595
11
i
j
e
g
f
h
.
. Fig. 11.43 (continued)
11.3 · Case Studies: Projection
596
11
l
k
.
. Fig. 11.43 (continued)
Chapter 11 · Tip Refinement in Primary Rhinoplasty
597
11
m
.
. Fig. 11.43 (continued)
11.3 · Case Studies: Projection
598
11
11.3.6 Case 15: Increasing the Projection
by Grafting
A 22-year-old female presented with a wide and underpro-
jected nasal tip.
Modest increases in tip projection often result from
suture techniques to narrow the domes, but additional tip
augmentation with onlay or cap grafts is required for greater
degrees of projection. Tip-plasty was begun with transdomal
sutures, which narrowed the domes and provided a modest
initial increase in tip projection. Additional projection was
then obtained using a cap graft. To prevent unwanted visibil-
ity of the graft edges, multiple layers of allogenic fascia lata
were then used for graft camouflage (. Fig. 11.44).
.
. Fig. 11.44 (a–d) Increasing
projection with onlay graft. (a)
Tip onlay graft from allogenic
fascia lata. (b–d) Front
view,profile view, base view
pre-op/post-op
a
b
Chapter 11 · Tip Refinement in Primary Rhinoplasty
599
11
c
d
.
. Fig. 11.44 (continued)
11.3 · Case Studies: Projection
600
11
11.3.7 Case 16: Increasing the Projection
A 43-year-old male presented with a wide, ptotic, and under-
projected nasal tip. When large increases in projection are
required in a wide tip, the lateral crural “steal” can be used.
However, the lateral crural steal requires strong central tip
support using a columellar strut or a caudal septal extension
graft for successful tip reconfiguration. In this patient, tip-
plasty was initiated with a double-layered conchal strut graft
for increased central tip support. After suturing the medial
crura and intermediate crura to the strut graft, medial
portions of the lateral crura were inverted and sewn to the
upper end of the strut graft. This served to simultaneously
elongate the central support column for increased tip projec-
tion and to narrow the domes for improved tip refinement
(. Fig. 11.45).
Chapter 11 · Tip Refinement in Primary Rhinoplasty
601
11
a
b
.
. Fig. 11.45 (a–b) Increasing of the projection by lateral crural steal technique in combination with columellar strut from sandwich graft. (c–e)
Front view, profile view, base view pre-op/post-op
11.3 · Case Studies: Projection
602
11
c
d
.
. Fig. 11.45 (continued)
Chapter 11 · Tip Refinement in Primary Rhinoplasty
603
11
e
.
. Fig. 11.45 (continued)
11.3 · Case Studies: Projection
604
11
11.3.8 Case 17: Increasing the Projection
by Grafting
When even greater tip projection is required, a new and
larger tip framework can be constructed on top of the natural
tip tripod. This approach worked effectively in this 56-year-
old female with a substantially underprojected ethnic nose
(. Fig. 11.46).
.
. Fig. 11.46 (a–c) Increasing
of the projection by complex
grafts from septal cartilage in
combination with soft tissue
graft
a
b
Chapter 11 · Tip Refinement in Primary Rhinoplasty
605
11
c
.
. Fig. 11.46 (continued)
11.3 · Case Studies: Projection
606
11
11.4 Case Studies: Rotation
11.4.1 Case 18: Lengthening: Derotation
by Columellar Strut Combined
with Extended Spreader Grafts
Lengthening of the nose requires counterrotation of the
nasal tip framework. However, counterrotation of the nasal
tip is often limited or even prohibited by noncompliant and
inelastic nasal skin. Therefore, when elongating the nasal
framework, the counterrotated tip must be supported with
extended spreader grafts to avoid upward tip displacement
from an inelastic or a contracting skin envelope. In this
scenario, a columellar strut graft is stabilized using bilateral
extended
spreader
grafts
for
maximum
stability
(. Fig. 11.47).
a
b
.
. Fig. 11.47 (a, b)
Lengthening = derotation by
columellar strut and extended
spreader grafts
Chapter 11 · Tip Refinement in Primary Rhinoplasty
607
11
11.4.2 Case 19: Lengthening: Derotation
by Septal Extension Graft
At present our preferred technique for nasal elongation is a
septal extension graft as advocated by Rick Davis.
