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244
5
5.2.7 Case 7: Widening of Internal Valves
with Spreader Flaps
The technique of spreader flaps was used. Spreader flaps have
three main goals: widening of the internal nasal valves,
­creating a smooth dorsum, and creating attractive dorsal aes-
thetic lines.
After separating the ULC from the septum and resecting
the cartilaginous hump, attachments of the ULC are dis-
sected from the undersurface of the nasal bones for better
mobilization. The ULCs are then invaginated (i.e., folded
inward with toothed forceps) and then sutured flush with the
new dorsal septum. Spreader flaps must encompass the
K-area to avoid an open roof deformity.
A 24-year-old female presented for surgical treatment
with a severe septal deformity. Examination revealed dis-
placement of the caudal septum into the right nasal vestibule
and a narrow and overly high cartilaginous dorsum consis-
tent with a tension-nose deformity. Additionally, the nasal
skin was very thin, and the nasal cartilages were unusually
weak. On profile examination, the nasolabial angle was also
overly obtuse, in part due to the tension effect. Endonasal
examination revealed bilateral nasal valve collapse.
Using the external rhinoplasty approach, the base of the
caudal septum was trimmed and sutured in the midline (via
ANS drill holes) after trimming the nasal spine to deepen the
nasolabial angle. The dorsum was then lowered using the
component technique in which the ULCs were individually
separated from the dorsal septum. However, instead of trim-
ming the ULCs, they were used for spreader flaps to widen
the nasal dorsum and eliminate pinching of the internal nasal
valves. Care was taken to suture the spreader flaps loosely in
order to optimize dorsal width and valve patency. Tip contour
was enhanced by first strengthening the lateral crura using
cephalic fold-under flaps. After placement of a columellar
strut graft, spanning sutures and a tip suspension suture with
an anterior sling were used for tip support, refinement, and
stabilization. Because of exceedingly thin nasal skin, the dor-
sum was then camouflaged using finely diced cartilage cov-
ered with a single layer of allogenic fascia lata (. Fig. 5.21).
.
. Fig. 5.21  (a) Widening of
internal valves using spreader
flaps (b–d) Front view, profile
view, base view pre-op/post-op
a

Chapter 5 · Primary Reduction of the Dorsum

245
5
b
c
.
. Fig. 5.21  (continued)
5.2 · Case Studies

246
5
d
.
. Fig. 5.21  (continued)

Chapter 5 · Primary Reduction of the Dorsum

247
5
5.2.8 Case 8: Overprojected Dorsum
Combined with Underprojected Tip
A 36-year-old woman presented with an overprojected dor-
sum, bulbous ptotic tip, and a narrow nasolabial angle. The
entire nose was canted to the right side as a result of deviation
of both the bony and cartilaginous vaults.
Using the open approach with an inverted-V incision, the
septum was released from the nasal spine, shortened at its base,
and fixed in the midline using a transverse drill hole through
the anterior nasal spine. The hump was resected using the com-
pound technique. Following hump reduction, the nasal dor-
sum was then narrowed and straightened using a Lindemann
fraise to perform the paramedian osteotomy and an unguarded
2-mm osteotome to perform the percutaneous low-to-low lat-
eral and transverse osteotomies. A tongue-in-groove technique
was used for increased tip rotation, and the lobule was refined
using a shield graft and transdomal sutures (. Fig. 5.22).
.
. Fig. 5.22  Overprojected dorsum combined with underprojected tip (a–b) increasing tip projection. (c-e) (Front view, profile view, base view
pre-op/post-op.)
a
b
c
5.2 · Case Studies

248
5
d
e
.
. Fig. 5.22  (continued)

