645
12
e
.
. Fig. 12.8 (continued)
12.2 · Case Studies
646
12
12.2.3 Case 3: Fold-Under Flap Combined
with Lateral Crural Overlay
A 25-year-old male presented for revision rhinoplasty
(. Fig. 12.9). Examination revealed a polly-beak profile
deformity and external valve collapse during inspiration. On
frontal view, the nose was canted to the patient’s right side,
and on basal view an oblique columella resulted in nostril
asymmetry. Using the external approach, the overprojected
cartilaginous dorsum was lowered and reconstructed with
spreader flaps. The tip was strengthened with fold-under
flaps (lateral crural underlay technique) on both sides, and
tip symmetry was achieved using a one-sided lateral crural
overlap technique. The tip was further contoured using a
shield graft harvested from the tragus, and alar rim grafts
were placed bilaterally.
.
. Fig. 12.9 (a–e) Tip
reconstruction with fold-under
flaps on both sides combined
with an overlap technique on the
left. Additional shield graft. (f–h)
Front view, profile view, base
view pre-op/post-op
a
b
Chapter 12 · Tip Refinement in Secondary Rhinoplasty
647
12
c
d
e
.
. Fig. 12.9 (continued)
12.2 · Case Studies
648
12
f
g
.
. Fig. 12.9 (continued)
Chapter 12 · Tip Refinement in Secondary Rhinoplasty
649
12
h
.
. Fig. 12.9 (continued)
12.2 · Case Studies
650
12
12.2.4 Case 4: Combination Columellar Strut/
Cephalic Fold-Under Flap/Suspension
Suture with Anterior Sling
A 30-year-old female presented after unsuccessful rhino-
plasty with nasal obstruction (. Fig. 12.10). Examination
revealed a deformed (oblique) anterior septum obstructing
both nasal passages, and the right nostril was observed to
collapse on gentle inspiration. The tip was bulbous, wide, and
ptotic, with unusually thick skin and poor definition, and the
dorsum was overprojected.
Using the open rhinoplasty approach, the residual sep-
tum was removed, and spreader grafts were used to create a
straight neoseptum. After dorsal hump reduction and oste-
otomies, the neoseptum was replaced and sutured to the
ULCs, nasal bones, and anterior nasal spine (ANS) using
drill holes. Following columellar strut placement, the lateral
crura were strengthened using cephalic fold-under flaps. A
suspension suture with an anterior sling, combined with
spanning sutures, was then used for tip rotation and con-
touring.
.
. Fig. 12.10 (a–e)
Extracorporeal septal
reconstruction, cephalic
fold-under flaps. (a) Severe septal
deformity. (b) Extracorporeal sep-
tal reconstruction, cephalic
fold-under flaps. (c–e) Front view,
profile view, base view pre-op/
post-op
a
b
Chapter 12 · Tip Refinement in Secondary Rhinoplasty
651
12
c
d
.
. Fig. 12.10 (continued)
12.2 · Case Studies
652
12
e
.
. Fig. 12.10 (continued)
Chapter 12 · Tip Refinement in Secondary Rhinoplasty
653
12
12.2.5 Case 5: Technique: Supratip Excision
In cases of tip refinement with very thick and scarred tip
skin, shrinkage and adherence of the skin envelope to the
reduced cartilaginous framework is often incomplete and
prone to dead space formation and additional subcutaneous
scarring (. Fig. 12.11). In order to achieve an attractive tip
profile, there are only two options to eliminate this problem:
either enlarge the framework to stretch the scarred and thick-
ened tip skin or reduce the size of the nasal skin envelope.
Since most patients will refuse a bigger nose to achieve better
tip contour, reduction of the skin envelope may be advisable.
To reduce skin volume and tighten the skin envelope, a
supratip elliptical skin excision is performed in the midline
just behind the tip-defining point. When the amount of skin
excision is judged correctly, the wound edges collapse auto-
matically and need almost no suturing. Only a subcutaneous
suture approximation and supportive taping are required.
