Mastering Advanced Rhinoplasty

796
12
h
i
.
. Fig. 12.54  (continued)

Chapter 12 · Tip Refinement in Secondary Rhinoplasty

797
12
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
A 42-year-old female presented after three previous nasal
surgeries with numerous nasal base abnormalities, including
a bulky tip, a hanging columella, pinched alae, asymmetrical
nostrils, and fullness of the supratip (. Fig. 12.55). A retracted
V-shaped transcolumellar scar was also observed.
Using the external rhinoplasty approach, the retracted
columellar scar was excised. Surgical exploration then
revealed damaged medial crura and a concave right lateral
crus. Dissection of the septum also revealed an L-shaped
frame with a strong dorsum but a weak caudal septum. The
left concha was then harvested and scored in the midline,
and the convex sides were sutured back-to-back to create a
flat double-layered sandwich graft. The graft was then sewn
to the anterior border of the septum (modified septal exten-
sion graft). The hanging columella was corrected using a
tongue-in-groove technique in which the fragmented and
scarred medial crura were sewn directly to the sandwich
graft. For alae contouring rim grafts on both sides. To avoid
an overly short nose, a double-layered shield graft was
placed and covered with soft tissue. Finally, the dorsum was
smoothed with the powered cylindrical drill bit.
12.2 · Case Studies

798
12
.
. Fig. 12.55  (a–b) Correction
of hanging columella with
sandwich graft plus
double-layered shield graft,
covered with soft-tissue graft.
(c–e) Front view, profile view,
base view pre-op/post-op
a
b

Chapter 12 · Tip Refinement in Secondary Rhinoplasty

799
12
c
d
.
. Fig. 12.55  (continued)
12.2 · Case Studies

800
12
e
.
. Fig. 12.55  (continued)

Chapter 12 · Tip Refinement in Secondary Rhinoplasty

801
12
12.2.50  Case 50: Correction of Hanging
Columella with Columellar Strut
and Extended Spreader Grafts, Total
Reconstruction of the Lower
Framework
A 25-year-old female presented following septorhinoplasty
that was performed elsewhere (. Fig. 12.56). Examination
revealed an overrotated tip with overly prominent soft-tis-
sue facets and a hanging columella. A straight-line trans-
columellar scar was visible, and an inverted-V deformity
and a wide bony vault were also observed. To revise the
nose, an inverted-V-type transcolumellar incision was used
for the open approach. Surgical exploration revealed
­subtotal absence of both LLCs. Only the right medial crus
and half of the left medial crus remained, although multiple
fragments of tip cartilage were scattered throughout the
nasal tip. Septal cartilage was used to rebuild the missing tip
framework. A columellar strut was placed and supported
with bilateral extended spreader grafts. The medial crural
remnants were also sewn to the strut graft. Long strips of
septal cartilage were then sewn to the upper end of the strut
graft and then thinned using a motorized drill to recreate
domal folds, replacing the missing domes and lateral crura.
The dorsum was then smoothed and covered with allogenic
fascia lata.
12.2 · Case Studies

802
12
.
. Fig. 12.56  (a–b) Correction of hanging columella with strut, combined with 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

Chapter 12 · Tip Refinement in Secondary Rhinoplasty

803
12
d
c
.
. Fig. 12.56  (continued)
12.2 · Case Studies

804
12
e
.
. Fig. 12.56  (continued)

