Mastering Advanced Rhinoplasty

192
4
n
o
.
. Fig. 4.2  (continued)

Chapter 4 · Functional Aspects in Secondary Rhinoplasty

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4
4.3.3 Case 3: Bony Out-Fracture
and Spreader Grafts
A 44-year-old male hemophiliac (. Fig. 4.3) with a history of mul-
tiple prior nasal surgeries, including septorhinoplasty, presented
complaining of worsening nasal airway obstruction and frequent
sinus headaches. Recurrent frontal sinusitis with multiple courses
of antibiotic therapy led to the development of pseudomembra-
nous colitis, making the patient extremely apprehensive about
further treatment. His anxiety was heightened by the refusal of
other surgeons to reoperate. Physical examination revealed an
exceedingly narrow bony nasal vault with greater narrowing on
the right. Endoscopic examination confirmed an ultranarrow
bony vault. A surgically widened bony nasal vault was recom-
mended to improve nasal airway obstruction and frontal sinus
aeration. The patient was advised about the high probability of
treatment failure. Increased tip projection and dorsal augmenta-
tion were also recommended to minimize the visual appearance
of excessive nasal width and to create a balanced nasal contour.
zz
Surgical Steps
1. Harvest of left conchal and tragal cartilages.
2. Parasagittal median, transverse, and low-low lateral
osteotomies to open both the bony base and roof.
3. Extended butterfly-type spreader graft placement to
maintain widening of the bony vault.
4. Septal extension graft placement to enable
tongue-in-groove tip support.
5. Excision of scarred soft tissues from the supratip area.
6. Placement of diced cartilage wrapped in allogenic fascia
to the nasal dorsum for additional augmentation.
The postoperative course was uneventful. Epistaxis was
avoided with a combination of clotting factor replacement
and application of inflatable nasal packs with hemostatic
coating. At long-term follow-up, the patient reported a
marked improvement in nasal airflow, a substantial reduc-
tion in sinus infections, and far less anxiety regarding his
nose.
4.3 · Case Studies

194
4
.
. Fig. 4.3  (a) Narrow upper airway on endoscopic view, (b) butterfly-
type spreader graft, and (c) schematic showing graft placement
beneath the dorsal side walls. (d) Schematic representation of bony
out-fracture for airway enhancement followed by dorsal augmentation
to maintain a slender frontal contour. (e) Prerevision frontal view dem-
onstrating an asymmetrical and pinched bony and middle nasal vault
and (f) postrevision frontal view. (g) Prerevision profile view and (h)
postrevision profile view. (i) Prerevision base view and (j) postrevision
base view
a
c
d
b

Chapter 4 · Functional Aspects in Secondary Rhinoplasty

195
4
g
h
e
f
.
. Fig. 4.3  (continued)
4.3 · Case Studies

196
4
i
j
.
. Fig. 4.3  (continued)

Chapter 4 · Functional Aspects in Secondary Rhinoplasty

197
4
4.3.4 Case 4: Bony Out-Fracture
A 20-year-old male with a history of blunt nasal trauma at
age 13 presented for primary rhinoplasty consultation.
External examination (. Fig. 4.4a) suggested a probable prior
septal hematoma with loss of septal projection, but the endo-
nasal examination showed only an intact quadrangular sep-
tum with a high leftward deviation and a minor deviation at
the inferior aspect of the caudal septum. The left nasal bone
was depressed, but rhinomanometry was normal. Ultimately
the patient disagreed with the diagnostic assessment and was
treated elsewhere.
Four months after initial presentation, the patient
returned complaining of an unsatisfactory rhinoplasty out-
come and development of severe breathing impairment.
Examination revealed an overresected and pinched bony
vault with persistent depression of the left nasal bone
(. Fig.  4.4b). A polly-beak profile deformity was also
observed, and the endonasal examination revealed narrow
internal nasal valves and narrow nasal cavities. Spreader graft
simulation using a small glass spatula to widen the upper
nasal valve resulted in significant breathing improvement,
thereby convincing the patient to undergo widening of the
lower nasal side walls. Repeat rhinomanometry showed
(150 Pa): R 80 mL/s, L 416 mL/s.
Revision surgery was delayed until 1 year following pri-
mary rhinoplasty. Treatment recommendations included
widening the cartilaginous and bony vaults with bony out-­
fracture if necessary and dorsal profile realignment by lower-
ing the anterior septal polly-beak and augmenting the
remaining dorsum.
zz
Surgical Steps
1. Harvest of left conchal and tragal cartilages.
2. Resection of subcutaneous supratip scar tissue and
out-fracture of both nasal bones.
3. Septal extension graft placement using a reciprocally
curved graft to straighten the caudal septum.
4. Reduction of the left inferior turbinate head.
5. Tongue-in-groove fixation of the medial crura to the
septal extension graft using transfixion sutures.
6. Dorsal augmentation with diced cartilage wrapped in
allogenic fascia lata.
Postoperatively the patient reported normal nasal breathing.
Examination revealed improved dorsal and frontal nasal contours.
4.3 · Case Studies

198
4
a
d
g
h
i
e
f
b
c
.
. Fig. 4.4  (a) Frontal view at the time of first consultation prior to
rhinoplasty performed elsewhere: (b) prerevision frontal view and (c)
postrevision frontal view. (d) Left profile view at the time of first consul-
tation prior to rhinoplasty performed elsewhere: (e) ­prerevision left
profile view and (f) postrevision left profile view. (g) Base view at the
time of first consultation prior to rhinoplasty performed elsewhere: (h)
prerevision base view and (i) postrevision base view

