Mastering Advanced Rhinoplasty

848
13
Case 5: Modified Upside-Down Technique
Combined with Total Septal Reconstruction
Using Both Conchae (See Secondary
Septoplasty, 2.2.14)
A 26-year-old female presented complaining of nasal obstruc-
tion and a persistent congenital nasal tip deformity after two
previous unsuccessful nasal surgeries. Examination revealed
a wide nose with a collapsed middle vault and ­concave mal-
formations of both lower lateral cartilages. Surgical explora-
tion with the open approach revealed ­insufficient septal
donor cartilage for complete reconstruction. Conchal
­cartilage was then harvested from both ears and used for
L-strut reconstruction. The lateral crural concavities were
eliminated using a modified “upside-down-technique” in
which a small rim of the lateral crus was preserved, and the
deformed segment was then resected, flipped 180°, and
sutured on top of the ipsilateral remnant of crural cartilage.
Following cartilage transposition, spanning sutures were
used to control flaring. The bony hump was also reduced with
a rasp, and the middle vault was augmented with a small
residual piece of morselized septal cartilage (. Fig. 13.18).
.
. Fig. 13.18  (a) Total septal reconstruction. (b–d) Modified upside-down tehnique. (e) Ala spanning suture. (f) Morselized cartilage graft for cam-
ouflaging the dorsum. (g–i) Front view, profile view, base view pre-op/post-op
a
b
c
e
d
f

Chapter 13 · Malformation

849
13
h
g
.
. Fig. 13.18  (continued)
13.2 · Case Studies

850
13
i
.
. Fig. 13.18  (continued)

Chapter 13 · Malformation

851
13
Case 6: Modified Upside-Down Technique
Combined with Dorsal Reconstruction
A 47-year-old male presented after ten previous nasal surger-
ies requesting a more attractive nose with the creation of a
slight dorsal hump. Examination revealed a conspicuous dor-
sal deformity with scarred and discolored skin and numerous
contour irregularities. The middle vault was overprojected
and deviated to the right as a result of a warped underlying rib
cartilage graft. Tip ptosis and an overly acute nasolabial angle
were also observed. Upon surgical exploration with the open
rhinoplasty approach, a crudely shaped piece of rib cartilage
was found serving as a columellar strut graft. Concavities of
both lateral crura were hidden beneath onlay grafts of rib car-
tilage. After removing the onlay grafts, the lateral crura were
observed to be abnormally wide. This permitted the entire
crus to be removed, flipped 180°, divided longitudinally, and
then used to reconstruct both lateral crura. The dorsum was
then augmented with a DC-F graft fashioned from autolo-
gous temporalis fascia filled with diced cartilage obtained
from the previously implanted rib grafts (. Fig. 13.19).
.
. Fig. 13.19  (a–d) Modified
upside-down technique. (e–g)
Front view, profile view, base
view pre-op/post-op
a
b
13.2 · Case Studies

852
13
c
d
.
. Fig. 13.19  (continued)

Chapter 13 · Malformation

853
13
f
e
.
. Fig. 13.19  (continued)
13.2 · Case Studies

854
13
g
.
. Fig. 13.19  (continued)

Chapter 13 · Malformation

855
13
Case 7: Upside-Down Technique Combined
with Batten Graft
A 49-year-old male presented for revision rhinoplasty after
five unsuccessful surgeries performed elsewhere. On exam-
ination, persistent malformations of the lateral crura with
nostril asymmetry were observed. In addition, the dorsum
was overly wide and crooked. Palpation revealed absence
of the caudal septum. Using the external approach, recon-
struction of the L-strut was accomplished using bilateral
conchal grafts to create an L-shaped replacement graft. The
replacement graft was then sutured to the nasal spine and
integrated into the residual dorsal septum. Misshapen and
collapsed medial crura were then sutured to the L-strut
replacement graft for support. Deep ­concavities of both lat-
eral crura were then eliminated using the “upside-down”
technique in which the deformed segments were excised,
flipped, and reattached. Finally, spanning sutures were
used to control flaring, and a tip suspension suture with a
posterior sling was used to strengthen tip support
(. Fig. 13.20).
.
. Fig. 13.20  (a–b)
Upside-down technique
combined with batten graft.
(c–e) Front view, profile view,
base view pre-op/post-op
a
b
13.2 · Case Studies

