Mastering Advanced Rhinoplasty

90
2
e
.
. Fig. 2.24  (continued)

Chapter 2 · Secondary Septoplasty

91
2
.
. Fig. 2.24  (continued)
f
2.2 · Case Studies

92
2
2.2.11 Case 11: Technique: Extracorporeal
Septal Reconstruction with
Double-Layered L-Strut
A 36-year-old female presented after previous septoplasty
with left-sided nasal airway obstruction. In addition, she
complained of an overprojected dorsum and a bulbous tip.
Using an external rhinoplasty approach, an extramucosal
septal dissection was performed with bilateral tunnel dissec-
tion both high and low, followed by release of both ULC
from the septum. After exposing the dorsum, paramedian
osteotomies were created with the Lindeman bur. The bur
was also used to cut the vertical ethmoid plate (at the level of
the intercanthal line) at a 60° downward tilt in order to avoid
injury to the overlying skull base. The remaining soft-tissue
and skeletal attachments to the septum were then released
and the entire septal partition was removed en bloc. From
the explanted septal tissue a new septal L-strut was created.
A cartilage splinting graft was placed on the right side to
simultaneously strengthen both the caudal and dorsal struts.
A spreader graft was then added to the left side to improve
airway function. Next, the bony pyramid was straightened
and narrowed using percutaneous low-to-low lateral and
transverse osteotomies. The neoseptum was then placed
back into the septal pocket and sutured to the ANS, and to
the nasal bones/ULC complex, using osseous drill holes.
Following a cephalic trim and columellar strut placement,
the bulbous tip was contoured using a combination of trans-
domal and lateral crural spanning sutures. Owing to thick
nasal tip skin, a supratip suture of 5-0 Vicryl was placed, and
finely diced cartilage was used for final contour refinement
(. Fig. 2.25).

Chapter 2 · Secondary Septoplasty

93
2
.
. Fig. 2.25  (a–c) Explanted septum and reconstruction of a straight double-layered L-strut. (d) Remaining septal cartilage,which was diced for
final refinements. (e–g) Front, profile, and base views before revision surgery and 1 year postoperative
a
2.2 · Case Studies

94
2
b
.
. Fig. 2.25  (continued)

Chapter 2 · Secondary Septoplasty

95
2
.
. Fig. 2.25  (continued)
c
d
2.2 · Case Studies

96
2
e
.
. Fig. 2.25  (continued)

Chapter 2 · Secondary Septoplasty

97
2
.
. Fig. 2.25  (continued)
f
2.2 · Case Studies

98
2
g
.
. Fig. 2.25  (continued)

Chapter 2 · Secondary Septoplasty

99
2
2.2.12 Case 12: Technique: Extracorporeal
Septal Reconstruction
and Repositioning of the Anterior
Nasal Spine
If there is only a minor dislocation and the ANS is wide, it
can be reduced from one side so that the residual bone rests
in the midline. If the dislocation is more severe, we cut the
bone horizontally at its base with a Lindemann fraise so that
this bone is pedicled to the maxilla. We reposition the ANS
into the midline and secure it with an angled 4-hole micro-
plate, using two 3-mm or 5-mm microscrews. Usually the
repositioned spine is not large enough to allow a drill hole for
suture fixation of the replanted septum. Therefore, the sep-
tum is usually fixed directly to the microplate.
A 40-year-old male presented after previous rhino-
plasty for revision nasal surgery. Examination revealed a
severely deviated nose with an oblique columella and air-
way obstruction caused by dislocation of the caudal sep-
tum into the left nasal vestibule. In addition, concave
deformities were present in both lateral crura, and the tip
was asymmetrical. Surgical exploration using the external
rhinoplasty approach revealed a dislocation of the caudal
septum from the anterior nasal spine, causing a leftward
septal deviation.
To return the caudal septum back to the midline, the
anterior nasal spine was first osteotomized, repositioned, and
fixated in the midline with microplates and microscrews. The
caudal septum was then sutured directly to the microplates
for secure stabilization. Spreader grafts harvested from the
posterior septum were used to widen the internal nasal
valves, and cephalic fold-under flaps were used to correct
concave deformities of the lateral crura. At the conclusion of
surgery, a straight nasal axis with a straight caudal septum
and an attractive tip contour with improved nostril symme-
try were achieved (. Fig. 2.26a–d).
2.2 · Case Studies

100
2
.
. Fig. 2.26  Transposition of the dislocated anterior nasal spine (ANS)
and osseus fixation using microplate and microscrews. (a) Dislocated
anterior nasal spine implemented dislocation of the caudal septal
­border. After transposition and fixation of the ANS, the caudal border of
the septum sits in the midline. (b–d) Front view, profile view, base view
pre-op/post-op
a
b