Chapter 12 · Tip Refinement in Secondary Rhinoplasty

805
12
Suggested Reading
à Wengen D, Daniel RK. Secondary rhinoplasty: surgical techniques. In:
Daniel RK, editor. Mastering rhinoplasty: a comprehensive atlas of
surgical techniques with integrated video clips. Heidelberg: Springer;
2010. p. 349–78.
Davis RE. Revision of the overresected tip/alar cartilage complex. Facial
Plast Surg. 2012;28(4):427–39.
Eichhorn SJ, Gubisch W. Overresection of the lower lateral cartilage: a fre-
quent cause of revision rhinoplasty. HNO. 2009;57(11):1113–20.
Fedok FG. Revision rhinoplasty. Facial Plast Surg. 2008;24(3):269.
Gubisch W. Secondary Surgery of the Septum and the Tip. In: Rohrich RJ,
Ahmad JA. Secondary Rhinoplasty by the Global Masters. New York,
Stuttgart. Thieme, Publishers, 2017;945–989.
Kridel R, Undavia S. Deprojection of the nasal tip in revision rhinoplasty.
Facial Plast Surg. 2012;28(4):440–6.
Lemperle G, Biewener A. External skin excision in the sebaceous nose and
supratip deformity. Aesth Plast Surg. 1992;16:303–7.
Meyer R. Secondary rhinoplasty. Berlin: Springer; 1988.
Sheen JH. Supratip deformity. Ann Plast Surg. 1979;3(6):498–504.
Shipchandler TZ, Papel ID.  The crooked nose. Facial Plast Surg.
2011;27(2):203–12.
Suggested Reading

807
V
Malformations
Content
Chapter 13
Malformation – 809

809
© Springer International Publishing AG 2018
W. Gubisch, Mastering Advanced Rhinoplasty,
13
Malformation
13.1
Surgical Principles – 810
13.2
Case Studies – 815
13.2.1
Primary Cases – 815
13.2.2
Secondary Cases – 837

Suggested Reading – 868

810
13
13.1 Surgical Principles
Naturally occurring malformations of the lower lateral
­cartilages (LLCs) are common, and the use of the open
­rhinoplasty approach makes the recognition and character-
ization of tip malformations far more reliable and precise.
Likewise, many unsuccessful rhinoplasties result from the
inability to properly recognize and treat congenital LLC mal-
formations because of poor surgical exposure using the
closed approach. Malformations of the nasal tip may occur
unilaterally or bilaterally with variations in both type and
magnitude. Virtually any segment of the LLC can be affected
by congenital anomalies, including the medial crural foot-
pods, the medial crura themselves, or the nasal domes. How-
ever, the most common site for naturally occurring tip
malformations is the lateral crus, with crural concavity being
the most commonly seen anomaly. Although most malfor-
mations of the LLC are associated with cosmetic distur-
bances, concave malformations of the lateral crura are also
commonly associated with functional impairment, particu-
larly in noses with weak lateral crura that are prone to inspi-
ratory collapse or in noses with an adjacent septal deformity
that exacerbates nasal valve obstruction. In the thin-skinned
nose, concavities of the lateral crus are often visible exter-
nally, but overlying soft tissues may conceal smaller concavi-
ties, underscoring the importance of a careful endonasal
examination as part of the preoperative evaluation process.
While some LLC deformities are hidden by the overlying soft
tissues, we prefer not to rely solely on soft-tissue camouflage
for treatment. Instead, correction of all skeletal deformities is
preferred in order to optimize both the functional and cos-
metic results. Although Daniel feels that a slight crural con-
cavity (coupled with convexity of the intermediate crura) will
yield the best tip contour, we believe that flat and sturdy lat-
eral crura yield not only a pleasant tip contour but also pro-
vide the structural rigidity necessary for reliable function of
the nasal airway.
Many LLC deformities lend themselves to straightforward
surgical correction. For example, asymmetrical or overly pro-
trusive medial crural footpods can be corrected by transect-
ing the medial crus just above the footpod and then coapting
the footpods with intercrural sutures or transcutaneous mat-
tress (transfixion) sutures. Alternatively, the footpods can be
completely excised, and the columellar pedestal can be con-
toured with only transfixion sutures. Another common defor-
mity is buckling of the intermediate crura within the infratip
lobule. This can be corrected by suturing the intermediate
crura to a columellar strut graft or, if unilateral, by perform-
ing a unilateral medial crural overlap procedure.
The most common LLC deformities are concavities of the
lateral crura, which can be oriented longitudinally or trans-
versely and which may be unilateral or bilateral. For trans-
verse concave deformities of the lateral crus, excising and
flipping the concave segment (upside-down technique
(. Fig. 13.1) is recommended, whereas we prefer leaving a
narrow caudal rim strip to facilitate suture reattachment as
recommended by Aiach (. Fig. 13.2). Occasionally in bilat-
eral deformities, the flipped segment is returned to the con-
tralateral side (contralateral upside-down technique) to
enhance bilateral symmetry.
In a longitudinally oriented concavity, a variety of tech-
niques are possible. If the lateral crus is overly weak and the
defect is small to intermediate in size, we prefer placement of
horizontal mattress sutures to simultaneously flatten and
stiffen the lateral crus (. Fig. 13.3). As the mattress suture is
slowly tightened, the concavity is gradually eliminated, and a
knot is tied while the suture is held with forceps to prevent
slippage. Typically, multiple sutures are placed in series to
completely flatten and strengthen the affected crural seg-
ment. And unlike excisional techniques, the horizontal mat-
tress suture technique is potentially reversible.
Another option for treatment of a longitudinal crural con-
cavity is the fold-over flap technique. In this technique, the
cephalic margin is incised during a cephalic trim and is par-
tially undermined so that it remains pedicled to the peri-
chondrium just above the incision line. The flap is then
rotated superiorly and inverted so that it rests on top of the
crural concavity. When sutured to the underlying cartilage,
the fold-over flap serves to fill the concavity as well as to
strengthen and flatten the lateral crus (. Fig.  13.4).
Alternatively, the flap can be rotated in the opposite direction
to fill a pocket created beneath the crural concavity. Again,
suture fixation serves to flatten and strengthen the lateral
crural remnant (. Fig. 13.5). Although the fold-under flap is
more effective at strengthening weak lateral crura, wide dis-
section of vestibular skin from beneath the lateral crus is
more difficult and more time-consuming.
If the lateral crus is too narrow to permit a fold-over or
­fold-under technique, a batten graft fashioned from septal
cartilage will simultaneously correct the crural concavity and
eliminate the strength deficiency. Batten grafts are a valuable
technique in both cosmetic and functional rhinoplasty
(. Fig.  13.6). For optimal cosmetic results, batten grafts
should be carefully beveled along their outer edges for
­concealment. Batten grafts are sometimes positioned beyond
the caudal border of the lateral crura to stabilize the alar rim
against cephalic retraction and to simultaneously strengthen
the alar rim against alar collapse. Similarly, batten grafts can
also be extended laterally to prevent inward collapse of the
lateral crura near the piriform aperture. Finally, if lateral
­crural concavity is combined with an overprojected tip, a
­lateral crural overlap technique is preferred, since both tip
deprojection and crural flattening are accomplished
­simultaneously (. Fig. 13.7).

