly graft prominence can develop many years follow-
ing graft placement. Consequently, in noses with thin or
intermediate skin thickness that are at risk for excessive
graft visibility, we use a soft-­tissue overlay graft such as allo-
genic fascia lata or perichondrium to cover the cartilage
framework and prevent excessive graft prominence
(. Fig.  11.19). Finally, in cases where tip projection is
exceedingly poor, such as some ethnic noses, total recon-
struction of the nasal tip framework may be needed to
achieve adequate tip projection (. Fig. 11.20).

Chapter 11 · Tip Refinement in Primary Rhinoplasty

543
11
a
b
.
. Fig. 11.11  (a, b) Medial sliding technique
a
c
d
b
.
. Fig. 11.12  (a–d) Lateral sliding technique
11.1 · Surgical Principles

544
11
a
b
.
. Fig. 11.13  (a, b) Medial sliding with cranial rotation

Chapter 11 · Tip Refinement in Primary Rhinoplasty