A 41-year-old female presented with an overly short but
severely overprojected nose and a low radix. The nasolabial
angle was also overly obtuse. Bilateral concavities of the lat-
eral crura were also seen on inspection.
Using the open rhinoplasty approach, the dorsum was
lowered using a component hump reduction technique as
follows: after extramucosal dissection and separation of the
ULCs from the dorsal septum, the cartilaginous septum was
lowered with straight scissors. The bony dorsum was then
resected level with the newly established profile line using a
sharpened chisel. A large piece of cartilage was then harvested
from the quadrangular septum and used to create a septal
extension graft (SEG). The SEG was secured using side-to-
side suture fixation to the caudal septum. To create symmetry
with the nasal dorsum, the previously resected cartilaginous
hump was also used as a spreader graft on the opposite side.
After narrowing the bony pyramid using parasagittal medial
osteotomies and percutaneous low-to-low lateral and trans-
verse osteotomies, the overprojected ULCs were used to cre-
ate spreader flaps and sutured flush with the new dorsal line.
The medial crura were then advanced caudally and sutured
to the leading edge of the SEG in a tongue-in-groove configu-
ration. To eliminate the lateral crural concavities, cephalic
fold-under flaps were performed bilaterally. Owing to the
patient’s extremely thin and shiny nasal skin, the domes were
then covered with a single layer of allogenic fascia lata
(. Fig. 11.48).
.
. Fig. 11.48 (a–d) Derotation (lengthening) with septal extension graft and camouflaging the tip with allogenic fascia lata. (e–g) Front view,
profile view, base view pre-op/post-op
a
b
c
d
11.4 · Case Studies: Rotation
608
11
e
f
.
. Fig. 11.48 (continued)
Chapter 11 · Tip Refinement in Primary Rhinoplasty
609
11
g
.
. Fig. 11.48 (continued)
11.4 · Case Studies: Rotation
610
11
11.4.3 Case 20: Shortening: Cranial Rotation
by Tongue-in-Groove Technique
A 48-year-old male presented with pronounced tip ptosis result-
ing from childhood trauma. Treatment of tip ptosis required tip
rotation, which resulted in a reduction of nasal length. However,
because decreasing nasal length is not influenced by the skin
soft-tissue envelope, tip rotation is typically much easier than
counterrotation. A reliable and exacting procedure for increas-
ing tip rotation is the tongue-in-groove technique, in which the
medial crura are sutured to the caudal septum for precise tip
repositioning. Noses with a protrusive caudal septum allow for
greater versatility in tip positioning, but the tongue-in-groove
technique may result in considerable tip rigidity (. Fig. 11.49).
a
b
.
. Fig. 11.49 (a) Cranial
rotation (shortening) by
tongue-in-groove technique.
(b–d) Front view,profile view,
base view pre-op/post-op
Chapter 11 · Tip Refinement in Primary Rhinoplasty
611
11
d
c
.
. Fig. 11.49 (continued)
11.4 · Case Studies: Rotation
612
11
11.4.4 Case 21: Shortening: Cranial Rotation
by Modified Tongue-in-Groove
Technique
A 27-year-old female presented for primary rhinoplasty with
an overly long nose. Surgical exploration revealed inadequate
septal length for execution of the tongue-in-groove technique.
Using a modification described by Marten, the anterior septal
border was sharply divided from the caudal septum, but the
attachments to the nasal spine were preserved. The severed
segment was then hinged caudally and secured using
extended spreader grafts, thereby lengthening the caudal
septum and facilitating use of the tongue-in-groove tech-
nique (. Fig. 11.50).
.
. Fig. 11.50 (a, b) Modified tongue-in-groove technique
a
b
Chapter 11 · Tip Refinement in Primary Rhinoplasty
613
11
11.4.5 Case 22: Shortening: Cranial Rotation
by Suspension with Anterior Sling
Plasty
A 22-year-old female presented with an oversized and
conspicuous nose. Examination revealed an overprojected
dorsum, an overly long nose, and a short upper lip. Treatment
began with cephalic fold-under flaps to strengthen the lateral
crura, and tip rotation was increased using the lateral crural
steal technique. A shield graft covered with soft tissue was
used for additional tip contouring. The repositioned tip was
then stabilized using a tip suspension suture with an anterior
sling (. Fig. 11.51).
11.4 · Case Studies: Rotation
614
11
a
b
.
