Mastering Advanced Rhinoplasty

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.
. Fig. 11.16  Intradomal
sutures (identical with dome
defining suture (RK Daniel))
.
. Fig. 11.17  Lateral crural steal technique

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11
.
. Fig. 11.18  Cap graft from cartilage
.
. Fig. 11.19  Cap graft from fascia
11.1 · Surgical Principles

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11
.
. Fig. 11.20  Reconstruction of
a new lower framework from
strips of septal cartilage, fixed to
a columellar strut from the
septum

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11.1.3 Rotation of the Tip
The extent of tip rotation governs the absolute length of the
nose. According to Jack Gunter, nasal length is defined as the
distance separating the nasal starting point from the tip
defining point. Positioning of the nasal starting point can be
altered by either raising or lowering radix height. Increasing
radix height by augmenting the nasion will result in cephalic
repositioning of the nasal starting point, whereas lowering
the nasion will deproject the radix and shift the nasal starting
point caudally. Although repositioning the nasal starting
point is cosmetically significant, these changes are primarily
visual, since the absolute distance from the nasal tip to the
brow ridge does not change. However, unlike changes in
radix height, which fail to alter absolute nasal length, changes
in tip rotation physically alter absolute nasal length. For
instance, when tip rotation is increased, the lobule is reposi-
tioned cephalically and absolute nasal length is decreased.
Conversely, when the nasal tip is counterrotated (i.e., reduced
tip rotation), the lobule moves away from the nasal starting
point, and absolute nasal length is increased. For this reason,
changes in tip rotation can be used to correct an overly long
or short nose. The overly short and upturned “piggy” nose is
highly objectionable because it results in excessive nostril
show, whereas the overly long nose is often characterized by
a droopy and aged appearance. Because tip rotation is largely
governed by tip support, a droopy nasal tip may also be asso-
ciated with an acute nasolabial angle, which is often an indi-
cator of inadequate tip support.
One of the most difficult challenges in rhinoplasty is nasal
lengthening. Even in primary rhinoplasty, it is usually far
more difficult to lengthen the nose than to shorten it, since
the soft-tissue envelope and scar contracture often resist sub-
stantial nasal elongation. Previously we used the closed rhi-
noplasty approach in conjunction with a complete transfixion
incision to lengthen the nose. However, this approach typi-
cally cut all tip support mechanisms, resulting not only in
counterrotation of the tip but also in tip deprojection and
ultimately in tip ptosis. While this approach can be used for
modest nasal lengthening, the procedure is imprecise and
unpredictable. Moreover, using finger pressure applied to the
nasolabial angle to predict the drooping of the tip and the
extent of nasal lengthening is equally unreliable and will only
provide a crude estimate of counterrotation. Finally, weaken-
ing of septal support may also lead to some degree of tip
counterrotation. However, trimming the anterior septum is
both destructive and imprecise and is ill-advised. On the
other hand, using the medial crural sliding overlay technique
will produce noticeable counterrotation, but at the expense
of tip deprojection. Consequently, this approach for nasal
lengthening should be reserved for short, overprojected
noses (. Fig. 11.21).
At present we prefer the external rhinoplasty approach
for nasal lengthening, and cartilage augmentation grafts are
our preferred method for creating precise increases in nasal
length. For modest increases in nasal length, a shield graft, or
several layers of shield graft, can be used to counterrotate the
tip and create modest increases in nasal length (. Fig. 11.22).
However, for sizable increases in nasal length, the most effec-
tive technique in our hands is to lengthen the entire carti-
laginous framework. One approach for aggressive lengthening
is to place an ultrawide columellar strut graft in which the
upper half is much broader than the typical columellar strut
graft. The best graft for this purpose is the double-layered
conchal sandwich graft (. Fig.  11.23). Owing to the extra
graft width and double-layered graft construction, the con-
chal sandwich graft can be positioned and secured to the cau-
dal septum using a tongue-in-groove fixation. In addition to
providing a strong and stable union, tongue-in-groove fixa-
tion to the caudal septum serves to buttress the elongated tip
against upward displacement by a tight or inelastic skin enve-
lope. For noses that require even greater elongation, we use
extended spreader grafts to maintain positioning of a colu-
mellar strut graft (. Fig. 11.24). Alternatively, septal cartilage
can be used to create a septal extension graft for aggressive
nasal elongation (. Fig. 11.25). There are two different ways
to fix such a graft: end to end or side to side. Using an end-to-­
end fixation, the septal extension graft must be contoured
carefully so that it fits precisely with the anterior septal bor-
der. To provide a strong fixation to the septum, we prefer
using either a splinting graft of perpendicular ethmoid bone
or extended spreader grafts for tip stabilization. Alternatively,
a side-to-side fixation is possible, which gives a firmer con-
struction, but by overlapping cartilages, a slight asymmetry
may result.
In contrast to nasal lengthening, decreasing nasal length is
not restricted by soft-tissue elasticity. Modest decreases in nasal
length can be achieved by increasing tip rotation. Historically
this has been accomplished with excision of the cephalic mar-
gin of the lateral crus—the so-called “cephalic trim” procedure.
Although this technique simultaneously reduces tip volume
and potentially facilitates cephalic tip rotation, it also frequently
results in unsightly upward retraction of the alar rims. Because
of that possible complication, the cephalic trim should be
regarded as an unreliable and unpredictable technique for tip
rotation. Shortening the nose by excising a vertical strip of ves-
tibular skin or nasal mucosa and trimming the caudal septum
are other destructive procedures that should be reserved for
extreme circumstances in which severe tissue excess justifies
potentially irreversible tissue excision.
Our preference for modest reductions in nasal length is to
rotate the nasal tip using suspension sutures. In noses with
cartilage of sufficient rigidity, we often combine the suspen-
sion suture with a spanning suture to prevent the lateral cru-
ral flaring that results from aggressive tip rotation
(. Fig. 11.10). However, with weak tip cartilages, the com-
bined suture may result in concave collapse of the lateral
crura. Consequently, in noses with weak tip cartilage, the lat-
eral crura must first be strengthened with cephalic fold-
under (. Fig.  11.4) or fold-­over flaps (. Fig.  11.8) or with
augmentation grafts such as ­crural batten grafts. When using
the combined suture, a spanning suture is placed first and
then knotted to preserve the desired tip contour. The same
suture is then sewn to the dorsal septum, tightened to achieve
11.1 · Surgical Principles