A 40-year-old female presented with a conspicuous polly-
beak deformity after two previous rhinoplasties. The tip skin
was extremely thick and sebaceous. The nostrils were also
asymmetrical, and the endonasal examination revealed a
septal deviation to the left and a subluxation of the caudal
septum to the right. The right lateral crus also appeared to
have been overresected.
Using an open rhinoplasty approach, the scars on the tip
framework and the dorsum were removed, but the skin flap
was not thinned. The caudal septum was then shortened at its
base and sutured back to the ANS through transverse osse-
ous drill holes. Harvesting of the left concha cartilage was
challenging because of previous otoplasty, but it was still pos-
sible to fabricate a double-layered sandwich graft from the
left ear. The graft was placed in the membranous septal
pocket using a percutaneous columellar guiding suture and
then sutured to the caudal septum as a septal extension graft.
The weak lateral crura were then augmented with onlay bat-
ten grafts fashioned from ear cartilage on the left side and
septal cartilage on the right. To improve tip contour, a nonin-
tegrated shield graft was placed so that the graft projected
slightly higher than the domes. As the final step, a longitudi-
nal supratip skin excision was performed to eliminate the
stubborn polly-beak deformity.
a
b
c
.
. Fig. 12.11 (a) Scarred tip.
(b) Contouring the tip with
suture technique. (c) Non
integrated shield graft to support
the contouring. (d ) Supratip
excision: technical details.
(e–g) Polly-beak correction with
supratip excision. Front view,
profile view, base view pre-op/
post-op
12.2 · Case Studies
654
12
d
.
. Fig. 12.11 (continued)
Chapter 12 · Tip Refinement in Secondary Rhinoplasty
655
12
e
f
.
. Fig. 12.11 (continued)
12.2 · Case Studies
656
12
g
.
. Fig. 12.11 (continued)
Chapter 12 · Tip Refinement in Secondary Rhinoplasty
657
12
12.2.6 Case 6: Reconstruction of the Lower
Framework with Septum via Bending
Technique
A 27-year-old female presented drooped tip with overpro-
jected dorsum after previous operation (. Fig. 12.12).
After opening the nose via external approach resection of
both intermediate and both lateral crura has been revealed.
The septum was intact, so that after separating the ULC
both upper and lower tunnels have been dissected, the dor-
sum was lowered then the central part of the septum has
been harvested, leaving back a 25 mm wide framework. The
bony pyramid was narrowed after low-to-low lateral, para-
sagittal medial, and transcutaneus transverse osteotomies.
The excess of the ULC, which resulted from lowering the
dorsal septum, was invaginated and fixed to the septum as
spreader flaps. Two long strips from septal cartilage have
been fixed to the residual medial crural, a columellar strut
has been put in between the thin septal cartilage strips could
be bended in the dome area, fixed by intradomal sutures and
then the lateral part has been fixed directly to the scars on top
of the vestibular skin. The contour was shaped by spanning
suture, which has been fixed to the dorsal septum (tip sus-
pension suture with posterior sling). A shield graft was placed
and two layers of allogenic fascia covered the dorsum.
.
. Fig. 12.12 (a–c) Reconstruction of the lower framework with bending technique using septal cartilage. (d–f) Front view, profile view, and
base view preoperative and 17 months postoperative
a
12.2 · Case Studies
658
12
.
. Fig. 12.12 (continued)
b
c
Chapter 12 · Tip Refinement in Secondary Rhinoplasty
659
12
.
. Fig. 12.12 (continued)
d
e
12.2 · Case Studies
660
12
f
.