Chapter 4 · Functional Aspects in Secondary Rhinoplasty

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4
4.3.5 Case 5: Underscoring the Importance
of Septal Support to Nasal Valve
Function
A 32-year-old female presented seeking revision surgery for
nasal airway obstruction and a misshapen nose (. Fig. 4.5).
The patient reported childhood trauma followed by unsuc-
cessful surgery at age 12 and again at age 23. Examination
revealed an asymmetrical tip with a conspicuous supratip
depression. A dorsal onlay graft with visible edges was also
evident. Endonasal examination revealed absence of the cau-
dal septum and a severe posterior septal deviation behind a
large septal perforation. Deformed alar cartilages were also
present.
Treatment recommendations included L-strut recon-
struction to restore both dorsal and caudal septal projections,
closure of the septal perforation, tip reconstruction, and aug-
mentation and simultaneous smoothing of the dorsum. The
importance of the valvular support by the septum is demon-
strated by the case of this patient.
zz
Surgical Steps
1. Harvest of left conchal and tragal cartilages bilaterally.
2. Removal of old septal cartilage (dorsal) onlay graft.
3. Septal perforation repair (via external rhinoplasty
approach) using mucosal advancement flaps from the
roof, side walls, surrounding septum, and nasal floor.
Separation of the mucoperichondrial flaps facilitated by
a sharpened metal suction-dissector. Interposition with
a flattened conchal cartilage graft and everting sutures
helped to prevent recurrence.
4. Submucous resection of the (bony) inferior turbinates
to eliminate perforation-induced turbinate hypertrophy.
5. Septal extension graft placement using the recycled
dorsal (septal) onlay graft. Drill hole graft fixation to the
left side of the nasal spine and maxillary crest using a
contralateral ethmoid splinting graft to prevent
displacement.
6. Dorsal L-strut reconstruction using a double-layered
conchal cartilage graft to bridge the keystone area to the
upper septal extension graft.
7. Bony out-fracture after parasagittal medial osteotomies
(with a small bony wedge resection on the left),
transverse osteotomies, and low-low lateral osteotomies.
8. Cephalic margin fold-under flaps to correct LLC
concavity and improve rigidity.
9. Revision of the vertical dome division with an LLC
overlap technique (sliding technique in our
nomenclature).
10. Tongue-in-groove fixation of the medial crura to the
septal extension graft for improved tip support.
11. Dorsal augmentation with diced cartilage in allogenic
fascia.
12. Shield graft placement using tragal cartilage for
increased tip projection and counterrotation.
13. Onlay allogenic fascia graft to augment thin tip skin.
Postoperatively, the patient reported the best nasal func-
tion of her entire life. Aesthetically, the nose was also greatly
improved except for a modest rightward tip deviation. Tip
displacement most likely resulted from asymmetrical L-strut
fixation at the nasal spine.
4.3 · Case Studies

200
4
a
d
e
f
b
c
.
. Fig. 4.5  Patient after trauma and two rhinoplasties.
(a) Prerevision frontal view and (b) postrevision frontal
view. (c) Prerevision profile view and (d) postrevision
profile view. (e) Prerevision base view and (f)
postrevision base view

Chapter 4 · Functional Aspects in Secondary Rhinoplasty

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4
4.3.6 Case 6: Bony Out-Fracture and Dorsal
Narrowing
A 38-year-old female presented complaining of persistent
nasal airway obstruction after previous rhinoplasty 3 years
prior (. Fig. 4.6). We had performed the initial surgery for
hump reduction and airway improvement. For better breath-
ing, we had corrected the septum, reduced the turbinates,
and applied spreader flaps to open the very narrow airway in
an overall very narrow nose. The patient stated a partially
successful functional surgery but asked for further improve-
ment and simultaneously complained of a wider nasal dor-
sum compared with her former appearance.
Examination revealed a persistent narrow base of the
bony pyramid, while the bony and cartilaginous dorsum now
appeared too wide. The tip was a little too pointed after the
previous lateral steal tip plasty and the columella-labial angle
still too obtuse although reduced.
Revision surgery was recommended to open the bony
pyramid at the base by out-fracture and simultaneously nar-
row the nasal dorsum, improve the profile by changing the
tip-dorsum relation, and reduce the lower columella show for
a balance and attractive contour.
zz
Surgical Steps
1. Reosteotomies transverse and lateral.
2. Opening the base of the bony pyramid (out-fracture).
3. Transosseus suture cerclage at the rhinion to close the
bony roof.
4. Separation of the spreader flaps from the septum and
adjustments with a bilateral scoring incision and
U-shaped tightening sutures.
5. Application of small strips of donor fascia for camouflage
to balance the profile (nasion, supratip, infratip).
6. Reduction of the membranous septum at the columella
base to restrain the medial crura footplates improving
the former tongue in groove maneuver.
For stabilizing the out-fracture maneuver, nasal sponge
tamponades where left in place over 4 days.
Postoperatively, the patient enjoys good nasal airway
function and very satisfactory cosmesis.
.
. Fig. 4.6  One year after primary rhinoplasty the bony and cartilagi-
nous dorsum appeared too wide while the sidewalls and piriform aper-
ture appeared too narrow at the base, a major reason for residual
breathing problems in the physical reexamination of the patient. The
series of the patient’s photos show the development towards the final
result after revision rhinoplasty with outfracturing of the nasal bones at
the bottom and closure of the open roof as well as narrowing of the
former spreader flaps by secondary scoring and suture adaptation (a)
initial frontal view, (b) frontal view after previous rhinoplasty, (c) post-
revision frontal view, (d) initial profile view, (e) profile view after previ-
ous rhinoplasty, (f) postrevision profile view, (g) initial base view, (h)
base view after previous rhinoplasty, (i) postrevision base view
a
b
c
4.3 · Case Studies

202
4
g
h
i
d
e
f
.
. Fig. 4.6  (continued)

