Mastering Advanced Rhinoplasty

899
14
14.7 Case 7: Scar Correction After a Failed
Open Approach
A 31-year-old female presented after open rhinoplasty per-
formed elsewhere. Her recovery was complicated by inade-
quate wound healing and severe scarring and distortion of
the tip and columella. Examination revealed a counterrotated
and tethered tip/infratip complex with retraction of the colu-
mella. Massage and stretching of the columella did not
improve the deformity. The patient sought second opinions
from other surgeons, some of whom blamed the open
­rhinoplasty approach. However, from our perspective, the
problem resulted from the shortcomings of the previous
­surgeon. After allowing the nose to heal for 1 year, augmenta-
tion of the columella with a postauricular chondrocutaneous
composite graft was undertaken. Upon opening the nose and
excising the columellar scar, an 8-mm columellar skin defect
resulted. However, the composite graft was too thick to create
a smooth and attractive columellar profile. Consequently, we
removed and thinned the auricular skin, sutured the conchal
cartilage into the columellar defect, and used the thinned
auricular skin as a full-thickness graft to cover the cartilage
graft. Owing to the small graft size, healing was favorable. Six
months later, the dorsum was lowered, and the tip was aug-
mented using a cap graft to complete the staged reconstruc-
tion (. Fig. 14.9).
14.7 · Case 7: Scar Correction After a Failed Open Approach

900
14
.
. Fig. 14.9  (a, b) Severe scarring and distortion of the columella after open approach. (c) Revision revealed skin defect of 8 mm. (d) Reconstruc-
tion of the columella by cartilage graft and full-thickness skin graft from the auricle. (e, f) Pre-/post-op after 2 years
b
d
c
a

Chapter 14 · Complex Revisions

901
14
e
f
.
. Fig. 14.9  (continued)
14.7 · Case 7: Scar Correction After a Failed Open Approach

902
14
14.8 Case 8: Complex Tip Reconstruction
A 65-year-old female presented with a complaint of nasal
obstruction after four unsuccessful nasal surgeries performed
elsewhere. Examination revealed a malformed tip, a stenotic
left nostril, and an overresected, scarred, and severely retracted
columella. The endonasal examination revealed previous
removal of the entire bony and cartilaginous septum, except
for a narrow L-strut. Open access was performed using the
previous columellar scar, but an inverted-V type incision was
employed rather than the straight-line incision used previ-
ously. Dissection was challenging because of heavy scarring,
and exposure of the tip framework revealed subtotal absence
of both LLCs. For skeletal reconstruction, both conchae were
harvested. One concha was used to create a double-layered
columellar sandwich graft, which was supported from behind
by extended (conchal) spreader grafts. The missing domes and
lateral crura were then reconstructed from thin strips of the
opposite concha. The dorsum was then smoothed with two
layers of allogenic fascia lata. Silicone nostril stents were used
for 3 months postoperatively to prevent recurrent stenosis and
collapse. Although additional surgery was recommended, the
patient was so pleased with her functional and cosmetic out-
come that she declined further treatment (. Fig. 14.10).
.
. Fig. 14.10  (a) Subtotal
absence of both LLCs after four
previous surgeries,
reconstruction with thin strips of
conchal cartilage (bending
technique) and double-layered
sandwich graft used as a
modified septal extension graft.
(b–d) Pre-/postoperative images
after 1 year, having used silicone
stents for 3 months. The stent is
shown in B
a

Chapter 14 · Complex Revisions

903
14
b
c
.
. Fig. 14.10  (continued)
14.8 · Case 8: Complex Tip Reconstruction

904
14
d
.
. Fig. 14.10  (continued)