856
13
c
d
.
. Fig. 13.20  (continued)

Chapter 13 · Malformation

857
13
e
.
. Fig. 13.20  (continued)
13.2 · Case Studies

858
13
Case 8: Upside-Down Technique Combined
with Batten Graft
A 41-year-old female presented complaining of nasal obstruc-
tion with collapse of the left nostril after rhinoplasty was per-
formed elsewhere. The patient also reported gradual loss of
tip projection resulting in an overly prominent ­dorsum.
Examination also revealed an overresected bony vault result-
ing in an underprojected nasion. After exploration of the nose
via the open approach, overresected and concave lateral crura,
overly sharp angulations of the nasal domes, and vertical divi-
sion of the right nasal dome were observed. After resection of
the deviated central septum and cartilaginous dorsum,
spreader flaps were used to reconstitute the middle vault. The
resected cartilaginous hump was then used as a columellar
strut graft, and both lateral crural remnants were sutured to
the strut after the right crural remnant was flipped to elimi-
nate the concave deformity. A batten graft fashioned from
septal cartilage was then placed to prevent collapse of the left
lateral crus, and a small cephalic trim from the left lateral crus
was used to augment the right side. Spanning sutures were
then used for contour refinement. Two layers of allogenic fas-
cia lata were used to camouflage the dorsum (. Fig. 13.21).

Chapter 13 · Malformation

859
13
.
. Fig. 13.21  (a–d) Upside-down technique (right) combined with batten graft (both sides). (e–g) Front view, profile view, base view
pre-op/post-op
a
c
b
d
e
13.2 · Case Studies

860
13
f
g
.
. Fig. 13.21  (continued)

Chapter 13 · Malformation

861
13
Case 9: Lateral Crural Strut Graft
A 17-year-old female patient presented with nasal obstruc-
tion following a horseback riding accident and previous rhi-
noplasty. Examination revealed a round and amorphous
nasal tip with collapse of the left nostril from scar contrac-
ture. Opening the internal nasal valve by insertion of a small
glass spatula revealed a positive Cottle test, as nasal breathing
returned to normal with this maneuver. The dorsum revealed
a C-shaped curvature to the right, and the profile revealed a
small dorsal hump.
Using the external rhinoplasty approach, surgical explora-
tion revealed a severe deformity of the right lateral crus. After
separating the ULCs from the septum, the deformed central
septum was excised, and the cartilaginous dorsum was low-
ered by scissors resection. The bony hump was lowered using
an electric drill fitted with a cylindrical drill bit. After
straightening the deviated bony pyramid using parasagittal
medial, percutaneous low-to-low lateral, and percutaneous
transverse osteotomies, spreader grafts fashioned from the
excised septum were sutured into position. Another piece of
septal cartilage was thinned and sutured on top of the dam-
aged right lateral crus. On the left side, a lateral crural strut
graft was used to strengthen the lateral crus, and a columellar
strut graft was placed for tip support. After partially closing
the skin flap, finely diced residual cartilage was injected for
radix augmentation (. Fig. 13.22).
13.2 · Case Studies

862
13
.
. Fig. 13.22  (a–b) Lateral crural
strut graft (left) and batten graft
(right). (c–e) Front view, profile
view, base view pre-op/post-op
a
c
b

