Mastering Advanced Rhinoplasty

746
12
d
e
.
. Fig. 12.40  (continued)

Chapter 12 · Tip Refinement in Secondary Rhinoplasty

747
12
f
g
.
. Fig. 12.40  (continued)
12.2 · Case Studies

748
12
12.2.35  Case 35: Deprojection by Lateral
Crural Overlap (Lateral Sliding)
A 25-year-old female presented after failed cosmetic rhi-
noplasty elsewhere (. Fig.  12.41). Examination revealed
an overprojected and scoliotic nose with an open roof
deformity from previous resection of the bony dorsum.
The left external valve was obstructed as a result of left-
ward deviation of the caudal septum and dislocation from
the nasal spine. Using the external approach, the deviated
caudal septum was excised and replaced with a septal
extension graft fashioned from a posterior segment of the
quadrangular septum. The tip was deprojected and coun-
terrotated using the medial crural overlap technique,
which resulted in a desired increase in nasal length. The
nasion was then augmented, using the original caudal sep-
tum after it was lightly morselized in order to raise the
nasal starting point.
.
. Fig. 12.41  (a–b)
Replacement of the deformed
anterior septum by septal
extension graft, kept in position
by extended spreader grafts,
deprojection by medial crural
overlap. (c–e) Front view, profile
view, base view pre-op/post-op
a
b
a

Chapter 12 · Tip Refinement in Secondary Rhinoplasty

749
12
b
c
.
. Fig. 12.41  (continued)
12.2 · Case Studies

750
12
d
e
.
. Fig. 12.41  (continued)

Chapter 12 · Tip Refinement in Secondary Rhinoplasty

751
12
12.2.36  Case 36: Complex Tip Reconstruction
with Deprojection and Lengthening
by Sandwich Graft, Combined with
Push Down, Reconstruction of the
Missing Dome with Ear Cartilage
A 39-year-old male presented for revision surgery after four
previous rhinoplasty procedures (. Fig. 12.42). Examination
revealed an overly short nose with an overprojected tip, an
obtuse nasolabial angle, and nostril asymmetry from colu-
mellar deviation. Irregularities of the dorsum were also
noted. Exploration of the nose via the open approach
revealed warped rib cartilage used as a columellar strut graft.
The rib cartilage was then replaced with a double-layered
strut graft fashioned from conchal cartilage. On the left side,
the medial crus was intact and could be sutured to the colu-
mellar strut. However, the right intermediate crus was miss-
ing, and a conchal cartilage graft was needed to reconstruct
the dome. The lateral crura were then contoured with span-
ning sutures, and a double-layered shield graft was used to
counterrotate the tip and improve contour. The dorsum was
augmented with two layers of allogenic fascia lata. The result
was improved tip symmetry and better alar contour with
increased nasal length and a more acute nasolabial angle.
.
. Fig. 12.42  (a–d)
Reconstruction of the
overresected dome using
conchal cartilage, double-layered
conchal cartilage as columellar
strut, onlay graft from soft tissue,
spanning sutures. (e–g) Front
view, profile view, base view
pre-op/post-op
a
b
12.2 · Case Studies

752
12
d
c
.
. Fig. 12.42  (continued)

Chapter 12 · Tip Refinement in Secondary Rhinoplasty

753
12
e
f
.
. Fig. 12.42  (continued)
12.2 · Case Studies

754
12
g
.
. Fig. 12.42  (continued)

Chapter 12 · Tip Refinement in Secondary Rhinoplasty

755
12
12.2.37  Case 37: Deprojection by Lateral
Crural Overlap (Lateral Sliding)
and Setback by Septal Extension
Graft
A 24-year-old female presented after previous rhinoplasty
with a long and deviated nose and drooping of an overpro-
jected tip resulting in an overly acute nasolabial angle and a
retracted columella (. Fig. 12.43). Using the open approach,
exploration revealed intact LLCs, but the caudal septum was
damaged and displaced to the right side. The deformed cau-
dal septum was then removed, and a septal extension graft
was fashioned from quadrangular cartilage and placed with
the aid of a guiding suture. After suture fixation of the septal
extension graft, the overprojected and ptotic nasal tip was
repositioned using the lateral crural overlap technique (i.e.,
the lateral crural sliding technique) to allow precise tip
deprojection and simultaneous tip rotation. Additionally, a
tongue-in-groove technique was used to fix the medial crura
anterior to the caudal border of the septal extension graft for
correction of the retracted columella. Both soft triangles
were then augmented with allogenic fascia lata.
.
. Fig. 12.43  (a) Deprojection
by lateral crural overlap (lateral
sliding), setback by septal
extension graft. (b–d) Front view,
profile view, base view pre-op/
post-op
a
b
12.2 · Case Studies