Chapter 5 · Primary Reduction of the Dorsum

249
5
5.2.9 Case 9: Rhinomegaly: Reduction
Rhinoplasty Combined with
Extracorporeal Septal Reconstruction
A 19-year-old female presented for corrective surgery after
childhood nasal trauma. Examination revealed a long, ptotic,
and overprojected nose with a rounded tip and an acute
nasolabial angle. The nasal axis was also deviated to the left.
Endonasal examination revealed a severe septal deformity
obstructing the right nasal airway.
Using the open rhinoplasty approach, we removed the
entire septum and rotated it 90° so that the existing bony-
cartilaginous junction became the new nasal dorsum, and
the existing nasal dorsum replaced the deformed caudal sep-
tum. To maintain a straight neoseptum, bilateral spreader
grafts were applied and the new caudal septum was rein-
forced with a batten graft fashioned from septal cartilage. To
augment central tip support, a double-layered “sandwich”
graft fabricated from conchal cartilage was used as columellar
strut graft, and placed in front of the neoseptum. After lower-
ing the cartilaginous dorsum incrementally with scissors, the
bony dorsum was reduced with a chisel, and the nasal pyra-
mid was straightened with percutaneous low-to-low lateral
and transverse osteotomies. The neoseptum was replaced and
sutured to the nasal bones after creating osseous drill holes in
the upper/caudal aspect of the bony vault. Fixation was com-
pleted using horizontal mattress sutures to the upper lateral
cartilages (ULC) and transosseous (drill hole) fixation to the
anterior nasal spine (ANS).
For tip refinement, interdomal sutures and crural span-
ning sutures were first placed, followed by placement of a tip
suspension suture with posterior sling to suspend the tip
complex from the neoseptum. A nonintegrated shield graft
was placed for improved tip contour and projection, and
finely diced cartilage was used for final surface refinement
and smoothing (. Fig. 5.23).
.
. Fig. 5.23  (a–j) Extracorporeal septal reconstruction, double-layered conchal strut graft, tip contouring with shield graft, free diced cartilage
for final refinements. (k–m) Front view, profile view, base view pre-op/post-op
a
b
c
d
5.2 · Case Studies

250
5
g
i
j
h
e
f
.
. Fig. 5.23  (continued)

Chapter 5 · Primary Reduction of the Dorsum

251
5
k
l
.
. Fig. 5.23 
(continued)
5.2 · Case Studies

252
5
m
.
. Fig. 5.23 
(continued)

Chapter 5 · Primary Reduction of the Dorsum

253
5
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
A 27-year-old thin-skinned female presented with rhinomeg-
aly and an hourglass-shaped dorsum. The nasal tip was broad,
overprojected, and slightly ptotic.
Using an external rhinoplasty approach, extramucosal dis-
section was used to divide ULCs and denude the dorsal septum.
The dorsal septum was then lowered with scissor resection.
Next, the ULC attachments to the bony pyramid were released
in the area of planned hump resection using blunt dissection,
and the bony hump was resected with a sharp chisel. Owing
to the wide-open roof produced by hump removal, no medial
osteotomy was needed. After narrowing the bony pyramid
with low-to-low lateral and transverse osteotomies, the ULCs
were invaginated medially and used to form spreader flaps.
Mattress sutures were used to secure the flaps in the desired
position. The overprojected LLCs were then deprojected using
the lateral crural overlap (sliding) technique. After deprojec-
tion, the medial crura were displaced anteriorly and cranially,
and sutured to the caudal septum using the tongue-in-groove
technique to upwardly rotate the ptotic tip. Transdomal sutures
were applied near the cranial margin of the domes to maintain
satisfactory infratip divergence, and an extended shield graft
was used to augment the infratip lobule. Following placement
of bilateral alar rim grafts, finely diced septal cartilage was used
for final refinements and smoothing the dorsum.
For additional profile enhancement, augmentation genio-
plasty was also performed via a submental (extraoral)
approach using a medium anatomically shaped silicone chin
implant (MentorR) (. Fig. 5.24).
a
b
c
d
.
. Fig. 5.24  (a–h) Component hump reduction, percutaneous osteotomies, septal fixation to the ANS, spreader flaps, tip correction, FDC applica-
tion. (i–k) Front view, lateral view, base view pre-op/post-op
5.2 · Case Studies

254
5
e
f
g
h
i
.
. Fig. 5.24  (continued)