Chapter 14 · Complex Revisions

905
14
14.9 Case 9: Complex Reconstruction
of the Nasal Framework in Severely
Scared Skin
A 41-year-old male presented after three previous rhinoplas-
ties with severe deformity of the external and internal nose.
Examination revealed a C-shaped nasal axis and severe
retraction of both soft-tissue triangles. The columella was
tilted obliquely, and dislocation of the caudal septum from
the ANS was obstructing the left nasal vestibule. The nostrils
were severely asymmetrical, and the transcolumellar scar was
plainly visible. On profile view, the radix was severely over-
projected and virtually eliminated the nasofrontal angle.
Additionally, severe overrotation of the rounded nasal tip
resulted in a conspicuous pig-nose deformity. Endonasal
examination revealed copious scars and synechiae on both
sides.
Using the open approach (but positioning the incision at
the narrowest segment of the columella and ignoring the
previous low V-shaped incision), we encountered a twisted
and useless columellar strut graft that was removed.
Moreover, on further exploration, both LLCs were com-
pletely absent. The caudal septum was also overresected, and
the residual septum was overly thick and consisted largely of
bone.
A 12-mm-wide dorsal L-strut was preserved, but the
remaining septum was harvested and thinned using a
­cylindrical drill bit. A double-layered sandwich graft was then
fashioned from conchal cartilage and sutured in front of the
ANS via transosseous drill hole fixation. To stabilize the sand-
wich graft at its opposite end, the septal graft material was used
to bridge the sandwich graft and the dorsal L-strut, thereby
enabling the counterrotation of the nasal tip and lengthening
of the nose. The missing LLCs were then reconstructed using
strips of autologous rib cartilage sutured to the sandwich graft.
To bend the rib grafts and create natural-­appearing domes, the
strips were thinned with the cylindrical drill bit, and spanning
sutures were used to contour the domal arches. A shield graft
was used to further improve contour and to augment the
retracted soft-tissue triangles. The radix was then lowered with
the drill, and the bony pyramid was straightened with osteoto-
mies. To correct saddling of the middle vault, a DC-F was fash-
ioned from rib cartilage and allogenic fascia lata.
Two years after the initial reconstruction, the dorsum was
smoothed by shaving the now solidified DC-F graft, and the
tip was further counterrotated using another shield graft
fashioned from tragal cartilage. A third and final stage after
two additional years completed the reconstruction with
placement of free diced cartilage to the dorsum harvested
from the contralateral concha (. Fig. 14.11).
14.9 · Case 9: Complex Reconstruction of the Nasal Framework in Severely Scared Skin

906
14
a
b

Chapter 14 · Complex Revisions

907
14
.
. Fig. 14.11  (a) Severe webbing of both vestibules. After opening
the nose, both LLCs were missing. (b) Residual septum was very thick
and largely bone; severe scarring of the tip. (c) After removing the scars
and the thin columellar strut, the tip collapsed and appeared severely
pinched. (d) Straightening and thinning of the removed septum; the
bony part was applied with multiple drill holes so soft tissue could grow
through for better blood supply and for stabilization. (e, f) Rib cartilage
for reconstruction of the LLCs and for fabricating a DC-F, conchal carti-
lage for constructing a double-layered sandwich graft. (g) DC-F graft for
dorsal reconstruction. (h–j) Pre-op/4yr post-op
c
d
.
. Fig. 14.11  (continued)
14.9 · Case 9: Complex Reconstruction of the Nasal Framework in Severely Scared Skin

908
14
e
f
.
. Fig. 14.11  (continued)

Chapter 14 · Complex Revisions

909
14
g
h
.
. Fig. 14.11  (continued)
14.9 · Case 9: Complex Reconstruction of the Nasal Framework in Severely Scared Skin

910
14
i
j
.
. Fig. 14.11  (continued)