Chapter 13 · Malformation

863
13
d
e
.
. Fig. 13.22  (continued)
13.2 · Case Studies

864
13
Case 10: Combination Overlap Technique,
Horizontal Mattress Sutures, and Batten Graft
Refinements with free diced cartialge
A 32-year-old female presented after three previous rhino-
plasties with a deformed and deviated nasal tip and a small,
narrow, and asymmetrical nasal dorsum with a depressed
right nasal bone. The patient also complained of nasal
obstruction, which was alleviated by manual distention of
the internal nasal valves.
Surgical exploration revealed untreated malformations of
both LLCs and no sign of previous spreader graft placement.
After removal of the nasal tip scars, a pinched and concave
left lateral crus and a missing right lateral crus were found.
Exploration of the bony vault revealed that previous lateral
osteotomies were positioned too high on the bony side wall,
and the right cranial fragment had collapsed inward. Repeat
osteotomies seemed ill-advised; therefore, camouflage of the
collapsed bony segment with free diced cartilage was planned.
A residual septal deformity was resected and used for
spreader grafts. The ANS was malpositioned 4 mm to the left
of midline, but owing to the small size of the nasal spine, tran-
section and relocation of the bone with microplates were not
feasible. Consequently, the straightened caudal septum was
sutured to the perforated ANS in a side-to-side configuration.
The tip deformity was first addressed with placement of a
columellar strut graft. Next, buckling of the right intermedi-
ate crus was eliminated with a medial crural overlap (sliding)
technique, and the left lateral crus was flattened with hori-
zontal mattress sutures and splinted with a batten graft. A
batten graft was also used to replace the missing right lateral
crus. Finally, the tip was then contoured with transdomal
sutures, the flaring was controlled with spanning sutures, and
the tip position was stabilized using a tip suspension suture.
In order to avoid any irregularities, allogenic fascia was
placed over the dorsum, and free diced cartilage was used for
smoothing the tip contour (. Fig. 13.23).

Chapter 13 · Malformation

865
13
.
. Fig. 13.23  (a–f) Combination lateral crural overlap technique, horizontal mattress sutures, and batten graft. Additionally allogenic fascia lata
for smoothing the dorsum and free diced cartilage for smoothing the lateral wall and the tip
a
b
13.2 · Case Studies

866
13
c
d
.
. Fig. 13.23  (continued)

Chapter 13 · Malformation

867
13
e
f
.
. Fig. 13.23  (continued)
13.2 · Case Studies

868
13
Suggested Reading
Aiach G.  Personal communication at the 12th international Stuttgart
course for functional and aesthetic rhinoplasty, 9–11 Mar 2005.
Boccieri A, Marianetti TM.  Barrel roll technique for the correction of
long and concave lateral crura. Arch Facial Plast Surg. 2010;12(6):
415–21.
Gruber RP, Peled A, Talley J. Mattress sutures to remove unwanted convex-
ity and concavity of the nasal tip—12-year follow-up. Aesthet Surg
J. 2015;35(1):20–7.
Guyuron B, Ghavami A, Wishnek SM. Components of the short nostril.
Plast Reconstr Surg. 2005;116(5):1517–24.
Haack S, Gubisch W. Lower lateral crura reverse plasty: a technique to correct
severe concavities of the lateral crus. Aesth Plast Surg. 2011;35(3):349–56.

Chapter 13 · Malformation

869
VI
Complex Revision
Content
Chapter 14
Complex Revisions – 871

871
© Springer International Publishing AG 2018
W. Gubisch, Mastering Advanced Rhinoplasty,
14
Complex Revisions
14.1
Case 1: Long-Term Result of Complex Tip Reconstruction
(12-Year Follow-Up) – 872
14.2
Case 2: Complex Reconstruction with Extracorporeal Septal
Reconstruction, Cartilage Grafts from Ear and Rib and Dorsal
Reconstruction with DC-F Graft – 878
14.3
Case 3: Complex Nose Reconstruction in a Patient with Partial
Necrosis of the Columella – 882
14.4
Case 4: Reconstruction of Tip and Dorsum with Rib Grafts – 886
14.5
Case 5: Complex Tip Reconstruction – 890
14.6
Case 6: Severe Psychological Problems After Minor Surgical
Deformity with 15-Year Follow-Up – 894
14.7
Case 7: Scar Correction After a Failed Open Approach – 899
14.8
Case 8: Complex Tip Reconstruction – 902
14.9
Case 9: Complex Reconstruction of the Nasal Framework
in Severely Scared Skin – 905
14.10
Case 10: Complex Tip and Dorsal Reconstruction
Including Extracorporeal Septal Reconstruction – 911