Chapter 5 · Primary Reduction of the Dorsum

255
5
j
k
.
. Fig. 5.24  (continued)
5.2 · Case Studies

256
5
5.2.11  Case 11: Reduction Rhinoplasty
Combined with Extracorporeal Septal
Reconstruction Plus Shortening
of the Nasal Spine
A 31-year-old male presented with rhinomegaly and a
severely deviated septum that led to a narrowing of the inter-
nal valve and airway obstruction. The tip was wide, overpro-
jected, and counterrotated. Using the external rhinoplasty
approach, the dorsum was lowered using the compound
technique with an en bloc hump resection. The severity of the
septal deformity also necessitated extracorporeal septal
reconstruction. However, because the septal deviation also
included the dorsal septum, the small residual framework
required spreader grafts from the deviated central septum for
adequate stabilization. In addition, by reducing the size of the
reimplanted L-strut, additional reduction in dorsal height
was achieved. Tip projection was reduced using a lateral slid-
ing technique, which also increased cephalic rotation. After
reinserting the neoseptum, dorsal height was partially
restored by reimplanting the composite dorsal hump after it
was contoured with a power drill. The modified composite
hump served as a full-length onlay graft, also augmenting the
underprojected nasion (. Fig. 5.25).
.
. Fig. 5.25  (a) Reduction
rhinoplasty combined with
extracorporeal septal
reconstruction plus
shortening of the nasal spine
(b–d) Front view, profile view,
base view pre-op/post-op
a
b

Chapter 5 · Primary Reduction of the Dorsum

257
5
c
d
.
. Fig. 5.25  (continued)
5.2 · Case Studies

258
5
5.2.12  Case 12: Overprojected Dorsum
and Overprojected Tip and Long Nose
A 32-year-old woman presented with rhinomegaly.
Additionally, the septum was deviated to the right, and the
left lower lateral cartilage (LLC) was malformed and prone to
dynamic collapse on inspiration. A broad columellar base
and asymmetry of the facial skeleton were also observed.
Using the open approach with extramucosal dissection,
the split technique was used to separate the upper lateral
cartilages and lower the cartilaginous dorsum. Owing to an
exceptionally large hump, bony reduction was first per-
formed with a flat chisel and then refined with a carbide
rasp. Following paramedian, low-to-low lateral, and
­transverse osteotomies, the protruding remnants of the
ULC were scored, folded inward, and sutured flush with the
newly resected cartilaginous dorsum. The cephalic portion
of the lower lateral cartilages was also folded under the lat-
eral crura (fold-under flap technique) in order to preserve
stiffness and facilitate further contouring with spanning
sutures. Cephalic rotation and deprojection of the tip were
achieved using the tongue-in-groove technique. To prevent
a groove between the medial crura, a small columellar strut
graft was used to fill the dead space and add additional
structural support. The flared footpods were partially
resected after trimming of the depressor muscle. Alar rim
grafts were also placed to optimize contour of the nostril
rims (. Fig. 5.26).

Chapter 5 · Primary Reduction of the Dorsum

259
5
.
. Fig. 5.26  (a–c)
Overprojected dorsum and
overprojected tip and long nose.
Front view, profile view, base
view pre-op/post-op
a
b
5.2 · Case Studies

260
5
c
.
. Fig. 5.26  (continued)