Chapter 13 · Malformation

811
13
.
. Fig. 13.1  Upside-down
technique
a
b
.
. Fig. 13.2  (a, b) Modified
Upside-down technique
13.1 · Surgical Principles

812
13
a
b
.
. Fig. 13.3  (a, b) Horizontal
mattress suture
.
. Fig. 13.4  Cephalic turn-over flap

Chapter 13 · Malformation

813
13
.
. Fig. 13.5  Cephalic fold-under flap
.
. Fig. 13.6  Batten graft
technique
13.1 · Surgical Principles

814
13
a
b
.
. Fig. 13.7  (a, b) Lateral crural
overlay technique

Chapter 13 · Malformation

815
13
13.2 Case Studies
13.2.1 Primary Cases
Case 1: Horizontal Mattress Sutures
A 19-year-old female presented complaining of a
­peculiar-­looking nasal tip. Examination revealed ­prominent
concavities of both lateral crura and a tilted columella
from caudal septal dislocation. Using the open approach, the
caudal septum was repositioned and secured to a transverse
drill hole created within the nasal spine. Fading (oblique)
medial
osteotomies,
combined
with
percutaneous
­low-to-high ­lateral osteotomies, were then used to narrow
the bony ­pyramid. For correction of the crural concavity,
a cephalic trim was performed, and the excised cartilage was
retained. After elevating the vestibular skin from the ­residual
lateral crus, horizontal mattress sutures were used to flatten
the concavity, and the previously excised cephalic specimen
was used as an onlay batten graft for additional stability.
The procedure was performed bilaterally. Owing to the
­additional crural rigidity obtained through the aforemen-
tioned procedures, spanning sutures could be used to ­control
flaring without fear of recurrent crural collapse. A columel-
lar strut graft was also placed to enhance tip ­support
(. Fig. 13.8).
13.2 · Case Studies