Chapter 4 · Functional Aspects in Secondary Rhinoplasty

203
4
4.3.7 Case 7: Spreader Grafts and Alar
Batten Grafts
A 32-year-old patient (. Fig. 4.7) had had four previous rhino-
plasties, the last including porous polyethylene implants for
alar stabilization. He suffered from continuous breathing
impairment and was bothered by the nasal deformity. He had
a very low bony dorsum, a parrot beak, a hidden columella,
asymmetry of the nostrils, and septal deviation with a narrow
inner valve on the right side. The alloplastic implants were
found to be located too far cephalically, and the right alar
wing had no structural support. The septum was empty of
grafting material.
Rhinomanometry (results 150  Pa), right 92  mL/s, left
204 mL/s, displayed severe right-sided and mild left-sided
nasal breathing impairment (without decongestion).
Revision septorhinoplasty was planned, including cre-
ation of a stabile L-frame, spreader grafts for opening the
inner valves, replacement of the alloplastic alar implants by
autologous grafts, and dorsal augmentation for a balanced
profile and a narrow roof.
zz
Surgical Steps
1. Rib cartilage harvest.
2. Deep temporal fascia harvest.
3. Removal of one single complex porous polyethylene
implant bridging alae and tip from one side to the other,
an additional porous polyethylene implant from the right
ala, a solid silicone implant from the tip, and a mass of
scar tissue.
4. Anterior septal reconstruction with a reinforced
double-layered rib cartilage graft was taken from the
dislocated previous rib cartilage septal reconstruction. It was
placed in a more anterior position to gain a normal columella
show. Placement of the graft like an inverted Y onto the
maxillary crest inferior to the missing anterior nasal spine
and suture fixation via a drill hole through the maxillary crest.
5. A bony cartilaginous graft of the previous reconstruction
of the cartilaginous dorsum was left in place, as it was
stable and in a straight position. However, it was
extended by two spreader grafts to fix the
septum-columellar strut in a distal position and prevent
cephalic tip rotation and thus a short nose.
6. Tip reconstruction by suturing the original alar cartilages
on top of the strut.
7. Alar support by two thin symmetrically shaped and
bended rib cartilage grafts positioned more caudally in
the alar base.
8. Dorsal augmentation with diced cartilage in autologous
fasciae to compensate for the increased tip projection.
zz
Result
Dramatic improvement of nasal breathing and normalization
of the nasal shape occurred.
An accidental click phenomenon was noted at the colu-
mella base despite suture fixation of the strut at its bottom.
4.3 · Case Studies

204
4
.
. Fig. 4.7  Revision rhinoplasty patient Case 7. (a) Silicone cap graft
removal; (b) high-density porous polyethylene (HDPP) alar framework
exposed. (c) HDPP implant still in position before removal; the tip of a
sharp-tipped scissors is seen underneath the tip of the graft. (d) HDPP
implant removed; intended to act like a splay graft and bilateral batten
grafts simultaneously but finally did not work. (e) The additional grafts
were removed: silicone tip onlay, right alar HDPP batten graft. (f) Placement
of a columellar strut created from a previous rib cartilage septal replace-
ment graft, suture placed to fixate the graft at the anterior nasal spin. (g)
New rib cartilage batten grafts carved out in a curved shape ready for
implantation, to be supported by the columellar strut. (h) Prerevision fron-
tal view and (i) postrevision frontal view. (j) Prerevision left profile view
and (k) postrevision left profile view, the dorsum augmented with a DC-F
graft. (l) Prerevision base view and (m) postrevision base view
a
e
f
b
c
d

Chapter 4 · Functional Aspects in Secondary Rhinoplasty

205
4
i
j
k
g
h
.
. Fig. 4.7  (continued)
4.3 · Case Studies

206
4
l
m
.
. Fig. 4.7  (continued)

Chapter 4 · Functional Aspects in Secondary Rhinoplasty

207
4
4.3.8 Case 8: Septal Reconstruction with Rib
Cartilage, Cephalic Fold-Under Flap
A 28-year-old female patient (. Fig.  4.8) reported nasal
trauma 12 years prior to consultation. Three years later, she
had a septoplasty and removal of polyps. Consecutively she
developed a severe saddle-nose deformity. Four years later,
she underwent a rhinoplasty for dorsal augmentation, and
5 years later she came for consultation for the first time, still
with a supratip saddle, and asked for revision rhinoplasty for
further augmentation of the dorsum and increase of tip pro-
jection.
She felt no breathing impairment, but the objective rhi-
nomanometry data suggested a one third reduction on the
right side (R 208 mL/s vs. L 348 mL/s).
We planned elongation of the short nose and colu-
mella by a septal extension graft placed like a columellar
strut, anticipating that its height would help to increase
tip projection. Thus, the supratip saddle was expected to
be increased and had to be augmented even more.
Therefore, spreader grafts were planned to be fixated on a
high dorsal level, 2–3 mm higher than the septal dorsum
and the ULCs, fixated to the augmented septum—a func-
tional saddle-nose correction completed by a DC-F onlay
for additional aesthetic saddle-­nose correction. The
spreader grafts were expected to stabilize the septal exten-
sion graft as they are extended beyond the anterior septal
angle and work like bilateral splints (extended spreader
grafts).
zz
Surgical Steps
1. Harvest of rib cartilage, right number 9.
2. Temporal fascia harvest.
3. Removal of a hypermobile old dorsal onlay to create a
better condition for a new dorsal onlay integration.
4. Anterior septal reconstruction by solid rib graft, tailored
and inverted Y-shaped at the bottom; fixation with 4-0
Prolene suture through the right branch, then the drill
hole in the maxillary crest, and lastly through the left
branch of the graft (a 3-point fixation preventing
dislocation).
5. Septal dorsum reconstruction by solid rib graft, split on
both sides for tongue-in-groove fixation to the septal
remnant at the key area and to the anterior strut to
construct a stable L-frame. There was no septal material
found for fixation of typical spreader grafts nor were
there ULCs except for scarred remnants.
6. Lateral osteotomy unilateral right was sufficient for
correction of the deviation of the bony pyramid in this
particular case.
7. Rectangular infolding of the cephalic third of the concave
LLCs for straightening and stabilization (L-profile).
8. Additional dorsal augmentation by DC-F.
9. Tip refinements for dome symmetry.
zz
Result
Nasal breathing was unimpaired at 9 months after the sur-
gery, and the patient was highly satisfied with the result of the
nasal augmentation.
4.3 · Case Studies