756
12
c
d
.
. Fig. 12.43  (continued)

Chapter 12 · Tip Refinement in Secondary Rhinoplasty

757
12
12.2.38  Case 38: Deprojection Combined
with Cranial Rotation by Septal
Extension Graft
A 38-year-old male presented after aesthetic rhinoplasty per-
formed elsewhere (. Fig.  12.44). The patient disliked his
“Greek” profile, which had a poorly defined nasofrontal angle,
and he also complained of an overly short nose with excessive
nostril visibility. On surgical exploration, the lateral crura and
the left nasal dome were missing. The resulting lack of skeletal
support led to overrotation of the nasal tip, which was
­exacerbated by overresection of the caudal septum. Although
very little septal cartilage was available for cartilage grafting,
conchal cartilage was unavailable as a result of prior otoplasty.
Consequently, the remaining quadrangular cartilage was har-
vested, leaving only a 10-mm dorsal strut (after dorsal reduc-
tion). The L-strut was then reconstituted using a columellar
strut graft held in place with bilateral extended spreader
grafts. The remaining septal cartilage was used to replace the
missing lateral crura and the left nasal dome and to create a
nonintegrated shield graft, which was covered with soft tissue.
Transdomal sutures were also used for tip refinement.
12.2 · Case Studies

758
12
.
. Fig. 12.44  (a–d) Derotation
and lengthening by columellar
strut combined with extended
spreader grafts and shield graft,
reconstruction of the
overresected LLCs using batten
grafts, DC-F. (e–g) Front view,
profile view, base view pre-op/
post-op
a
b
c

Chapter 12 · Tip Refinement in Secondary Rhinoplasty

759
12
d
e
.
. Fig. 12.44  (continued)
12.2 · Case Studies

760
12
g
f
.
. Fig. 12.44  (continued)

Chapter 12 · Tip Refinement in Secondary Rhinoplasty

761
12
12.2.39  Case 39: Deprojection Combined
with Cranial Rotation and Total
Reconstruction of the Lower
Framework
A 47-year-old patient presented for revision rhinoplasty after
severe nasal trauma and four previous nasal surgeries
(. Fig. 12.45). Examination revealed a widened nose with a
C-shaped dorsal curvature, a plunging tip, and a retracted
columella. The skin was overly thin and scarred, and both
nasal side walls revealed numerous contour irregularities
with malpositioned (overly high) osteotomy lines.
Using the open approach, dissection was difficult because of
the scarred, thin, and tethered skin envelope. The residual sep-
tum was deformed, floppy, and dislocated from the midline.
After parasagittal osteotomies were created using the Lindemann
burr, extended spreader grafts (fabricated from the tenth rib)
were used to straighten and stabilize the cartilaginous dorsum.
Transverse osseous drill holes were then placed in the ANS, and
the caudal septum was trimmed at its base and sutured in the
midline. Percutaneous low-to-low lateral and transverse oste-
otomies were then used to straighten and narrow the bony vault.
Severe tip ptosis was corrected using the tongue-in-­
groove technique, in which the medial crura were sutured to
the caudal septum in order to increase (cranial) tip rotation.
A 1.5-mm strip of rib cartilage was first used to reinforce the
flimsy caudal septum. Upon achieving adequate tip rotation,
overprojection of the tip complex became evident. This was
corrected using the lateral crural overlay technique to shorten
the lateral crura. A shield graft of allogenic fascia lata was
used to camouflage the tip complex, and free diced cartilage
was used to smooth the nasal dorsum.
12.2 · Case Studies

762
12
.
. Fig. 12.45  (a) Totally deformed and scarred tip complex. (b) Severly deformed septum. (c) Straightening the septum with extended spreader
grafts, deprojection by lateral sliding (overlap) technique. (d–f) Front view, profile view, base view pre-op/post-op
a
b

Chapter 12 · Tip Refinement in Secondary Rhinoplasty

763
12
c
d
.
. Fig. 12.45  (continued)
12.2 · Case Studies

764
12
e
f
.
. Fig. 12.45  (continued)

