Mastering Advanced Rhinoplasty

696
12
c
d
.
. Fig. 12.24  (continued)

Chapter 12 · Tip Refinement in Secondary Rhinoplasty

697
12
f
e
.
. Fig. 12.24  (continued)
12.2 · Case Studies

698
12
12.2.19  Case 19: Reconstruction of the Lower
Framework with Septum via Batten
Graft Technique
A 27-year-old female presented after two previous rhinoplas-
ties with a round, pinched, and amorphous nasal tip, asym-
metrical nostrils that showed collapse during forced
inspiration, and a wide nasal pyramid (. Fig. 12.25).
During surgical exploration using the open approach, we
observed severe overresection of the LLCs. For reconstruction,
we harvested a large piece of septal cartilage and cut five strips
from the specimen. One strip was used as columellar strut
graft, two strips were used as spreader grafts to widen the nar-
row internal valves, and the remaining two strips were used for
reconstruction of the LLC framework. After fixing the colu-
mellar strut graft, paired cartilage strips were sutured to it.
They were then bent to reform the missing domes and sutured
to the lateral crural remnants and the vestibular skin. To facili-
tate bending of the grafts, the domes were first thinned with an
electric cylindrical drill. The new framework was then molded
with spanning sutures combined with a tip suspension suture
and a posterior sling to stabilize tip position. After narrowing
the nasal pyramid with our standard osteotomy technique, the
dorsum was covered with one layer of allogenic fascia lata.
.
. Fig. 12.25  (a–d)
Reconstruction of the
overresected LLCs with septal
cartilage using bending
technique and columellar strut.
(e–g) Front view, profile view,
base view pre-op/post-op
a
b

Chapter 12 · Tip Refinement in Secondary Rhinoplasty

699
12
c
d
e
.
. Fig. 12.25  (continued)
12.2 · Case Studies

700
12
g
f
.
. Fig. 12.25  (continued)

Chapter 12 · Tip Refinement in Secondary Rhinoplasty

701
12
12.2.20  Case 20: Reconstruction of the Lower
Framework with Septum via Batten
Graft Technique
A 34-year-old female presented after previous rhinoplasty
with a polly-beak deformity combined with an overresected
dorsum (. Fig. 12.26). Tip ptosis and a hyperacute nasolabial
angle (less than 90°) were also observed. Finally, the colu-
mella had a conspicuous transcolumellar scar from the previ-
ous rhinoplasty incision, and the columellar pedestal was
overly wide and asymmetrical.
Using the open approach, copious scars were resected
before an analysis was possible. The lateral crura were over-
resected, and the remnants were collapsed medially. After
lowering the cartilaginous dorsum, a large septal cartilage
graft was harvested and used for spreader grafts. Septal carti-
lage was also used to create a columellar strut graft and to
support the lateral crura with bilateral batten grafts. The bony
vault was then straightened and narrowed using parasagittal
medial osteotomies combined with percutaneous low-to-low
lateral and percutaneous transverse osteotomies. Following
partial resection of the depressor septi muscle, the columellar
strut graft was sutured to the caudal septum, and the medial
crura were sutured to the strut graft. Rim grafts were placed
to eliminate alar pinching, and the dorsum was augmented
with two layers of allogenic fascia lata.
.
. Fig. 12.26  (a–c)
Reconstruction of the
overresected LLCs with batten
grafts. (d–f) Front view, profile
view, base view pre-op/post-op
a
b
12.2 · Case Studies

702
12
c
d
.
. Fig. 12.26  (continued)

Chapter 12 · Tip Refinement in Secondary Rhinoplasty

703
12
e
f
.
. Fig. 12.26  (continued)
12.2 · Case Studies

704
12
12.2.21  Case 21: Correcting the Lower
Framework with Septum via Batten
Graft Technique
A 36-year-old female patient presented after previous rhino-
plasty with a quadrangular-shaped nasal tip, asymmetrical
tip-defining points, and nostril asymmetry (. Fig. 12.27). On
profile view, a residual dorsal hump was evident, and
extremely thin and shiny skin was also observed.
Using the open rhinoplasty approach, we encountered a
double-layered cartilage graft serving as a left lateral crural
batten graft. After lowering the dorsal septum with the com-
ponent technique, the oversized ULCs were folded inward as
spreader flaps. Transdomal sutures were then placed for tip
contouring after a lateral crural strut graft was placed on the
right side for tip symmetry. Minor tip irregularities were
camouflaged with free diced cartilage, and the dorsum was
smoothed with a layer of allogenic fascia lata.
.
. Fig. 12.27  (a–b) Correcting
the lower framework by
unilateral batten graft, molding
the tip with transdomal sutures.
(c–e) Front view, profile view,
base view pre-op/post-op
a
b

