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3
a
b
.
. Fig. 3.6  Intraoperative examples of (a) spreader grafts and (b) additional ULC suture suspension for vault reconstruction on top of the dorsal
septal rim widened with spreader graft
3.2 · Surgical Principles

142
3
.
. Fig. 3.7  A patient for
primary reduction rhinoplasty
surgically managed with a similar
technique to that shown
in Fig. 3.6. (a) Profile view
preoperatively; (b) spreader
grafts in place 1 mm lower than
the dorsal septal border; (c) ULCs
sutured at the septum over the
spreader grafts. The septum had
to be lowered adequately to
avoid a parrot-beak formation.
(d) Profile view 8 months
postoperatively. Frontal view (e)
preoperatively and (f) 8 months
postoperatively. Note: despite
the applied technique of
cartilaginous vault
reconstruction, the dorsum is not
overly widened. Base view (g)
preoperatively and (h)
postoperatively
d
c
b
a

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e
g
h
f
.
. Fig. 3.7  (continued)
3.2 · Surgical Principles

144
3
3.2.3 Spreader Flaps and Anatomic Details
of the Nasal Dorsum
In primary hump reduction, spreader flaps are becoming an
increasingly popular means of reconstituting middle vault
support, particularly since they don’t require additional carti-
lage for reconstruction. However, not all noses are well suited
to spreader flaps. Noses with long nasal bones and/or overly
short ULCs are poor candidates for spreader flap reconstruc-
tion, since invagination of the ULCs is often impossible.
Conversely, some ultra-long and narrow middle vaults have
cartilage that is too thin or soft to use as spreader flaps.
Various other anatomic variations must also be considered.
Of primary importance is the extension of the ULC beneath
the nasal bones, since the overlap between cartilage and bone
varies widely in length, width, and strength. Long extensions
of the ULC can fill an open roof deformity created by nasal
hump reduction—the ideal configuration—whereas in other
cases there may be little if any cartilage to conceal an open
roof deformity. Nasal bones also show distinctive features in
the bony cartilaginous transition zone of the dorsum. These
are displayed by separating the bone from the ULCs in a pre-
vious case of composite (en bloc) hump reduction (. Fig. 3.8).
Important anatomic variations exist in the distance
between the central bony extension and the lateral bony
extensions as well as in their length and symmetry. One of
the most important variables is the height of the lateral bony
extensions. In some noses the lateral extensions are equal in
height to the dorsum, while in others the lateral extensions
may be considerably lower. These skeletal variations are criti-
cal considerations in extracorporeal septoplasty because they
determine fixation techniques. In noses with high lateral
bony extensions, bones perforated with drill holes can be
used for secure suture fixation of the reimplanted septal con-
struct, whereas in the underprojected caudal nasal bones,
extreme care must be taken not to disrupt the bony cartilagi-
nous interface because the ULCs must be used for suture
fixation. And while underprojected lateral extensions are not
amenable to drill hole fixation, they are usually well suited to
the application of spreader flaps.
To create spreader flaps, the ULCs must be released from
the undersurface of the bony hump with blunt dissection.
Once the ULCs have been divided from the dorsal septum
(Fig. 3.9a), we initiate the dissection by scoring the caudal
margin of the bony hump with a no. 15 blade (. Fig. 3.9b)
and then continue the dissection using either a semisharp
(Haraldsson) suction dissector or some type of periosteal
elevator such as a Freer, McKenty, or Cottle elevator. Care
must be taken not to dissect below the desired profile line so
that the remaining ULC/nasal bone attachments are pre-
served. Next, the cartilaginous dorsal hump is sharply
resected (. Fig. 3.9c), and submucosal pockets are developed
on both sides of the dorsal septum to accommodate the
spreader flaps. When necessary, such as with large cartilagi-
nous humps, the ULCs are trimmed to avoid excessive bulk
within the internal nasal valves (. Fig. 3.9d, e). Finally, the
ULCs are folded into the submucosal pockets and temporar-
ily secured with small-bore needles (. Fig.  3.9f). With the
ULCs safely repositioned just below the desired profile line,
elimination of the bony hump can proceed. We prefer to
resect the bony hump using a thin and ultrasharp chisel
(. Fig. 3.9g) and to fine-tune the bony contour with a carbide
rasp. Hump refinement with a carbide rasp is preferred
because it removes bone effectively with little or no trauma to
the underlying cartilage extensions.
Once hump reduction is complete, spreader flaps are
secured with slowly resorbing 5-0 monofilament sutures
(Fig. 3.9h, i). By using resorbable suture material, complica-
tions stemming from permanent suture material penetrating
the nasal cavity are minimized, and extensive elevation of
mucosa from the ULCs becomes unnecessary. It is also
important to remember that while suturing the spreader
flaps, they should be kept under constant symmetrical down-
ward tension using a double-skin hook. Care must also be
taken to ensure correct sagittal alignment, and in cases of
pre-existing deformity, slight overcorrection of septal align-
ment is often needed to overcome intrinsic tissue memory. In
addition to septal alignment, suture fixation can also be used
to control dorsal width. Cranially, suture fixation can be used
to control the width of the bony cartilaginous junction and
reduce bony flaring. When bony drill holes are available, a
cerclage suture can be used to aggressively narrow the bony
cartilaginous junction and/or close a persistent open roof
deformity. Excess middle vault width stemming from overly
rigid ULCs can also be treated by perforating, scoring, or
incising the spreader flaps for increased narrowing.
Depending upon the site of cartilage modification, narrow-
ing can be limited to the upper, central, or lower middle vault
or combinations thereof. Furthermore, the kind of suture
technique can be altered in weak cartilages (. Fig. 3.9j, k).
In summary, spreader flaps are an effective technique for
creating a natural-appearing nasal dorsum with attractive dor-
sal aesthetic lines in most noses. Spreader flaps are also easily
fine-tuned using suture techniques, and they frequently obvi-
ate the need for spreader graft harvest. In our hands, the need
for camouflage (fascia) grafts has also greatly diminished with
the advent of spreader flaps. Unfortunately, intraoperative
adjustments to middle vault projection require redoing flap
fixation—a significant limitation of this otherwise user-
friendly technique. Likewise, noses with ultra-­pliable ULCs
make poor candidates for spreader flap reconstruction since
cosmetic and functional deformities may result.
.
. Fig. 3.8  Anatomy: dissection of the hump resected as a monobloc
of bone and cartilage. Note the shape of bone and cartilage; the bone
originally overlapped the cartilage