. Fig. 12.12 (continued)
Chapter 12 · Tip Refinement in Secondary Rhinoplasty
661
12
12.2.7 Case 7: Reconstruction of the Lower
Framework with Septum via Bending
Technique
A 29-year-old female presented for revision rhinoplasty after
two previous failed attempts at rhinoplasty elsewhere
(. Fig. 12.13). The patient sought correction of the C-shaped
dorsal curvature, pinching of the dorsum, and poor tip pro-
jection. Using the open rhinoplasty approach, an S-shaped
curvature of the dorsal septum was observed. Correction of
the crooked L-strut involved shortening the caudal septum at
its base so that it fit into the sagittal groove of the nasal spine,
followed by suture fixation of the caudal septum. The carti-
laginous dorsum was then lowered and reconstituted using
spreader flaps to straighten and widen the middle vault. Strips
of septal cartilage were then used to reconstruct the deformed
nasal domes previously treated with vertical dome division.
The newly created domes were then stabilized with a shield
graft. Because of exceptionally thin nasal skin, the tip con-
struct was also covered with two layers of allogenic fascia lata.
.
. Fig. 12.13 (a–b)
Reconstruction of the
overresected LLCs with septal
cartilage using bending
technique. (c–e) Front view,
profile view, base view pre-op/
post-op
a
b
12.2 · Case Studies
662
12
c
d
.
. Fig. 12.13 (continued)
Chapter 12 · Tip Refinement in Secondary Rhinoplasty
663
12
e
.
. Fig. 12.13 (continued)
12.2 · Case Studies
664
12
12.2.8 Case 8: Reconstruction of the Lower
Framework with Septum via Bending
Technique
A 24-year-old male presented for revision surgery after two
previous rhinoplasties elsewhere (. Fig. 12.14). He com-
plained of a feminized nose with overresection of the dor-
sum, tip deformity, and alar retraction. Using the open
approach, the tip framework was found to be severely dam-
aged. Autologous septal cartilage was used to create narrow
strips for tip reconstruction using the bending technique.
Paired grafts were first sutured to the medial crura and then
carefully thinned at the domes using a motorized drill
equipped with a diamond fraise. This enabled folding of the
grafts to create neodomes, which were then further con-
toured using transdomal sutures. The opposite ends were
then sutured to the underlying lateral crura to contour the
alar rims, and the domes were padded with a soft-tissue
onlay. The dorsum was also augmented with conchal carti-
lage and covered with allogenic fascia lata.
.
. Fig. 12.14 (a–c)
Reconstruction of the
overresected LLCs with septal
cartilage using bending
technique. (d–f) Front view,
profile view, base view pre-op/
post-op
a
b
Chapter 12 · Tip Refinement in Secondary Rhinoplasty
665
12
c
d
.
. Fig. 12.14 (continued)
12.2 · Case Studies
666
12
e
f
.
. Fig. 12.14 (continued)
Chapter 12 · Tip Refinement in Secondary Rhinoplasty
667
12
12.2.9 Case 9: Reconstruction of the Lower
Framework with Septum via Bending
Technique
A 31-year-old female presented after two unsuccessful rhi-
noplasty procedures (. Fig. 12.15). The patient complained
of a persistent dorsal hump and a wide underprojected nasal
tip. Open rhinoplasty revealed bilateral alar cartilage mal-
formations involving the lateral and intermediate crura on
both sides. Dorsal reduction was performed using the
spreader flap technique to straighten and widen the dorsum,
widen the internal valves, and improve the dorsal aesthetic
lines. Thin battens of septal cartilage were used as onlay
grafts to replace the nasal domes and to smooth the lateral
crura. Tip sutures were then used to contour the domal
replacement grafts and to conceal intermediate crural asym-
metry. A well-defined and narrow tip with better projection
was achieved.
.
. Fig. 12.15 (a–c)
Reconstruction of the
overresected LLCs with septal
cartilage using bending
technique. (d–f) Front view,
profile view, base view pre-op/
post-op
a
b
12.2 · Case Studies
668
12
c
d
.
. Fig. 12.15 (continued)
Chapter 12 · Tip Refinement in Secondary Rhinoplasty
669
12
e
f
.