Chapter 5 · Primary Reduction of the Dorsum

261
5
5.2.13  Case 13: Dorsal Reduction Combined
with Chin Augmentation
The technique of chin augmentation was utilized. For opti-
mal profile harmony, a chin augmentation is sometimes
necessary. We prefer to perform chin augmentation through
the submental approach, with the incision about 1.0  cm
behind the submental crease. Using the extraoral approach,
implant positioning and soft-tissue coverage are enhanced
over the intraoral method. We also prefer using anatomi-
cally shaped silicone implants. The pocket is developed
using blind subperiosteal dissection and controlling the
instrument by palpating the tip of the elevator. Pocket size
should be approximately the same size as the implant, and
bilateral sutures are placed through mandibular drill holes
for stabilization.
A 21-year-old female presented complaining of an unattract-
ive facial profile. Profile examination revealed a prominent dor-
sal hump exacerbated by an underprojected chin. The occlusion
was normal. On frontal view, the dorsal aesthetic lines were nar-
row and uneven. A seagull deformity was present on basal view.
Following hump reduction using the open rhinoplasty
approach, spreader grafts were used to widen the narrow inter-
nal nasal valves and straighten the crooked dorsum. For elimi-
nation of the seagull deformity, the LLCs were first dissected off
the underlying vestibular skin while keeping the perichon-
drium attached. The cephalic margin was then folded under the
lateral crus for improved support and contour, and spanning
sutures were added for additional contour enhancement. To
create a more harmonious profile, chin augmentation was per-
formed using a large, anatomically shaped silicone prosthesis
inserted through the extraoral submental approach (. Fig. 5.27).
5.2 · Case Studies

262
5
.
. Fig. 5.27  Dorsal reduction
combined with chin
augmentation. (a–b) Spreader
grafts and augmentation of the
soft triangle with morselized
cartilage. (c–e) Front view, lateral
view, base view pre-op/post-op
a
b
c

Chapter 5 · Primary Reduction of the Dorsum

263
5
d
e
.
. Fig. 5.27  (continued)
5.2 · Case Studies

264
5
Suggested Reading
Cakmak O.  Crushed cartilge grafts: is overcorrection necessary? Arch
Facial Plast Surg. 2008;10(6):428.
Cakmak O, Bircan S, Buyuklu F, Tuncer I, Dal T, Ozluoglu LN. Viability of
crushed and diced cartilage grafts: a study in rabbits. Arch Facial Plast
Surg. 2005;7(1):21–6.
Daniel RK. Mastering Rhinoplasty: a comprehensive Atlas of surgical tech-
niques with integrated video clips. Heidelberg: Springer; 2010.
Gruber RP, Peck GC. Rhinoplasty: state of the art. St. Louis: Mosby-Year Book; 1993.
Gruber RP, Perkins SW. Humpectomy and spreader flaps. Clin Plast Surg.
2010;37(2):285–91.
Gruber RP, Park E, Newman J, et al. The spreader flap in primary rhino-
plasty. Plast Reconst Surg. 2007;119(6):1903–10.
Gunter JP, Rohrich RJ, Adams WP. Dallas rhinoplasty: nasal surgery by the
masters. St. Louis: Quality Medical Publishing; 2002.
Guyuron B. Rhinoplasty. New York: Elsvier; 2012. p. 307–9.
Kovacevic M, Wurm J. Spreader flaps for middle vault contour and stabili-
sation. Facial Plast Surg Clin North Am. 2015;23(1):1–9.
Pirsig W, Fischer P. Behaviour of growing septal cartilage after autoge-
nous transplantation into the retroauricular region (author’s
transl). [Article in German]. Laryngol Rhinol Otol (Stuttg).
1982;61:115–9.
Rohrich RJ, Muzzafar AR, Janis JE. Component dorsal hump reduction: the
importance of maintaining dorsal aesthetic lines in rhinoplasty. Plast
Reconstr Surg. 2004;114(5):1298–308.
Sykes JM, Tapias V, Kim JE. Managment of the nasal dorsum. Facial Plast
Surg. 2011;27:192–202.