816
13
.
. Fig. 13.8  (a) Cephalic
resection. (b) Horizontal mattress
sutures. (c) Batten graft from the
excised cephalic portion. (d)
Applying spanning sutures. (e)
Placing a columellar strut. (f–h)
Front view, profile view, base
view pre-op/post-op
a
b
c
d

Chapter 13 · Malformation

817
13
e
f
.
. Fig. 13.8  (continued)
13.2 · Case Studies

818
13
g
h
.
. Fig. 13.8  (continued)

Chapter 13 · Malformation

819
13
Case 2: Upside-Down Technique
A 31-year-old male presented after previous septoplasty
complaining of persistent bilateral nasal obstruction that
had failed to improve with septal surgery. Examination
revealed bilateral lateral crural concavities, a persistent
septal deviation, and bilateral synechiae. After opening the
nose, deep transverse concavities were observed involving
both lateral crura. After dividing the synechiae, the L-strut
was straightened using spreader grafts. The concavities
were corrected by excising the involved cartilage segments,
­turning the specimens 90°, and suturing each specimen to
the contralateral defect to produce a modest bilateral
­crural convexity. Transdomal sutures and a tip graft were
then used for further tip refinement, correcting both the
crural concavities and the alar rounding simultaneously
(. Fig. 13.9).
13.2 · Case Studies

820
13
.
. Fig. 13.9  (a–b) Upside-down
technique. (c–e) Front view, profile
view, base view pre-op/post-op
a
b
c

Chapter 13 · Malformation

821
13
d
e
.
. Fig. 13.9  (continued)
13.2 · Case Studies

822
13
Case 3: Upside-Down Technique
A 44-year-old male presented with nasal airway
­obstruction. Examination revealed pronounced concave
collapse involving the central aspect of both lateral crura.
Dynamic valve collapse was observed upon gentle nasal
inspiration. Surgical exploration with the open approach
revealed deep lateral crural concavities immediately
­adjacent to both nasal domes. After columellar strut
­placement, a left unilateral upside-­down procedure was
used to correct the left concavity and a septal onlay batten
graft was used to fill the right concavity. Small onlay carti-
lage grafts were also used to fill concavities of the interme-
diate crura. Improved contour and nasal function were
achieved (. Fig. 13.10).

Chapter 13 · Malformation

823
13
.
. Fig. 13.10  (a–b) Upside-down technique.
(c–e) Front view, profile view, base view
pre-op/post-op
a
b
c
13.2 · Case Studies

824
13
e
d
.
. Fig. 13.10  (continued)

Chapter 13 · Malformation

825
13
Case 4: Modified Upside-Down Technique
A 43-year-old male was seen complaining of a nasal tip defor-
mity which he feared was produced by a nasal tumor.
Examination revealed a conspicuous concavity of the right lat-
eral crus, which was confirmed using open rhinoplasty. Because
of the presence of thick tip cartilages, the deep concavity was
eliminated using a (right) upside-down technique in which a
narrow caudal rim strip was preserved to facilitate suture fixa-
tion of the inverted segment. As a result of improved stability,
spanning sutures were then used for tip refinement (. Fig. 13.11).
.
. Fig. 13.11  (a–c) Modified
upside-down technique with
preserving a caudal strip of the
lateral crus. (d) Ala spanning
suture. (e–g) Front view, profile
view, base view pre-op/post-op
a
b
13.2 · Case Studies

826
13
.
. Fig. 13.11  (continued)
c
d

Chapter 13 · Malformation

827
13
e
f
.
. Fig. 13.11  (continued)
13.2 · Case Studies

828
13
g
.
. Fig. 13.11  (continued)