Chapter 14 · Complex Revisions

911
14
14.10 Case 10: Complex Tip and Dorsal
Reconstruction
Including Extracorporeal Septal
Reconstruction
A 37-year-old male presented for secondary rhinoplasty after
a failed aesthetic procedure that also resulted in nasal airway
obstruction. A C-shaped and overresected dorsum with a
wide, asymmetric, and deviated nasal pyramid was seen on
examination. The tip was also bulbous and ptotic with a
pinched right nostril. On gentle inspiration, the right nostril
also collapsed producing additional airway obstruction.
Endonasal examination revealed obstruction of both nasal
passages from transverse deviation of the anterior septum.
Using an open rhinoplasty approach through an inverted-V
incision, surgical exploration revealed weak and overresected
lateral crura with concave collapse on the right side. The cau-
dal septum was also dislocated from the ANS producing
obstruction of both nasal passages anteriorly. Following
bilateral paramedian sagittal osteotomies with a side-cutting
burr, the septal partition was removed for extracorporeal
septal reconstruction. The bony pyramid was then mobilized,
straightened, and narrowed using bilateral transverse and
low-to-low (percutaneous) lateral osteotomies. The ninth rib
was then harvested to create rough-cut cartilage strips mea-
suring 2.0–2.5  mm in thickness, which were then further
thinned to a final thickness of 1.5  mm using a cartilage
sculpting board (Medicon; Tuttlingen, Germany). Extended
spreader grafts were then sutured to the septum to achieve
the desired increase in nasal length, and the neoseptum was
reimplanted by suturing the construct to the nasal bones in
the midline with paired transcutaneous/transosseous sutures.
After passing the sutures through the nasal skin and bony
pyramid, the suture “tails” were then pulled into the subcuta-
neous pocket and tied over the nasal bones. The neoseptum
was also sutured to both ULC. A 2-mm-thick septal exten-
sion graft was then fashioned from additional rib cartilage
and sutured to the right side of the ANS using drill hole fixa-
tion. The opposite end was then secured to the extended
spreader grafts resulting in midline graft placement. The
medial crura were then sutured to the SEG in a tongue-in-­
groove relationship to stabilize the columella. The weakened
right lateral crus was then augmented with a lateral crural
strut graft, and the intermediate and (concave) left lateral
crura were both excised. The intermediate crus was replaced
with a thinned segment of septal cartilage which was folded
and sutured to create a new left dome unit. After suturing the
dome to the SEG, the left lateral crus was replaced with a rib
cartilage graft. After placement of right tip sutures, lateral
crural spanning sutures were placed for additional tip refine-
ment. The remaining rib cartilage was then diced to create a
DC-F graft using allogenic fascia lata. The proximal end of
the graft was sutured closed, and the graft was then inserted
into the subcutaneous pocket overlying the dorsum. The cen-
tral columellar incision was also sutured closed, and the
DC-F graft was then molded digitally and sutured into posi-
tion. The marginal skin incisions were then closed, and the
nose was bandaged (. Fig. 14.12).
14.10 · Case 10: Complex Tip and Dorsal Reconstruction Including Extracorporeal Septal Reconstruction

912
14
.
. Fig. 14.12  (a) Weak and
overresected lateral crura with
concavity on the right side.
(b) Transverse deviation of the
anterior septum. (c) Explanted
septum with deformed anterior
part. (d, e) Reconstruction of a
neoseptum with extended
spreader grafts. (f) TTC technique
(transcutaneous-transosseous-
cerclage technique) for
reconstruction of the keystone
area. (g) DC-F graft for dorsal
augmentation. (h) Adjusting the
DC-F graft. (i, j) Reconstruction of
the lower framework.
(k–m) Pre-op/2 yr post-op
a
b
c

Chapter 14 · Complex Revisions

913
14
d
e
g
f
h
.
. Fig. 14.12  (continued)
14.10 · Case 10: Complex Tip and Dorsal Reconstruction Including Extracorporeal Septal Reconstruction

914
14
i
k
j
.
. Fig. 14.12  (continued)

Chapter 14 · Complex Revisions

915
14
l
m
.
. Fig. 14.12  (continued)
14.10 · Case 10: Complex Tip and Dorsal Reconstruction Including Extracorporeal Septal Reconstruction