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© Springer International Publishing AG 2018
W. Gubisch, Mastering Advanced Rhinoplasty,
6
Secondary Correction of the
Dorsum Including Polly-Beak
Deformity
6.1
Surgical Principles – 266
6.2
Treatment of the Undersupported Nasal Tip – 268
6.3
Case Studies – 278
6.3.1
Case 1: Polly-Beak Deformity with Tip Ptosis
and Deviated Nose in a Thin-Skinned Patient – 278
6.3.2
Case 2: Complex Deformity with Polly-Beak Parrot Beak
from Incomplete Hump Reduction – 281
6.3.3
Case 3: Polly-Beak Deformity Following Septal Overresection
and Increased Scarring – 285
6.3.4
Case 4: Inverted-V Deformity Combined with Underresected
Dorsum – 292
6.3.5
Case 5: Inverted-V Deformity Combined
with Polly-Beak Deformity – 297
6.3.6
Case 6: Insufficient Tip Support with Retracted Columella – 300
6.3.7
Case 7: Underresected and Overprojected Dorsal Septum
with Underprojected Tip (Sheep’s Nose Deformity) – 303
6.3.8
Case 8: Irregular Overprojected Dorsum with Overresected
Septum – 307
6.3.9
Case 9: C-Shaped Tension-Nose Deformity with Long,
Displaced Septum – 310
6.3.10
Case 10: Polly-Beak Deformity in a Short Nose – 313
6.3.11
Case 11: Polly-Beak Deformity After Total Resection of the LLC
in a Thick-Skinned Patient with Bad Scarring – 316
6.3.12
Case 12: Irregular, Overprojected Dorsum with Ptotic Nasal Tip
and Severe Septal Deformity – 321
6.3.13
Case 13: Overresection of the Dorsum with Saddle-Nose
Deformity Combined with Inverted-V and Polly-Beak Deformity – 325
6.3.14
Case 14: Overresected Dorsum Combined with Polly-Beak
Deformity – 328
6.3.15
Case 15: Overresected and Deviated Dorsum – 331

Suggested Reading – 336

266
6
6.1
Surgical Principles
The most common cosmetic profile deformity in secondary
rhinoplasty is irregularity of the nasal dorsum. Dorsal irregu-
larities can be minor or major and can arise from overresec-
tion, underresection, or insufficient skeletal camouflage. In
the overresected dorsum, restoration requires replacement
grafting similar to treatment of a saddle-nose deformity.
Conversely, the underresected dorsum merely needs removal
of the overprojected segment, and in minor cases this may be
accomplished with a sharp rasp or power drill (. Fig. 6.1).
Another common postsurgical dorsal irregularity is the
polly-beak deformity. In this deformity, the cartilaginous
dorsum represents the highest point in the nasal profile, and
there are a wide variety of underlying causes for this kind of
deformity. According to Foda, postoperative tip droop is the
most common cause of the polly-beak deformity, but the
deformity may also arise from overresection of the bony dor-
sum, underresection of the cartilaginous dorsum, or scar-­
mediated thickening of the supratip skin where the soft
tissues are comparatively thick. Postoperative tip droop
occurs more often with the closed rhinoplasty approach,
because many surgeons fail to adequately compensate for the
fact that ligamentous soft-tissue support mechanisms are dis-
rupted during exposure of the tip cartilages. Various tech-
niques can be used to reconstitute disrupted tip support,
including columellar strut graft placement, the tongue-in-­
groove technique, or the application of tip suspension sutures.
Another cause of compromised tip support and loss of tip
projection is overresection. Similarly, overresection of the
lower lateral cartilages (LLCs) may also reduce tip support,
and this commonly results from misguided attempts to cre-
ate a more delicate tip using only extended cartilage resec-
tion. In addition to loss of tip support, overresection of the
LLCs can also produce unsightly deformities of the ala and
nasal tip. Combined overresection of the LLCs and anterior
septum can also result in a multifaceted deformity of even
greater magnitude.
.
. Fig. 6.1  (a–c) Motor drill for
correcting bony irregularities
a