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11
the appropriate degree of tip rotation, and knotted a second
time to suspend the tip (7 see Fig. 11.10).
When pure tip rotation is desired without changes in lat-
eral crural contour, we use nonresorbable 4-0 monofilament
suspension sutures without the combined spanning suture.
Two suspension options are available: suspension with a pos-
terior sling (. Fig. 11.26) or suspension with an anterior sling
(. Fig. 11.27). Although the posterior sling utilizes a deeply
buried and fully hidden knot, the anterior sling offers easier
insertion and greater precision with an increased risk of a
visible subcutaneous knot.
For this purpose, R.K. Daniel uses a suture catching the
posterior part of the medial crura and fixing them to the
anterior border of the septum (called a tip position suture).
Fixation of the medial crura to the anterior septal border
by the tongue-in-groove technique is also very effective to
control tip rotation. This technique requires a long septum.
Therefore, we always try to avoid shortening the anterior sep-
tum in case we want to apply this technique for a precise tip
rotation. The disadvantage of the tongue-in-groove technique
is the loss of natural mobility. Therefore, some patients com-
plain about unnatural stiffness, which is a high but acceptable
price to be sure that the tip does not droop (. Fig. 11.28).
If the anterior border of the septum is far behind so that
such a tongue-in-groove technique would lead to an
­overrotated tip, the following technique advised by Tim
Marten is possible: the anterior border of the septum is cut but
stays pedicled to the periosteum of the premaxilla. Then this
strip of cartilage is down-rotated until the medial crura can be
fixed to it in the planned way. To fix this amount of rotation,
the new position of this anterior septal border is anchored by
extended spreader grafts. Alternatively, a thin splint from the
perpendicular plate is also possible for fixation.
Specifically in older patients in whom an excess of skin
exists that will not shrink after cranial rotation and may lead
to additional wrinkles, a nose lift (. Fig. 11.29) at the root of
the nose will not only remove the excess of skin but will also
be an additional technique for cranial rotation of the tip,
especially if the undermined skin envelope of the nose is
fixed to the frontal periosteum.
The tongue-in-groove technique and the tip suspension
techniques, specifically in the modification with the ante-
rior sling, enable us to position the tip and to anchor it by
nonresorbable sutures so that there is no chance of droop-
ing. This was a common problem in the older techniques
that used a closed approach because the sacrificed support
mechanisms could not be reconstructed properly. With
these new suspension techniques, by using an open
approach, polly-beak deformity as a result of drooping of
the tip can be avoided.
.
. Fig. 11.21  Medial sliding technique
a
b
.
. Fig. 11.22  (a, b) Shield grafts