916
14
Suggested Reading
Davis R, Bublik M. Psychological considerations in the revision rhinoplasty
patient. Facial Plast Surg. 2012;28(4):374–9.
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.
Gruber RP, Wall Jr SH, Kaufman DL, Kahn DM. Secondary rhinoplasty. In:
Neligan PC, Chang J, editors. Plastic surgery. 3rd ed. Philadelphia:
Elsevier Saunders Publishing; 2013.
Meyer R. Secondary rhinoplasty. Berlin: Springer; 2002.
Rezaeian F, Gubisch W, Janku D, Haack S.  New suturing techniques to
reconstruct the keystone area in extracorporeal septal reconstruc-
tion. Plast Reconstr Surg. In press.

Chapter 14 · Complex Revisions

917
VII
Software
Content
Chapter 15
New Software for Rhinoplasty Documentation and
Record Keeping – 919

919
© Springer International Publishing AG 2018
W. Gubisch, Mastering Advanced Rhinoplasty,
15
New Software for Rhinoplasty
Documentation and Record
Keeping
15.1
Case 1: Overprojected Dorsum with Bulbous Tip
and Thin Skin – 921
15.2
Case 2: Overprojected, Hourglass-Shaped Narrow
Dorsum – 926
15.3
Case 3: Primary Rhinoplasty in a Thin-Skinned Patient – 930
15.3.1
Technique: Camouflaging with Allogenic Fascia – 930
15.4
Case 4: Secondary Rhinoplasty After Overresection
of the Dorsum and the LLCs – 934

Suggested Reading – 938

920
15
Jack Gunter first introduced schematic illustrations for rhi-
noplasty in a specific software, “the Gunter Rhinoplasty
Diagrams,” which gained worldwide acceptance for clarify-
ing surgical procedures in rhinoplasty. A new approach was
then developed by Gilbert Aiach by the creative use of
detailed illustrations that he had personally drawn, depicting
single and specific steps of the procedure. However, this tool,
which explained his complex surgeries in an easy way, was
again used almost exclusively by its author, since no corre-
lated software was available.
In the meantime, more sophisticated techniques have
been progressively developed. Denis Codazzi, from the team
of Enrico Robotti in Bergamo, generated a very detailed new
3D imaging program, the “Bergamo 3D Rhinoplasty soft-
ware,” which is currently in its first version. The project was
partly funded from the revenues of the Bergamo Open
Rhinoplasty biannual course and in equal part by the
Sanvenero Rosselli Foundation of Professor Riccardo
Mazzola in Milano. The objective is to have a software that is
commercially available and easy to use and that includes in
detail all the maneuvers performed during a rhinoplasty in a
graphic format with easy interpretation. The purpose is both
documenting what was specifically done in a single case
(record keeping) and to simplify teaching and didactics for
future cases. For example, two primary and two secondary
cases are presented.

Chapter 15 · New Software for Rhinoplasty Documentation and Record Keeping

921
15
15.1 Case 1: Overprojected Dorsum
with Bulbous Tip and Thin Skin
(See Sect. 12.2.40)
A 39-year-old female patient was seen after previous rhino-
plasty and an unsuccessful attempt to close a septal perfora-
tion with a severe plunged tip deformity. The anterior septum
was largely missing. The dorsum was overprojected, and the
nasal pyramid was very wide.
Using an open approach method, the perforation was
closed with a four-flap technique. After harvesting the con-
cha from the right side, a sandwich graft was placed and fixed
to the overshortened caudal septum border, giving support to
the tip. The bony dorsum was lowered by rasping, and then
the nasal pyramid was straightened and narrowed by trans-
cutaneous low-to-low lateral and transverse osteotomies.
The overprojected LLCs were corrected with the sliding
or overlap technique. The overlay was 6  mm. The medial
crura were fixed to the sandwich graft, and the domes were
contoured with transdomal sutures. Spanning sutures and tip
suspension sutures were placed, and an extended shield graft
was fixed to the dome area.
At the end allogenic fascia lata grafts were tried but
removed again because free diced cartilage gave a better
result.
Later on function could be improved by inserting a
Breathe implant (Karl Storz; Tuttlingen, Germany), to which
the upper lateral cartilages were sutured (. Figs. 15.1, 15.2,
15.3, 15.4, 15.5, 15.6, 15.7, 15.8, 15.9, 15.10, 15.11, 15.12, and
15.13).
.
. Fig. 15.1  Lowering the dorsum
15.1 · Case 1: Overprojected Dorsum with Bulbous Tip and Thin Skin