208
4
a
b
c
d
.
. Fig. 4.8  (a) Septum-columellar strut; (b) schematic drawing of
strut-anchoring on top of the ANS or on the maxillary crest just below
the ANS, of sutures passing one limb of the strut, a drill hole in the bone,
and the other limb of the strut. (c) Inserting the dorsal graft. (d)
Anchoring the dorsal sandwich graft at the columella graft applying the
tongue-in-groove principle. (e) Prerevision frontal view and (f) postrevi-
sion frontal view. (g) Prerevision left profile view and (h) postrevision
left profile view. (i) Prerevision base view and (j) postrevision base view

Chapter 4 · Functional Aspects in Secondary Rhinoplasty

209
4
e
f
g
h
.
. Fig. 4.8  (continued)
4.3 · Case Studies

210
4
i
j
.
. Fig. 4.8  (continued)

Chapter 4 · Functional Aspects in Secondary Rhinoplasty

211
4
Suggested Reading
Maring VP, Landecker A, Gunter JP. Harvesting rib cartilage grafts for sec-
ondary rhinoplasty. In: Gunter JP, Rohrich RJ, Adams WP, editors.
Dallas rhinoplasty. 2nd ed. St. Louis: Quality Medical Publishing;
2007. p. 705.
Toriumi DM.  Structural approach to rhinoplasty. Facial Plast Surg Clin
North Am. 2005;13:93–113.
Suggested Reading

213
II
External Nose
Contents
Chapter 5
Primary Reduction of the Dorsum – 215
Chapter 6
Secondary Correction of the Dorsum Including
Polly-Beak Deformity– 265
Chapter 7
Primary Augmentation of the Dorsum – 337
Chapter 8
Secondary Augmentation of the Dorsum – 395

215
© Springer International Publishing AG 2018
W. Gubisch, Mastering Advanced Rhinoplasty,
5
Primary Reduction of the
Dorsum
5.1
Surgical Principles – 216
5.2
Case Studies – 225
5.2.1
Case 1: Minor Hump Reduction with Power Drill – 225
5.2.2
Case 2: Hump Reduction with Compound Technique – 227
5.2.3
Case 3: Major Reduction for Rhinomegaly with Chisel Combined
with Lateral Sliding Technique for Deprojection of the Tip – 231
5.2.4
Case 4: Lowering the Dorsum Combined
with Extracorporeal Septal Reconstruction – 234
5.2.5
Case 5: Lowering the Dorsum Plus Spreader Flaps – 236
5.2.6
Case 6: Reduction for Rhinomegaly Combined
with Extracorporeal Septal Reconstruction – 240
5.2.7
Case 7: Widening of Internal Valves with Spreader Flaps – 244
5.2.8
Case 8: Overprojected Dorsum Combined
with Underprojected Tip – 247
5.2.9
Case 9: Rhinomegaly: Reduction Rhinoplasty Combined with Extracor-
poreal Septal Reconstruction – 249
5.2.10
Case 10: Rhinomegaly with Hypoplasia of the Chin: Reduction
Rhinoplasty Combined with Lateral Crural Overlap (Sliding) Technique,
Tongue-in Groove Technique, Spreader Flaps,
and Chin Augmentation – 253
5.2.11
Case 11: Reduction Rhinoplasty Combined
with Extracorporeal Septal Reconstruction Plus Shortening
of the Nasal Spine – 256
5.2.12
Case 12: Overprojected Dorsum and Overprojected Tip
and Long Nose – 258
5.2.13
Case 13: Dorsal Reduction Combined with Chin Augmentation – 261