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.
. Fig. 11.23  Sandwich graft from the concha
.
. Fig. 11.24  Extended spreader grafts with columellar strut
11.1 · Surgical Principles

552
11
.
. Fig. 11.25  Septal extension graft, end to end-fixation with extended spreader grafts
.
. Fig. 11.26  Tip suspension
suture with posterior sling

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11
a
c
b
.
. Fig. 11.27  (a–c) Tip suspension suture with anterior sling
11.1 · Surgical Principles

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11
.
. Fig. 11.28  Tongue-in-groove technique
.
. Fig. 11.29  External nose lift

Chapter 11 · Tip Refinement in Primary Rhinoplasty

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11
11.2 Case Studies: Contour
11.2.1 Case 1: Debulking of the Tip
A 19-year-old female presented for primary rhinoplasty. On
examination, the profile view revealed an overly short nose
and a low nasal dorsum. On frontal view, a wide and bulky
nasal tip was observed.
Using the external rhinoplasty approach, a large fat pad
was removed from between the lower lateral cartilages.
Nasal length was increased using a columellar strut graft
buttressed by bilateral extender spreader grafts. Spanning
sutures were also used for further tip refinement. The
­dorsum was augmented with three layers of allogenic fascia
lata (. Fig. 11.30).
.
. Fig. 11.30  (a–d) Debulking
of the tip. (a) Removal of the
intercrural fat pad. (b–d) Front
view, profile view, base view
pre-op/post-op
a
b
11.2 · Case Studies: Contour

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11
c
d
.
. Fig. 11.30  (continued)

Chapter 11 · Tip Refinement in Primary Rhinoplasty

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11
11.2.2 Case 2: Debulking of the Tip
An 18-year-old female presented with an overprojected dor-
sum and a wide nasal pyramid that made it difficult for her to
comfortably wear eyeglasses. The tip was also very bulky.
Using an open rhinoplasty approach, we first removed a
large interdomal fat pad. After dividing the ULCs from the
dorsal septum, we harvested septal cartilage for fabrication of
a columellar strut graft. The bony dorsum was then lowered
with a carbide rasp, and the dorsal septum was trimmed with
a straight scissors. A thick Lindemann burr was used to cre-
ate parasagittal (medial) osteotomies and to widen both oste-
otomy cuts by 1.5 mm for more aggressive bone narrowing.
The bony pyramid was then successfully narrowed using per-
cutaneous low-to-low lateral and transverse osteotomies. The
overprojected ULCs were then invaginated and sewn flush
with the cartilaginous dorsum as spreader flaps. A columellar
strut graft was placed into a small pocket created between the
medial crura. Vestibular skin pockets were also dissected on
the underside of the lateral crura, leaving the skin attached
along a 2.0-mm strip at the caudal margin. The cephalic mar-
gins of the lateral crura were then marked and cut and turned
under the lateral crura, where they were fixated with suture.
Transdomal sutures were also placed near the cephalic mar-
gins of both domes in order to narrow the domes but pre-
serve the divergence. Lateral crural flaring was controlled
using a spanning suture. A rim graft was placed to shape the
alar margin, and after closing the transcolumellar incision,
the nasion was augmented using free diced cartilage (FDC)
injected through a tuberculin syringe (. Fig. 11.31).
11.2 · Case Studies: Contour

558
11
.
. Fig. 11.31  (a) Debulking. (b) Transdomal (= interdomal) suture
after fold-under flaps (= lateral crural underlay). (c) Rim graft.
(d) ­Spanning suture fixed to the dorsal septum (tip suspension suture
with posterior sling). (e–g) Narrowing the tip: Front view, profile view,
base view pre-op/post-op
a
b