922
15
.
. Fig. 15.2  Lowering the dorsum
.
. Fig. 15.3  Osteotomies: paramedian, low to low lateral, and trans-
verse; spreader flaps
.
. Fig. 15.4  Osteotomies: paramedian, low to low lateral, and trans-
verse; spreader flaps

Chapter 15 · New Software for Rhinoplasty Documentation and Record Keeping

923
15
.
. Fig. 15.5  Cephalic trim
.
. Fig. 15.6  Lateral sliding (lateral crural overlay)
.
. Fig. 15.7  Double-layered conchal graft working as columellar strut
.
. Fig. 15.8  Fixing the medial crura to the sandwich graft; transdomal
sutures; tip suspension suture; transseptal mattress sutures = kilting
sutures
15.1 · Case 1: Overprojected Dorsum with Bulbous Tip and Thin Skin

924
15
.
. Fig. 15.9  Fixing the medial crura to the sandwich graft; transdomal
sutures; tip suspension suture; transseptal mattress sutures = kilting
sutures
.
. Fig. 15.10  Contouring the dorsum with free diced cartilage;
extended shield graft
.
. Fig. 15.11  Front view:
Pre-op/post-op

Chapter 15 · New Software for Rhinoplasty Documentation and Record Keeping

925
15
.
. Fig. 15.12  Lateral view:
Pre-op/post-op
.
. Fig. 15.13  Base view:
Pre-op/post-op
15.1 · Case 1: Overprojected Dorsum with Bulbous Tip and Thin Skin

926
15
15.2 Case 2: Overprojected,
Hourglass-Shaped Narrow Dorsum
A 26-year-old patient presented with an overprojected
hourglass-­shaped narrow dorsum. In an open rhinoplasty
approach, the dorsum was lowered with a component tech-
nique. After dissecting the extended parts of the ULCs from
the undersurface of the bony pyramid, the septum was low-
ered with a straight scissors. The bony dorsum was then
reduced with a chisel so that the excess could be removed in
one piece. After transcutaneous low-to-low lateral and trans-
verse osteotomies for narrowing the nasal bones, the leftover
ULCs were invaginated and fixed as spreader flaps to the new
dorsal septum. The weak lateral crura were strengthened by
fold-under flap technique (slipping the cephalic portion under
the lateral crus). After placing a columellar strut, the tip was
contoured by transdomal sutures. For narrowing the tip, span-
ning sutures were applied, and the tip complex was fixed by tip
suspension suture with a posterior sling to the dorsal septum.
The depressor muscle was partially resected, a rim graft was
placed on the left side for symmetry, and both soft triangles
were augmented with allogenic fascia lata after using this kind
of graft as a full-length graft for camouflaging the dorsum
(. Figs. 15.14, 15.15, 15.16, 15.17, 15.18, 15.19, 15.20, and 15.21).
.
. Fig. 15.14  Dorsal reduction
.
. Fig. 15.15  Osteotomies: paramedian, low to low lateral, and trans-
verse