Chapter 13 · Malformation

829
13
Case 5: Fold-under flap (lateral crural
underlay)Technique
A 27-year-old male presented with a deviated nose and irreg-
ularities of the nasal dorsum. The tip was overly round, and
concavities of the lateral crura were observed through the
nasal skin. Both soft triangles were retracted, and protruding
medial crural footpods produced an overly wide columellar
pedestal. Endonasal examination revealed a deviated septum.
Using the open rhinoplasty approach, surgical explora-
tion confirmed the preoperative diagnosis of lateral crural
concavities. In combination with septal deviation, the left
crural concavity resulted in complete left nasal airway
obstruction. After removing the deformed central septum,
the nasal pyramid was straightened using parasagittal
medial and percutaneous low-to-low lateral and transverse
osteotomies. The caudal septum was then shortened at its
base and placed into a groove created within the anterior
nasal spine (ANS) for stabilization. After creating trans-
verse drill holes using a Lindemann burr, the caudal septum
was sutured to the midline groove of the ANS using three
separate sutures.
Spreader grafts fashioned from septal cartilage were then
sutured to the dorsal septum. The concave left LLC was elim-
inated using a cephalic fold-under flap to flatten the lateral
crus. On the contralateral side, the cephalic margin was
excised for symmetry. Before suturing the medial crura to
the columellar strut graft, both medial crural footpods were
transected but not removed. Mattress sutures were then
applied to narrow the protruding footpods and contour the
columellar pedestal. Narrow skin pockets were dissected
along both alar margins, and alar rim grafts were placed
bilaterally. Finally, three layers of allogenic fascia lata were
soaked in gentamicin antibiotic solution and used to aug-
ment the nasal dorsum (. Fig. 13.12).
13.2 · Case Studies

830
13
.
. Fig. 13.12  (a–b) Fold-under flap technique left side combined with columellar strut graft. (c) Contouring the tip with transdomal sutures. (d–g)
Front view, profile view, base view pre-op/post-op
a
b

Chapter 13 · Malformation

831
13
d
c
.
. Fig. 13.12  (continued)
13.2 · Case Studies

832
13
f
e
.
. Fig. 13.12  (continued)

Chapter 13 · Malformation

833
13
Case 6: Fold-under Flap Technique
A 33-year-old male presented for primary rhinoplasty com-
plaining of bilateral nasal obstruction and collapse of the
nostrils on inspiration. Examination revealed an overly long
nose with an overprojected dorsum, a ptotic and overpro-
jected tip, and an overly acute nasolabial angle. Surgical
exploration with the open approach showed deep concavities
of both lateral crura. After lowering the dorsum and recon-
structing the middle vault with spreader flaps, both crural
concavities were corrected using cephalic fold-under flaps.
For additional lateral crural support and for increased tip
rotation, a lateral crural overlap procedure was performed
near the piriform area and reinforced with an onlay graft of
septal cartilage (. Fig. 13.13).
13.2 · Case Studies

834
13
.
. Fig. 13.13  (a–b) Fold-under
flap (Lateral crural underlay)
technique, drawing of an
additional lateral crural overlap
(sliding) technique. (c–e) Front
view, profile view, base view
pre-op/post-op
a
b

Chapter 13 · Malformation

835
13
c
d
.
. Fig. 13.13  (continued)
13.2 · Case Studies

836
13
e
.
. Fig. 13.13  (continued)

Chapter 13 · Malformation

837
13
13.2.2 Secondary Cases
Case 1: Lateral Crural Overlap Technique
A 29-year-old male presented for revision rhinoplasty and
airway restoration after three unsuccessful nasal surgeries.
Examination revealed an overprojected and deviated nasal
dorsum with an obvious malformation of the right lower
­lateral cartilage. After straightening the nose with an extra-
corporeal septoplasty and reconstructing the middle vault
with bilateral spreader grafts, the right lateral crural malfor-
mation was corrected using a lateral crural overlap technique.
Both cosmetic and functional improvements were achieved
(. Fig. 13.14).
.
. Fig. 13.14  (a–b) Lateral crural
overlap technique. The cephalic
portion is flipped over to fill the
concavity of the lateral crus. (c–e)
Front view, profile view, base
view pre-op/post-op
a
b
13.2 · Case Studies

838
13
c
d
.
. Fig. 13.14  (continued)