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3
.
. Fig. 3.9  Spreader flap technique. (a) ULC separation off the sep-
tum, and (b) from underneath the bony vault. (c) Reduction of the sep-
tal component of the cartilaginous hump. (d) Marking and (e) resection
of the surplus of ULC to avoid partial upper airway obstruction. (f) Inter-
mediate infolding of the ULCs for better access to (g) bony hump reduc-
tion with an extremely sharp chisel for the major part of the hump (and
a rasp for residual adjustment, not shown). Spreader flap suturing with
5.0 PDS (h) horizontal mattress sutures, and (i) adjusting dorsal width by
the degree of tension. Incisions or scoring on the apex of the vault is an
option in very rigid cartilage or in the distal third of the dorsum (valve
area). Spreader flap suturing with 5.0 PDS. (j) Alternatively, in very weak
cartilage vertically double U-shaped sutures can be applied and (k)
knotted over the septum provided that the dorsal height must not be
further reduced
a
b
d
c
3.2 · Surgical Principles

146
3
e
f
h
g
.
. Fig. 3.9  (continued)

Chapter 3 · Functional Aspects in Primary Rhinoplasty

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3
k
j
i
.
. Fig. 3.9  (continued)
3.2 · Surgical Principles

148
3
3.2.4 Batten Grafts or Lateral Crural Strut
Grafts
Batten grafts are used mostly in revision rhinoplasty. They
are indicated to strengthen lateral crura weakened by cephalic
trimming and/or to strengthen collapsed (concave) lateral
crura. Battens can be placed in pockets either superficial to
the LLC (over the batten graft) or deep to the LLC (under the
batten graft), or they can be sutured directly to the exposed
overlying LLC (lateral crural strut graft). By adding rigidity
to the lateral crura, batten grafts stabilize the lower nasal side
wall against premature inspiratory collapse. Batten grafts are
also especially useful in boxy tip correction (. Fig. 3.10) to
prevent exacerbating lateral crural recurvature deformity
caused by tip sutures.
There are more techniques for correction of alar concavi-
ties or malformations with aesthetic as well as functional
impact.
.
. Fig. 3.10  (a) Boxy tip
deformity; (b) simulation of tip
correction and impact on alar
position. Strut grafts are planned
for straightening the LLCs and
prevent medial displacement. (c)
Early postoperative base view.
Resection of the deviated lateral
segment of the LLC: (d) incision
at the line of deviation, (e)
resection of the small segment.
The gap is bridged with the
lateral crural strut (and
simultaneously extension) graft.
Alternatively, strong cartilage can
be straightened by horizontal
mattress sutures in ideal cases.
Lateral crural strut graft (f)
demonstrating and (g) fixating
the position. Vestibular view (h)
before resection of the lateral
LLC segment and (i) after fixation
of the lateral crural strut graft
c
d
b
a

Chapter 3 · Functional Aspects in Primary Rhinoplasty

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3
g
h
f
e
.
. Fig. 3.10  (continued)
3.2 · Surgical Principles

150
3
i
.
. Fig. 3.10  (continued)

Chapter 3 · Functional Aspects in Primary Rhinoplasty

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3
3.2.5 Reduction of Columellar Width
In most noses, the columella widens gradually toward its
base—the columellar pedestal. However, excessive width of
the columellar pedestal can also become pathologic. An
extremely wide columellar pedestal can contribute to nasal
airway dysfunction, and in rare cases this may be the sole
cause of nasal airway obstruction (7 see Fig. 3.5a). An impor-
tant part of the physical examination includes the columellar
pinch test. In healthy noses, manual compression of the colu-
mellar pedestal makes no difference in nasal airflow. However,
a small subset of patients have reported a dramatic improve-
ment in symptomatic nasal obstruction after columellar
compression. For these patients, surgical narrowing of the
columella is indicated, if only as part of a larger septorhino-
plasty.
Various surgical techniques for columellar narrowing
have been described, including permanent buried sutures,
medial crural footpod resection, or combined footpod tran-
section and suturing. Resection of the intercrural soft tissues
followed by transcolumellar mattress suture placement using
slowly resorbable monofilament sutures is our preferred
method for achieving safe and reliable columellar narrowing
(. Fig. 3.11). When suitable, this procedure can also be com-
bined with a tongue-in-groove imbrication to further
enhance tip support.
.
. Fig. 3.11  (a) Wide columella
base and breathing impairment
bilaterally, (b) as confirmed by
rhinomanometry (Atmos
Company; Lenzkirch, Germany)
showing nearly horizontal curves
(R and L). The functional impact
recorded by the columella pinch
test (see Fig. 3.4d). (c) Result after
thinning the columella and tip
projection by the lateral steal
technique. (d) Resection of
depressor muscle in a different
patient. (e) As a result, the medial
crura and footplates become
exposed
a
c
b
3.2 · Surgical Principles

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3
e
d
.
. Fig. 3.11  (continued)