Chapter 12 · Tip Refinement in Secondary Rhinoplasty

765
12
12.2.40  Case 40: Deprojection by Lateral
Crural Overlap Combined
with Sandwich Graft Working
as a Septal Extension Graft
A 39-year-old female presented for revision rhinoplasty with
a severe plunging tip deformity (. Fig. 12.46). Examination
revealed near total absence of the caudal septum and a wide
and overprojected nasal dorsum. Endonasal examination
revealed a persistent 8-mm septal perforation despite previ-
ous attempts at perforation closure.
Using an open rhinoplasty approach, the septal perfora-
tion was repaired using the four-flap technique. Conchal car-
tilage was then harvested from the right ear to create a
sandwich graft, which was sutured to the septal remnant for
improved tip support working as a septal extension graft. The
bony hump was lowered with a rasp, and the nasal pyramid
was narrowed using parasagittal medial osteotomies fol-
lowed by percutaneous low-to-low lateral and transverse
osteotomies. Overly long and overprojected LLCs were
­corrected using the lateral crural overlap (sliding) technique
with a 6-mm overlap. The medial crura were sutured to the
sandwich graft (modified tongue-in-groove technique), and
the domes were contoured with transdomal sutures. An
extended shield graft was placed in front of the domes, and
spanning sutures were then used for tip refinement. A tip
suspension suture was then used for tip immobilization.
Allogenic fascia lata onlay grafts were used in an attempt to
eliminate minor surface irregularities, but these grafts were
replaced by finely diced cartilage, which led to a better result.
Additional functional improvement was later achieved by
resecting the medial crural footpods and narrowing the colu-
mellar pedestal. Additionally, a Breathe (Karl Storz Co.;
Tuttlingen, Germany) implant was inserted and sutured to
both ULCs.
A Breathe implant is a saddle-shaped titanium device
developed by Daniel à Wengen for spreading and stabilizing
the internal nasal valve. It is placed on top of the middle vault
to permit suture suspension of the ULCs for improved nasal
valve patency.
.
. Fig. 12.46  (a–c) sandwich graft working as septal extension graft, deprojection by lateral crural overlay (lateral sliding). (d) Insertion of Breath
implant. (e–g) Deprojection combined with increasing tip support. Front view, profile view, base view pre-op/post-op
a
b
12.2 · Case Studies

766
12
c
d
.
. Fig. 12.46  (continued)

Chapter 12 · Tip Refinement in Secondary Rhinoplasty

767
12
e
f
.
. Fig. 12.46  (continued)
12.2 · Case Studies

768
12
g
.
. Fig. 12.46  (continued)

Chapter 12 · Tip Refinement in Secondary Rhinoplasty

769
12
12.2.41  Case 41: Lengthening by Columellar
Strut and Extended Spreader Grafts,
Reconstruction of the Lower
Framework with Septal Cartilage
A 54-year-old female presented after two previous cosmetic
nasal surgeries performed elsewhere (. Fig. 12.47). Examination
revealed conspicuous overprojection of the nasal tip, pinching
of the middle vault with internal valve collapse, and dislocation
of the caudal septum into the left nasal vestibule. Surgical explo-
ration with the external approach initially revealed only diffuse
scarring of the nasal tip. However, after resection of the tip scar
tissue, absence of both lateral crura and portions of the left
intermediate crus were observed. Total tip framework recon-
struction via the external approach was accomplished using
septal cartilage graft material. Extended spreader grafts were
used to widen the middle vault, lengthen the nose by 12 mm,
and support the newly placed columellar strut graft. Additional
strips of septal cartilage were then used to replace the missing
segments of LLC and reconstruct the tip framework.
.
. Fig. 12.47  (a–d)
Lengthening by columellar strut
and extended spreader grafts. (e)
Batten grafts for framework
reconstruction. (f–h) Front view,
profile view, base view pre-op/
post-op
a
b
12.2 · Case Studies

770
12
c
d
.
. Fig. 12.47  (continued)

Chapter 12 · Tip Refinement in Secondary Rhinoplasty

771
12
e
f
.
. Fig. 12.47  (continued)
12.2 · Case Studies

772
12
h
g
.
. Fig. 12.47  (continued)