. Fig. 11.51 (a, b) Tip suspension suture with anterior sling, knot covered with shield graft. (c–e) Reduction rhinoplasty with shorthening the
length by tip rotation. Front view, profile view, base view pre-op/post-op
Chapter 11 · Tip Refinement in Primary Rhinoplasty
615
11
c
d
.
. Fig. 11.51 (continued)
11.4 · Case Studies: Rotation
616
11
e
.
. Fig. 11.51 (continued)
Chapter 11 · Tip Refinement in Primary Rhinoplasty
617
11
11.4.6 Case 23: Shortening: Cranial Rotation
by Suspension with Anterior Sling
Plasty
A 54-year-old female presented with an overly long and
overprojected nose. The nasolabial angle was hyperacute,
measuring only about 45°. The radix was also underpro-
jected, and the left alar rim was retracted. Intraoperative
exploration revealed severe malformation of the right LLC
with a concave lateral crus and buckling of the intermediate
crus. Using an open rhinoplasty approach, we first corrected
the crural malformation using a cephalic fold-under flap and
horizontal mattress sutures to flatten the buckled segment.
The overprojected dorsum was then lowered using a compo-
nent technique, and the bony hump was resected using a
power drill. Before using the overprojected ULC to create
spreader flaps, a columellar strut graft was harvested from
the quadrangular septum. The graft was placed in a separate
pocket anterior to the caudal septum in order to augment
the retracted columella, and the medial crura were then
sutured to the strut graft in a tongue-in- groove configura-
tion. To reduce nasal length, a suspension suture with an
anterior sling was placed to rotate the tip complex. This tech-
nique enabled us to adjust the nasolabial angle to the precise
degree. The radix was then augmented with a tragal cartilage
graft, and a composite graft was used to correct the alar
retraction. However, the composite graft failed to adequately
correct the retraction, and therefore the cartilaginous por-
tion of the composite graft was used as a unilateral rim graft
(. Fig. 11.52).
11.4 · Case Studies: Rotation
618
11
a
b
Knot of the anterior sling
for suspension
.
. Fig. 11.52 (a) Tip correction by fold-under flap and additional horizontal mattress sutures on the right side. (b) Cranial rotation by tip suspen-
sion suture with anterior sling. (c–e) Shortening the nasal length by suture technique: front view, profile view, base view pre-op/post-op
Chapter 11 · Tip Refinement in Primary Rhinoplasty
619
11
c
d
.
. Fig. 11.52 (continued)
11.4 · Case Studies: Rotation
620
11
e
.
. Fig. 11.52 (continued)
Chapter 11 · Tip Refinement in Primary Rhinoplasty
621
11
11.4.7 Case 24: Shortening: Cranial Rotation
by Suspension with Posterior Sling
Plasty
A 32-year-old female presented with modest tip ptosis.
Increased tip rotation was achieved using only a tip suspen-
sion suture with a posterior sling (. Fig. 11.53).
.
. Fig. 11.53 Tip suspension
suture with posterior sling
11.4 · Case Studies: Rotation
622
11
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
An 18-year-old female presented with a narrow and overpro-
jected dorsum, a wide nasal tip, and obstruction of the nasal
airway. On profile examination, the nasolabial angle was
overly obtuse (130°).
Using the external rhinoplasty approach, tip refinement
began with cephalic fold-under flaps of the lateral crura
followed by transdomal tip sutures to reduce tip width. The
domes were temporarily stabilized in the desired position by
pinning the cartilages transversely with a small-caliber nee-
dle until transdomal suture placement was complete. After
strengthening the lateral crura with cephalic fold-under
flaps, spanning sutures were used to reduce crural flaring
without risking iatrogenic collapse. Finally, the residual
septal cartilage was finely diced and injected beneath the skin
flap (via the marginal incisions after closing the columellar
incision) to smooth and refine the outer nasal contour
(. Fig. 11.54).
a
b
.
. Fig. 11.54 (a–d) Tip
correction with fold-under flap
transdomal suture, spanning
suture and tip suspension suture
with posterior sling. (e–g) Front
view, profile view, base view
pre-op/post-op
Chapter 11 · Tip Refinement in Primary Rhinoplasty
623
11
c
d
.
. Fig. 11.54 (continued)
11.4 · Case Studies: Rotation
624
11
f
e
.