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3
3.2.6 Turbinate Reduction
In the presence of long-standing septal deviation, such as
may occur following childhood nasal trauma, compensatory
hypertrophy of the inferior and/or middle turbinate (on the
side of septal concavity) is commonplace. Often the hyper-
trophy is substantial, with turbinate enlargement extending
well beyond the sagittal midline. In the presence of signifi-
cant compensatory turbinate hypertrophy, turbinate reposi-
tioning and/or turbinate reduction is necessary to allow
return of the deviated septum to the midline. Variation in
conchal bone size is an important determinant in surgical
management of compensatory turbinate hypertrophy. A thin
turbinate bone can be easily out-fractured for lateralization,
but long-term outcomes are often poor because postopera-
tive swelling may lead to recurrent malposition during heal-
ing. However, for significant cases in inferior turbinate
hypertrophy, we prefer partial resection of the conchal bone
using a submucosal technique (. Fig. 3.12). Submucosal tur-
binate reduction is begun by creating a small incision along
the leading edge of the turbinate over the anterior-most por-
tion of the conchal bone. Medial and lateral flaps are then
developed using a Cottle elevator to lift mucosa off the
underlying conchal bone. Often the conchal bone must be
in-fractured to facilitate dissection of the lateral mucosa. The
anterior conchal bone is then resected, preserving the turbi-
nate mucosa for continued humidification, warming, and
filtration of inspired air. When necessary, the mucosal edges
are lightly cauterized for hemostasis.
.
. Fig. 3.12  Pieces of turbinate bone resected from the anterior part
of the lower turbinates via longitudinal incisions on the lower borders.
Note: there is no turbinate soft tissue attached
3.2 · Surgical Principles

154
3
3.3
Functional Aspects in Primary
Rhinoplasty: Case Studies
3.3.1 Case 1: Spreader Grafts
The spreader graft technique is widespread and well known.
Case 1 concerns a unilateral spreader graft application in
combination with several other measures (7 see Fig. 3.6a–e).
A 31-year-old former boxer with a history of repeated
nasal trauma presented with a deviated nose, severe septal
deviation, and nasal airway obstruction. A dorsal hump was
also present, but the patient declined treatment for this.
Examination revealed short nasal bones with a depressed left
nasal bone. A septal fold of the anterior quadrangular carti-
lage, together with left dorsal side wall collapse, produced sub-
total obstruction of the left internal valve. On the right side, a
protruding maxillary crest and compensatory hypertrophy of
the inferior turbinate led to contralateral nasal airway obstruc-
tion as well. Rhinomanometric measurements confirmed the
functional impairment: (150 Pa) R 192 mL/s, L 16 mL/s and
after decongestion R 232 mL/s, L 52 mL/s—highly pathologic
compared with the normal measurement of 300 mL/s.
Opening the left internal nasal valve using a unilateral
spreader graft was the primary objective of surgical treat-
ment. Spreader graft placement and additional procedures
are described below.
zz
Surgical Steps
1. Endonasal septoplasty: excision of a large scar from the
concave side of the anterior septal deviation, mild scoring,
and placement of a flattening suture on the convex side.
Creation of a midline sagittal groove in the nasal spine
and reattachment of the caudal septum.
2. Submucous resection of the inferior turbinates.
3. Osteotomies: paramedian, transverse, and lateral
(high-low-low).
4. Spreader flaps.
5. Infolding of the cephalic rim of lower lateral cartilages
(LLC).
6. Tip rotation with the lateral crural overlap technique,
tongue-in-groove setback, and septal suspension suture.
7. Profile-plasty by placement of supratip and radix
augmentation grafts.
zz
Result
The patient reported elimination of nasal airway obstruction
at 9 months follow-up examination. Examination revealed a
straight nose with improved profile and nostril contour and a
straight nasal septum. Increased columellar show could have
been avoided by placement of alar rim grafts (. Fig. 3.13).

Chapter 3 · Functional Aspects in Primary Rhinoplasty

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3
.
. Fig. 3.13  (a) Unilateral spreader graft for left cartilaginous side wall
support. Additional techniques applied: (b) left LLC transection, (c)
overlapping 5–6 mm (our lateral sliding technique), (d) performed bilat-
erally, resulting in tip rotation. Thirty-one-year-old patient from Case 1:
(e) frontal view showing septal deviation, left side wall ­impression, and
LLC concavity. (f) Result 6 months after unilateral spreader graft on the
left side. Additional procedures: septoplasty, turbinate reduction
(see Fig. 3.12), LLC infolding, spreader flaps. Left profile view (g) preop-
eratively and (h) postoperatively. Base view (i) preoperatively and (j)
postoperatively
a
d
b
c
3.3 · Functional Aspects in Primary Rhinoplasty: Case Studies

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3
e
h
f
g
.
. Fig. 3.13  (continued)

Chapter 3 · Functional Aspects in Primary Rhinoplasty

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3
i
j
.
. Fig. 3.13  (continued)
3.3 · Functional Aspects in Primary Rhinoplasty: Case Studies

158
3
3.3.2 Case 2: Spreader Grafts
A 45-year-old female presented with nasal airway obstruc-
tion and a post-traumatic nasal deformity resulting from a
horseback riding accident. Physical examination revealed a
widened nasal pyramid with depression of the middle vault
and nasal tip, foreshortening of the septum, and deviation of
the nose to the right (. Fig.  3.14). The turbinates were also
hypertrophic, and scarring of the nasal sill was observed. Septal
reconstruction, spreader graft placement, and increased tip
projection were performed to enlarge the internal nasal valves.
zz
Surgical Steps
1. Harvesting of bilateral conchal cartilage.
2. Septoplasty and removal of a scarred mass of deviated
cartilage. Insufficient cartilage was available for total
extracorporeal septoplasty.
3. Replacement of the caudal septum with a
double-layered conchal cartilage graft. Fixation of the
graft via nasal spine drill hole and three-point suture
placement.
4. Saddle-nose reconstruction with extended (bilateral)
conchal spreader grafts to buttress the caudal septal
replacement graft. Grafts were also positioned above the
dorsal line to restore middle vault projection.
5. Submucous resection of the inferior turbinate bone.
6. Parasagittal medial osteotomies with bone excision to
enlarge the osteotomy line.
7. Percutaneous transverse osteotomies and high-low-low
lateral osteotomies.
8. Supratip conchal onlay graft placement and three layers
of allogenic fascia lata onlay graft to offset the increase
in tip projection.
9. Transdomal and interdomal sutures.
10. Lateral crural steal procedure for tip rotation and
increasing projection.
11. Right nostril sill scar revision.
Postoperatively satisfactory nasal function was achieved,
but visibility of the spreader grafts within the nasal vestibule
tainted the cosmetic outcome. However, the patient declined
minor revision surgery.