Suggested Reading – 916

872
14
The nose is the central aesthetic element of the face, and a
failed rhinoplasty may lead to significant psychosocial stress
and dysfunction. The impact of a failed rhinoplasty should
prompt the surgeon to explore the cause of treatment failure
and to consider attempting to salvage the outcome with sec-
ondary surgery. However, the inexperienced surgeon often
exacerbates the initial treatment failure when attempting to
correct his or her own work, creating an ever greater chal-
lenge for the next surgeon. In such cases, the patient is often
apprehensive, skeptical, and mistrusting of further surgery,
even at the hands of an accomplished revision rhinoplasty
specialist. However, the embarrassment and emotional angst
of a failed rhinoplasty eventually prompt further surgery
despite the associated fear and anxiety. Yet, in addition to the
psychological issues of the revision rhinoplasty patient, the
revision surgeon must also contend with the technical chal-
lenges of a previously operated nose. Disruption of surgical
navigation planes, excessive bleeding, and dense scarring
typically make the dissection far more challenging.
Moreover, missing, distorted, or damaged skeletal structures
typically necessitate complex skeletal grafting, and graft sur-
vival is less reliable due to compromised circulation. In the
worst-­case scenario, vascular insufficiency can lead to graft
or skin necrosis. Even when the technical aspects of surgery
are successful, postoperative swelling is often increased, and
the healing process is usually prolonged. For all of these rea-
sons, a candid and explicit preoperative discussion in which
the limitations, risks, and complications of revision rhino-
plasty are reviewed in detail must be undertaken. Additional
time must also be allotted for a complete discussion of the
relevant issues.
14.1 Case 1: Long-Term Result of Complex
Tip Reconstruction (12-Year Follow-Up)
A 50-year-old patient presented following two functional
and cosmetic septorhinoplasties. Examination revealed
retraction, fixation, and scarring of the supratip skin from
previous surgical perforation. Asymmetrical nasal bones
with a C-shaped dorsal deformity, overly prominent soft-­
tissue triangles, and left-sided alar retraction were also
observed. Although the open approach carried an increased
risk of skin necrosis in the area of iatrogenic skin perfora-
tion, the advantage of a precise diagnostic assessment
made the open approach justifiable. Upon opening the
nose, the left lateral crus and the nasal dome were both
missing and had been replaced with a malpositioned carti-
lage onlay graft. Reconstruction was achieved using donor
septal cartilage. Both lower lateral cartilages (LLCs) were
reconstructed using narrow strips of septal cartilage
thinned with a motorized diamond fraise to create indi-
vidual domal/lateral crural replacement grafts. Spanning
sutures were then used to contour the lobule, and a shield
graft fashioned from tragal cartilage was added for addi-
tional tip contour. A suspension suture with a posterior
sling was then used for tip rotation and stabilization
(. Figs. 14.1 and 14.2).

Chapter 14 · Complex Revisions

873
14
.
. Fig. 14.1  (a, b) Left lateral
crus and both domes have been
removed and replaced by a
combined shield-onlay graft,
which has been dislocated. (c, d)
Reconstruction of the missing
parts by septal cartilage grafts,
shield graft from tragus for tip
contouring. (c–e) Pre-/
postoperative images after 1 year
a
b
c
d
14.1 · Case 1: Long-Term Result of Complex Tip Reconstruction (12-Year Follow-Up)

874
14
e
f
.
. Fig. 14.1  (continued)

Chapter 14 · Complex Revisions

875
14
g
.
. Fig. 14.1  (continued)
14.1 · Case 1: Long-Term Result of Complex Tip Reconstruction (12-Year Follow-Up)

876
14
.
. Fig. 14.2  (a–c) Twelve-year
follow-up
a
b

Chapter 14 · Complex Revisions

877
14
c
.
. Fig. 14.2  (continued)
14.1 · Case 1: Long-Term Result of Complex Tip Reconstruction (12-Year Follow-Up)