Chapter 2 · Secondary Septoplasty

101
2
.
. Fig. 2.26  (continued)
c
c
d
2.2 · Case Studies

102
2
2.2.13 Case 13: Technique: Reconstruction
of the Inner Valve with PDS Foil
One option for improving internal nasal valve width is the use
of PDS foil. The perforated version of PDS foil is cut to the
appropriate dimension and fixed to the dorsal septum. The foil
is then folded laterally, creating a spring-like effect that lifts
and widens the ULC in order to widen the internal nasal valve.
A 24-year-old male presented 2 years after previous rhi-
noplasty with a C-shaped deviation to the right side, an over-
projected dorsum with a ptotic nasal tip, and an acute
nasolabial angle. Very broad lower lateral cartilage (LLC)
with retracted columella was also seen.
Intraoperatively, we found a severe septal deformity with
multiple scoring incisions that failed to correct the C-shaped
deformity. Large portions of the central septum had also
been removed during the first procedure. ­Consequently, we
removed all of the remaining residual septal cartilage,
thinned it, and straightened it using a splinting graft fash-
ioned from perforated ethmoid bone. Because there was no
cartilage left for spreader grafts, we reconstructed the inter-
nal nasal valve using PDS foil as a supporting beam. The foil
was folded so that a triangularly shaped cross section resulted,
analogous to a butterfly graft. At the same time, the PDS foil
also served to straighten and stabilize the long axis of the
nose. The hanging tip was corrected by a tongue-in-groove
fixation of the medial crura to the new anterior septal border
as well as with tip suspension sutures (. Fig. 2.27a–e).

Chapter 2 · Secondary Septoplasty

103
2
.
. Fig. 2.27  Extracorporeal septal reconstruction with perpendicular
plate and PDS foil. (a) The septum has been scored, but not splinted
during previous operation. (b) The deformed septum is splinted with
thinned ethmoid bone graft. Folded PDS foil is used for reconstruction
of the internal nasal valve. (c–e) Front view, profile view, base view pre-
op/post-op
a
b
2.2 · Case Studies

104
2
c
d
.
. Fig. 2.27  (continued)

Chapter 2 · Secondary Septoplasty

105
2
e
.
. Fig. 2.27  (continued)
2.2 · Case Studies

106
2
2.2.14 Case 14: Technique: Total
Reconstruction of the Septum
with Both Conchae
If there is insufficient local material to create a sturdy L-strut
for septal reconstruction, both conchae can be used. The
entire concha on each side is harvested, and the convex sides
are sutured against each other with several lines of continu-
ous running sutures. These are best applied when the con-
chae are immobilized using a modified Aiach clamp. With
the Aiach clamp, the cartilage is held perfectly flat during
suture placement to ensure a flat construct. After the graft is
sutured, the construct can be refined to create smooth edges.
The central part can also be resected and used for other pur-
poses, or it can be thinned out, since this portion is not nec-
essary for the stabilization,
In a situation of total septal reconstruction using both
conchae, a 26-year-old woman was seen after two previous
septal corrections. Malformation of both lower lateral carti-
lages with concavity of both lateral crura and an overly
pointed tip from both the frontal a basal view were observed.
In profile, a pseudo-hump resulted from overresection of the
cartilaginous dorsum. According to the patient, she previ-
ously
had
had
a
slightly
overprojected
dorsum.
Intraoperatively a small residual piece of cartilage with
severe deviation was found despite cross-hatching from the
concave side. This remnant piece of septal cartilage was very
unstable and could not be used in the reconstruction.
Additionally, we found a small residual dorsal strip of carti-
laginous septum that appeared to have buckled following
overresection of the central part. These minor residual pieces
of septal cartilage did not provide enough stability for a
sound reconstruction; therefore, we decided in favor of a
total L-strut reconstruction using both conchae. After har-
vesting both conchae, we sutured the opposing convexities
using a modified Aiach clamp and three parallel suture lines
in both a horizontal and vertical orientation. We then shaved
the newly stabilized graft and replanted it after lowering the
bony dorsum. For narrowing of the bony nasal pyramid, we
performed a paramedian as well as transverse and low-to-
low lateral osteotomies. We also drilled holes in the upper
edge of both nasal bones and suture-fixated the replant to the
nasal bones and to the upper lateral cartilages. Caudally, we
also suture-fixated the neoseptum through a drill hole placed
in the anterior nasal spine. Malformations of the lower lat-
eral cartilages were corrected using a modified upside-down
technique, preserving a small strip of cartilage at the ante-
rior-most border to make refixation of the flipped cartilage
easier.
Postoperatively we achieved a nice dorsum with good aes-
thetic dorsal lines from brow to tip. The axis of the nose was
straightened, and in profile we obtained a harmonious dorsal
line with a good tip contour (. Fig. 2.28a–e). (7 See Chap. 13,
“Malformation,” case 5.)