Chapter 3 · Functional Aspects in Primary Rhinoplasty

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3
.
. Fig. 3.14  (a) Patient from
Case 2, many years before her
nasal trauma. (b) Post-traumatic
deformity immediately before
and (c) after delayed septal
reconstruction, spreader grafts,
and tip correction. Left profile (d)
preoperatively and (e)
postoperatively. Base view (f)
preoperatively and (g)
postoperatively
a
b
c
3.3 · Functional Aspects in Primary Rhinoplasty: Case Studies

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3
e
f
g
d
.
. Fig. 3.14  (continued)

Chapter 3 · Functional Aspects in Primary Rhinoplasty

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3
3.3.3 Case 3: Spreader Flaps
A 45-year-old female with an overprojected dorsum and a
bulbous/ptotic nasal tip presented with nasal obstruction
and dynamic nasal valve collapse (. Fig. 3.15; same patient
as in . Fig.  3.1). Examination revealed a tension-nose
deformity
with
hypertrophic
inferior
turbinates.
Rhinomanometry before and after topical decongestion
revealed a symmetrical reduction of nasal airflow (over
baseline) after topical decongestion. This paradoxical
finding was most likely a measurement artifact resulting
from inconsistent mask placement or poor mask fit caus-
ing constriction of the nasal valves. Additionally, we have
occasionally observed increased dynamic valve collapse
following decongestion caused by reduced support of the
lower nasal side wall from a shrunken turbinate. However,
based upon strongly positive results of the alar support
test conducted in this patient (7 see Fig.  3.1d), surgical
reinforcement of the lower nasal side wall and enlarge-
ment of the internal valve were performed. The limitations
of conflicting treatment objectives of an aesthetically
smaller nose with functionally enlarged nasal passages
were first discussed with the patient prior to informed
consent. The patient agreed to conservative dorsal height
reduction in order to preserve the internal valve cross-
sectional area.
zz
Surgical Steps
1. Turbinate bone resection was deferred because of unusu-
ally thin bone. Out-fracture of the inferior turbinate bone
and conservative bipolar cauterization of the inferior tur-
binate mucosa were performed to reduce turbinate size.
2. Resection of a large vomerine spur.
3. Conservative cephalic trim and lateral crural sliding (a
lateral crural overlay technique) to stabilize the lateral
crura and improve tip rotation.
4. Lateral crural strut graft placement with suture fixation
to correct recurvature.
5. Hump reduction with chisel and rasp.
6. Percutaneous transverse osteotomies and high-low-low
lateral osteotomies for preservation of the lower
piriform aperture.
7. Bilateral spreader flaps for middle vault reconstruction
and increased valve width.
8. Tongue-in-groove setback for increased tip rotation.
9. Nasal tip suspension suture between the caudal septum
and the medial crura.
10. Lateral crural spanning sutures for supratip refinement.
11. Allogenic fascia for dorsal smoothing.
Postoperative follow-up revealed a satisfactory functional
improvement and a very satisfied patient. The patient was
also pleased with the tip stabilization on robust smiling.
3.3 · Functional Aspects in Primary Rhinoplasty: Case Studies

162
3
.
. Fig. 3.15  Patient in Case 3
(a) before and (b) after reduction
rhinoplasty with spreader flaps.
(c) Profile, and (d) plan for
reduction. (e) Postoperative
result at rest and (f) at animation.
The stability of tip projection
with the tongue-in-groove
technique was accepted or
appreciated by most of the
patients after informed consent.
Base view (g) preoperatively and
(h) postoperatively
a
b
d
c

Chapter 3 · Functional Aspects in Primary Rhinoplasty

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3
e
f
h
g
.
. Fig. 3.15  (continued)
3.3 · Functional Aspects in Primary Rhinoplasty: Case Studies

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3
3.3.4 Case 4: Spreader Flaps
A 38-year-old male presented with nasal obstruction.
Although he denied prior nasal trauma, the patient reported
progressive nasal airway dysfunction during adulthood and
desired both functional and cosmetic enhancement. Physical
examination revealed an oversized tension nose with bony
vault deviation (. Fig. 3.16). Endonasal examination revealed
obstruction of the left internal nasal valve from a hinge-like
septal deviation. Examination of the right nasal cavity
revealed a severe septal concavity of the posterior septum.
Rhinomanometry at 150 Pa: R 248 mL/s, L 16 mL/s indicated
nearly no airflow on the left side. The preoperative treatment
plan included septoplasty (most likely extracorporeal), dor-
sal reduction as permitted by functional limitations, spreader
grafts, and osteotomies.
zz
Surgical Steps
1. Endonasal septoplasty with central submucous resection
and right-sided cartilage scoring (near transsection).
2. Reinforcement of the L-strut with an ethmoid bone
graft applied to the caudal septum and a left-sided
spreader graft applied to the dorsal septum. The
perpendicular ethmoid graft was created by first
thinning the graft with a power drill and then placing
multiple drill holes to permit suture fixation.
3. Resection of the deviated maxillary crest and vomerine
spur.
4. Submucous turbinate cauterization with out-fracture.
5. Scissors resection of the cartilaginous hump after
release of the ULCs.
6. Bony hump reduction with chisel and rasp.
7. Medial (parasagittal), transverse, and low to-low lateral
osteotomies.
8. Bilateral spreader flaps for middle vault reconstruction
and additional valve support.
9. LLC cephalic resection and asymmetrical lateral sliding
(LLC overlap technique) for increased tip rotation and
improved symmetry.
10. Intradomal and interdomal tip sutures.
11. Lateral crural spanning sutures.
12. Tongue-in-groove setback.
13. Dorsal camouflage with allogenic fascia.
zz
Result
At 15-month follow-up, the patient was pleased with the cos-
metic result but complained of right-sided nasal obstruction.
Examination revealed septal deviation into the right internal
valve. The most likely explanation was excessive scoring of
the septum outside the area of surgical splinting. Focal resec-
tion of the septum beneath the L-strut eliminated the airway
obstruction.