. Fig. 12.15 (continued)
12.2 · Case Studies
670
12
12.2.10 Case 10: Reconstruction of the Lower
Framework with Septum via Bending
Technique
A 27-year-old female presented with fullness of the supratip
after previous rhinoplasty (. Fig. 12.16). The dorsum revealed
irregularities, and she complained about deviation of the
bony pyramid. Scars resulting from previous alar base resec-
tions were also quite obvious.
Surgical exploration using the open approach revealed total
resection of both the lateral crura and the right intermediate
crus. A large septal cartilage graft was harvested leaving a 15-mm
L-strut. The nasal axis was straightened with osteotomies and
placement of spreader grafts. The medial crural footpods were
resected to narrow the columellar pedestal, and a columellar
strut was placed for tip support. On the right side, the interme-
diate and lateral crura were reconstructed using a long cartilagi-
nous strip fashioned from donor septal cartilage. The graft was
thinned with a scalpel at the dome for easier bending. On the left
side, a cartilage graft was fixed to the remnant intermediate crus
and thinned at the dome; both domes were then formed using a
transdomal suture. For better contour, a shield graft was sewn to
the infratip, and because of thin nasal tip, skin allogenic fascia
lata was used to cover the tip construct.
.
. Fig. 12.16 (a–b) Reconstruction of the overresected LLCs with septal cartilage using bending technique, additional shield graft, covered with
allogenic fascia. (c–e) Front view, profile view, base view pre-op/post-op
a
b
Chapter 12 · Tip Refinement in Secondary Rhinoplasty
671
12
.
. Fig. 12.16 (continued)
c
d
12.2 · Case Studies
672
12
e
.
. Fig. 12.16 (continued)
Chapter 12 · Tip Refinement in Secondary Rhinoplasty
673
12
12.2.11 Case 11: Reconstruction of the Lower
Framework with Septum via Bending
Technique
A 29-year-old female presented after previous rhinoplasty
with a wide and droopy nasal tip, pinched alae, a pseudo-hump
deformity, and deviation of the nasal axis (. Fig. 12.17).
Using the open approach, surgical exploration revealed
previous resection of both lateral crura and a dislocated
shield graft. A large piece of septal cartilage was harvested for
graft fabrication while preserving a strong residual L-strut.
After straightening and narrowing the bony pyramid with
parasagittal medial osteotomies combined with percutane-
ous low-to-low lateral and transverse osteotomies, spreader
grafts were placed for dorsal stabilization. The tip was also
reconstructed using septal cartilage to create a double-
layered columellar strut graft and lateral crural replacement
grafts, which were sculpted with both transdomal and span-
ning sutures. A tragal graft was used to create a shield graft,
which was covered with intercrural soft tissue. The original
malpositioned shield graft was divided longitudinally and
used to create bilateral rim grafts. To improve surface con-
tour, the tip and dorsum were then draped in a layer of allo-
genic fascia lata.
12.2 · Case Studies
674
12
.
. Fig. 12.17 (a–d) Reconstruction of the overresected LLCs with septal cartilage using bending technique. (e–g) Front view, profile view, base
view pre-op/post-op
a
b
c
d
Chapter 12 · Tip Refinement in Secondary Rhinoplasty
675
12
e
f
.
. Fig. 12.17 (continued)
12.2 · Case Studies
676
12
g
.
. Fig. 12.17 (continued)
Chapter 12 · Tip Refinement in Secondary Rhinoplasty
677
12
12.2.12 Case 12: Reconstruction of the Lower
Framework with Septum via Bending
Technique
A 23-year-old female presented after two previous rhinoplas-
ties with a slight nasal deviation resulting from a deformed dor-
sal septum in an asymmetric face (. Fig. 12.18). Additionally, a
conspicuous tip asymmetry with bossae formation was also
observed. The sharp tip edges mimicked a poorly shaped tip
graft protruding through the extremely thin nasal skin. Supratip
fullness was also observed on profile examination.