. Fig. 11.54 (continued)
Chapter 11 · Tip Refinement in Primary Rhinoplasty
625
11
g
.
. Fig. 11.54 (continued)
11.4 · Case Studies: Rotation
626
11
11.4.9 Case 26: Shortening: Cranial Rotation
by External Nose Lift
A 59-year-old female presented with severe tip ptosis and
nasal skin laxity. Owing to an extreme abundance of nasal
skin, the rhino-lift procedure was used to simultaneously
increase tip rotation and reduce the excess nasal skin. The
external skin excision was performed using a trapezoidal
shape in order to limit lateral extension of the scar. In addi-
tion to increasing tip rotation for a satisfactory cosmetic
result, the patient also experienced better nasal airflow. At
the same time the tip was narrowed. Because of the thick
sebbaceus skin a dome division technique was used
(. Fig. 11.55).
.
. Fig. 11.55 (a–c) External
nose lift
b
a
Chapter 11 · Tip Refinement in Primary Rhinoplasty
627
11
c
.
. Fig. 11.55 (continued)
11.4 · Case Studies: Rotation
628
11
11.4.10 Case 27: Shortening: Cranial
Rotation by Dome Division
Combined with Internal Nose Lift
A 41-year-old female presented with a large ptotic nose.
Previously we preferred endonasal techniques for rhino-
plasty. However, in this case we performed a complete trans-
fixion incision and resected a strip of the membranous septal
skin to shorten the nose. Vertical dome division was then
used to increase tip rotation and to narrow the tip. Although
the cosmetic result was satisfactory, we have since abandoned
this method because it is far less precise and reproducible
compared with the contemporary suture-based technique
(. Fig. 11.56).
a
.
. Fig. 11.56 (a–c) Internal
nose lift
Chapter 11 · Tip Refinement in Primary Rhinoplasty
629
11
b
c
.
. Fig. 11.56 (continued)
11.4 · Case Studies: Rotation
630
11
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)
A 51-year-old female presented with a long nose and a
ptotic nasal tip. Examination revealed an overly acute
(45°) nasolabial angle from a retruded maxilla, a short-
ened columella, and collapse of the right lateral crus. Using
the open rhinoplasty approach, a DC-F graft fashioned
from autologous temporalis fascia and conchal cartilage
was first used to augment the premaxilla. Tip support and
rotation were then increased using a double-layered con-
chal strut graft from the contralateral ear. Tip rotation and
refinement were further enhanced using the lateral crural
steal technique. The right crural concavity was eliminated
using the cephalic margins of both sides as a double-layered
augmentation graft, and prophylactic augmentation grafts
were placed into both soft-tissue facets because of the high
risk of facet deformity from extreme tip rotation
(. Fig. 11.57).
Chapter 11 · Tip Refinement in Primary Rhinoplasty
631
11
.
. Fig. 11.57 (a–b) Fabricating a DCF for maxillary augmentation,
correction of right concave lateral crus by horizontal mattress sutures
followed by double layered onlay grafts from both cephalic portions.
Columellar strut from double layered conchal graft. (c–e) Front view,
profile view, base view pre-op/post-op
a
Concavity of the right lateral crus
b
11.4 · Case Studies: Rotation
632
11
d
c
.
. Fig. 11.57 (continued)
Chapter 11 · Tip Refinement in Primary Rhinoplasty
633
11
e
.
. Fig. 11.57 (continued)
11.4 · Case Studies: Rotation
634
11
Suggested Reading
Adamson PA, Litner JA, Dahyia R. The M-arch model: a new concept of
nasal tip dynamics. Arch Facial Plast Surg. 2006;8:16–25.
Aiach G. Atlas of rhinoplasty: open and endonasal approaches. 2nd ed. St.
Louis: Quality Medical Publishers; 2003.
Anderson JR. A new approach to rhinoplasty. Trans Am Acad Opthalmol
Otolaryngol. 1966;70:183–92.
Anderson JR. The dynamics of rhinoplasty. Presented at: Proceedings of
the Ninth International Congress in Otolaryngology, 10–14 Aug
1969; Mexico City. Exerpta Medica; International Congress Series 206,
Amsterdam, 1970.
Byrd S, Andochick HS, Copit SA, Walton KG. Septal extension grafts: a
method of controlling tip projection shape. Plast Reconstr Surg.
1997;100:999–1010.