Chapter 3 · Functional Aspects in Primary Rhinoplasty

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3
.
. Fig. 3.16  Patient in Case 4,
frontal view (a) preoperatively
and (b) postoperatively. Profile
view (c) preoperatively and
(d) postoperatively. Base view
(e) preoperatively and
(f) postoperatively
a
b
c
d
3.3 · Functional Aspects in Primary Rhinoplasty: Case Studies

166
3
e
f
.
. Fig. 3.16  (continued)

Chapter 3 · Functional Aspects in Primary Rhinoplasty

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3
3.3.5 Case 5: Functional Correction
of Complex Alar Deformities
A 47-year-old female presented with nasal airway obstruc-
tion. Physical examination revealed a twisted and collapsed
nasal base with dynamic nasal valve collapse (. Fig. 3.17).
The lateral crus revealed asymmetrical concavities with
pinching of the lobule. The columella was twisted and dis-
placed to the right, while caudal deviation of the septum
resulted in displacement of the left crural footpod into the
adjacent nasal vestibule. Surgical treatment required reposi-
tioning of the columella and widening of the collapsed lower
nasal side walls. Functional objectives were prioritized over
cosmetic goals.
zz
Surgical Steps
1. Septal graft harvest.
2. Columellar strut for increased central tip support.
3. LLC cephalic trim.
4. Vertical dome division.
5. Sliding advancement of the lateral crus overlapping the
dome by approximately 8 mm. This serves to tighten and
suspend the collapsed lateral crus and to stabilize the tip
tripod by creating symmetrical opposing tensions
between the right and left lateral crura.
6. Onlay batten grafting of the lateral crus using the
previously excised cephalic margin for contour
refinement, improving symmetry, and additional LLC
reinforcement.
7. Hump reduction.
8. Spreader grafts.
Postoperatively the functional and cosmetic results were
excellent (7 see Fig. 3.10f). However, we have since modified our
surgical technique to include Gruber-type horizontal mattress
sutures to enhance flattening and stabilization of the lateral crus.
3.3 · Functional Aspects in Primary Rhinoplasty: Case Studies

168
3
a
b
c
d
.
. Fig. 3.17 
Patient in Case 5 with severe alar deformities. (a) Frontal
view and (b) base view. (c) Concept of dome reconstruction by over-
lapping the intermediate crus by the lateral crus, simultaneously
improving tension, opening the dome, and deprojecting the tip. (d)
Sliding the lateral crus over the dome to overlap the intermediate
crus, thus creating a wide stable and rigid dome and contributing to
the lateral crural concavity correction. (e) Dome overlap finished with
permanent sutures. (f) Trimmed LLCs before and (g) after placement
of additional batten grafts in cephalic portions correcting the concav-
ity and strengthening the lateral crura. (h) Same patient’s frontal view
before and (i) after surgery. Profile view (j) preoperatively and
(k) postoperatively. Base view, complex tip and alar deformity. (l) Pre-
operative view at rest, and (m) under forced inspiration. (n) Postopera-
tive result

Chapter 3 · Functional Aspects in Primary Rhinoplasty

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3
e
f
g
.
. Fig. 3.17  (continued)
3.3 · Functional Aspects in Primary Rhinoplasty: Case Studies

170
3
i
j
k
h
.
. Fig. 3.17  (continued)

Chapter 3 · Functional Aspects in Primary Rhinoplasty

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3
m
n
l
.
. Fig. 3.17  (continued)
3.3 · Functional Aspects in Primary Rhinoplasty: Case Studies

172
3
3.3.6 Case 6: Functional Correction of Severe
Deviation of the Anterior Nasal Spine
(ANS)
A 16-year-old female presented with complete left-sided nasal
obstruction, a dorsal hump, and deviation of the bony pyra-
mid to the left side following childhood trauma (. Fig. 3.18).
Examination revealed total blockage of the left nasal passage
caused by a hinge-like deviation of the anterior septum. Right
inferior turbinate hypertrophy was also observed. Palpation of
the anterior nasal spine revealed deviation to the left of the
sagittal midline. The Cottle maneuver normalized left-sided
nasal breathing, indicating the absence of further anatomic
obstruction in the left nasal cavum. Rhinomanometry at
150 Pa: right 184 mL/s, left 24 mL/s according to complete
left-sided obstruction. Normal values would be 300 mL/s.
Surgery to straighten the nose was recommended, and
restoring a midline caudal septum/nasal spine relationship
was anticipated.
zz
Surgical Steps
1. Hump reduction including radix deprojection.
2. Extracorporeal septal reconstruction in which the lower
septal border becomes the new dorsal septum.
3. Spreader grafts are affixed to the septal construct prior to
reimplantation. The keystone area is reconstituted with
bilateral suture fixation of the reimplanted septum using
drill holes in the distal edge of the nasal bones.
4. Submucous resection of the inferior turbinates (greater
on the right side).
5. Repositioning of the malpositioned nasal spine after
osteotomy with a 5-mm flat chisel. The repositioned
spine was then stabilized in the midline using a four-hole
microplate and microscrew fixation.
6. Low-low lateral and transverse osteotomies. Medial
osteotomies were obviated by the large open roof created
by extended hump reduction.
7. Domal and interdomal sutures for tip refinement.
8. Tongue-in-groove setback with soft-tissue debulking for
narrowing of the columellar pedestal.
Postoperative follow-up revealed midline sagittal
realignment of the nose, including the columella and colu-
mellar pedestal. Marked functional improvement was also
achieved.