Chapter 13 · Malformation

839
13
e
.
. Fig. 13.14  (continued)
13.2 · Case Studies

840
13
Case 2: Turn-over-flap (Lateral Crural Overlay)
Technique Combined with Batten Graft
A 46-year-old male presented for correction of a
­postsurgical saddle-nose deformity. Examination revealed
an overprojected tip with weak tip cartilage, a concavity of
the right lateral crus, and a deepened nasolabial angle. The
septum was deviated to the left, and the caudal septum was
dislocated from the nasal spine and displaced into the right
nasal ­vestibule. Surgical correction via the open approach
included straightening of the septum and rasping the
­dorsum to create a straight bony profile. A columellar strut
was placed for medial crural support, and an onlay batten
graft was used to fill the right crural concavity. The left
­lateral crus was strengthened with a lateral crural overlap
technique, and the tip was rotated using a suspension
suture. The saddled dorsum was augmented with mor-
selized septal cartilage to create a straight dorsal profile
(. Fig. 13.15).
.
. Fig. 13.15  (a) Lateral crural
overlay (fold-over flap) technique
on the right side, batten onlay
graft on the left side. (b–d) Front
view, profile view, base view
pre-op/post-op
a
b

Chapter 13 · Malformation

841
13
d
c
.
. Fig. 13.15  (continued)
13.2 · Case Studies

842
13
Case 3: Fold-over Flap Technique
(Lateral Crural Overlap)
A 37-year-old male patient presented after previous nasal
surgery with a C-shaped nasal deviation resulting from a
severe persistent septal deformity. The tip was asymmetrical,
and dimpling of both alae, caused by pronounced concavities
of both lateral crura, was also observed. The columella was
oblique, and endonasal examination revealed obstruction of
both internal valves.
Using the open approach, surgical exploration revealed a
severe septal deformity that necessitated an extracorporeal
septal reconstruction. Spreader grafts fashioned from ­conchal
cartilage were used to widen the internal nasal valves. The
oblique columella was straightened using a columellar strut
graft created from a double-layered conchal sandwich graft.
The crural concavities were corrected using a fold-over flap
technique, in which the cephalic portion has been flipped
over to fill the concavity. However, during the overlap proce-
dure, the axis of the segments was reoriented and rotated
outward so that a normal contour resulted. The deviated and
widened bony pyramid was then corrected using parasagittal
medial and percutaneous low-to-low lateral and transverse
osteotomies (. Fig. 13.16).
a
b
.
. Fig. 13.16  (a–b) Fold-over
flap technique: the wide cephalic
portion is flipped over to fill the
concavity and to smooth the
contour. (c–e) Front view, profile
view, base view pre-op/post-op

Chapter 13 · Malformation

843
13
c
d
.
. Fig. 13.16  (continued)
13.2 · Case Studies

844
13
e
.
. Fig. 13.16  (continued)

Chapter 13 · Malformation

845
13
Case 4: Upside-Down Technique
A 36-year-old female presented for revision rhinoplasty.
Examination revealed an overprojected tip and dorsum
canted to the patient’s left side by a persistent septal devia-
tion. Untreated concavities of the lateral crura were also evi-
dent, particularly on the right side. Surgical exploration with
open rhinoplasty revealed a deep concavity of the right lat-
eral crus and malpositioning of the anterior nasal spine to
the left of midline. To reposition the nasal septum, the nasal
spine was fractured, relocated to the sagittal midline, and
immobilized with microplates and screws. Spreader grafts
were also used to maintain a straight dorsal septum. Using
the “upside-down” technique, the deformed right crural seg-
ment was excised, flipped 180°, and used to reconstruct the
ipsilateral defect. On the left side the small cephalic excess
was flipped over and fixed. A lateral crural overlap technique
was then used bilaterally to deproject the nasal tip, but
deprojection was greater on the left side to equalize domal
projection. A shield graft was also used for enhanced con-
tour and stabilization, and morselized cartilage was used as a
dorsal onlay graft to camouflage minor surface irregularities
(. Fig. 13.17).
.
. Fig. 13.17  (a–c) Upside-down
technique on the right side
and lateral crural overlay on
the left side. (d–f) Front view, profile
view, base view pre-op/post-op
a
b
13.2 · Case Studies

846
13
c
d
.
. Fig. 13.17  (continued)

Chapter 13 · Malformation