Chapter 12 · Tip Refinement in Secondary Rhinoplasty

705
12
c
d
.
. Fig. 12.27  (continued)
12.2 · Case Studies

706
12
e
.
. Fig. 12.27  (continued)

Chapter 12 · Tip Refinement in Secondary Rhinoplasty

707
12
12.2.22  Case 22: Reconstruction of the Lower
Framework with Septum via Batten
Graft Technique
A 41-year-old female presented for revision nasal surgery;
she complained about nasal airway obstruction and a poor
cosmetic outcome (. Fig.  12.28). Examination revealed a
foreshortened nose from overresection of the anterior sep-
tum coupled with saddle-nose collapse of the middle vault.
Left alar retraction and hypoplasia of the maxilla were also
observed.
Surgical exploration via the open approach revealed com-
plete absence of both lateral crura as well as most of both
intermediate crura. The anterior septal remnant was deviated
superiorly, creating a high septal deformity blocking the left
nasal airway, and deformity of the central septum was also
seen. The overresected dorsal septum was also buried beneath
deformed ULCs, and both inferior conchal bones were
enlarged.
Partial submucosal resection of the enlarged inferior tur-
binate bones was performed for airway enhancement, and the
angulated high septal deviation was also resected. However,
the already overresected cartilaginous dorsum became weak
and unstable with additional cartilage removal. Consequently,
paired 1.5-mm-thick extended spreader grafts fashioned
from autologous rib cartilage were used to augment and
strengthen the middle vault. These were also used to support
a septal extension graft harvested from the posterior septum
as suggested by Davis to stabilize the tip upon nasal lengthen-
ing. Thin 1.0-mm strips of rib cartilage were also used to fab-
ricate LLC replacement grafts, which were contoured with
transdomal and spanning sutures combined with a tip sus-
pension suture. A double-layered caudal septal replacement
graft was also fabricated from conchal cartilage, and two
diced (rib) cartilage-fascia grafts were used to augment the
premaxilla and nasal dorsum. The tip was then camouflaged
with a layer of perichondrium, and finely diced cartilage was
injected beneath the skin to hide minor contour irregularities.
12.2 · Case Studies

708
12
.
. Fig. 12.28  (a) Scar removal
from tip, submucous resection of
turbinate bone. (b) Extracorporeal
septal reconstruction, DCF graft
for maxillary augmentation.
(c) Strips from rib cartilage for
reconstruction of the lateral crura.
(d) Reconstruction of the lower
framework. (e) Dorsal
reconstruction with DCF graft.
(f–h) Front view, profile view,
base view pre-op/post-op
a
b

Chapter 12 · Tip Refinement in Secondary Rhinoplasty

709
12
c
d
e
.
. Fig. 12.28  (continued)
12.2 · Case Studies

710
12
f
g
.
. Fig. 12.28  (continued)

Chapter 12 · Tip Refinement in Secondary Rhinoplasty

711
12
h
.
. Fig. 12.28  (continued)
12.2 · Case Studies

712
12
12.2.23  Case 23: Reconstruction of the Lower
Framework with Rib Grafts
A 45-year-old female presented with a classic polly-beak
deformity after previous rhinoplasty (. Fig. 12.29). In addi-
tion, the bony dorsum had been overresected, and the nasal
skin was extremely thick.
Using an open approach, severe scars were found cover-
ing overresected LLCs. Only the stumps of the intermediate
crura and medial crura could be identified. In this patient,
overresection of the tip cartilage had been used in a mis-
guided attempt to reduce nasal tip width but resulted only in
loss of essential tip support and excessive scar formation.
We elected to augment the overresected bony dorsum by
first lowering the cartilaginous dorsum to create a dorsal
bed in order to accommodate a full-length dorsal onlay
graft. Since there was not enough septal cartilage to con-
struct the onlay graft, the 11th rib was harvested from the
right chest wall, from which four long strips of cartilage
were cut. Two were used as spreader grafts, and the other
two were used for reconstruction of the LLCs. For tip recon-
struction, the grafts were shaved to a thickness of 1.0 mm
and then sutured to the medial crura. The grafts were
thinned further in the area of the domes to allow bending
and formation of new domes, which were created with
transdomal sutures. The lateral ends of both grafts were then
sutured to the vestibular skin. The previously inserted colu-
mellar strut graft was very weak, and it was replaced with a
strut graft fashioned from rib cartilage. Rib perichondrium
was used to augment the atrophic septal mucosa (after pre-
vious harvest of septal cartilage) and to cover the recon-
structed tip framework. For augmentation of the dorsum, a
DC-F graft was fashioned from autologous deep temporalis
fascia and diced rib cartilage. However, the volume of resid-
ual rib cartilage was insufficient, and the right concha was
also harvested to construct the DC-F graft.