Chapter 2 · Secondary Septoplasty

107
2
.
. Fig. 2.28  Total septal reconstruction using both conchae, because the
residual septum was not sufficient to rebuild a strong L-shaped frame-
work. (a) The insufficient septal remnants and both conchae are harvested.
(b) Construction of a double-layered, strong, L-shaped septal framework,
using a modified Aiach clamp. (c–e) Front view, profile view, base view pre-
op/post-op
a
b
2.2 · Case Studies

108
2
c
d
.
. Fig. 2.28  (continued)

Chapter 2 · Secondary Septoplasty

109
2
e
.
. Fig. 2.28  (continued)
2.2 · Case Studies

110
2
2.2.15 Case 15: Technique: Total Septal
Reconstruction with Both Conchae,
Reconstruction of the Dorsum
with DC-F
A 34-year-old male was seen after two previous operations.
Findings included collapse of the septum with a large septal per-
foration, deformity and destruction of both lower lateral carti-
lages, and an overly low dorsum with an underprojected nasion.
We removed the entire residual septum, but the remnant
was too weak to create a strong, well-shaped frame for satis-
factory reconstruction. Therefore we harvested both conchae
and created a neoseptum by suturing opposite curvatures to
one another. We reconstructed only an L-shaped frame in
order to use the remaining cartilage as batten grafts as well as
diced cartilage. The batten grafts were used to strengthen and
supplement the lateral crura. For reconstruction of the
L-strut, the convex sides of the conchae were sutured together
using three layers of running sutures while immobilized with
a modified Aiach clamp.
This newly created neoseptum was secured to the upper
lateral cartilages as well as to drill holes within the anterior
nasal spine. Additionally, a columellar strut was placed ante-
rior to the L-strut. After grafting the lower lateral cartilages,
the tip was contoured using transdomal sutures, followed by
placement of lateral crural spanning sutures and multiple tip
suspension sutures. Finally, a diced cartilage-fascia graft was
constructed by sewing a 7 × 4 cm piece of deep temporalis fas-
cia around a tuberculin syringe and then filling the newly con-
structed fascial sleeve with residual diced conchal cartilage.
The graft was placed over the dorsum in order to raise dorsal
height and create a smooth dorsal contour (. Fig. 2.29a–h).

Chapter 2 · Secondary Septoplasty

111
2
.
. Fig. 2.29  Total septal reconstruction using both conchae, reconstruc-
tion of the dorsum with DC-F. (a) The removed weak septum. (b) Both
conchae are sutured together to a strong double-layered neoseptum. (c)
Replantation and fixation of the straight neoseptum. (d) Reconstruction
of the destroyed tip framework. (e) Harvesting deep temporalis fascia for
constructing a DC-F, the concha is already harvested. (f–h) Front view,
profile view, base view pre-op/post-op
a
b
2.2 · Case Studies

112
2
c
d
.
. Fig. 2.29  (continued)

Chapter 2 · Secondary Septoplasty

113
2
e
f
.
. Fig. 2.29  (continued)
2.2 · Case Studies

114
2
g
h
.
. Fig. 2.29  (continued)

Chapter 2 · Secondary Septoplasty

115
2
2.2.16 Case 16: Technique: Augmentation
of the Maxilla with a DC-F Graft
Retraction of the columellar base with an acute nasolabial
angle can be corrected using a diced cartilage-fascia graft
(DC-F graft). This technique was developed for saddle-nose
correction and augmentation of the dorsum, but it can also
be used for augmentation of the maxilla.
The DC-F can be constructed from rib or ear cartilage;
however, septal cartilage with its unique physical characteris-
tics seems too precious to use in this manner. It is important
to dice the cartilage as finely as possible but to avoid crushing
it. Therefore, we use a dermatome blade.
To create the fascial tube, autogenous tissue from the
deep temporalis fascia or allogenic fascia lata (Tutoplast) can
be used. The fascia is sutured into a cylinder while wrapped
around a small tuberculin syringe.
After opening up the nose, we dissect the maxilla and put
the DC-F graft via this approach onto the bone. In this case
we close the fascia tube on both sides. In the case of simulta-
neous extracorporeal septal reconstruction, the septum is
put back onto the DC-F.
A 55-year-old man presented following septal surgery
with a severely deformed septum and deviation of the outer
nose. An overresected anterior septum with drooping of the
tip and an acute nasolabial angle were also observed. This
nasal base deformity was worsened by retrognathia. Finally,
an overprojected dorsum combined with an overprojected
tip (partially compensated for by retropositioning of the
maxilla) was also noted.
The treatment plan included augmentation of the canine
fossae with a DC-F graft and removal of the residual septum,
replacing it with a newly constructed neoseptum.
After opening up the nose via the external approach
and dissecting the membranous septum, it was noted that
only a small residual septum was present. Therefore, it
became evident that additional cartilage was needed to cre-
ate a proper neoseptum, and we harvested conchal carti-
lage to supplement the reconstruction. The ear cartilage
was doubled to create a sandwich graft and then integrated
into the straightened residual septum. The opposite concha
was then harvested to create diced cartilage. After harvest-
ing autogenous deep temporalis fascia, a DC-F graft was
created. However, the volume of cartilage from the concha
was insufficient; therefore, rib cartilage was also harvested.
A sufficiently sized DC-F was created out of the mixed
diced cartilage concha as well as the rib. This enabled us to
augment the maxilla. The neoseptum with an integrated
double layered conchal graft was then placed and the
medial crura were sutured to it. Furthermore, two rim
grafts were implanted, and a batten graft was put onto the
right lateral crus. In the end, both soft triangles were
­augmented by the cephalic portion of the lower lateral
crura (. Fig. 2.30a–f).
2.2 · Case Studies