Suggested Reading – 264

216
5
5.1
Surgical Principles
Most patients seeking rhinoplasty desire enhancements of
their nasal profiles. In fact, more than 80 % of all rhinoplasty
patients are seeking a reduction rhinoplasty because they feel
their nasal profiles are too prominent. However, it is first nec-
essary to determine why the patient feels this way, since there
are many different causes of the overly prominent nose.
Proper characterization is critical, since failure to correctly
analyze the cosmetic deformity may lead to inappropriate
treatment and patient dissatisfaction. Is the problem a simple
overprojected dorsal hump? Or is the entire nasal profile,
including the nasal tip, overprojected (i.e., rhinomegaly)?
Alternatively, does the excessive prominence result from a
tension-nose deformity in which an overprojected dorsal
septum gives rise to pinching of the middle vault and exces-
sive elongation of the nostrils (. Fig. 5.1)?
The typical nasal hump is a combination of an overpro-
jected cartilaginous dorsum and an overprojected bony dor-
sum. On the other hand, overprojection can be restricted to
either the bony or the cartilaginous segment. The latter is
known as an idiopathic parrot-beak deformity.
For surgical reduction of the nasal dorsum, different
treatment options are available. However, regardless of the
method chosen, nasal mucosa should first be elevated from
the undersurface of the cartilaginous hump to expose the
junction of the upper lateral cartilages and the dorsal septum.
This enables a so-called extramucosal dissection, which pre-
serves the protective mucosal barrier and stabilizes the over-
lying graft material. Additionally it minimizes contracture
following hump resection. We perform dorsal reduction in
most cases using the open approach. We first begin by divid-
ing the membranous septum in order to expose the leading
edge of the caudal septum. We then elevate the outer peri-
chondrium off the inner perichondrium. Histologic analysis
of the septal mucosa has identified two layers of perichon-
drium (Pirsig and Fischer 1982). The inner layer is tightly
adherent to the cartilage matrix, whereas the outer layer is
more easily elevated for flap dissection. We denude the septal
cartilage of the outer perichondrium, which provides a com-
paratively bloodless plane of dissection and tends to produce
fewer lacerations in the septal flaps. The extramucosal dissec-
tion can then be performed easily after entering the correct
plane, for example, by using a suction dissector (. Fig. 5.2).
The instrument we are using for this purpose was developed
by Haraldsson (Medicon eG, Tuttlingen, Germany); it has a
semisharp tip and a revolving handle. This instrument
enables us to safely and quickly dissect the mucosa, even
without direct visualization.
For many years, we have been using a compound (or en
bloc) resection technique for hump removal (. Fig. 5.3). The
cartilaginous hump was transected at the desired height
using a no. 11 blade, beginning caudally at the distal margin
of the hump and ending cephalically at the bony cartilagi-
nous junction. The left upper lateral cartilage was then tran-
sected, followed by the dorsal septum and the right upper
lateral cartilage. After all three components of the
­cartilaginous hump have been cut, we inserted a sharpened
chisel into the newly made gap and engaged the lower end of
the bony hump. Once the proper trajectory has been con-
firmed, we transected the bony hump and completed the en
bloc resection. We preferred not to use an osteotome for
bony hump resection since osteotome movement is more
likely to result in inadvertent overresection of the nasal bone.
Overresection is less likely with a sharp chisel with a long flat
blade that cuts like a knife (. Fig. 5.4). However, it is impor-
tant to sharpen the blade before each use because it dulls eas-
ily. A major advantage of the compound resection technique
is the comparatively large block of composite tissue that is
generated by hump removal. When necessary, the resected
hump can be remodeled and reshaped using a power drill to
create an onlay graft, which is ideal for refinement of the dor-
sum. The graft can be used to cover minor contour irregu-
larities or to conceal an open roof deformity (. Fig. 5.5). The
major disadvantage of this technique is resection of the ULC
where it is fused to undersurface of the bony hump. By resect-
ing a tall bony hump, a bony cartilaginous open roof may be
created potentially causing irregularities in the surface con-
tour of the rhinion.
As an alternative to the en bloc method, the component
technique can be used for dorsal hump resection. Because of
its ease and precision, it has become our preferred technique
for hump removal (. Fig. 5.6). After completing the extramu-
cosal dissection, we divide the upper lateral cartilages from
the dorsal septum and treat each anatomic component of the
cartilaginous dorsum separately (i.e., a split technique). First
we lower the dorsal septum using a straight scissors. Unless
we are planning to reconstitute the middle vault with spreader
flaps, each upper lateral cartilage is then trimmed individu-
ally with a straight scissors prior to spreader graft placement.
When using spreader flaps, the upper lateral cartilages are
bluntly detached from the undersurface of the nasal bones
prior to bony hump resection. Typically, there is a 10- or
12-mm overlap.
The next step in the component technique is resection of
the bony dorsum. Often, the bony hump is much smaller
than expected, since the bony contribution to the dorsal
hump is usually only 5–8 mm in length. Therefore, in most
cases we prefer reducing the bony hump with a rasp rather
than with a chisel. At present we prefer a rasp with disposable
blades (. Fig. 5.7) so that a sharp instrument is always avail-
able. Only with very large and thick humps is our algorithm
changed, and the hump is removed using a chisel.
Transection of the dorsal hump is then followed by oste-
otomies to remodel the nasal pyramid. Osteotomies can be
classified according to their shape: curved or straight. Curved
osteotomy cuts are commonly used for paramedian osteoto-
mies that diverge or “fade” laterally at their upper ends, often
to join curved lateral osteotomy cuts that have either a high-­
to-­low-to-high or a low-to-high configuration (. Fig.  5.8).