Chapter 11 · Tip Refinement in Primary Rhinoplasty

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11
.
. Fig. 11.31  (continued)
d
c
11.2 · Case Studies: Contour

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11
e
f
.
. Fig. 11.31  (continued)

Chapter 11 · Tip Refinement in Primary Rhinoplasty

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11
g
.
. Fig. 11.31  (continued)
11.2 · Case Studies: Contour

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11
11.2.3 Case 3: Augmentation of the Soft
Triangle
A 28-year-old female with facial asymmetry presented for
primary rhinoplasty. Examination revealed a deviated
nose with a prominent rhinion hump. Inspection of the
nostrils revealed retraction of the left alar rim with accen-
tuation of the soft-tissue facet and pronounced nostril
asymmetry.
Using the external rhinoplasty approach, rightward sublux-
ation of the caudal septum was corrected by midline reposi-
tioning and suture fixation to the anterior nasal spine. Following
hump reduction, the dorsum was narrowed and straightened
using parasagittal and lateral (low-to-low) osteotomies. Tip
refinement was achieved using a cephalic trim, transdomal and
spanning sutures, and a tip suspension suture with a posterior
sling. The overly prominent soft-­tissue facet was augmented
using remnants of the cephalic resection (. Fig. 11.32).
.
. Fig. 11.32  (a–c)
Augmentation of the soft triangle
and ­lowering the retracted ala.
Front view, profile view, base
view pre-op/post-op
a
b

Chapter 11 · Tip Refinement in Primary Rhinoplasty

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11
c
.
. Fig. 11.32  (continued)
11.2 · Case Studies: Contour

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11
11.2.4 Case 4: Contouring by Suture
Technique
A 36-year-old female with tip bifidity and an overly
wide columellar pedestal presented for primary rhino-
plasty.
Tip-plasty was accomplished using both transdomal and
spanning sutures. The overly wide columella was treated by
resecting the intercrural component of the depressor septi
muscle, dividing both medial crura just proximal to the cru-
ral footpods and then using transseptal mattress sutures to
narrow the columellar pedestal (. Fig. 11.33).

Chapter 11 · Tip Refinement in Primary Rhinoplasty

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11
.
. Fig. 11.33  (a–j) Suture techniques with ten years follow-up : Transdomal suture with columellar strut
a
b
11.2 · Case Studies: Contour

566
11
c
d
.
. Fig. 11.33  (continued)

Chapter 11 · Tip Refinement in Primary Rhinoplasty

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11
e
f
.
. Fig. 11.33  (continued)
11.2 · Case Studies: Contour

568
11
g
h
.
. Fig. 11.33  (continued)

Chapter 11 · Tip Refinement in Primary Rhinoplasty

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11
i
j
.
. Fig. 11.33  (continued)
11.2 · Case Studies: Contour

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11
11.2.5 Case 5: Contouring by Suture
Technique After Lateral Crural
Overlay
A 25-year-old female presented with rhinomegaly in which
the entire nose was overly large. The nasal skin was also noted
to be exceptionally thin. Treatment necessitated lowering
dorsal height and tip projection, tip refinement, and narrow-
ing the columellar pedestal.
Using the open approach, the dorsum was lowered with a
component (split) technique in which various components
are resected individually. In this case, the upper lateral carti-
lages were preserved and used as spreader flaps for middle
vault reconstruction. Owing to weak lower lateral cartilages
and bilateral crural concavities, the cephalic margins (and
the perichondrium) were used as fold-over flaps to stiffen the
lower lateral cartilages and simultaneously eliminate the cru-
ral concavities. Tip projection was reduced using a tongue-­
in-­groove setback (or “push-down”) technique, and the
soft-tissue facets were augmented with bruised septal carti-
lage grafts. Tip rotation was stabilized using a tip suspension
suture with a posterior sling. Owing to exceptionally thin
nasal skin, a single layer of allogenic fascia lata was used to
ensure a smooth dorsal contour (. Fig. 11.34).