Chapter 12 · Tip Refinement in Secondary Rhinoplasty

773
12
12.2.42  Case 42: Lengthening by Septal
Extension Graft
A 30-year-old male patient presented after previous rhino-
plasty with a severe pig’s nose. The nose was overshortened,
the nasolabial angle increased. Very obvious asymmetry of
the nostrils was seen. The cartilaginous dorsum was not low-
ered sufficiently, and the nasal pyramid was deviated
(. Fig. 12.48).
Using an open approach, dome division on the left was
revealed. The overshortened nose resulted from an overre-
sected anterior septum. The caudal framework was destroyed.
The scar formations between the LLCs and ULCs were cut
through to the inner lining, so that the LLCs could be pushed
caudally. After lowering the cartilages, a septal extension
graft was harvested from the central septum and fixed to the
right side, because the anterior border of the resected septum
was slightly shifted to the left. The deviated nasal pyramid
was straightened and narrowed with percutaneous low-to-
low lateral and transverse osteotomies. From a harvested rib,
cartilaginous strips were thinned with a sculpture board to
1.5 mm thickness. These spreader grafts were fixed to the
dorsum of the septum. Tip reconstruction was achieved on
the left side with lateral crural overlap. On the right side, a
medial sliding was performed to bring the domes into a sym-
metric position. Only then, the crura medialia were fixed to
the septal extension graft. Additionally, batten grafts were
placed. Residual cartilage was diced and used as free diced
cartilage for final smoothening and augmentation of both
soft triangles.
12.2 · Case Studies

774
12
.
. Fig. 12.48  (a) Open approach, using a cotton stick for protection of
the medial crura. (b) Removal of scar tissue. (c) Overshorthened anterior
septal border. (d–f) Placing a septal extension graft. (g) Fixing spreader
grafts. (h) Tip reconstruction. (i–k) Front view, profile view, base view
pre-op/post-op
a
b
c
d
e
f
g
h

Chapter 12 · Tip Refinement in Secondary Rhinoplasty

775
12
i
j
.
. Fig. 12.48  (continued)
12.2 · Case Studies

776
12
k
.
. Fig. 12.48  (continued)

Chapter 12 · Tip Refinement in Secondary Rhinoplasty

777
12
12.2.43  Case 43: Lengthening
by Combination from Sandwich Graft
and Septal Extension Graft
A 32-year-old female presented after two failed rhinoplasty
surgeries (. Fig. 12.49). The patient reported that the first rhi-
noplasty resulted in an overly short nose. Consequently, a
second rhinoplasty was performed only 2  months later to
increase nasal length using cartilage grafts. However, the
patient remained dissatisfied with her nasal length and
returned seeking a second revision surgery to elongate her
nose. Using a double-layered conchal sandwich graft sup-
ported with bilateral extended spreader grafts, the nasal tip
was counterrotated to the patient’s satisfaction.
.
. Fig. 12.49  (a) Lengthening
by combination from sandwich
graft and septal extension graft.
(b–d) Front view, profile view,
base view pre-op/post-op
a
b
12.2 · Case Studies

778
12
c
d
.
. Fig. 12.49  (continued)

Chapter 12 · Tip Refinement in Secondary Rhinoplasty

779
12
12.2.44  Case 44: Lengthening by Two
Doublelayered Sandwich Grafts
from both Conchae
A 58-year-old female presented after multiple unsuccessful
rhinoplasty procedures performed elsewhere (. Fig. 12.50).
Examination revealed a small and overly short nose with an
overresected dorsum. Using the external approach, the lat-
eral crura were found to be missing and only an L-strut
remained of the quadrangular septum, leaving very little sep-
tal cartilage for graft harvest. To lengthen the nose and repro-
ject the tip, a double-layered conchal strut graft was placed
and supported from behind by a second double-layered strut
graft sewn to the caudal septum. Septal batten grafts were
then used to replace the missing lateral crura, and a noninte-
grated shield graft fashioned from conchal cartilage was used
to further increase tip projection. Additional conchal carti-
lage was crosshatched (while leaving the perichondrium
intact) and used for dorsal augmentation. To straighten the
nasal dorsum, the right nasal bone was in-fractured, and the
left nasal bone was augmented with a thin cartilage onlay
graft. Previous radix augmentation grafts were removed, and
the nasion was lowered using a motorized drill. The dorsum
was then smoothed with alloplastic fascia. One year postop-
eratively, minor irregularities were successfully camouflaged
with microinjections of autologous fat.
12.2 · Case Studies