Chapter 15 · New Software for Rhinoplasty Documentation and Record Keeping

927
15
.
. Fig. 15.16  Fold-under flaps (lateral crural underlay)
.
. Fig. 15.17  Columellar strut; transdomal sutures, spanning sutures
combined with tip suspension suture and posterior sling
.
. Fig. 15.18  Full-length graft from allogenic fascia lata to the dorsum;
augmentation of both soft triangles with allogenic fascia; rim graft on
the left side
15.2 · Case 2: Overprojected, Hourglass-Shaped Narrow Dorsum

928
15
.
. Fig. 15.19  Front view, profile
view, base view. Pre-op/post-op
.
. Fig. 15.20  Front view, profile
view, base view. Pre-op/post-op

Chapter 15 · New Software for Rhinoplasty Documentation and Record Keeping

929
15
.
. Fig. 15.21  Front view, profile
view, base view. Pre-op/post-op
15.2 · Case 2: Overprojected, Hourglass-Shaped Narrow Dorsum

930
15
15.3 Case 3: Primary Rhinoplasty
in a Thin-Skinned Patient
15.3.1 Technique: Camouflaging
with Allogenic Fascia
In a thin-skinned patient, there is always the risk of visibility
of grafts or even the exposure of minor irregularities. In such
patients we shape the necessary grafts from fascia lata and
handle them like cartilage grafts.
A 16-year-old female patient presented for rhinoplasty
because of continuous criticism at her school.
The dorsum was broad and overprojected, the tip was bul-
bous, but the skin was very thin and shiny. The nasolabial angle
was about 135°, but the patient did not complain about that.
The septum was deviated to the left with an extended spur.
During open approach rhinoplasty, the spur was
resected, and the septum was trimmed at the base so that it
could be fixed to the perforated nasal spine. The dorsum was
reduced by component technique, and the exceeding ULCs
were invaginated and used as spreader grafts after narrow-
ing the nasal bones with paramedian, transcutaneous low-
to-low lateral, and transverse osteotomies. Transdomal and
spanning sutures were used for narrowing the tip after the
medial crura were sutured directly to the caudal septal bor-
der (tongue-in-­groove technique). Because of the patient’s
thin skin, the whole dorsum was covered with one layer of
allogenic fascia, and a cartilaginous shield graft was removed
again and was replaced by a double-layered fascia graft from
allogenic fascia lata, cut in the shape of a shield graft
(. ‑Figs. 15.22, 15.23, 15.24, 15.25, 15.26, 15.27, 15.28, 15.29,
15.30, and 15.31).
.
. Fig. 15.22  Dorsal reduction; fixation of the anterior septum to the
ANS via a drill hole
.
. Fig. 15.23  Osteotomies: parasagittal, low to low lateral, and trans-
verse

Chapter 15 · New Software for Rhinoplasty Documentation and Record Keeping

931
15
.
. Fig. 15.24  Osteotomies: parasagittal, low to low lateral, and trans-
verse
.
. Fig. 15.25  Spreader flaps
.
. Fig. 15.26  Fold-under flaps (lateral crural underlay); spanning
sutures
.
. Fig. 15.27  Transdomal sutures; tongue-in-groove technique (fixa-
tion of the medial crura to the anterior septum; shield graft from allo-
genic fascia lata; full-length graft from allogenic fascia lata to the dorsum;
rim grafts both sides; transseptal mattress sutures
15.3 · Case 3: Primary Rhinoplasty in a Thin-Skinned Patient

932
15
.
. Fig. 15.28  Transdomal sutures; tongue-in-groove technique (fixa-
tion of the medial crura to the anterior septum; shield graft from allo-
genic fascia lata; full-length graft from allogenic fascia lata to the dorsum;
rim grafts both sides; transseptal mattress sutures
.
. Fig. 15.29  Front view, profile
view, base view. Pre-op/post-op

Chapter 15 · New Software for Rhinoplasty Documentation and Record Keeping

933
15
.
. Fig. 15.30  Front view, profile
view, base view. Pre-op/post-op
.
. Fig. 15.31  Front view, profile
view, base view. Pre-op/post-op
15.3 · Case 3: Primary Rhinoplasty in a Thin-Skinned Patient