Chapter 11 · Tip Refinement in Primary Rhinoplasty

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11
.
. Fig. 11.34  (a–d) Fold-over
flap technique (lateral crural
overlay). (a) Marking the cephalic
portion, incising the cartilage
from below, the flipped over and
fixed cephalic part of the LLC
a
b
11.2 · Case Studies: Contour

572
11
c
d
.
. Fig. 11.34  (continued)

Chapter 11 · Tip Refinement in Primary Rhinoplasty

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11
11.2.6 Case 6: Contouring by Lateral Crural
Steal and Transposition
A 29-year-old female presented with a bulbous and overly
round nasal tip. Pinched alae were observed caused by
cephalic malposition of both lateral crura. From the frontal
view, an hourglass-type deformity led to disruption of the
dorsal aesthetic lines.
Using an open rhinoplasty approach, the vestibular skin
was dissected off the undersurface of both lateral crura. The
cephalic portion of the lateral crus was then trimmed and
folded under the residual lateral crus and sutured into posi-
tion. After sharply dividing both ULCs from the dorsal sep-
tum and removing the deviated central septum, the bony
dorsum was lowered using a carbide rasp, and the cartilagi-
nous dorsum was trimmed with straight scissors. Parasagittal
(medial) osteotomies were performed using a powered
­Lindemann burr, and percutaneous low-to-low lateral and
transverse osteotomies were then performed to narrow the
bony vault. The overprojected ULCs were then used to create
spreader flaps and sewn flush to the dorsal septal line for cor-
rection of the hourglass-type dorsal deformity.
After placement of a columellar strut graft harvested
from the septum, both medial crura were sutured to the graft.
A lateral crural steal technique was performed to increase tip
projection and narrow the lobule. The lateral crura were also
transposed inferiorly, the cephalic portion was flipped under
and then they were sutured into position for elimination of
alar pinching (seagull deformity). Additionally, rim grafts
were placed (. Fig. 11.35).
.
. Fig. 11.35  (a) Tip correction
by fold-under flap with lateral
crural steal and transposition.
(b–d) Front view, profile view and
base view pre-op/post-op
a
b
11.2 · Case Studies: Contour

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11
c
d
.
. Fig. 11.35  (continued)

Chapter 11 · Tip Refinement in Primary Rhinoplasty

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11
11.2.7 Case 7: Contouring in a Thick LLC
by Dome Division Technique
A 57-year-old female presented with a very wide nasal tip
and ultrathick lower lateral cartilages. Owing to excessive
cartilage thickness, tip suture techniques alone were inade-
quate. Consequently, tip refinement was accomplished using
a cephalic trim and vertical dome division followed by imme-
diate suture reapproximation of the divided domes. By divid-
ing the ultrathick tip cartilages, the lobule was narrowed
sufficiently to produce a smaller, more attractive, and natural-­
appearing nasal tip (. Fig. 11.36).
.
. Fig. 11.36  (a) Tip correction
with dome division technique.
(b–c) Front view, profile view and
base view pre-op/post-op
a
b
11.2 · Case Studies: Contour

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11
c
d
.
. Fig. 11.36  (continued)

Chapter 11 · Tip Refinement in Primary Rhinoplasty

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11
11.2.8 Case 8: Contouring in a Thick LLC
by Dome Division Technique
A 19-year-old female presented with an overly wide and
bulky nasal tip and thick tip cartilage. Tip-plasty included
cephalic trim to reduce cartilage bulk, columellar strut place-
ment to maintain tip support, vertical dome division with
reanastomosis to narrow the lobule, and placement of alar
rim grafts to ensure contour stability (. Fig. 11.37).
.
. Fig. 11.37  (a–d) Tip correction with dome division technique. (a) Defining the dome before division, placing a columellar strut, inserting a rim
graft. (b–d) Front view, profile view, base view pre-op/post-op
a
b
11.2 · Case Studies: Contour

578
11
c
d
.
. Fig. 11.37  (continued)