780
12
.
. Fig. 12.50  (a–d)
Lengthening by two sandwich
grafts and shield graft, covered
with soft-tissue onlay graft,
dorsal augmentation with
crosshatched conchal graft,
reconstruction of the
overresected LLCs with batten
grafts. (e–h) Front view, profile
view, base view pre-op/post-op
a
b
c
d

Chapter 12 · Tip Refinement in Secondary Rhinoplasty

781
12
e
f
.
. Fig. 12.50  (continued)
12.2 · Case Studies

782
12
g
h
.
. Fig. 12.50  (continued)

Chapter 12 · Tip Refinement in Secondary Rhinoplasty

783
12
12.2.45  Case 45: Shortening by Tip
Suspension Suture with Anterior
Sling, Additionally Columella
Shortening
A 47-year-old male presented after three previous rhinoplas-
ties with a polly-beak deformity, tip ptosis, and a deficient
infratip (. Fig. 12.51). A deep scar of the left ala (from previ-
ous laser treatment) was also observed.
Using an open rhinoplasty approach, subcutaneous scar
tissue was excised, and tip ptosis was corrected using a sus-
pension suture with an anterior sling. The suspension suture
was placed as follows. After fixing a 4-0 resorbable polydioxa-
none suture to the dorsal septum, the suture tails were passed
retrograde through small needles inserted beneath the colu-
mellar/vestibular skin at the desired point of tip suspension. A
single loose throw was placed between both ends of the suture
(with the knot in the midline of the infratip lobule), while the
columellar skin flap was sewn closed. Once the flap was
returned to its normal position, the final tightening and tying
of the knot were completed. Using this method, long-lasting
tip support was established. Prior to closure, the deep alar scar
was augmented from beneath with a soft-tissue graft created
from the previously excised fibrous scar of the nasal tip.
.
. Fig. 12.51  (a–e) Shortening the nose by tip suspension suture and anterior sling combined with columella shortening. (f–h) Front view, profile
view, base view pre-op/post-op
a
b
c
e
d
12.2 · Case Studies

784
12
f
g
.
. Fig. 12.51  (continued)

Chapter 12 · Tip Refinement in Secondary Rhinoplasty

785
12
h
.
. Fig. 12.51  (continued)
12.2 · Case Studies

786
12
12.2.46  Case 46: Shortening by Sandwich
Graft for Tip Support
A 22-year-old female presented after two previous rhinoplas-
ties with an ultranarrow, crooked, and sharp-looking dorsum
(. Fig. 12.52). Presumably a reduction rhinoplasty had been
performed previously for treatment of a tension-nose defor-
mity. Examination revealed severe alar concavities bilaterally
and ptosis of the nasal tip. A C-shaped dorsal curvature and
saddle-nose deformity (arising from an underlying defor-
mity of the septum) were also observed, and the bony dor-
sum remained overprojected.
Surgical exploration with the external approach revealed
overresection of the caudal septum. This was reconstructed
with a double-layered sandwich graft fabricated from ­conchal
cartilage. Spreader grafts, also fabricated from conchal carti-
lage, were used to straighten the dorsal curvature. After rasp-
ing down the bony dorsum, the bony pyramid was
straightened with percutaneous low-to-low lateral and trans-
verse osteotomies. The cephalic portion of the LLCs was
resected and used as batten onlay grafts to camouflage sharp
edges of the domes and to fill the concavities of both lateral
crura. Augmentation of the saddled dorsum was initially
attempted using four layers of allogenic fascia lata, but the
result was unsatisfactory. Consequently, two layers of allo-
genic fascia lata were used to create a fascial sleeve and then
filled with diced cartilage to create a DC-F onlay graft. The
remaining two layers of fascia lata were then used to cover
the DC-F graft. A tragal graft was also used to correct a
retracted left alar rim.

Chapter 12 · Tip Refinement in Secondary Rhinoplasty

787
12
a
b
.
. Fig. 12.52  (a) Severe scarring. (b) Placing a sandwich graft used as
septal extension graft for fixing the medial crura with a tongue-in
groove for shortening, correcting the concave lateral crura by batten
grafts from the cephalic portion. (c–e) Front view, profile view, base
view pre-op/post-op
12.2 · Case Studies

788
12
c
d
.
. Fig. 12.52  (continued)