116
2
.
. Fig. 2.30  Extracorporeal septal reconstruction combined with DC-F
for premaxillary augmentation. (a) The explanted deformed septum
and the reconstructed straight neoseptum. (b) The neoseptum before
replantation, DC-F for maxillary augmentation. (c) The neoseptum is
put on top of the DC-F. (d–f) Front view, profile view, base view pre-op/
post-op
a
b

Chapter 2 · Secondary Septoplasty

117
2
c
d
.
. Fig. 2.30  (continued)
2.2 · Case Studies

118
2
e
f
.
. Fig. 2.30  (continued)

Chapter 2 · Secondary Septoplasty

119
2
2.2.17 Case 17: Technique: Reconstruction
of the Septal Framework Using Rib
Cartilage
Total loss of the nasal septum, coupled with depletion of
auricular graft material, necessitates L-strut reconstruction
using rib cartilage to achieve a strong and stable nasal frame-
work. Following graft harvest, the rib is sectioned into mul-
tiple longitudinal (2-mm thick) slices oriented perpendicular
to the superficial rib surface. Dorsal augmentation is begun
by creating drill holes in the nasal bones for suture fixation of
the dorsal augmentation grafts. Paired strips of rib cartilage
are then sutured together and secured to the nasal bones and
upper lateral cartilages with multiple fixation sutures. A sec-
ond graft is then created to replace the missing caudal sep-
tum. The caudal replacement graft is positioned anterior to
the nasal spine and secured through a transverse drill hole
placed through the anterior nasal spine. After determining
optimal graft angulation, the caudal septal replacement graft
is sutured to the dorsal replacement graft to recreate the ante-
rior septal angle.
A 33-year-old female presented after 12 previous rhino-
plasties for revision. Examination for revision rhinoplasty.
Examination revealed a polly-beak deformity with a ptotic
tip, an overresected dorsum, and a retracted columella.
Cutaneous scars were evident from multiple prior nasal
surgeries and from abscess formation following treatment
with injectable filler material. Both conchal cartilages had
been previously harvested. Surgical exploration using the
external approach began with excision of the retracted col-
umellar scar. Subcutaneous collections of abnormal tissue,
likely resulting from previous filler treatment, were
encountered interspersed among small fragments of septal
cartilage and were causing obstruction of both nasal pas-
sages. The lower lateral cartilages had also been removed.
The dorsal septum was reconstructed using a double-­
layered structural graft fashioned from rib cartilage. Simi-
larly, the caudal framework was also reconstructed with
solid rib cartilage, and an electrical drill with a cylindrical
bit was used to thin the cartilage and permit bending of
the graft. After fixation, the solid rib graft was covered
with a DC-F graft fashioned from rib cartilage and allo-
genic fascia lata. The DC-F graft was initially digitally
molded to the desired contour, and the excess cartilage
was “milked” from the caudal end and removed with
­suction (. Fig. 2.31a–g).
.
. Fig. 2.31  Reconstruction of the septal framework using rib cartilage.
(a) Correction of the bad columella scar, severe scaring of the tip with
unknown implants. (b) Destruction of the tip framework. (c) Stabilization
of insufficient septal remnants with rib grafts. (d) Reconstruction of the
tip framework with rib cartilage. (e–g) Front view, profile view, base view
pre-op/post-op
Scars – filler residuals ?
a
2.2 · Case Studies

120
2
c
b
Caudal framework destroyed
unknown implants – lyo-cartilage ?
Septum destroyed, deformed and weak
therefore spreader grafts from the rib
C
.
. Fig. 2.31  (continued)

Chapter 2 · Secondary Septoplasty

121
2
e
d
Resection of the destroyed cartilage
and rebuilding of a new framework from rib
cartilage
.
. Fig. 2.31  (continued)
2.2 · Case Studies

122
2
f
g
.
. Fig. 2.31  (continued)