Using an open surgical approach, exploration revealed
severe overresection of both lateral crural cartilages. On the
left side, the lateral crus must have been malpositioned
because the remnants remained asymmetrical. Additionally,
no reconstruction of the internal valve had been performed,
and both valves were now exceedingly narrow. Treatment
began by harvesting spreader grafts and two long thin carti-
lage strips for LLC reconstruction from the quadrangular
septum. The paired tip grafts were then sutured to the medial
crura, bent to create new domes, and secured with a trans-
domal suture. The lateral segments of the tip grafts were then
sewn directly to the scarred vestibular skin to complete the
LLC reconstruction. Final contouring of the reconstructed
tip framework was achieved using spanning sutures in com-
bination with a tip suspension suture with a posterior sling.
To conceal the tip grafts, a layer of allogenic fascia lata was
used to cover the reconstructed tip.
Straightening of the nasal axis was accomplished using
paired spreader grafts to straighten the dorsal septum (and
open the nasal valves), coupled with parasagittal medial and
percutaneous low-to-low lateral and transverse osteotomies
of the bony vault. Because of facial asymmetry, the axis of the
nose could not be exactly vertical.
12.2 · Case Studies
678
12
.
. Fig. 12.18 (a–c) Different
grafts from the septum: spreader
grafts combined with
reconstruction of the
overresected LLCs using bending
technique. (d–f) Front view,
profile view, base view pre-op/
post-op
a
b
Chapter 12 · Tip Refinement in Secondary Rhinoplasty
679
12
c
d
.
. Fig. 12.18 (continued)
12.2 · Case Studies
680
12
e
f
.
. Fig. 12.18 (continued)
Chapter 12 · Tip Refinement in Secondary Rhinoplasty
681
12
12.2.13 Case 13: Reconstruction of the Lower
Framework with Septum via Batten
Graft Technique
A 31-year-old female presented after two prior cosmetic
rhinoplasties with a conspicuous polly-beak deformity
(. Fig. 12.19). Surgical exploration with the open approach
revealed complete absence of the right lateral crus and
malpositioning of the intermediate crural remnant.
Reconstruction included columellar strut placement fol-
lowed by replacement of the missing right lateral crus with a
batten graft fashioned from septal cartilage. A shield graft
with carefully beveled edges was also placed to enhance tip
contour and projection. Allogenic fascia lata was then used
to camouflage the tip reconstruction.
.
. Fig. 12.19 (a–c)
Reconstruction of the
overresected LLC using batten
graft, columellar strut, and shield
graft, covered with allogenic
fascia lata. (d–e) Front view,
profile view pre-op/post-op
a
c
b
12.2 · Case Studies
682
12
d
e
.
. Fig. 12.19 (continued)
Chapter 12 · Tip Refinement in Secondary Rhinoplasty
683
12
12.2.14 Case 14: Reconstruction of the Lower
Framework with Septum via Batten
Graft Technique
A 39-year-old female presented 10 years after previous rhino-
plasty (elsewhere) (. Fig. 12.20). Examination revealed a wide,
amorphous, and asymmetrical tip, bilateral alar retraction, and
an inverted-V deformity of the middle vault. External rhino-
plasty revealed total destruction of both lower lateral carti-
lages. Tip reconstruction was performed using a columellar
strut and bilateral crural batten grafts fashioned from septal
cartilage. Spanning sutures were then added for tip contour-
ing, and spreader grafts were used to eliminate the inverted-V
deformity. Finally, a cap graft fashioned from allogenic fascia
lata was used to cushion the tip framework, and the dorsum
was also camouflaged with a layer of allogenic fascia lata.
.
. Fig. 12.20 (a–b)
Reconstruction of the
overresected LLCs using batten
grafts and columellar strut. (c–e)
Front view, profile view, base
view pre-op/post-op
a
b
12.2 · Case Studies
684
12
c
d
.
. Fig. 12.20 (continued)
Chapter 12 · Tip Refinement in Secondary Rhinoplasty
685
12
e
.