Chapter 12 · Tip Refinement in Secondary Rhinoplasty

789
12
e
.
. Fig. 12.52  (continued)
12.2 · Case Studies

790
12
12.2.47  Case 47: Shortening by Combination
of Different Techniques
A 57-year-old male presented after septorhinoplasty per-
formed elsewhere (. Fig.  12.53). Examination revealed an
overly long nose with severe tip ptosis and a hyperacute
nasolabial angle from overresection of the anterior septum.
Using the external rhinoplasty approach, anterior septal sup-
port was reconstituted using a double-layered conchal graft.
Previously divided domes were then repaired with sutures
and sewn to the columellar strut graft. The tip complex was
then resuspended using a suspension suture with a posterior
sling. Because of the severity of tip ptosis, a full-thickness
fusiform excision of the membranous septum, combined
with a full-thickness radix skin excision (i.e., a rhino-lift pro-
cedure, also known as an “external nose lift” procedure), was
also performed to eliminate redundant soft tissue and to con-
solidate tip support.
.
. Fig. 12.53  (a–b) Shortening by combination of different techniques. (c–e) Front view, profile view, base view pre-op/post-op
a
b

Chapter 12 · Tip Refinement in Secondary Rhinoplasty

791
12
d
c
.
. Fig. 12.53  (continued)
12.2 · Case Studies

792
12
e
.
. Fig. 12.53  (continued)

Chapter 12 · Tip Refinement in Secondary Rhinoplasty

793
12
12.2.48  Case 48: Shortening by Combination
of Different Techniques
A 45-year-old male presented after severe nasal trauma and
two previous unsuccessful nasal surgeries; he complained of
nasal obstruction and an unattractive nose (. Fig.  12.54).
Examination revealed a wide bony pyramid and ptosis of an
overprojected nasal tip. Overall, the nose was overly long,
and the nasolabial angle was overly acute at 45° with a
retracted columella. Despite thickened skin of the nasal dor-
sum, numerous irregularities were observed along the nasal
bridge, and a retracted horizontal scar was present at the base
of the glabella. Endonasal examination revealed a septal per-
foration measuring 12.0 mm.
Surgical exploration via the open approach revealed
destruction of the anterior septum with a weak and insuffi-
cient caudal border. Both LLCs were deformed, with concav-
ities of the lateral crura. After dissection of the septum, a
residual dorsal L-strut measuring 6.0 mm was found, but it
was not straight because of a high septal deviation. For recon-
struction, we first performed a hydro-dissection of the endo-
nasal mucosa, followed by careful dissection from beneath
the ULCs and from the septum, including the nasal floor and
the inferior turbinate, where the flap was cut horizontally. In
this manner, successful closure of the perforation was per-
formed using two cranially based septal advancement flaps
and two transposition flaps based anteriorly and posteriorly
at the nasal floor (i.e., the four-flap technique).
Two straight rib cartilage segments measuring approxi-
mately 7.0 cm in length were then harvested from the eighth
and ninth ribs. These were then sectioned into multiple strips
measuring 1.5 mm thick by using a sculpture board (Medicon;
Tuttlingen, Germany). Two strips were used as extended
spreader grafts after correcting the high septal deviation with
parasagittal medial osteotomies using a Lindemann burr. By
using the Lindemann burr to perform the medial osteoto-
mies, parallel osteotomy cuts were positioned precisely on
either side of the sagittal midline, and additional bone was
removed to create space for the extended spreader grafts.
These grafts were then fixed to the residual septum and used
to stabilize a columellar strut graft that was sutured between
the distal ends. The medial crura were then sutured to the
columellar strut graft for tip support. Concavity of the lateral
crus could not be fully corrected with a lateral crural fold-­
under flap because crural width was too narrow to permit a
flap of adequate size. Therefore, lateral crural strut grafts
fashioned from rib cartilage were used instead.
The nasal pyramid was then narrowed using percutane-
ous low-to-low lateral and transverse osteotomies. The nose
was also shortened using the tongue-in-groove technique
and by performing a fusiform skin excision to rotate the tip
while simultaneously resecting the depressed glabellar scar.
After partially closing the nasal skin flap, the dorsum was
refined by injecting free diced cartilage paste created from
residual rib cartilage.
12.2 · Case Studies

794
12
.
. Fig. 12.54  (a–b) Reconstruction of strong septal frame. (c–d) Reconstruction of the lower framework. (e–f) Direct nose lift ,smoothening the
reconstructed dorsum with fdc. (g–i) Front view, profile view, base view pre-op/post-op
a
b

Chapter 12 · Tip Refinement in Secondary Rhinoplasty