878
14
14.2 Case 2: Complex Reconstruction
with Extracorporeal Septal
Reconstruction, Cartilage Grafts
from Ear and Rib and Dorsal
Reconstruction with DC-F Graft
A 41-year-old female presented after three previous septorhi-
noplasties complaining of nasal obstruction and a misshapen
nose. Examination revealed an overly short and saddled
nose, a pinched tip with retracted soft-tissue facets, and
asymmetrical nostrils from a malpositioned columella.
Endonasal examination revealed nasal polyposis and an
18-mm septal perforation high in the nasal vault. Open
access was achieved via an inverted-V transcolumellar inci-
sion located at the narrowest segment of the columella, above
the previous malpositioned columellar incision. Dissection
was challenging because of extensive surgical scarring, and
large portions of quadrangular cartilage were found to be
missing, including the caudal septum and the anterior septal
angle. Large portions of the LLCs were also previously
resected. Reconstruction of the L-strut was accomplished
using a double-layered conchal cartilage graft reinforced
from behind with small residual strips of septal cartilage
sewn to a PDS foil scaffold. The L-strut replacement graft was
secured to the nasal spine using a transverse drill hole for
suture fixation. The septal perforation was closed using a
four-flap technique in which the superior flap was an
advancement flap from the upper lateral cartilage mucosa
and not a bridging flap, as recommended in some textbooks.
The nasal polyps were also removed. Thin and malleable rib
cartilage grafts fashioned from the tenth rib were then used
to replace the missing LLCs, and a nonintegrated shield graft
was also placed. A DC-F graft constructed from autologous
temporalis fascia and filled with a combination of diced
­conchal and rib cartilage was then used to augment the
­overresected nasal dorsum (. Fig. 14.3).
.
. Fig. 14.3  Residual straightened parts of the septum are sutured to
a PDS foil. (a) In front of this reconstruction, a double-layered concha
graft was placed to reconstruct the anterior septal angle to support the
tip and to lengthen the nose. (b) The L-strut replacement graft is
brought into position with a translabial guiding suture; rib graft and
deep temporalis fascia are harvested; LLCs are reconstructed with strips
from rib grafts. (c) DC-F for dorsal reconstruction. (d–f) pre-op/2 yr
­post-op
a

Chapter 14 · Complex Revisions

879
14
b
.
. Fig. 14.3  (continued)
14.2 · Case 2: Complex Reconstruction with Extracorporeal Septal Reconstruction

880
14
c
d
.
. Fig. 14.3  (continued)

Chapter 14 · Complex Revisions

881
14
e
f
.
. Fig. 14.3  (continued)
14.2 · Case 2: Complex Reconstruction with Extracorporeal Septal Reconstruction

882
14
14.3 Case 3: Complex Nose Reconstruction
in a Patient with Partial Necrosis
of the Columella
A 43-year-old female presented after four previous open rhi-
noplasties complicated by ischemic necrosis of the columella.
Although the primary surgeon recommended immediate
columellar reconstruction, we persuaded the patient to wait
until the necrotic segment healed by secondary intention.
Examination of the nose also revealed a rightward C-shaped
deformity of the dorsum, collapse of the right lateral crus,
and conspicuous nostril asymmetry. Following healing of the
columella, a two-stage revision surgery was recommended in
which the columellar scar would be treated secondarily.
Open rhinoplasty was performed via a transcolumellar inci-
sion located at the upper edge of the depressed columellar
scar. Only minor fragments of LLCs remained, and all of the
surplus septal cartilage was missing, making septal graft
­harvest impossible. Although rib cartilage was ultimately
used for reconstruction, breast implants, a pectus excava-
tum, and diffusely calcified rib cartilage made an inframam-
mary crease incision ill-advised. Thin strips of rib cartilage
were then fabricated and placed over the LLC remnants.
However, owing to excessive cartilage rigidity, transdomal
sutures failed to provide a satisfactory tip contour.
Consequently, the domes were vertically divided and sutured
back together to achieve the desired shape. Dorsal irregu-
larities were then excised, and two layers of allogenic fascia
lata were also used for camouflage, for profile augmentation,
and for improved dorsal aesthetic lines. Three months later,
the patient returned for treatment of the depressed columel-
lar scar. The depressed segment was carefully de-epithelial-
ized and covered with a full-thickness postauricular skin
graft (. Fig. 14.4).