Chang DCW, Davis RE. The anchor graft: a novel technique in rhinoplasty.
Arch Facial Plast Surg. 2008;10(1):50–5.
Constantian MB. The boxy nasal tip, the ball tip and alar cartilage malposi-
tion: variation on a theme—a study in 200 consecutive primary and
secondary rhinoplasty patients. Plast Reconstr Surg. 2004;30:487–99.
Constantinidis M, Liu ES, Miller PJ, Adamson PA. Vertical lobule division in
rhinoplasty: maintaining an intact strip. Arch Facial Plast Surg.
2001;3(4):258–63.
Daniel RK. Anatomy and aesthetics of the nasal tip. Plast Reconstr Surg.
1992;89:216.
Daniel RK. Rhinoplasty: open tip suture techniques: a 25-year experience.
Facial Plast Surg. 2011;27:213–24.
Davis RE. Lateral crural tensioning for refinement of the wide and under-
projected nasal tip: rethinking the lateral crural steal technique.
Facial Plast Surg Clin N Am. 2015;23(1):23–53.
Foda HMT, Kridel RWH. Lateral crural steal and lateral crural overlay: an
objective
evaluation.
Arch
Otolaryngol
Head
Neck
Surg.
1999;125:1365–70.
Gruber RP, Nahai F, Bogdan MA, Friedman GD. Changing the convexity
and concavity of nasal cartilages and cartilage grafts with horizontal
mattress sutures: part I. Experimental results. Plast Reconstr Surg.
2005;115:589–94. Part II. Clinical results. Plast Reconstr Surg.
2005;115:595–605. Aesth Plast Surg. 2008;31:772–8.
Gubisch W, Eichhorn-Sens J. The sliding technique: a technique to treat
the overprojected nasal tip. Aesth Plast Surg. 2009;33:6–13.
Gunter JP, Rohrich RJ, Adams WP. Nasal surgery by the masters. St. Louis:
Quality Medical Publishers; 2002.
Guyuron B. Rhinoplasty. Edinburgh: Elsevier; 2010.
Hamra ST. Crushed cartilage over alar dome reduction in open rhino-
plasty. Plast Reconstr Surg. 1993;92(2):352–6.
Katira K, Guyuron B. Contemporary techniques for effective nasal length-
ening. Facial Plast Surg Clin N Am. 2015;23(1):81–91.
Kridel RWH, Scott B, Foda HMT. The tongue-in-groove technique in septo-
rhinoplasty: a ten-year experience. Arch Facial Plast Surg.
1999;1(4):246–56.
Marten T. Caudal septal transposition strut for columella strengthening
and tip support. Beauty through science congress, June 4–6, 2015,
Stockholm, 2015.
Pastorek NJ, Bustillo A, Murphy MR, Becker GD. The extended columellar
strut-tip graft. Arch Facial Plast Surg. 2005;7(3):176–84.
Perkins SW, Sufyan AS. The alar spanning suture: a useful tool in rhino-
plasty to refine the nasal tip. Facial Plast Surg. 2011;13(6):421–4.
Row-Jones J. Refining the nasal tip: an anatomical approach. Facial Plast
Surg. 2014;30(2):113–22.
Timperley D, Stow N, Srubiski A, Harvey R, Marcells G. Structured nasal tip
refinement. Arch Facial Plast Surg. 2010;12(5):298–304.
Toriumi DM. New concepts in nasal tip contouring. Arch Facial Plast Surg.
2006;8:156–85.
Warner JW, Adamson P. The crooked nasal tip. Facial Plast Surg.
2011;27:442–55.