Chapter 12 · Tip Refinement in Secondary Rhinoplasty

713
12
a
b
.
. Fig. 12.29  (a–b)
Reconstruction of the
overresected LLCs using bending
technique in rib cartilage grafts.
(c–e) Front view, profile view,
base view pre-op/post-op
12.2 · Case Studies

714
12
c
d
.
. Fig. 12.29  (continued)

Chapter 12 · Tip Refinement in Secondary Rhinoplasty

715
12
e
.
. Fig. 12.29  (continued)
12.2 · Case Studies

716
12
12.2.24  Case 24: Reconstruction of the Lower
Framework with Rib Grafts
A 47-year-old male presented after nasal trauma and previ-
ous rhinoplasty with a narrow middle vault, a deviated nose,
and an underprojected nasal tip (. Fig.  12.30). Endonasal
examination revealed a residual septal deviation and obstruc-
tion of both nasal passages. Using the external approach, sur-
gical exploration revealed partial loss of the right intermediate
crus. The right lateral crus was also displaced and deformed.
On the left side, the intermediate crus was divided from the
lateral crus, and portions of the left LLC had been resected.
The septum revealed a severe C-shaped deformity, and the
deformed segments were resected leaving stable L-strut. The
bony pyramid was straightened using parasagittal medial
osteotomies made with a Lindemann burr and percutaneous
low-to-low and transverse osteotomies. For widening of the
narrow internal valves, the right concha cymba was har-
vested and split in the midline to create paired spreader
grafts. Spreader graft placement served not only to recon-
struct the internal valves but also to straighten the septum
and to keep the nasal bones in proper position. A rib graft
was then harvested to create a columellar strut graft, and the
medial crura were sutured to the graft. Because of weakness
of the residual left lateral crus, it was removed and replaced
by a batten graft fashioned from rib. A reciprocal batten graft
was then placed on the right. For fine-tuning of the outer
contour, the residual donor cartilage was diced into a fine
paste-like consistency and injected over the dorsum and into
the soft-tissue facets beneath the partially closed skin flap.

Chapter 12 · Tip Refinement in Secondary Rhinoplasty

717
12
a
b
.
. Fig. 12.30  (a–b)
Reconstruction of the
overresected LLCs using rib
grafts as batten grafts,
fine-tuning with free diced
cartilage. (c–e) Front view, profile
view, base view pre-op/post-op
12.2 · Case Studies

718
12
c
d
.
. Fig. 12.30  (continued)

Chapter 12 · Tip Refinement in Secondary Rhinoplasty

719
12
e
.
. Fig. 12.30  (continued)
12.2 · Case Studies

720
12
12.2.25  Case 25: Reconstruction of the Lower
Framework with Rib Grafts
A 66-year-old female presented after three rhinoplasties
complaining of inadequate tip projection and an overpro-
jected dorsum (. Fig.  12.31). Examination also revealed
pinching of the right ala with asymmetrical nostrils and a
collapsed left nasal side wall. The nasal skin was very thin and
atrophic. Endonasal examination revealed a 5.0-mm septal
perforation and a residual deviation of the septum.
Using an open approach, the soft-tissue dissection was chal-
lenging because of extensive scarring and extremely thin nasal
skin. After lowering and smoothing the dorsum, the ULCs were
divided from the septum, and the residual septal cartilage was
harvested for graft material. A thickened portion of septal car-
tilage was then split into thin wafers and interposed between
the mucosal flaps in the area of perforation repair. A columellar
strut was fashioned from septal cartilage and used to support
the medial crura. After removal of scar tissue from the lateral
crura, only weak and insufficient residual cartilage was found.
Consequently, the 11th rib was harvested and cut into small
strips to create lateral crural batten grafts. The dorsum was then
augmented using a thin DC-F graft constructed from rib carti-
lage and deep temporalis fascia. Pinching of the right ala was
corrected with a tragal cartilage graft. Temporalis fascia was
also used to cover the newly reconstructed tip framework.
.
. Fig. 12.31 
(a–b)
Reconstruction of the
overresected LLCs using rib
grafts as batten grafts. (c–e) Front
view, profile view, base view
pre-op/post-op
a
b