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3
.
. Fig. 3.18  Case 6, intraoperative photographs. (a) The straightened
septum with spreader grafts is already sutured, ready for replantation.
(b) Anterior nasal spine (ANS) repositioned in the midline and fixed by a
microplate, two screws in the bony floor of the nose, and one screw in
the ANS. (c) Drilling a hole into the tip of the right nasal bone for reliably
anchoring the septum in the keystone area. Frontal view (d) preopera-
tively and (e) postoperatively. Left profile (f) preoperatively and
(g) postoperatively. Base view (h) preoperatively and (i) postoperatively
a
b
c
3.3 · Functional Aspects in Primary Rhinoplasty: Case Studies

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3
e
f
g
d
.
. Fig. 3.18  (continued)

Chapter 3 · Functional Aspects in Primary Rhinoplasty

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3
i
h
.
. Fig. 3.18  (continued)
3.3 · Functional Aspects in Primary Rhinoplasty: Case Studies

176
3
3.3.7 Case 7: Balancing Airway Cross Section
and Nasal Aesthetics
A 25-year-old male complaining of right-sided nasal obstruc-
tion and an overly broad nasal tip was seen (. Fig.  3.19).
Examination revealed a wide nasal tip, an underprojected nasal
dorsum, and a depressed right nasal bone. Endonasal examina-
tion revealed septal deviation to the right side and compensa-
tory hypertrophy of the left inferior turbinate. Rhinomanometry
confirmed right-sided airway dysfunction. Treatment recom-
mendations included out-fracture of the right nasal bone,
extracorporeal septal reconstruction with application of
spreader grafts, and dorsal augmentation to improve profile
aesthetics and to maintain a slender-­appearing dorsum.
zz
Surgical Steps
1. Extracorporeal septal reconstruction with resection of
bony septal spurs. Spreader graft placement. Creation of a
drill channel in the midnasal spine using a Lindemann
crosscut burr to facilitate midline suture fixation of the
reimplanted caudal septum. Reimplantation of the septal
construct in a more caudal position to allow fixation of
the medial crura.
2. SMR of the left inferior turbinate to compensate for
midline septal repositioning.
3. Osteotomies for sagittal realignment of the bony
pyramid.
4. Suture fixation of the neoseptal/spreader graft construct
to the ULCs.
5. Dorsal augmentation using a diced (left) conchal
cartilage-(allogenic) fascia graft.
6. Cephalic trim (very strong cartilage, no fold-under
flaps).
7. Intradomal and interdomal tip sutures.
8. Tip suspension suture between the dorsal septum and the
infratip.
9. Tongue-in-groove fixation of the medial crural footpods
with transfixion mattress sutures.
Two years follow-up revealed elimination of nasal airway
obstruction and a favorable cosmetic outcome. Mild supratip
fullness was acceptable to the patient.

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3
.
. Fig. 3.19  Patient in Case 7.
(a) Planning only mild tip/
supratip deprojection and
augmentation of the cephalic
profile to avoid reduction of the
inner valve and further airway
cross-sectional area and to
improve aesthetics. (b)
Rhinomanometry shows a
right-sided curve turning
horizontally with increasing
pressure displaying severe
breathing reduction according to
the right sides’ anterior septal
deviation. The left airway was
open despite an existing
compensatory lower turbinate
hypertrophy. Frontal view (c)
preoperatively and (d)
postoperatively. Left profile view
(e) preoperatively and (f)
postoperatively. Base view (g)
preoperatively and (h)
postoperatively
a
b
c
d
3.3 · Functional Aspects in Primary Rhinoplasty: Case Studies

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3
e
f
g
h
.
. Fig. 3.19  (continued)

Chapter 3 · Functional Aspects in Primary Rhinoplasty

179
3
Suggested Reading
Ballert JA, Park SS.  Functional considerations in revision rhinoplasty.
Facial Plast Surg. 2008;24:348–57.
Boccieri A, Macro C, Pascali M. The use of spreader grafts in primary rhino-
plasty. Ann Plast Surg. 2005;55:127–31.
Byrd HS, Meade RA, Gonyon Jr DL. Using the autospreader flap in primary
rhinoplasty. Plast Reconstr Surg. 2007;119:1897–902.
Gruber RP, Park E, Newman J, Berkowitz L, Oneal R. The spreader flap in
primary rhinoplasty. Plast Reconstr Surg. 2007;119:1903–10.
Neu BR. Use of the upper lateral cartilage sagittal rotation flap in nasal
dorsum reduction and augmentation. Plast Reconstr Surg.
2009;123:1079–87.
Ozmen S, Ayhan S, Findikcioglu K, Kandal S, Atabay K. Upper lateral carti-
lage fold-in flap: a combined spreader and/or splay graft effect with-
out cartilage grafts. Ann Plast Surg. 2008;61:527–32.
Suggested Reading

181
4
Functional Aspects in Secondary
Rhinoplasty
Helmut Fischer
H. Fischer, MD
Department of Facial Plastic Surgery, Marienhospital Stuttgart, Stuttgart 70199, Germany
e-mail: helmut.Fischer@vinzenz.de
4.1
Diminished Side Wall Support – 182
4.2
Surgical Principles – 182
4.3
Case Studies – 183
4.3.1
Case 1: Spreader Grafts and Extended Alar Batten Grafts – 183
4.3.2
Case 2: Spreader Grafts and Alar Batten Grafts – 188
4.3.3
Case 3: Bony Out-Fracture and Spreader Grafts – 193
4.3.4
Case 4: Bony Out-Fracture – 197
4.3.5
Case 5: Underscoring the Importance of Septal
Support to Nasal Valve Function – 199
4.3.6
Case 6: Bony Out-Fracture and Dorsal Narrowing – 201
4.3.7
Case 7: Spreader Grafts and Alar Batten Grafts – 203
4.3.8
Case 8: Septal Reconstruction with Rib Cartilage,
Cephalic Fold-Under Flap – 207