Chapter 11 · Tip Refinement in Primary Rhinoplasty

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11
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
In the thin-skinned nose, there is a greater risk of skeletal
irregularities becoming visible through the overlying skin.
This problem is best prevented by avoiding imperfections in
the skeletal framework. However, when minor irregularities
are unavoidable, camouflage of the skeletal imperfections
with an onlay of allogenic fascia lata will typically result in a
smooth and even outer nasal contour.
This fascia graft is first rehydrated in antibiotic solution
before the final thickness can be determined. It has an excel-
lent structure with parallel collagen fibers and can be used as
a multilayered onlay graft.
A 22-year-old female presented for primary rhinoplasty
with ultrathin nasal skin and weak tip cartilages. Tip-plasty
began with lateral crural fold-under flaps to stiffen the natu-
rally weak lateral crura against collapse. Crural stiffening
then permitted the use of lateral crural spanning sutures to
control flaring. However, tip narrowing led to an unwanted
increase in tip projection that was eliminated using a
tongue-­in-­groove setback. To stabilize the alar rims and
prevent alar retraction, alar rim grafts were also used.
Finally, owing to the overly thin nasal tip skin, the entire tip
complex was draped in allogenic fascia lata for camouflage
(. Fig. 11.38).
11.2 · Case Studies: Contour

580
11
.
. Fig. 11.38  (a) Tip and dorsum camouflage with allogenic fascia lata. (b–d) Front view, profile view, base view pre-op/post-op
a
b

Chapter 11 · Tip Refinement in Primary Rhinoplasty

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11
c
d
.
. Fig. 11.38  (continued)
11.2 · Case Studies: Contour

582
11
11.3 Case Studies: Projection
11.3.1 Case 10: Deprojection
and Lengthening of the Nose
by Modified Lateral Sliding (Overlay)
Technique
A 23-year-old female presented with an overprojected tip
and dorsum and an obtuse nasolabial angle. Hence, both
deprojection and counterrotation of the tip were needed.
Tip-plasty was accomplished using a modified lateral
crural overlay technique. Unlike the classic lateral crural
overlay technique in which the divided crural segments
remain in perfect longitudinal alignment, in the modified
version the medial segments are angled 40° caudally to facili-
tate counterrotation of the tip (. Fig. 11.39).
b
a
.
. Fig. 11.39  Modified lateral
sliding (overlay) technique with
derotation of the tip. (a)
Overprojected tip. (b) Lateral
sliding (crural overlay) technique
through a closed approach. (c–d)
Profile view, base view pre-op/
post-op

Chapter 11 · Tip Refinement in Primary Rhinoplasty

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11
c
d
.
. Fig. 11.39  (continued)
11.3 · Case Studies: Projection

584
11
11.3.2 Case 11: Deprojection by Medial
Sliding
A 49-year-old female presented with a strongly overprojected
tip and dorsum. Although deprojection of the tip and dor-
sum was planned, no change in tip rotation was desired.
Since the classic medial crural overlap technique results in
counterrotation of the tip, a modified technique was used for
tip deprojection in which the deprojected segment is rotated
cephalically to prevent derotation. After suture fixation of the
overlapping medial crura, a protruding triangle of cartilage
was excised to restore the columellar profile (. Fig. 11.40).
.
. Fig. 11.40  (a–e) Deprojection by medial crural overlay (sliding) technique. (a) Planning of the medial sliding (overlay). (b) Simultaneous cranial
rotation creates an excess at the anterior border. (c–e) Front view, profile view, base view pre-op/post-op
a
b
c

Chapter 11 · Tip Refinement in Primary Rhinoplasty

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11
d
e
.
. Fig. 11.40  (continued)
11.3 · Case Studies: Projection

586
11
11.3.3 Case 12: Deprojection by Medial
and Lateral Sliding
A 41-year-old female presented with an overprojected tip
and dorsum and satisfactory tip rotation. Tip deprojection
was performed using a combined medial and lateral crural
overlap technique in order to avoid changes in tip rotation.
Ten-year follow-up (. Fig. 11.41)
.
. Fig. 11.41  (a) Medial sliding
(crural overlay). (b) Contouring
the tip. (c) Lateral sliding (crural
overlay). (d–f) Front view, profile
view, base view pre-op/post-op.
(g–i) Ten-year follow-up
a
b

Chapter 11 · Tip Refinement in Primary Rhinoplasty

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11
d
c
.
. Fig. 11.41  (continued)
11.3 · Case Studies: Projection

588
11
e
f
.
. Fig. 11.41  (continued)

Chapter 11 · Tip Refinement in Primary Rhinoplasty

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11
g
h
.
. Fig. 11.41  (continued)
11.3 · Case Studies: Projection