Chapter 2 · Secondary Septoplasty

123
2
Suggested Reading
Davis RE. Revision rhinoplasty. In: Johnson JT, Rosen CA, editors. Bailey’s
head and neck surgery—otolaryngology. 5th ed. Philadelphia:
Wolters Kluwer/Lippincott, Williams & Wilkins; 2014. p. 2989–3052.
Foda HMT. The caudal septum replacement graft. Arch Facial Plast Surg
J. 2008;10:152–7.
Foda HMT. The crooked nose: correction of the dorsal and caudal septum
deviations. HNO J. 2010;58:889–906.
Fuchshuber G.  Komplikationen bei der Nasenseptumrekonstruktion
mit  Ploydioxanonfolie (Thesis) [in German]. Heidelberg: Medical
Department of Ruprecht-Karls-University; 2003.
Gomulinski L.  The severely deviated septum. Facial Plast Surg.
2006;22:240–8.
Gubisch W. Extracorporeal septoplasty for the markedly deviated septum.
Facial Plast Surg. 2006;22:4.
Gubisch W. Treatment of the scoliotic nose with extracorporeal septo-
plasty. Facial Plast Surg Clin North Am. 2015;23:11–22.
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.
Heppt W, Gubisch W.  Septal surgery in rhinoplasty. Facial Plast Surg.
2011;27:167–78.
Sheen JH. Spreader graft method of reconstructing the roof of the middle
nasal vault following rhinoplasty. Plast Reconstr Surg. 1984;73:230–9.
Suggested Reading

125
© Springer International Publishing AG 2018
W. Gubisch, Mastering Advanced Rhinoplasty,
3
Functional Aspects in Primary
Rhinoplasty
Helmut Fischer
H. Fischer, MD
Department of Facial Plastic Surgery, Marienhospital Stuttgart, Stuttgart 70199, Germany
e-mail: helmut.Fischer@vinzenz.de
3.1
Physical Examination – 127
3.2
Surgical Principles – 138
3.2.1
Septoplasty – 138
3.2.2
Spreader Grafts and Upper Lateral Cartilage (ULC)
Suture Techniques – 139
3.2.3
Spreader Flaps and Anatomic Details of the Nasal Dorsum – 144
3.2.4
Batten Grafts or Lateral Crural Strut Grafts – 148
3.2.5
Reduction of Columellar Width – 151
3.2.6
Turbinate Reduction – 153
3.3
Functional Aspects in Primary Rhinoplasty: Case Studies – 154
3.3.1
Case 1: Spreader Grafts – 154
3.3.2
Case 2: Spreader Grafts – 158
3.3.3
Case 3: Spreader Flaps – 161
3.3.4
Case 4: Spreader Flaps – 164
3.3.5
Case 5: Functional Correction of Complex Alar Deformities – 167
3.3.6
Case 6: Functional Correction of Severe Deviation
of the Anterior Nasal Spine (ANS) – 172
3.3.7
Case 7: Balancing Airway Cross Section and Nasal Aesthetics – 176

Suggested Reading – 179

126
3
Most primary rhinoplasties are intended to reduce a dorsal
hump or overall nasal size. Although reduction rhinoplasty
may seem a simple task, the nose is neither a solid nor a uni-
form physical structure, and reshaping the nose is commonly
regarded as among the most challenging of all cosmetic pro-
cedures. Not only is the nose a delicate and complicated
three-dimensional structure composed of dissimilar tissues,
but it is also an important component of the human airway.
As such, satisfactory cross-sectional airway dimensions must
be maintained in all segments of the nasal airway despite cos-
metic reductions of the outer skeletal framework. This must
be accomplished without incurring excessive skeletal rigidity,
structural compromise, or distortion from the potent forces
of soft-tissue contracture.
In many noses, reduction rhinoplasty may inadvertently
decrease the cross-sectional area of the anterior nasal airway,
particularly at the naturally narrowest and most vulnerable
segment of the human nose, the internal nasal valve. Unless
this narrowing is recognized and compensated for with
reconstructive surgical techniques, symptomatic nasal air-
way obstruction may ensue. This chapter reviews our
approach to preventing and/or treating functional distur-
bances associated with primary cosmetic rhinoplasty.
Accurate preoperative analysis is fundamental to success-
ful nasal airway preservation. Particular attention is paid to
the preoperative functional status and the presence of ana-
tomic airway deformities, features of latent airway obstruc-
tion, or indications of valvular dysfunction. When we
consider performing a reduction rhinoplasty in which cross-­
sectional airway dimensions are likely to decrease, we must
first answer the following questions:
5
5 Can the airway reduction be adequately compensated
for by compensatory treatment measures like thinning
the septum or the premaxillary crest?
5
5 Is there a need for turbinate reduction?
5
5 Is there an increased risk of nasal congestion for any
reason?
5
5 Is there an increased risk of mucosal dryness?
5
5 Is there an objective tolerance and a corresponding
subjective acceptance for widening an overly narrow
nasal dorsum to preserve adequate nasal airway
function?
Care must be taken to identify the rhinoplasty reduction
patient who simultaneously seeks functional improvement
but who will not permit modest increases in width needed to
ensure adequate airway function. Alternatively, some patients
with normal airway function may fraudulently claim func-
tional disturbances in order to provide justification for health
insurance coverage, and these patients must also be identified.