Chapter 5 · Primary Reduction of the Dorsum

217
5
However, we prefer straight osteotomies, which yield larger
bony fragments for more effective bone contouring.
Therefore, we perform a straight paramedian osteotomy, a
straight transverse osteotomy, and a straight low-to-low lat-
eral osteotomy as our standard technique (. Fig. 5.8). The
paramedian osteotomy is performed using a power-driven
Lindemann fraise, beginning inferiorly and extending supe-
riorly to create precise parasagittal cuts parallel to the sep-
tum. By using a fraise, we can also remove additional bone to
create a small open roof in order to prevent blocking of the
fragments during infracture. Hence, the Lindemann fraise
facilitates both precise placement of straight paramedian
osteotomies and narrowing of the central bony complex to
optimize infracture (. Fig. 5.9). This process is followed by
the transverse and the low-to-low lateral osteotomy, which
are always performed percutaneously (. Fig. 5.10). Two per-
cutaneous skin incisions are required, one vertically oriented
at the junction of the caudal and middle thirds and one trans-
versely oriented at the junction of the cranial and middle
thirds. For this procedure, we use a 2- or 3-mm unguarded
osteotome. After inserting the instrument through the skin
incision, we use the osteotome to elevate the soft tissues along
the osteotomy line in order to displace the vessels and reduce
bleeding (. Fig. 5.11).
Based upon our experience, the percutaneous technique
minimizes bone fragmentation by optimizing angulation of
the osteotome. Although the osteotomy lines converge near
the inner canthus, we prefer not to join the osteotomy cuts.
Instead, we use a greenstick fracture with manual pressure to
complete the release and mobilization of the nasal bones.
The next step is internal nasal valve reconstruction. In
most cases we use a spreader flap technique (. see Fig. 5.11).
Spreader flaps are created from upper lateral cartilage that
remains after cartilaginous (septal) hump resection. The
overprojecting edges of the upper lateral cartilage are scored
or nonscored, invaginated inward, and then sutured flush to
the newly established dorsal septum. We favor this technique
over the use of spreader grafts, since it creates a very smooth
dorsum as well as a favorable internal nasal valve configura-
tion. Furthermore, spreader flaps typically produce good aes-
thetic dorsal lines.
Another option for internal valve reconstruction is the use
of spreader grafts (. Fig. 5.12). However, like spreader flaps,
spreader grafts are also used to contour the middle vault, rein-
force a weak dorsal septum, or compensate for middle vault
asymmetries. Spreader grafts can be created from the previous
septal dorsum or from central parts of the quadrangular carti-
lage. Care must be taken to bridge the keystone area because
this is the most sensitive part of the dorsum. Typically,
spreader grafts have a width of 1–2  mm and a height of
approximately 3 mm. Fixation to the dorsal septum is accom-
plished by means of horizontal mattress sutures, which are
recessed to permit additional smoothing of the cartilaginous
dorsum when needed. Following spreader graft fixation, the
upper lateral cartilages are trimmed flush with the dorsal sep-
tum and sewn to the newly created dorsal construct.
The last step of this procedure is smoothing the dorsum.
For the bony dorsum, this can be accomplished with a power
drill to eliminate any contour irregularities. Smoothing the
bony cartilaginous junction or the cartilaginous dorsum is
accomplished with a no. 11 blade. The benefits of spreader
flaps or spreader grafts are many. These include maintaining
or improving internal valve patency and/or straightening the
cartilaginous dorsum. Pinching of the upper lateral cartilages
adjacent to the bony/cartilaginous junction—the so-called
inverted-V deformity—is also reversed and/or prevented
using spreader flaps or spreader grafts. The by-products of
these corrections are smooth and symmetrical and have con-
tinuous dorsal aesthetic lines.
Depending upon the desired cosmetic objective, the dor-
sum can be intentionally overreduced if immediate dorsal
augmentation is preplanned. In our hands, augmentation of
the dorsum is accomplished by reimplantation of a surgically
modified (composite) dorsal hump or by blanketing the nasal
bridge with one or two layers of autogenous or allogenic fas-
cia (TutoplastR; Tutogen Medical GmbH; Neunkirchen am
Brand, Germany) (. Fig. 5.13). In order to create a smooth
and even dorsal contour, full-length onlay grafts are prefera-
ble. In the case of an underprojected nasion, which is a com-
mon contour deficiency, we prefer to avoid isolated radix
grafts—which often produce step-off deformities—and use
full-­length fascial grafts instead.
For some time, our first choice of refining the dorsal con-
tour has been free diced cartilage. All residual cartilage rem-
nants are finely diced into a paste-like consistency and
injected using a plain tuberculin syringe. The injected mate-
rial is then gently molded with digital pressure until the
desired contour is achieved. After contouring is complete,
the dorsum is stabilized with an outer layer of adhesive tape
prior to final closure of marginal incisions (. Fig. 5.14).
5.1 · Surgical Principles

218
5
a
b
.
. Fig. 5.2  (a, b) Suction dissector with revolving handle
a
b
.
. Fig. 5.1  (a, b) Tension nose with elongated nostrils

Chapter 5 · Primary Reduction of the Dorsum

219
5
a
b
.
. Fig. 5.4  (a, b) Chisel with long flat blade
a
b
.
. Fig. 5.5  (a, b) Surgically modified hump for reinsertion as a dorsal onlay graft
a
b
.
. Fig. 5.3  (a, b) En bloc hump
resection
5.1 · Surgical Principles

220
5
a
b
d
c
.
. Fig. 5.6  (a–d) Component
hump resection
.
. Fig. 5.7  Manual rasp with disposable blades

Chapter 5 · Primary Reduction of the Dorsum

221
5
.
. Fig. 5.8  Planning of the osteotomies
.
. Fig. 5.9  (a, b) Using
Lindemann fraise for
paramedian osteotomy
5.1 · Surgical Principles

222
5
.
. Fig. 5.11  Spreader flap technique
.
. Fig. 5.10  (a, b) Small
osteotome inserted through a
percutaneous incision

Chapter 5 · Primary Reduction of the Dorsum

223
5
.
. Fig. 5.12  Spreader graft technique
5.1 · Surgical Principles

224
5
.
. Fig. 5.13  Allogenic fascia lata (Tutoplast)
.
. Fig. 5.14  Finely diced cartilage in tuberculin syringe for camou-
flaging irregularities