Chapter 12 · Tip Refinement in Secondary Rhinoplasty

721
12
c
d
.
. Fig. 12.31  (continued)
12.2 · Case Studies

722
12
e
.
. Fig. 12.31  (continued)

Chapter 12 · Tip Refinement in Secondary Rhinoplasty

723
12
12.2.26  Case 26: Reconstruction of the Lower
Framework with Rib Grafts
A 42-year-old female presented after previous rhinoplasty
with a round and bulbous nasal tip and retraction of the left
soft-tissue facet and alar rims (. Fig. 12.32). The dorsum was
also overly wide.
Ignoring the unusually high scar placement of the previ-
ous transcolumellar incision, we used a new inverted-V-­
shaped incision at the narrowest part of the columella.
Extensive subcutaneous scarring was encountered covering
the overresected LLCs. After removing the scar tissue, only
small remnants of the medial crura remained. Additionally,
the caudal septum was also overresected, necessitating rib
graft harvest for reconstruction. After harvesting an 8.0-cm
segment of the tenth rib, it was split longitudinally into
1.5-mm-thick strips. Two strips were sutured to the medial
crural remnants, and by thinning the grafts at the domes with
a cylindrical electric drill, they were folded at the domes.
Although the right rib graft fractured with folding, an accept-
able tip architecture was achieved using transdomal sutures
for stabilization. Spanning sutures were then placed for fur-
ther contour enhancement, and a tip suspension suture with
a posterior sling stabilized the reconstructed framework in
the desired position. A DC-F graft fashioned from finely
diced rib cartilage wrapped in allogenic fascia lata was used
as an augmentation graft for the underprojected dorsum. The
retracted soft-tissue facet was filled with free diced cartilage.
At a visit 1 year later, the reconstructed tip seemed over-
projected, and the infratip lobule was deficient. Therefore,
the rib grafts used for reconstruction of the tip framework
were shortened, and an additional shield graft from the con-
cha was used to counterrotate the nose and augment the
infratip lobule.
12.2 · Case Studies

724
12
.
. Fig. 12.32  (a–d) Severe scars after overresection of the LLCs. Reconstruction of the overresected LLCs using batten grafts from rib cartilage,
dorsal augmentation with DC-F. (e–g) Front view, profile view, base view pre-op/post-op
a
b

Chapter 12 · Tip Refinement in Secondary Rhinoplasty

725
12
c
d
.
. Fig. 12.32  (continued)
12.2 · Case Studies

726
12
e
f
.
. Fig. 12.32  (continued)

Chapter 12 · Tip Refinement in Secondary Rhinoplasty

727
12
g
.
. Fig. 12.32  (continued)
12.2 · Case Studies

728
12
12.2.27  Case 27: Reconstruction of Tip
Projection by Sandwich Graft,
Combined with Lateral Crural Steal
Technique
A 42-year-old male presented after gender-reassignment sur-
gery for revision rhinoplasty after a failed dorsal augmenta-
tion with a silicone dorsal implant (. Fig. 12.33). Columellar
retraction and tip ptosis resulted from infection and extru-
sion of the silicone implant. The radix was also quite low.
Using the open approach, the tip was reconstructed using
a double-layered sandwich graft constructed from conchal
cartilage, which was sutured to the caudal septum. Using a
lateral crural steal technique, tip projection and rotation were
increased. Additionally, an onlay graft was sutured on top of
the sandwich graft in order to provide even more tip projec-
tion. The wide bony pyramid was narrowed with parasagittal
medial osteotomies and percutaneous low-to-low lateral and
transverse osteotomies. The low nasal bridge was augmented
with solid conchal cartilage from the opposite ear.
.
. Fig. 12.33  (a–b) Increasing
tip projection by sandwich graft
combined with lateral crural steal
technique. (c–e) Front view,
profile view, base view pre-op/
post-op
a
b