Chapter 3 · Functional Aspects in Primary Rhinoplasty

127
3
3.1
Physical Examination
Physical examination of the nose, at rest and during the respi-
ratory cycle and with and without a nasal speculum is a critical
first step in assessing nasal airway function. Inspection of the
outer nose will reveal pinching or collapse of the middle vault,
the supra-alar side walls, the lobule, and/or the external nasal
valves. Palpation of the nasal side walls and lobule will also
reveal baseline cartilage rigidity and cartilage recoil—two
important parameters of nasal airway support. Pinching, devi-
ation, or twisting of the lower middle vault, deep supra-alar
indentations, severe lobular pinching, recurvature of the lat-
eral crura, and slit-like nostril openings are all visible manifes-
tations of static airway impingement, and these deformities
are particularly detrimental in noses with unusually weak
nasal cartilage and/or in noses with concomitant septal or
turbinate-mediated airway obstructions. In severe cases, gen-
tle inspiration will also lead to dynamic inspiratory valve col-
lapse, causing additional but transient obstruction to nasal
airflow. Although speculum examination will artificially elim-
inate collapse of the internal or external valves by stenting the
collapsed nasal side walls (except in patients with fixed
obstructions such as cicatricial epithelial stenosis), such exam-
ination is essential for the diagnosis and characterization of
anatomic deformities involving the nasal septum and inferior
and middle turbinates and for identification of lesions such as
nasal polyps or neoplasia. Various adjunctive tests such as the
Cottle maneuver, computed tomography, or rhinomanometry
are sometimes used for confirmatory diagnosis, but the expe-
rienced nasal surgeon can easily recognize anatomic nasal air-
way obstruction in the overwhelming majority of cases.
Figure  3.1a–e shows a patient with an oversized nose
seeking both reduction rhinoplasty and improved nasal air-
way function. Premature valvular collapse is observed on
gentle inspiration, and the patient is demonstrating relief
using the Cottle maneuver, thus indicating her existing val-
vular problem.
However, there are limitations to the Cottle maneuver.
Maximal inspiration will cause dynamic valve collapse in all
noses, even those with normal airway function. Similarly, the
Cottle maneuver will improve nasal airflow in healthy noses
and obstructed noses alike, making the test of questionable
utility. Also, a nose with internal valve collapse (from an
anterior septal deformity) and very strong tip cartilage may
have an unusually high threshold for dynamic collapse
despite fairly severe nasal dysfunction. Finally, the Cottle
maneuver will show no improvement in airflow for patients
with fixed airway deformities such as cicatricial (epithelial)
stenosis despite severe airway obstruction. Overall the Cottle
maneuver is often misused and misinterpreted. It is like a
guide leading to a focus but not a solution.
Simulation of spreader grafts by an ophthalmologic glass
stick improves the airflow (spreader graft test) (Fig. 3.1f–h).
The alar support test at the lateral segment of the lateral crus
produces maximal functional improvement in this case
(. Fig. 3.1i, j) by support at the area of the lower lateral carti-
lage (LLC) recurvature.
Our conclusion: Given the straight septum in this
patient’s nose, opening the internal valves and stabilizing the
alae are the most important goals of rhinoplasty, which by
necessity will limit the extent of nasal size reduction in this
individual.
In a separate case, the sequence of functional assessment
in a unilateral airway collapse is shown (. Fig. 3.2a–d). The
patient demonstrates left alar collapse by inspiration but also
has complained that the contralateral side is obstructed.
Occasionally, patients with unilateral alar collapse mis-
takenly identify their problem as being on the side of alar
collapse. Initially, it might be concluded that there is patho-
logic weakness of the external valve needing structural rein-
forcement, but endonasal examination in these patients often
reveals a septal deviation obstructing the contralateral nasal
airway—sometimes of only modest severity. Moreover, in a
significant number of these cases, correction of the septal
deformity is needed to restore a satisfactory nasal airway.
Palpation and/or rhinomanometry may sometimes yield the
correct diagnosis, but in many cases a conclusive diagnosis is
difficult to establish by current diagnostic means, especially
when the septal deviation is mild.
Figure 3.3 shows another patient in whom the obstruc-
tion was found on the side opposite the narrow external valve
(subluxation of the anterior septal border into the left vesti-
bule). Examination of the contralateral airway revealed
severe septal deviation obstructing the right internal nasal
valve. Right-sided airway obstruction was confirmed by rhi-
nomanometry.
Unilateral symptoms of sinusitis mostly are located on
the side of reduced ventilation and not on the side of the nar-
row external valve, as this alone does not cause a significant
limitation in nasal airflow.
Symptomatic nasal airway dysfunction is often multifac-
torial. The patient in Fig. 3.4 has nasal airway obstruction and
a saddle-nose deformity resulting from previous nasal
trauma. Excessive width of the columella and alar collapse
(greater on the right side) were also observed. The columella
pinch test contributed to significant airflow improvement
(. Fig. 3.4d).
However, temporarily eliminating the left nostril obstruc-
tion did not eliminate dynamic collapse of the right alar rim
(Fig. 3.4e, f). Endoscopy then revealed a hidden left-sided sep-
tal deviation presumably resulting from prior nasal trauma
(. Fig. 3.4h). To qualify its impact on the patient’s breathing
impairment, we applied a pair of silicone tubes (. Fig. 3.4g)
over some weeks and involved the patient in reevaluation of
the functional situation, which significantly improved. Thus,
the septal deviation proved to be of secondary (downstream)
importance, although it had to be corrected simultaneously.
3.1 · Physical Examination