934
15
15.4 Case 4: Secondary Rhinoplasty
After Overresection of the Dorsum
and the LLCs
A 35-year-old female presented after previous rhinoplasty
saddle-nose deformity with round uncontoured tip and
obtuse nasolabial angle. Endonasal view showed septal spur
to the right with large synechia. Using an open approach
technique, surgical examination revealed extensive overre-
section of the LLC: on the right side, the lateral crus was
missing, and on the left, the lateral and intermedial crura had
been resected. There was no strut, but a lot of scars, which
obviously had pulled up the tip.
After scar removal, a large piece of cartilage was har-
vested from the septum, preserving a firm 15-mm-wide car-
tilaginous L-strut. The spur was removed by shortening the
overlong septum at its base and fixing it to the ANS after
making a drill hole. The synechia was cut. After parasagittal
medial and percutaneous low-to-low lateral and transverse
osteotomies, narrowing of the bony pyramid became possi-
ble. For lengthening the nose, the right concha was harvested
and a double-layered sandwich graft fabricated, which was
kept in a more caudal position by two extended spreader
grafts from the septum. Two strips from the harvested sep-
tum were used for reconstruction of the LLC. The grafts were
carefully beveled and then fixed to the remnant medial crura.
After bending them, they were fixed directly to the vestibular
skin. The whole framework was then contoured by spanning
sutures after shaping the domes with transdomal sutures. To
secure the position of the reconstructed framework, the
medial crura including the overlying septal grafts were fixed
to the septal extension graft from the double-layered concha.
Additionally, tip suspension suture with posterior sling was
placed. The residual concha was diced finely, and, together
with allogenic fascia, a DC-F was built and placed to the dor-
sum. To prevent synechiae, new silicon sheets were placed
(. Figs.  15.32, 15.33, 15.34, 15.35, 15.36, 15.37, 15.38, 15.39,
15.40, and 15.41).
.
. Fig. 15.32  Harvesting cartilage graft from the septum, leaving
15-mm L-strut; fixing the L-strut to the ANS via a drill hole
.
. Fig. 15.33  Osteotomies: parasagittal, low to low lateral, and trans-
verse; narrowing of the bony pyramid

Chapter 15 · New Software for Rhinoplasty Documentation and Record Keeping

935
15
.
. Fig. 15.34  Double-layered conchal graft, working as septal exten-
sion graft; extended spreader grafts
.
. Fig. 15.35  Replacing the missing parts of the LLCs with cartilage
grafts from the septum; transdomal sutures, spanning sutures combined
with tip suspension suture and posterior sling
.
. Fig. 15.36  Replacing the missing parts of the LLCs with cartilage
grafts from the septum; transdomal sutures, spanning sutures combined
with tip suspension suture and posterior sling
.
. Fig. 15.37  DC-F to the dorsum
15.4 · Case 4: Secondary Rhinoplasty After Overresection of the Dorsum and the LLCs

936
15
.
. Fig. 15.38  DC-F to the dorsum
.
. Fig. 15.39  Front view, profile
view, base view. Pre-op/post-op

Chapter 15 · New Software for Rhinoplasty Documentation and Record Keeping

937
15
.
. Fig. 15.40  Front view, profile
view, base view. Pre-op/post-op
.
. Fig. 15.41  Front view, profile
view, base view. Pre-op/post-op
15.4 · Case 4: Secondary Rhinoplasty After Overresection of the Dorsum and the LLCs

938
15
Suggested Reading
Aiach G. Atlas de Rhinoplastie et de la Voie d’Abord Externe. Paris: Editions
Masson; 1993.
Gunter JP. A graphic record of intraoperative maneuvers in rhinoplasty:
the missing link for evaluating rhinoplasty results. Plast Reconstr
Surg. 1989;84(2):204–12.
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Chapter 15 · New Software for Rhinoplasty Documentation and Record Keeping