Chapter 5 · Primary Reduction of the Dorsum

225
5
5.2
Case Studies
5.2.1 Case 1: Minor Hump Reduction
with Power Drill
A 27-year-old female presented with a narrow and overpro-
jected dorsum complaining of left-sided nasal obstruction.
Endonasal examination showed a central septal deviation in
the left nasal passage. The tip was also bulbous and slightly
asymmetrical.
Using the open approach, interdomal soft tissues and por-
tions of the depressor septi muscle were excised. Following
extramucosal dissection of the middle vault, the upper later
cartilages (ULCs) were divided from the septum, and upper
submucosal tunnels were dissected over the septum. The dor-
sal septum was then lowered using a component resection,
but a 10.0-mm dorsal L-strut was preserved after removing
the central septal deformity. Using the Lindemann burr, the
ethmoid bone was then cut to prevent separation of the bony
cartilaginous septum and/or fracture of the cribriform plate
during blunt fracture of the perpendicular ethmoid bone
(with the 5.0-mm osteotome) while removing the septal par-
tition. The overprojected bony dorsum was then lowered with
an electric cylindrical drill, and the bony pyramid was also
straightened and narrowed using (internal) parasagittal
medial osteotomies, followed by percutaneous low-to-low lat-
eral and transverse osteotomies. The overprojected ULCs
were then invaginated medially and used to create spreader
flaps. The tip was also contoured with lateral crural strut
grafts (lateral crural underlay technique) to flatten the lateral
crura, and both spanning sutures and transdomal sutures
were used after inserting a columellar strut graft. Alar rim
grafts were also placed for contour and support of the nostril
rims (. Fig. 5.15).
a
b
.
. Fig. 5.15  (a) Cephalic fold-under flaps
(lateral crural underlay). (b–d) Minor hump
reduction with power drill (Front view,
profile view, base view pre-op/post-op.)
5.2 · Case Studies

226
5
d
c
.
. Fig. 5.15  (continued)

Chapter 5 · Primary Reduction of the Dorsum

227
5
5.2.2 Case 2: Hump Reduction
with Compound Technique
An 18-year-old female presented with a narrow and overpro-
jected dorsum, a wide nasal tip, and obstruction of the nasal
airway. The endonasal examination revealed pinched nasal
valves and a high septal deviation to the patient’s left side.
The septum was otherwise unremarkable without airway
obstruction.
Using the external rhinoplasty approach, we separated
the membranous septum and resected a majority of the
depressor septi muscle. The caudal border of the septum was
then trimmed to deepen the nasolabial angle. After exposing
the nasal dorsum, mucoperichondrial pockets were elevated
on the undersurface of the ULC/septal cartilage junction on
both sides, and the ULCs were then sharply separated from
the dorsal septum with straight scissors. Attachments of the
ULCs to the nasal bones were also elevated off the nasal
hump in order to preserve the underlying cartilage during
bony hump resection. The cartilaginous hump was first
resected with straight scissors, followed by transection of the
bone using a sharp chisel to remove the rhinion hump as a
single specimen. The bony pyramid was then narrowed using
parasagittal medial osteotomies and percutaneous transverse
and percutaneous (low-to-low) lateral osteotomies. The
overprojected ULCs were then used to create spreader flaps
to widen the internal nasal valves, fill the open roof, and
widen the previously pinched dorsal aesthetic lines.
Tip refinement began with cephalic fold-under flaps of
the lateral crura followed by intradomal tip sutures to reduce
tip width. The domes were temporarily stabilized in the
desired position by pinning the cartilages transversely with a
small-caliber needle until transdomal (=interdomal) suture
placement was complete. After strengthening the lateral
crura with cephalic fold-under flaps, spanning sutures were
used to reduce crural flaring without risking iatrogenic col-
lapse. Finally, the residual septal cartilage was finely diced
and injected beneath the skin flap (via the marginal incisions
after closing the columellar incision) to smooth and refine
the outer nasal contour (. Fig. 5.16).
5.2 · Case Studies

228
5
.
. Fig. 5.16  (a) Preparation of
free diced cartilage (FDC). (b)
Application of FDC. (c) Pre- and
post augmentation with FDC,
device for FDC application. (d–f)
Hump reduction with
compound technique and
covering the dorsum with FDC
(Front view, profile view, base
view pre-op/post-op.)
a
b

Chapter 5 · Primary Reduction of the Dorsum

229
5
.
. Fig. 5.16  (continued)
d
c
5.2 · Case Studies

230
5
e
f
.
. Fig. 5.16  (continued)

Chapter 5 · Primary Reduction of the Dorsum

231
5
5.2.3 Case 3: Major Reduction
for Rhinomegaly with Chisel Combined
with Lateral Sliding Technique
for Deprojection of the Tip
A 26-year-old male presented with a severely oversized nose.
Profile examination revealed a substantially overprojected
dorsum, an overly obtuse nasolabial angle, and a prominent
anterior nasal spine (ANS). Frontal examination revealed
deviation of the nasal axis to the right side with asymmetrical
aesthetic dorsal lines in an hourglass configuration. The tip
was also bulbous and overly wide.
Using the open rhinoplasty approach, the nasolabial
angle was reduced by trimming the caudal septum and
resecting a portion of the ANS. The M depressor septi was
released and partially resected. The dorsum was then lowered
using a component technique (with resection of 8  mm of
dorsal septum), and the bony pyramid was reconfigured
using paramedian and percutaneous transverse and low-to-­
low osteotomies. Tip deprojection and rotation were accom-
plished using a lateral crural overlap technique combined
with a tongue-in-groove setback. A shield graft combined
with spanning sutures and a posterior sling were used for tip
contouring and stabilization (. Fig. 5.17).
a
b
.
. Fig. 5.17  (a) Cephalic trim,
tongue-in-groove setback. (b, c)
Lateral sliding technique for
deprojecting the tip. (d–f)
Reduction for rhinoplasty in a
rhinomegaly (d, front view; e,
profile; f, base view pre-op/
postop.)
5.2 · Case Studies

232
5
d
c
.
. Fig. 5.17  (continued)