. Fig. 12.20 (continued)
12.2 · Case Studies
686
12
12.2.15 Case 15: Reconstruction of the Lower
Framework with Septum via Batten
Graft Technique
A 26-year-old male presented after unsuccessful rhinoplasty
(elsewhere) (. Fig. 12.21). The patient complained of a wide
and droopy nasal tip. Open rhinoplasty revealed overresec-
tion of both lateral crura and missing portions of the left
intermediate crus. In contrast, the cartilaginous dorsum
showed no indication of previous surgical intervention.
Septal cartilage replacement grafts were used to reconstruct
the damaged nasal domes using a motorized drill to permit
folding of the domes. After integration of the grafts into the
residual tip cartilage, a shield graft was sutured to the infratip
so that it extended above the reconstructed tip framework.
This served to stretch the scarred and noncompliant tip skin
for better tip definition. The dorsum was also lowered con-
servatively to create a straight dorsal profile.
a
b
.
. Fig. 12.21 (a–d)
Reconstruction of the
overresected LLCs using batten
grafts and shield graft. (e–g)
Front view, profile view, base
view pre-op/post-op
Chapter 12 · Tip Refinement in Secondary Rhinoplasty
687
12
c
d
.
. Fig. 12.21 (continued)
12.2 · Case Studies
688
12
e
f
.
. Fig. 12.21 (continued)
Chapter 12 · Tip Refinement in Secondary Rhinoplasty
689
12
g
.
. Fig. 12.21 (continued)
12.2 · Case Studies
690
12
12.2.16 Case 16: Reconstruction of the Lower
Framework with Septum via Batten
Graft Technique
A 25-year-old female presented for revision rhinoplasty after
treatment elsewhere (. Fig. 12.22). Examination revealed a
wide and amorphous tip, a polly-beak profile deformity, and
a conspicuous inverted-V deformity. External rhinoplasty
revealed prior resection of the lateral aspect of both lateral
crura. Septal cartilage was used to create batten grafts to
reconstruct the surgically weakened lateral crura. Spanning
sutures were then used to contour the now rigid lateral crura.
Tip projection was increased using a precisely shaped cap
graft.
.
. Fig. 12.22 (a) Reconstruction of the overresected LLCs using batten grafts and tip onlay graft from septal cartilage. (b–d) Front view, profile
view, base view pre-op/post-op
a
b
Chapter 12 · Tip Refinement in Secondary Rhinoplasty
691
12
c
d
.
. Fig. 12.22 (continued)
12.2 · Case Studies
692
12
12.2.17 Case 17: Reconstruction of the Lower
Framework with Septum via Batten
Graft Technique
A 36-year-old female presented with an overresected dorsum
and a conspicuous contour of the tip after two closed rhino-
plasties (. Fig. 12.23). After opening up the nose, we found a
concavity of both weak lateral crura and destructed interme-
diate crura. A big cartilage graft from the central septum was
harvested for a columellar strut and three batten grafts. The
columellar strut was fixed to the caudal septum, and the
medial crura were sutured to the graft. Two small batten
grafts were placed on top of the weak right lateral crus, a wide
one on top of the left one. A transdomal suture contoured the
tip, and a tip suspension suture with an anterior sling guaran-
teed the tip position. The dorsum was augmented with three
layers of allogenic fascia at the radix and two at the keystone
area and the cartilaginous dorsum.
.
. Fig. 12.23 (a–d)
Reconstruction of the
overresected LLCs using batten
grafts and dorsal augmentation
with three layers of allogenic
fascia lata. (f–h) Front view,
profile view, base view pre-op/
post-op
a
c
b
Chapter 12 · Tip Refinement in Secondary Rhinoplasty
693
12
d
e
f
.
. Fig. 12.23 (continued)
12.2 · Case Studies
694
12
h
g
.
. Fig. 12.23 (continued)
Chapter 12 · Tip Refinement in Secondary Rhinoplasty