Chapter 14 · Complex Revisions

883
14
.
. Fig. 14.4  (a) Severe nasal
deformity after four previous
rhinoplasty, last with open
approach, wound healing
problems, and partial necrosis of
the columellar flap. (b) Deep scar
after secondary healing.
(c) Reconstruction of the LLCs
with rib cartilage (dome division
technique). (d–f) Pre-/
postoperative images after the
first stage of reconstruction
(nose). (g) Second stage of recon-
struction: correcting the deep
retracted columellar scar
(f) by full-thickness postauricular
skin graft
a
b
14.3 · Case 3: Complex Nose Reconstruction in a Patient with Partial Necrosis of the Columella

884
14
c
d
.
. Fig. 14.4  (continued)

Chapter 14 · Complex Revisions

885
14
e
f
g
.
. Fig. 14.4  (continued)
14.3 · Case 3: Complex Nose Reconstruction in a Patient with Partial Necrosis of the Columella

886
14
14.4 Case 4: Reconstruction of Tip and
Dorsum with Rib Grafts
A 32-year-old patient presented for revision rhinoplasty after
several previous rhinoplasties. Her main complaints included
an over-shortened nose, a wide bony pyramid, a pollybeak
deformity, as well as a severely retracted transcolumellar
incision scar.
Using an open approach technique, the scar was carefully
excised. Dissection of the dorsum revealed a Medpor implant
which was removed. Following division of the tip consisting
only of scar tissue and cartilaginous fragments, the septum
was found to be over-resected anteriorly and no longer in
continuity with the ethmoid bone, whereas the central part
was deviated to the left. The bony pyramid was straightened
and narrowed by parasaggital, lateral low-to-low, and
­transverse osteotomies. Next, the deformed part of the sep-
tum was removed. Strips of rib cartilage were fixed to the
residual ULCs, and the residual septum was fixed in between
and to the ANS. For stabilization of the keystone area, a criss-
cross suture was applied. A septal extension graft was created
from the removed septum and put in front of the over-
resected anterior septal border. It was kept in position with
extended spreader grafts. The missing caudal framework was
replaced by cartilage strips from rib cartilage which were
thinned to 1 mm thickness using the sculpture board (Medi-
conR). They were fixed to a columellar strut made from rib
cartilage and then molded by transdomal and spanning
sutures. Before flipping back the skin flap, the nasofrontal
angle was deepened with a cylindrical drill and rim grafts
were placed. After suturing the skin flap, the nasal dorsum
was smoothed with free diced cartilage.

Chapter 14 · Complex Revisions

887
14
.
. Fig. 14.5  (a) Reconstruction of the dorsum with double-layered rib grafts. (b) Columellar strut from rib graft. (c, d) Reconstruction of the LLCs from
strips of rib graft, using bending technique. (e) Refinement with free diced cartilage
a
b
c
e
d
14.4 · Case 4: Reconstruction of Tip and Dorsum with Rib Grafts

888
14
g
h
.
. Fig. 14.5  (continued)

Chapter 14 · Complex Revisions

889
14
i
.
. Fig. 14.5  (continued)
14.4 · Case 4: Reconstruction of Tip and Dorsum with Rib Grafts