Chapter 12 · Tip Refinement in Secondary Rhinoplasty

729
12
c
d
.
. Fig. 12.33  (continued)
12.2 · Case Studies

730
12
e
.
. Fig. 12.33  (continued)

Chapter 12 · Tip Refinement in Secondary Rhinoplasty

731
12
12.2.28  Case 28: Increasing Projection by
Grafting
A 20-year-old male presented with a severely underprojected
tip after previous rhinoplasty (. Fig. 12.34). Additionally, the
dorsum was overprojected, and the bony vault was overly
wide. Endonasal examination revealed deviation of the sep-
tum to the left side and narrow internal nasal valves.
Using the external rhinoplasty approach with an inverted-
­V transcolumellar incision, surgical exploration revealed dif-
fuse scarring of the LLCs and overresection of the left
cephalic margin. After dismantling the cartilaginous dorsum
using the component technique, the dorsal septum was
trimmed with a straight scissors, and the bony dorsum was
lowered with a cylindrical power drill bit. The bony pyramid
was then straightened and narrowed using parasagittal
medial, percutaneous low-to-low lateral, and percutaneous
transverse osteotomies. The overprojected ULCs were also
invaginated and used as spreader flaps. For increased tip pro-
jection, a nonintegrated shield graft and a buttress graft were
covered with a soft-tissue wrap fashioned from scar tissue. To
complete the procedure, alar rim grafts were placed bilater-
ally, and the dorsum was covered with a layer of allogenic
fascia lata.
.
. Fig. 12.34  (a–b) Increasing
projection by nonintegrated
shield graft. (c–e) Front view,
profile view, base view pre-op/
post-op
a
b
12.2 · Case Studies

732
12
c
d
.
. Fig. 12.34  (continued)

Chapter 12 · Tip Refinement in Secondary Rhinoplasty

733
12
e
.
. Fig. 12.34  (continued)
12.2 · Case Studies

734
12
12.2.29  Case 29: Reconstruction of Tip
Support with Conchal Graft
(Sandwich)
A 67-year-old female was seen following unsuccessful septo-
rhinoplasty (. Fig. 12.35). Examination revealed a wide and
overprojected bony dorsum, tip ptosis from an overresected
anterior septum, and a septal perforation. Treatment involved
reduction of the bony dorsum and reprojection of the tip
using a double-layered columellar strut graft fashioned from
septal cartilage.

Chapter 12 · Tip Refinement in Secondary Rhinoplasty

735
12
.
. Fig. 12.35  (a–b) Increasing projection and rotation with conchal graft (sandwich graft). (c–e) Front view, profile view, base view pre-op/
post-op
a
b
12.2 · Case Studies

736
12
c
d
.
. Fig. 12.35  (continued)

Chapter 12 · Tip Refinement in Secondary Rhinoplasty

737
12
e
.
. Fig. 12.35  (continued)
12.2 · Case Studies

738
12
12.2.30  Case 30: Deprojection
with Simultaneous Correction
of Dysplastic LLCs by Medial Crural
Overlap (Medial Sliding)
A 27-year-old female presented after previous rhinoplasty
elsewhere (. Fig. 12.36). Examination revealed an overpro-
jected and overrotated tip with an obtuse nasolabial angle
and a wide infratip lobule. External rhinoplasty revealed
buckling of the intermediate crura at the junction of the
medial crura. Consequently, we used the medial crural over-
lap technique to simultaneously deproject, counterrotate,
and straighten the nasal tip cartilages.
c
.
. Fig. 12.36  (a–c)
Deprojection by medial crural
overlap (medial sliding)
a
b

Chapter 12 · Tip Refinement in Secondary Rhinoplasty

739
12
12.2.31  Case 31: Deprojection by Medial
Crural Overlap (Medial Sliding)
A 40-year-old female presented after failed rhinoplasty elsewhere
(. Fig. 12.37). According to the patient, she had had a large dor-
sal hump prior to her first surgery, but she presented for treat-
ment of an overprojected tip, indicating that she initially suffered
from rhinomegaly. Apparently, her previous surgeon failed to
recognize and to treat the entire ­rhinomegalic deformity.
Deprojection of the tip was then performed using a medial crural
overlap technique, and once tip projection was normalized, the
dorsum was again able to complement the new tip contour.
a
b
.
. Fig. 12.37  (a, b)
Deprojection by medial crural
overlap (medial sliding)
12.2 · Case Studies