Chapter 11 · Tip Refinement in Primary Rhinoplasty
635
© Springer International Publishing AG 2018
W. Gubisch, Mastering Advanced Rhinoplasty,
12
Tip Refinement in Secondary
Rhinoplasty
12.1
Surgical Principles in Secondary Tip Correction – 637
12.2
Case Studies – 640
12.2.1
Case 1: Suture and Shield Grafts – 640
12.2.2
Case 2: Alar Reconstruction with Septal Cartilage – 643
12.2.3
Case 3: Fold-Under Flap Combined with Lateral Crural Overlay – 646
12.2.4
Case 4: Combination Columellar Strut/Cephalic Fold-Under Flap/Sus-
pension Suture with Anterior Sling – 650
12.2.5
Case 5: Technique: Supratip Excision – 653
12.2.6
Case 6: Reconstruction of the Lower Framework with Septum via Bend-
ing Technique – 657
12.2.7
Case 7: Reconstruction of the Lower Framework with Septum via Bend-
ing Technique – 661
12.2.8
Case 8: Reconstruction of the Lower Framework with Septum via Bend-
ing Technique – 664
12.2.9
Case 9: Reconstruction of the Lower Framework with Septum via Bend-
ing Technique – 667
12.2.10 Case 10: Reconstruction of the Lower Framework with Septum
via Bending Technique – 670
12.2.11 Case 11: Reconstruction of the Lower Framework with Septum
via Bending Technique – 673
12.2.12 Case 12: Reconstruction of the Lower Framework with Septum
via Bending Technique – 677
12.2.13 Case 13: Reconstruction of the Lower Framework with Septum via Bat-
ten Graft Technique – 681
12.2.14 Case 14: Reconstruction of the Lower Framework with Septum via Bat-
ten Graft Technique – 683
12.2.15 Case 15: Reconstruction of the Lower Framework with Septum via Bat-
ten Graft Technique – 686
12.2.16 Case 16: Reconstruction of the Lower Framework with Septum via Bat-
ten Graft Technique – 690
12.2.17 Case 17: Reconstruction of the Lower Framework with Septum via Bat-
ten Graft Technique – 692
12.2.18 Case 18: Reconstruction of the Lower Framework with Septum via Bat-
ten Graft Technique – 695
636
12
12.2.19 Case 19: Reconstruction of the Lower Framework with Septum via Batten Graft Technique – 698
12.2.20 Case 20: Reconstruction of the Lower Framework with Septum via Batten Graft Technique – 701
12.2.21 Case 21: Correcting the Lower Framework with Septum via Batten Graft Technique – 704
12.2.22 Case 22: Reconstruction of the Lower Framework with Septum via Batten Graft Technique – 707
12.2.23 Case 23: Reconstruction of the Lower Framework with Rib Grafts – 712
12.2.24 Case 24: Reconstruction of the Lower Framework with Rib Grafts – 716
12.2.25 Case 25: Reconstruction of the Lower Framework with Rib Grafts – 720
12.2.26 Case 26: Reconstruction of the Lower Framework with Rib Grafts – 723
12.2.27 Case 27: Reconstruction of Tip Projection by Sandwich Graft, Combined with Lateral Crural Steal
Technique – 728
12.2.28 Case 28: Increasing Projection by Grafting – 731
12.2.29 Case 29: Reconstruction of Tip Support with Conchal Graft (Sandwich) – 734
12.2.30 Case 30: Deprojection with Simultaneous Correction of Dysplastic LLCs by Medial Crural Overlap
(Medial Sliding) – 738
12.2.31 Case 31: Deprojection by Medial Crural Overlap (Medial Sliding) – 739
12.2.32 Case 32: Deprojection by Medial Crural Overlap (Medial Sliding) – 740
12.2.33 Case 33: Deprojection by Medial Crural Overlap (Medial Sliding) – 742
12.2.34 Case 34: Deprojection by Medial Crural Overlap (Medial Sliding) – 744
12.2.35 Case 35: Deprojection by Lateral Crural Overlap (Lateral Sliding) – 748
12.2.36 Case 36: Complex Tip Reconstruction with Deprojection and Lengthening by Sandwich Graft, Com-
bined with Push Down, Reconstruction of the Missing Dome with Ear Cartilage – 751
12.2.37 Case 37: Deprojection by Lateral Crural Overlap (Lateral Sliding) and Setback by Septal Extension
Graft – 755
12.2.38 Case 38: Deprojection Combined with Cranial Rotation by Septal Extension Graft – 757
12.2.39 Case 39: Deprojection Combined with Cranial Rotation and Total Reconstruction of the Lower
Framework – 761
12.2.40 Case 40: Deprojection by Lateral Crural Overlap Combined with Sandwich Graft Working as a Sep-
tal Extension Graft – 765
12.2.41 Case 41: Lengthening by Columellar Strut and Extended Spreader Grafts, Reconstruction of the
Lower Framework with Septal Cartilage – 769
12.2.42 Case 42: Lengthening by Septal Extension Graft – 773
12.2.43 Case 43: Lengthening by Combination from Sandwich Graft and Septal Extension Graft – 777