Chapter 5 · Primary Reduction of the Dorsum

233
5
e
f
.
. Fig. 5.17  (continued)
5.2 · Case Studies

234
5
5.2.4 Case 4: Lowering the Dorsum
Combined with Extracorporeal Septal
Reconstruction
A 20-year-old male presented with an oversized nose and
severe septal deformity. Examination revealed a long, narrow,
and overprojected dorsum with an obtuse (85°) nasolabial
angle. Protruding ears were also observed and were corrected
simultaneously. Using the open rhinoplasty approach, the sep-
tum was removed. To create a straight neoseptum, the septal
partition was rotated 90° counterclockwise, and the deformed
caudal septum was resected and used for bilateral spreader
graft placement. For additional widening of the pinched inter-
nal valves, spreader flaps were also used in addition to spreader
grafts. After component reduction of the dorsum and reinser-
tion of the neoseptum, spreader flaps fashioned from the over-
projected ULCs were sewn to the spreader grafts, and osseous
suture fixation was performed at the nasal bones and ANS. The
tip was then deprojected and rotated cranially using the lateral
crural overlay technique, thereby also reducing nasal length.
Morselized septal cartilage grafts were then used to augment
both soft-tissue facets (. Fig. 5.18).
.
. Fig. 5.18  (a) Lowering the
dorsum combined with
extracorporeal septal
reconstruction and spreader
flaps (b–d) Front view, profile
view, base view pre-op/post-op
a
b

Chapter 5 · Primary Reduction of the Dorsum

235
5
d
c
.
. Fig. 5.18  (continued)
5.2 · Case Studies

236
5
5.2.5 Case 5: Lowering the Dorsum
Plus Spreader Flaps
Technique was as follows. In the thin-skinned nose, there
is a greater risk of skeletal irregularities becoming visible
through the overlying skin. This problem is best prevented
by avoiding imperfections in the skeletal framework.
However, when minor irregularities are unavoidable, cam-
ouflage of the skeletal imperfections with an onlay of allo-
genic fascia lata will typically result in a smooth and even
outer nasal contour.
This fascia graft is rehydrated in antibiotic solution before
the final thickness can be determined. It has an excellent
structure with parallel collagen fibers and can be used as a
multilayered onlay graft.
A 22-year-old female presented with an overprojected
dorsum, a wide and bulky nasal tip, asymmetry of the
nostrils, an overly wide columella, and very thin nasal
skin.
Using the open rhinoplasty approach, the dorsum was
lowered using the component technique in which each
skeletal element was resected individually. After trim-
ming the dorsal septum and upper lateral cartilage, the
middle vault was reconstructed with spreader grafts har-
vested from the quadrangular septum. Because of unusu-
ally thin lower lateral cartilages, a lateral crural fold-under
flap was used to add strength to the naturally weak lower
lateral cartilages. For better tip contour, an integrated
shield graft with rounded edges was sutured to the infratip
lobule. Alar rim grafts were also placed to improve the
alar rim contour, but asymmetry of the alar base could
not be fully eliminated. The newly shaped tip and the alae
were then covered with a layer of allogenic fascia lata
(. Fig. 5.19).

Chapter 5 · Primary Reduction of the Dorsum

237
5
.
. Fig. 5.19  (a) Covering the tip
in a thin-skinned patient with
allogenic fascia. (b) Applying of
rim grafts and shield graft. (c–e)
Front view, profile view, base
view pre-op/post-op
a
b
5.2 · Case Studies

238
5
c
d
.
. Fig. 5.19  (continued)

Chapter 5 · Primary Reduction of the Dorsum

239
5
e
.
. Fig. 5.19  (continued)
5.2 · Case Studies

240
5
5.2.6 Case 6: Reduction for Rhinomegaly
Combined with Extracorporeal Septal
Reconstruction
A 16-year-old boy presented with a large dorsal hump, a
severely deviated nose, and nasal airway obstruction. On
profile view, the nose was overly long with an acute nasola-
bial angle. From the base view, nostril asymmetry and an
overly wide tip were observed. The anterior border of the
septum was also subluxed into the left vestibule. Endonasally,
a severely deviated septum resulting from traumatic fracture
and dislocation of the septal cartilage was also found. Because
of the severity of the septal deformity, an extracorporeal
reconstruction was required.
After separating the upper lateral cartilages and removing
the entire septum en bloc, the specimen was turned 90°. In this
manner, the bony cartilaginous junction, which has adequate
length to maintain the existing dorsal length, can be used for
dorsal reconstruction, and the new caudal septum is created
from the previous dorsal septum. Spreader grafts were
­harvested from unused (deviated) segments of the original
specimen and sutured to the neodorsum. Spreader grafts are a
prerequisite for long-lasting correction of the crooked nose.
Before removing the septum for extracorporeal reconstruc-
tion, the upper lateral cartilages and the bony dorsum are first
reduced by the component technique, which we now prefer
over the composite method. In this manner, the septal parti-
tion remains fully intact to provide maximum tissue for the
cartilaginous reconstruction. Because this patient had rela-
tively short nasal bones, the neoseptum could only be reat-
tached to the upper lateral cartilages above and to the anterior
spine below after creating two transverse drill holes in the
nasal spine. The overprojected tip was reduced using the lat-
eral sliding technique, while the nostril asymmetry, excessive
nasal length, and tip ptosis were all corrected using the tongue-
in-groove technique: the medial crura were ­retrodisplaced
and deprojected and then sutured to the new caudal septum
with multiple transseptal sutures. The dorsum was covered
with a single layer of allogenic fascia lata. The tip itself was
contoured by transdomal and spanning sutures (. Fig. 5.20).

Chapter 5 · Primary Reduction of the Dorsum

241
5
.
. Fig. 5.20  (a–b) Reduction for
rhinomegaly combined with
extracorporeal septal
reconstruction (c-e) Front
view, profile view, base view
pre-op/post-op
a
b
5.2 · Case Studies

242
5
c
d
.
. Fig. 5.20  (continued)

Chapter 5 · Primary Reduction of the Dorsum