128
3
When contralateral turbinate hypertrophy is suspected of
contributing to nocturnal nasal valve dysfunction, silicone
nostril stents (NasiVent tube, Vital Health Products, The
Hague, the Netherlands) can be worn overnight to increase
diagnostic accuracy. By eliminating nasal valve stenosis, ­nostril
stents provide additional information regarding the potential
role of turbinate hypertrophy and/or mucosal ­congestion as a
potential cause of nocturnal nasal airway dysfunction.
Figure 3.4 shows a patient in whom we planned a reduc-
tion of columellar width, septoplasty, and augmented struc-
tural support for the cartilaginous vault using spreader grafts
to increase septal height and upper lateral cartilage flaring
sutures to increase valve patency. This resulted in a func-
tional saddle-nose correction compared with mere aesthetic
onlay grafting for profile enhancement. Figure 3.4j–o shows
the clinical results for this particular patient.
.
. Fig. 3.1  Patient with valvular
collapse (a) at rest; (b) mildly
forced inspiration; and (c) Cottle
maneuver. Endoscopic view of
left nostril and internal valve area
(d) at rest; and (e) collapsing
under forced inspiration.
Endoscopic view of the spreader
graft test: (f) narrow inner valve
at rest, (g) opening the valve with
a glass stick (spreader graft test),
and (h) glass sticks for endonasal
examination (originally
ophthalmologic device).
Endoscopic view of lateral alar
support test (i) at rest; (j) support
with glass stick at the lateral
aspect of the inner valve, here at
the area of the LLC recurvature
a
b
d
c

Chapter 3 · Functional Aspects in Primary Rhinoplasty

129
3
e
f
g
h
i
j
.
. Fig. 3.1  (continued)
3.1 · Physical Examination

130
3
.
. Fig. 3.2  Left-sided alar
collapse caused by right-sided
airway obstruction from septal
deviation, (a) at rest and (b)
under gentle forced inspiration.
Endonasal view of (c) right and
(d) left of internal valve. (e)
Completely harvested septum.
Note narrowing of the right nasal
valve from septal impingement.
Septal deviation corrected by
extracorporeal septoplasty and
replantation. Base view (f)
preoperative and (g)
postoperative
a
c
d
b

Chapter 3 · Functional Aspects in Primary Rhinoplasty

131
3
e
f
g
.
. Fig. 3.2  (continued)
3.1 · Physical Examination

132
3
.
. Fig. 3.3  Example of
obstruction on the side opposite
the narrow external valve. (a)
Base view; (b) endoscopic view
of left nostril; (c) internal nasal
valve area. Subluxation of the
anterior septal border into the
left vestibule is not the reason for
the patient’s breathing
impairment, which is located at
the right side. Examination of the
patient’s contralateral (right)
airway revealed severe septal
deviation obstructing the right
internal nasal valve area. (d)
Endoscopic view of right nostril,
and (e) internal nasal valve
subtotally obstructed. Endonasal
septoplasty, osteotomies for axial
realignment, and spreader flap
technique for cartilaginous vault
reconstruction result in normal
airflow bilaterally upon
reexamination. (f) Preoperative
and (g) postoperative base view
a
b
d
c

Chapter 3 · Functional Aspects in Primary Rhinoplasty

133
3
g
e
f
.
. Fig. 3.3  (continued)
3.1 · Physical Examination

134
3
.
. Fig. 3.4  Examination of the
influence of columellar width on
the airflow. (a) Left profile; (b)
base view at rest, and (c) under
forced inspiration. (d) Columella
pinch test revealed the influence
of columellar width and nostril
cross section on the airflow.
Examination of the influence of
increasing nostril cross section
by alar support on the left
side—the right nostril still
collapsed as a deeper left side
obstruction was not corrected by
this maneuver. (e) At rest, and (f)
under gentle forced inspiration.
(g) Long-term test with a pair of
silicone tubes to assess the
functional importance of the
subsequent anatomic airway
structures downstream in the
nostrils (external nasal valves).
Endoscopic view (h) of a patent
right airway, and (i) left-sided
airway obstruction from septal
deviation. The turbinates
appeared normal in size at the
time of examination. Frontal view
(j) preoperatively and (k)
postoperatively. Profile view (l)
preoperatively and (m)
postoperatively. Base view (n)
preoperatively and (o)
postoperatively
a
b
d
c

Chapter 3 · Functional Aspects in Primary Rhinoplasty

135
3
e
f
g
h
.
. Fig. 3.4  (continued)
3.1 · Physical Examination

136
3
j
k
i
.
. Fig. 3.4  (continued)