12.2.44 Case 44: Lengthening by Two Doublelayered Sandwich Grafts from both Conchae – 779
12.2.45 Case 45: Shortening by Tip Suspension Suture with Anterior Sling, Additionally Columella
Shortening – 783
12.2.46 Case 46: Shortening by Sandwich Graft for Tip Support – 786
12.2.47 Case 47: Shortening by Combination of Different Techniques – 790
12.2.48 Case 48: Shortening by Combination of Different Techniques – 793
12.2.49 Case 49: Correction of Hanging Columella with Columellar Strut from Double-Layered Conchal
Cartilage (Sandwich Graft) Plus Double-Layered Shield Graft and Soft-Tissue Graft – 797
12.2.50 Case 50: Correction of Hanging Columella with Columellar Strut and Extended Spreader Grafts,
Total Reconstruction of the Lower Framework – 801
Suggested Reading – 805
637
12
12.1 Surgical Principles in Secondary Tip
Correction
The principles of tip rhinoplasty are largely the same for both
primary and secondary rhinoplasty. However, in revision
surgery, a shortage of inner or outer nasal lining frequently
limits re-expansion of a foreshortened and/or underprojected
tip framework. Although release of the external skin envelope
with wide-field dissection may help to recruit additional
external lining, a scarred and contractured internal lining is
often the limiting factor in nasal re-expansion. In many cases,
the nose was initially shortened by resecting portions of the
internal nasal lining. Wide undermining alone seldom pro-
vides adequate soft-tissue lengthening, and relaxing incisions
may be needed to obtain additional length. In stubborn cases,
it is often useful to institute soft-tissue stretching exercises in
order to pre-expand the nasal soft tissues. This is accom-
plished by having the patient repeatedly pull downward on
the membranous septum, as well as on the outer nose, for
20–30 min daily over a period of at least 3 months. Sustained
and repeated stretching will gradually increase soft-tissue
compliance and length similar to tissue expansion.
The most common challenge encountered in secondary
tip rhinoplasty is overresection of the tip cartilaginous frame-
work—the lower lateral cartilages (LLCs), the nasal septum,
or both. Overresection of the LLCs originates from the mis-
conception that a smaller and more refined tip contour will
result merely from cartilage excision. Ironically, aggressive
cartilage excision will often have the opposite effect, resulting
in poor definition, skeletal destabilization, and unpredictable
cartilage collapse. In many cases, collapse will result in tip
droop and polly-beak formation, further exacerbating the
adverse cosmetic consequences.
To restore the overresected tip framework, the LLCs must
be strengthened and reshaped using autologous cartilage
grafts. In our hands, the preferred material for tip restoration
is septal cartilage. Surplus septal cartilage is frequently avail-
able following “aesthetic rhinoplasty,” in which the septum
remains untouched. We usually thin the stripes of septal
cartilage in the area of the intermediate crus with a motor
drill so that bending becomes easier (. Fig. 12.1). In cases of
previous septal cartilage depletion, we prefer autologous rib
or ear cartilage as alternatives. Rib cartilage can be easily and
precisely contoured using a motorized drill for thinning and
smoothing. In younger patients, progressive surgical thinning
of the rib graft on one side enables folding of the cartilage
without fracture. Folded rib cartilage can be used to replace
the nasal domes in reconstruction of overresected tip carti-
lages (7 see Chap. 4). In contrast, with many older patients or
in partially calcified rib specimens, the bending technique
often results in unwanted fractures at the domal fold. When
fractures are partial, scoring of the adjacent cartilage some-
times permits additional bending to create a suitable dome
unit (. Fig. 12.2). In contrast, when the fracture is complete,
the grafts are managed similar to a vertical dome division
(. Fig. 12.3). In the occasional patient, the septal cartilage is
extremely thick, enabling the distal columellar strut to be split
in two and allowing for replacement of damaged nasal domes
(. Fig. 12.4). When only segments of the lateral crura are
missing, these are replaced with batten grafts (. Fig. 12.5).