Suggested Reading – 211
© Springer International Publishing AG 2018
W. Gubisch, Mastering Advanced Rhinoplasty,

182
4
Flexibility of the lower nasal framework permits both tempo-
rary changes in nasal shape and a reliable return to normal
resting contour once the forces of deformation are with-
drawn. This skeletal “memory” is fundamental to normal
nasal physiology. Partial collapse of the nasal valve on deep
inspiration—a phenomenon seen in all healthy noses—con-
verts the normally (resting) laminar airflow into a more tur-
bulent flow for better mixing of the inspired air with the
highly vascular nasal mucosa during periods of increased
ventilatory demand. In turn, the increased mucosal contact
results in more effective filtration, humidification, and warm-
ing of the inspired air. Variations in mucosal congestion,
coupled with variations in dilator muscle activity, function to
further regulate the balance between the rate of airflow and
the efficiency of air purification. However, this delicate equi-
librium is often inadvertently disrupted by cosmetic nasal
surgery. In many instances the newly reshaped and often
smaller nose functions adequately at first, only to slowly
deteriorate as the forces of healing begin to progressively dis-
tort the surgically weakened skeletal framework. Although
symptoms of nasal obstruction may be present throughout
the day, symptoms are most severe during sleep when the
nose naturally congests owing to supine posture and reduced
activity levels. The result is often severe nocturnal nasal dys-
function, typically manifested by obligate nocturnal mouth
breathing, consistently dry throat, excessive thirst, and fre-
quent sleep disruption.
4.1
Diminished Side Wall Support
Without question, the recoil and structural “memory” of a
well-functioning nose may be compromised as a conse-
quence of cosmetic nasal surgery. Perhaps the most common
cause of nasal dysfunction is the cephalic trim procedure in
which a large (cephalic) segment of the lateral crus—includ-
ing the nasal scroll—is surgically resected for cosmetic
enhancement of the tip and supratip. Because the nasal scroll
is an anatomically reinforced junction between the upper
later cartilages (ULC) and the lower later cartilages (LLC), it
adds strength to the lower nasal side wall and helps to resist
premature collapse of the nasal valve. Overaggressive resec-
tion of the cephalic margin, including the nasal scroll, can
lead to concave (medial) collapse of the lower nasal side wall,
resulting in devastating valvular dysfunction that often wors-
ens with time. Batten grafts are intended to eliminate sagging
of the lateral crus and to reinforce the weakened nasal side
wall against premature inspiratory collapse. However, batten
grafts, especially thicker grafts fashioned from the ear or rib
cartilage, often greatly increase the thickness and mass of the
lower nasal side wall, producing inadvertent impingement of
the internal valve and increased susceptibility to premature
inspiratory collapse, particularly when the graft fails to
­provide a bridging effect between the tip and piriform aper-
ture. Although thin and lightweight alloplastic materials have
been used in an attempt to circumvent these problems, we
have encountered numerous complications stemming from
the use of synthetic materials such as high-density porous
polyethylene (HDPP). Scarring and inflammation resulting
from foreign-body reactions serve only to add difficulty to
already challenging revision cases.
Finally, the intricate yet delicate nasal airway is also easily
prone to dysfunction with aggressive nasal hump reduction.
Excessive narrowing of the bony piriform aperture and/or
cartilaginous side walls can be cosmetically desirable but
functionally so severe that even spreader grafts cannot offset
the loss of airway size. Revision patients who have experi-
enced this type of iatrogenic nasal airway dysfunction are
often far more willing to accept a somewhat larger nose in
exchange for a properly functioning nasal airway, but cir-
cumspect primary hump reduction is always preferable.
4.2
Surgical Principles
Techniques for surgical revision of the functionally
impaired nose are often similar to the preventive techniques
used in primary cosmetic rhinoplasty. These include
spreader grafts and/or suture techniques for increased valve
patency, batten or lateral crural extension grafts for
increased support at the piriform aperture, domal recon-
struction to widen pinched domes, and septal reconstruc-
tion for residual deformities or inadequate anterior septal
support. However, increasing the valvular cross-sectional
area often includes not only increasing valvular width but
also restoring lost septal height. Enlarging the entire L-strut
when necessary or using projecting spreader grafts above
the existing dorsal (septal) line improves valvular patency
far more effectively than dorsal onlay grafting alone. And
while septal cartilage graft material may be preferable for
airway reconstruction, prior depletion of surplus quadran-
gular cartilage may necessitate alternative sources of carti-
lage such as conchal or rib cartilage. Additionally, secondary
enlargement of the nasal valve may be limited by fibrosis
and contracture of the internal lining. In severe cases in
which release and unfurling of the internal lining is not
possible, insertion of a composite (auricular chondrocuta-
neous) graft is necessary to restore valvular patency.
Alternatively, a free buccal mucosal graft can be used when
the overlying framework is sufficiently stable, but prolonged
postoperative graft stenting (for approximately 6  months
until the risk of contracture has subsided), followed by
delayed skeletal reconstruction, is required when structural
stability is lacking. In rare cases, musculocutaneous island
flaps can also be tunneled through the alar base to repair
cicatricial stenosis of the nasal vestibule.