Chapter 3 · Functional Aspects in Primary Rhinoplasty

137
3
m
n
o
l
.
. Fig. 3.4  (continued)
3.1 · Physical Examination

138
3
3.2
Surgical Principles
3.2.1 Septoplasty
Eliminating septal deformities is a critical aspect of both
functional and cosmetic nasal surgery, and in many noses
both simultaneous functional and cosmetic enhancement is
required. Preoperative evaluation of the entire septal parti-
tion, from the caudal and dorsal margins to the posterior
bony segment, is a prerequisite for accurate diagnosis and
effective surgical management.
The functional and cosmetic importance of the anterior
septum is increasingly recognized in contemporary nasal
surgery. However, surgical correction of anterior septal
deformities is among the most difficult tasks in both func-
tional and cosmetic rhinoplasty. Moreover, the importance
of septal support cannot be underemphasized, since it is piv-
otal to the support, symmetry, and patency of the cartilagi-
nous nasal framework. Minor septal deviations in the area of
the internal nasal valve—which is the natural isthmus of the
nasal airway—may also have a disproportionately negative
impact on nasal airflow and may be exacerbated by anatomic
abnormalities and structural deficiencies of the adjacent alae
and nasal side walls. Moreover, traditional techniques used
to straighten a deformed anterior septum are often doomed
to failure, since scoring, curfing, and morselizing may com-
promise long-term structural support and lead to progres-
sive skeletal distortion as the nose gradually seeks a new
structural equilibrium. And while contemporary rhinoplasty
techniques can be used to both strengthen and reshape the
cartilaginous nasal framework to produce a well-function-
ing and attractive nose, overaggressive reduction rhinoplasty
will severely impair nasal airway function and should be
avoided. The following sections address functional aspects
of individual skeletal elements impacted by cosmetic nasal
surgery.

Chapter 3 · Functional Aspects in Primary Rhinoplasty

139
3
3.2.2 Spreader Grafts and Upper Lateral
Cartilage (ULC) Suture Techniques
Reduction of the typical dorsal hump for profile enhance-
ment obligates the surgeon to consider reconstruction of the
nasal dorsum in order to prevent both functional and cos-
metic complications caused by surgical destabilization.
Preventing “pinched” upper lateral cartilages (. Fig. 3.5c) is a
fundamental goal of hump reduction, and in our hands
spreader grafts, suture techniques, and/or a combined
approach was the preferred means of middle vault recon-
struction after hump reduction (. Fig.  3.5d–f) before the
spreader flap era. Conventional spreader graft techniques are
now familiar to most nasal surgeons. After obtaining satis-
factory graft material from the cartilaginous hump resection
and/or from cartilage harvest of the posterior quadrangular
cartilage, spreader graft thickness is carefully adjusted to pre-
serve middle vault width, thereby preventing an inverted-V
deformity while simultaneously avoiding excessive middle
vault width from overcorrection. Spreader grafts are first
sutured flush with the newly created cartilaginous dorsum to
form a three-layered reconstruction (7 see  Fig.  3.5d). The
upper lateral cartilages are then sutured to the construct in a
symmetrical fashion (7 see Fig. 3.5f). This is accomplished by
temporarily displacing the tip cartilages caudally and then
applying equal tension to the ULCs so they are held sym-
metrically while being reattached.
In some patients, thin nasal skin and a large open roof
resulting from bony hump reduction necessitate extending
the spreader grafts cephalically to avoid bony side wall col-
lapse with lateral osteotomies. Prophylaxis of bony vault col-
lapse will often prevent both functional and cosmetic
deformities of the upper nasal vault. A large clinical experi-
ence with revision rhinoplasty also attests to the benefits of
prophylactic spreader grafts.
In patients with weak cartilaginous side walls, a personal
modification of the spreader graft technique is sometimes
preferable. Using the modified technique, the upper lateral
cartilages are sutured to the top of the dorsal septum rather
than to its sides (. Figs. 3.6b and 3.7c). This minor change in
cartilage placement improves side wall support in noses with
weak upper lateral cartilage and functions much like a ULC
flaring suture. However, we feel that this technique provides
better long-term support in our hands when compared to
flaring sutures. In order to prevent overprojection of the dor-
sum, the spreader grafts must also be recessed slightly below
the dorsal line so that the ULC remains flush with the newly
established profile line (. Figs. 3.6 and 3.7). Suture techniques
can also be used in the absence of spreader grafts by lowering
the septum approximately 1 mm to compensate for the ULC
width (7 see Fig. 3.5e). However, care must be taken to adjust
the profile line precisely to prevent polly-beak deformity.
When functional considerations prevent adequate lowering
of the cartilaginous dorsum in order to prevent a polly-beak
type deformity, onlay grafts of cartilage or fascia must be used
to augment the adjacent bony vault and create an aesthetically
pleasing dorsal profile. Spreader graft and suture techniques
are equally effective for both primary and revision cases.
3.2 · Surgical Principles