Another problem in revision tip surgery, especially in
thick-skinned noses, is insufficient contracture and adhe-
sion of the skin envelope to the underlying skeletal frame-
work. The result is an imbalance in size between the nasal
skin envelope and the skeletal framework, ultimately result-
ing in the formation of dead space and poor soft-tissue defi-
nition. To avoid this problem, either the skeletal framework
must be increased in size to stretch the skin envelope or the
skin envelope must be reduced in size to improve surface
contour and definition. Many patients confronted with this
dilemma refuse skeletal enlargement because they are seek-
ing a smaller nose. In those cases that result in poor tip defi-
nition and/or supratip fullness (often with polly-beak
formation), a supratip skin excision can be helpful. A precise
midline fusiform excision of full-thickness skin and subcu-
taneous soft tissue, followed by a subcutaneous closure, is
used to enhance tip definition and minimize surface
scarring (. Fig. 12.6).
12.1 · Surgical Principles in Secondary Tip Correction
638
12
.
. Fig. 12.1 Bending technique
.
. Fig. 12.2 Scoring technique
.
. Fig. 12.3 Dome division technique
.
. Fig. 12.4 Split technique
Chapter 12 · Tip Refinement in Secondary Rhinoplasty
639
12
.
. Fig. 12.5 Batten graft technique
a
b
.
. Fig. 12.6 (a, b) Supratip excision
12.1 · Surgical Principles in Secondary Tip Correction
640
12
12.2 Case Studies
12.2.1 Case 1: Suture and Shield Grafts
A 37-year-old female presented after previous septorhino-
plasty with a 10-mm septal perforation, inadequate tip pro-
jection, and a persistent dorsal hump (. Fig. 12.7). Using the
open rhinoplasty approach and careful dissection at the
ULC/dorsal septal junction, the septal perforation was
repaired using the four-flap technique. Surgical exploration
also revealed an unstructured mass of cartilage fragments
within the nasal tip. The mass was divided vertically in the
midline, and a double-layered (conchal) sandwich graft was
then placed to stabilize and straighten the medial crura. After
lowering the dorsum with a component technique, the over-
projected upper lateral cartilages (ULCs) were invaginated
and sutured to the dorsal septum as spreader flaps. The tip
was then contoured by using horizontal mattress sutures to
shape the scar-embedded cartilage fragments. A double-
layered shield graft and bilateral alar rim grafts were then
placed for better tip projection and tip contour, followed by a
tip suspension suture to suspend and immobilize the tip
complex.
a
b
.
. Fig. 12.7 (a–b) Tip
contouring with double-layered
shield graft, horizontal mattress
sutures, and bilateral alar rim
grafts. (c–e) Front view, profile
view, base view pre-op/post-op
Chapter 12 · Tip Refinement in Secondary Rhinoplasty
641
12
c
d
.
. Fig. 12.7 (continued)
12.2 · Case Studies
642
12
e
.
. Fig. 12.7 (continued)
Chapter 12 · Tip Refinement in Secondary Rhinoplasty
643
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12.2.2 Case 2: Alar Reconstruction
with Septal Cartilage
A 26-year-old female presented for revision rhinoplasty
complaining of an unattractive nasal profile (. Fig. 12.8).
Examination revealed facial asymmetry; a polly-beak defor-
mity with a narrow, overprojected, and deviated dorsum; and
pinching of the internal nasal valves. Using the external rhino-
plasty approach, nasal exploration revealed heavy subcutane-
ous scarring and asymmetry of the lateral crura caused by
overresection of the right crus and inadequate resection of the
left. An overprojected and irregular dorsum was lowered to
create a straight and smooth dorsal profile. Spreader flaps
were then used to reconstitute the middle vault and eliminate
internal valve collapse. The bony vault was also reshaped with
bilateral osteotomies. Strips of autologous septal cartilage
were then harvested to reconstruct the right intermediate and
lateral crura, and transdomal sutures were used to contour the
tip. Tip rotation was stabilized using a tip suspension suture
with a posterior sling, and alar rim grafts were used for alar
contour enhancement. The reconstructed tip complex was
then covered with a double-layered allogenic fascia lata graft.
.
. Fig. 12.8 (a) Overresected
lateral crus right, inadequate
trimming of the lateral crus left.
(b) Reconstruction of the right
overresected lateral crus by
septal batten graft, then ala
spanning sutures. (c–e) Front
view, profile view, base view
pre-op/post-op
a
b
12.2 · Case Studies
644
12
c
d
.
. Fig. 12.8 (continued)
Chapter 12 · Tip Refinement in Secondary Rhinoplasty