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4
4.3
Case Studies
4.3.1 Case 1: Spreader Grafts and Extended
Alar Batten Grafts
A healthy young female presented after prior rhinoplasty
with a complaint of severe nasal airway dysfunction. Physical
examination revealed a severe saddle-nose concavity with
overly deep supra-alar grooves (. Fig. 4.1). Palpation revealed
ultrashort nasal bones with an open roof deformity in which
the central ethmoid complex projected above the overre-
sected nasal bones. Endonasal examination revealed bilateral
internal valve collapse, more on the left side, and mild nasal
inspiration produced total dynamic valve collapse. Previous
reduction of the inferior turbinates was also noted.
Rhinomanometry (150 Pa): R 16 mL/s, L 34 mL/s after
decongestion showed R 19 mL/s, L 50 mL/s. This is inter-
preted as near total obstruction.
Several causes for nasal airway dysfunction must be consid-
ered for this patient: (1) overresection of the lateral crura with
flaccid concave collapse as the primary cause of internal valve
dysfunction and (2) overresection of the nasal dorsum with
­saddle-nose collapse of the middle vault (disrupting the tent-like
side wall stability). Surgery was recommended to reconstruct
the LLCs, internal valves, and cartilaginous vault, to increase tip
projection, and to augment and conceal the nasal dorsum.
zz
Surgical Steps
1. Extracorporeal septal reconstruction with application of
cephalically extended spreader grafts.
2. Reimplantation and suture fixation of construct via nasal
bone drill holes.
3. Bilateral conchal cartilage harvest.
4. Harvest of right tragal cartilage.
5. Partial alar batten grafts for increased side wall support
at piriform aperture.
6. Tip-plasty with vertical dome division and suture
reapproximation.
7. Shield graft placement.
8. Harvest of temporalis fascia.
9. Dorsal augmentation with DC-F onlay graft.
Nasal breathing was fully restored, and the patient was
pleased despite a modest increase in outer nasal dimensions.
4.3 · Case Studies

184
4
.
. Fig. 4.1  (a) Resected septal specimen with maximal anterior devia-
tion corresponding to area of the left internal valve. (b) Profile view of
the neoseptal construct with cephalically extended spreader grafts
prior to reimplantation. Extended spreader grafts (needed to fill the
open roof) sutured via multiple drill holes placed within the bony sep-
tum. (c) Dorsal view of the neoseptal construct. Drill holes placed in the
nasal bones facilitate suture fixation of the construct at the keystone
area. (d) Twisted alar cartilage framework and overresected lateral
crura. (e) The axis was corrected by vertical dome division and suture
reapproximation. A lateral crural strut graft was already fixated in its
position. (f) Positioning of lateral crural strut grafts for increased sup-
port at the piriform aperture. Outline of desired graft position overly-
ing the alar groove. (g) Fixated graft sutured to the left lateral crus.
(h) Diced cartilage wrapped in allogenic fasciae used for dorsal aug-
mentation (seen beneath the Aufricht retractor). (i) Frontal view dem-
onstrating alar groove depressions and dorsal deficiency before and
(j) result 6 months after revision rhinoplasty. (k) Preoperative profile
view, (l) postoperative profile view. Base view (m) preoperatively; (n)
closer base view demonstrating severe internal valve collapse; (o)
postoperatively
a
d
e
b
c

Chapter 4 · Functional Aspects in Secondary Rhinoplasty

185
4
g
h
f
.
. Fig. 4.1  (continued)
4.3 · Case Studies

186
4
i
l
j
k
.
. Fig. 4.1  (continued)

Chapter 4 · Functional Aspects in Secondary Rhinoplasty

187
4
m
n
o
.
. Fig. 4.1  (continued)
4.3 · Case Studies

188
4
4.3.2 Case 2: Spreader Grafts and Alar
Batten Grafts
An 18-year-old female was seen after previous reduction rhino-
plasty with complaints of postsurgical nasal airway obstruction
and overprojection of the nasal tip and nasal root. Physical
examination revealed pinched internal nasal valves and severe
recurvature of the LLCs. LLC overresection was suspected.
Revision surgery to widen and augment the middle vault was
recommended rather than deprojecting the tip and nasal root.
In this manner, a wider middle vault would help address the
functional deficits, while a taller middle vault would avoid the
visual impression of a significantly wider nose. Restructuring of
the LLCs to eliminate concavity was also planned (. Fig. 4.2).
zz
Surgical Steps
1. Harvest of septal cartilage.
2. Spreader graft placement.
3. Middle vault suspension by reattaching ULCs to the
uppermost dorsal septum in near horizontal orientation.
4. Intradomal and interdomal suture placement.
5. Vertical infolding of the cephalic LLC, longitudinal
scoring, and spanning suture placement.
6. Bilateral batten graft placement.
7. Dorsal augmentation with allogenic fascia grafts.
Ultimately the patient accepted the profile augmentation
in exchange for much better breathing.
.
. Fig. 4.2  (a) Left, profile prior to revision surgery; center, patient’s (initial)
desired profile; and right, the recommended profile. (b) Right prerevision
endonasal view and (c) left prerevision endonasal view. (d) Intraoperative
view of spreader graft and suture reattachment of ULCs and (e) ­schematic
view of spreader grafts and suture reattachment of ULCs. (f) Rectangular
infolding of the cephalic rim in L shape for improved rigidity against
­collapse and (g) simultaneous supratip narrowing effect by flaring
sutures. (h) Septal cartilage batten grafts; (i) grafts sutured on top of the
LLCs. (j) Prerevision frontal view and (k) postrevision frontal view with
improved airway function. (l) Prerevision profile view and (m) postrevi-
sion profile view with improved airway function. (n) Prerevision base
view and (o) postrevision base view with improved airway function

Chapter 4 · Functional Aspects in Secondary Rhinoplasty

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4
a
b
c
e
d
4.3 · Case Studies

190
4
f
g
h
i
.
. Fig. 4.2  (continued)

Chapter 4 · Functional Aspects in Secondary Rhinoplasty