890
14
14.5 Case 5: Complex Tip Reconstruction
A 27-year-old female presented 10 years after a previous rhi-
noplasty for revision surgery (. Fig. 14.6c: profile before and
after first rhinoplasty). The patient stated that she had been
given the nickname of “rhino,” which made her reluctant to
participate in social activities. She further stated that the pri-
mary surgeon told her there was no chance of achieving a bet-
ter nose. Examination revealed a markedly overprojected
nasal tip with a protruding columella and a conspicuous low
columellar scar. The columella was also overly wide, asym-
metrical, and dislocated from the nasal spine, resulting in nos-
tril asymmetry. A heavily overresected dorsum with excessive
dorsal width was also observed. For reconstruction, the open
approach was performed through a new transcolumellar inci-
sion properly located above the old columellar scar.
Exploration revealed large missing segments of medial and
intermediate crura. Additionally, both lateral crural remnants
were collapsed and measured only 2–3 mm in width. The cau-
dal septum, which had been horizontally overexcised, was still
vertically too long and was dislocated from the nasal spine.
Consequently, it was trimmed to match the height of the nasal
spine and sutured in the midline using a transverse drill hole.
The quadrangular septum and right concha were then har-
vested for graft material. A double-layered conchal graft was
used to lengthen the septum and to provide tip support. Five-
millimeter strips of septal cartilage were used to replace the
overresected lateral crura, and the medial ends were sewn to
the conchal graft. Spanning sutures were then placed for tip
refinement, and a suspension suture with a ­posterior sling was
used for tip stabilization. After narrowing and straightening
the bony dorsum, a DC-F graft (created from allogenic fascia
lata and diced remnants of septal and conchal cartilage) was
used for dorsal augmentation (. Fig. 14.6).

Chapter 14 · Complex Revisions

891
14
.
. Fig. 14.6  (a) Large parts of the LLCs are missing but by an unknown
graft, used as a columellar strut resulted in an overprojection. (b)
Replacing the columellar strut by double-layered conchal graft,
­reconstruction of the missing LLCs with batten graft technique. (c) The
patient at the age of 17 before first operation when she first introduced
herself to us. (d, e) Pre-op/2yr post-op
a
b
14.5 · Case 5: Complex Tip Reconstruction

892
14
d
c
.
. Fig. 14.6  (continued)

Chapter 14 · Complex Revisions

893
14
e
.
. Fig. 14.6  (continued)
14.5 · Case 5: Complex Tip Reconstruction

894
14
14.6 Case 6: Severe Psychological Problems
After Minor Surgical Deformity
with 15-Year Follow-Up
A 17-year-old female presented after unsuccessful rhino-
plasty performed elsewhere. Postoperatively she became dis-
turbed about her unsightly nostril contour, and subsequently
she developed bulimia. Examination revealed a wide and
asymmetrical columella with retraction of the left alar rim.
The dorsum was still slightly overprojected and canted to her
right, and the caudal septum was dislocated to the left. Open
exploration of the nose revealed overresection of the left
­lateral crus, predisposing to alar retraction. The caudal
­septum was then repositioned to the midline by trimming
the base to match the height of the nasal spine and suturing it
to a nasal spine drill hole. In order to create a symmetrical tip
framework, a piece of septal cartilage was thinned on one
side with a motorized diamond fraise in order to create a
slightly convex shape. The modified cartilage was then used
to augment the overresected lateral crura. By recreating a
symmetrical and sturdy tip framework, alar retraction was
eliminated without the use of a chondrocutaneous composite
graft, which would have been a more complex alternative
option (. Figs. 14.7 and 14.8).
.
. Fig. 14.7  (a) Molding
bended cartilage graft from a
straight septum. This graft was
used to replace the missing part
of the left lateral crus, which was
pulled cranially. With this
reconstruction, a symmetrical
framework was achieved and the
retraction could be corrected.
(b–d) Pre-op/post-op. images
after 1 year
a

Chapter 14 · Complex Revisions

895
14
b
c
.
. Fig. 14.7  (continued)
14.6 · Case 6: Severe Psychological Problems After Minor Surgical Deformity with 15-Year Follow-Up

896
14
d
.
. Fig. 14.7  (continued)

Chapter 14 · Complex Revisions

897
14
.
. Fig. 14.8  (a–c) Fifteen-year
follow-up
a
b
14.6 · Case 6: Severe Psychological Problems After Minor Surgical Deformity with 15-Year Follow-Up