740
12
12.2.32  Case 32: Deprojection by Medial
Crural Overlap (Medial Sliding)
A 44-year-old female presented after multiple prior episodes
of nasal trauma and an unsuccessful septorhinoplasty
­elsewhere (. Fig. 12.38). Examination revealed a short and
overprojected nose (rhinomegaly) with a pronounced
C-shaped curvature of the nasal dorsum. Treatment with the
open approach included dorsal reduction followed by
spreader flap placement to support and straighten the middle
vault. Lateral crural strut grafts were then used to strengthen
weak lateral crura, and tip deprojection was accomplished
using the medial crural overlap technique. This simultane-
ously deprojected and lengthened the nose.
.
. Fig. 12.38  (a) Deprojection
by medial crural overlap (medial
sliding). (b–d) Front view, profile
view, base view pre-op/post-op
a
b

Chapter 12 · Tip Refinement in Secondary Rhinoplasty

741
12
d
c
.
. Fig. 12.38  (continued)
12.2 · Case Studies

742
12
12.2.33  Case 33: Deprojection by Medial
Crural Overlap (Medial Sliding)
An 18-year-old female presented with a need for revision rhi-
noplasty (. Fig. 12.39). Examination revealed an overly short
nose with an overprojected nasal tip. The surgical plan was to
physically lengthen the nose by counterrotating the tip with a
medial crural overlap technique and to visually lengthen it by
raising the nasal “starting point” with dorsal augmentation.
Consequently, after lowering the overprojected cartilaginous
dorsum, the bony vault was augmented with an onlay graft of
allogenic fascia lata. The tip was also counterrotated by over-
lapping the medial crura.
.
. Fig. 12.39  (a–b) Deprojection by medial crural overlap (medial sliding) combined with allogenic fascia for dorsal augmentation. (c–e) Front
view, profile view, base view pre-op/post-op
a
b
c

Chapter 12 · Tip Refinement in Secondary Rhinoplasty

743
12
d
e
.
. Fig. 12.39  (continued)
12.2 · Case Studies

744
12
12.2.34  Case 34: Deprojection by Medial
Crural Overlap (Medial Sliding)
A 29-year-old female presented with a severely overprojected
tip combined with a polly-beak deformity from an overpro-
jected cartilaginous dorsum (. Fig. 12.40). The bony pyramid
was overly narrow and deviated to the left side, and numer-
ous small contour irregularities were present throughout the
nasal bridge.
Surgical exploration using the open approach revealed
displacement of the ANS to the left of midline by 6.0 mm,
resulting in deviation of the caudal septum. Additionally,
the anterior septal angle was overresected. The displaced
nasal spine was partially resected on the left side using a
cylindrical drill bit, leaving a small remnant that was reposi-
tioned in the midline using a greenstick fracture pedicled to
the soft tissue. The septum was then shortened at its base
and then sutured to the ANS in the midline using osseous
drill holes. After dividing the ULCs from the dorsal septum,
the cartilaginous dorsum was lowered, and the bony pyra-
mid was mobilized and straightened using parasagittal
medial and percutaneous low-to-low lateral and transverse
osteotomies. Spreader grafts were placed for widening of the
narrow dorsum.
Dissection of the tip revealed kinking of the left LLC. To
eliminate this deformity and simultaneously correct the
overprojected tip, a lateral crural overlap procedure (lateral
sliding technique) was performed. The crural cartilage was
transected at the level of the kink, and an 8.0-mm overlap
was performed bilaterally. For additional stabilization of the
malformed left LLC, an additional thin underlying batten
graft was also placed. A columellar strut was then placed
using a guiding suture. To further contour the tip, an inte-
grated shield graft was sutured to the infratip lobule. The
final shape was achieved using spanning sutures combined
with a tip suspension suture with a posterior sling. After par-
tially closing the skin flap, the dorsum was smoothed by
injecting finely diced cartilage beneath the nasal skin.

Chapter 12 · Tip Refinement in Secondary Rhinoplasty