590
11
i
.
. Fig. 11.41  (continued)

Chapter 11 · Tip Refinement in Primary Rhinoplasty

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11
11.3.4 Case 13: Deprojection
A 30-year-old female presented with a bulbous and overpro-
jected tip and retraction of both soft-tissue facets. Both alae
were pinched, and the bony pyramid was asymmetrical from
lateral displacement of the left nasal bone.
Using an open rhinoplasty approach, the septal angle was
exposed, and both ULCs were divided from the dorsal sep-
tum. After elevating mucosal tunnels over the quadrangular
septum, a piece of septal cartilage was harvested for use as a
columellar strut graft and for creation of diced cartilage. The
depressor septi muscle was then partially resected, and after
dissecting the vestibular skin from the LLCs, a lateral crural
overlap procedure was performed. Reference marks were
placed at the domes as well as at 10.0 mm and 15 mm lateral to
the domes. The lateral crura were then divided vertically at the
10.0-mm reference mark and then overlapped and sutured at
the 15.0-mm reference mark. A columellar strut graft was then
inserted to augment tip support. For improved tip contour, a
transdomal suture was also used to narrow the domes. The
nasal pyramid was straightened and narrowed using (internal)
parasagittal medial osteotomies followed by percutaneous
low-to-low lateral and transverse osteotomies. After suturing
the nasal skin flap back into position, the final camouflage and
contour were established with free diced cartilage created
from the remaining cartilage graft material (. Fig. 11.42).
.
. Fig. 11.42  (a–f) Deprojection by lateral crural overlay (sliding) technique. (g) Tip contouring with transdomal suture. (h–i) Dorsal refinement
with free diced cartilage (FDC). (j–l) Front view, profile view, base view pre-op/post-op
a
b
c
d
e
f
11.3 · Case Studies: Projection

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11
g
h
i
j
.
. Fig. 11.42  (continued)

Chapter 11 · Tip Refinement in Primary Rhinoplasty

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11
k
l
.
. Fig. 11.42  (continued)
11.3 · Case Studies: Projection

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11
11.3.5 Case 14: Technique: Reduction
Rhinoplasty with Tip Deprojection
and Correction of Concave Lateral
Crura Using the Lateral Crural
(Sliding) Overlap Technique
A 36-year-old female presented with an overprojected and
pinched tip and an overprojected dorsum seeking reduction
rhinoplasty. Using an open rhinoplasty approach, the dorsal
septum was dissected in a submucosal plane allowing for
extramucosal separation of the ULC from the septal carti-
lage. Blunt dissection was then used to release the ULC from
the undersurface of the nasal bones in the area of planned
hump resection. The cartilaginous septum was lowered with
scissors, and the bony hump was resected with a sharpened
chisel. The resulting open roof was so large that no parame-
dian osteotomy was necessary. The bony pyramid was then
narrowed by percutaneous (low-to-low) lateral and trans-
verse osteotomies, bilaterally. The overprojected ULCs were
invaginated medially to form spreader flaps and then fixed to
the septum to fill the open roof and to reconstitute the mid-
dle vault for attractive dorsal aesthetic dorsal lines.
Additionally, the spreader flaps served to reshape the internal
nasal valves for optimal function. Tip refinement was begun
by placing a columellar strut graft and shaping the domes
with intradomal and dome equalization sutures. Then a lat-
eral crural (sliding) overlap technique was used to deproject
the tip and to simultaneously correct concavities of both lat-
eral crura. By using the lateral crural overlap technique, the
lateral crura were also strengthened so that spanning sutures
could be applied to control crural flaring without fear of con-
cave collapse. Rim grafts were then inserted and free diced
cartilage was used for final smoothing of the dorsum and for
augmentation of the soft triangles (. Fig. 11.43).
.
. Fig. 11.43  Reduction rhinoplasty. (a–d) Tip deprojection and
­correcting the concavity by lateral crural overlay (sliding) technique.
(e–f) Hump reduction using the component technique. (g–i) Lateral and
transverse osteotomies. (j) Placing a columellar strut. (k–m) Front view,
profile view, base view pre-op/post-op
a
c
d
b

Chapter 11 · Tip Refinement in Primary Rhinoplasty