Chapter 6 · Secondary Correction of the Dorsum Including Polly-Beak Deformity

267
6
c
b
.
. Fig. 6.1  (continued)
6.1 · Surgical Principles

268
6
6.2
Treatment of the Undersupported
Nasal Tip
Treatment of the poorly supported nasal tip depends upon
identifying and eliminating the underlying root cause.
Therefore, a careful surgical analysis is paramount, and
removal of overlying scar tissue is necessary before the true
etiology of tip droop can be correctly identified. In summary,
postsurgical tip droop may result from a variety of causes,
including inadequate ligamentous support, weak medial
crura, overresection of the caudal septum, and/or overresec-
tion of the LLCs. Frequently postsurgical tip droop is also
produced by more than one cause.
In the case of inadequate ligamentous support to the
medial crura, a columellar strut graft can be highly effective
at restoring lost tip support and projection. Donor graft
material is preferentially harvested from the septum, since it
is well suited to strut grafting and easy to harvest (. Fig. 6.2).
Although a large portion of the quadrangular septum may
have already been removed in secondary cases, frequently
the long cartilaginous “tail” of the quadrangular septum may
still be available for graft harvest. We have found that this
portion of the quadrangular cartilage makes an ideal colu-
mellar strut graft. However, if surplus septal cartilage is
unavailable, cartilage from the concha cymba can be used for
creation of a “sandwich”-type columellar strut graft
(. Fig.  6.3). The advantage of the conchal graft is derived
from suturing two reciprocally curved opposed segments
together to create a single, straight, and stable strut graft that
will resist warping over time. Usually the concha cymba pro-
vides adequate graft length and can be harvested from the
anterior approach to include the posterior perichondrium.
The cartilage can be divided along its long axis (while keep-
ing the perichondrium intact) and folded upon itself. A mod-
ified Aiach clamp is then used to immobilize the bivalved
cartilage halves during suture fixation to create the double-
layered conchal sandwich (. Fig. 6.4). If a longer graft is nec-
essary, it can be created by harvesting larger portions of the
conchal bowl or by suturing both conchae together
(. Fig. 6.5). When necessary, rib cartilage can also be used for
columellar strut grafting. However, in the past we rarely used
rib grafts, not only because of the risk of warping but also
because suture fixation with transseptal mattress sutures
often leads to infection, which can be avoided when using
auricular grafts. The differences in susceptibility to infection
may be explained by the presence of intact perichondrium,
which is absent from carved rib grafts. These days, we use
more and more rib grafts after developing instruments for
easier harvesting (Rollin Daniel at Medicon), using the ninth
or tenth rib instead of the sixth rib, which is quicker to dis-
sect and yields more firm cartilage in revision cases in which
septal and conchal cartilage have already been used. Further,
our actual concept includes a final touch-up with paste-like
free diced cartilage (FDC).
Inadequate tip support and nasal tip ptosis can also result
from overly weak medial crura. When tip ptosis occurs in the
presence of an overly long septum, the tongue-in-groove
technique can be used to suspend the weak medial crura and
correct the drooping nasal tip (. Fig. 6.6). By suturing the
medial crura to the anterior edge of the overprotruding cau-
dal septum, the tongue-in-groove technique restores tip pro-
jection, rotation, and support while simultaneously reducing
excessive columellar protrusion.
In secondary cases, tip ptosis often results from previous
overresection of the lower lateral cartilages. Treatment of
overresected tip cartilage inevitably involves cartilage aug-
mentation grafting, and various options are available for
reconstruction. In general, we prefer using septal cartilage
because of its favorable biomechanical characteristics, but rib
or conchal cartilage can also be used when surplus septal car-
tilage is unavailable. Preoperative planning is essential to
maximize utilization of limited septal graft material, espe-
cially when multiple grafts are needed (7 see Fig. 6.2), and the
maximum amount of cartilage is harvested as a single piece
to permit the greatest flexibility in treatment planning. When
available, residual septal cartilage remnants should be placed
back into the septum to minimize unwanted movement of
the donor site mucosa. In cases in which donor septal carti-
lage has been depleted, our next choice is rib cartilage graft
material harvested from the 9th, 10th, or 11th rib through a
small horizontal incision. Despite the donor site morbidity
associated with rib graft harvest, we prefer rib cartilage over
conchal cartilage because it is easily sculpted with a motor-­
driven fraise to produce thin and delicate lower lateral carti-
lage replacement grafts.
Regardless of the donor source, long, thin, and flexible
cartilage strips are needed to repair damaged or missing seg-
ments of the overresected LLCs, and we employ various tech-
niques, depending on the status of the residual framework. In
every case we first assemble the reconstructed framework
with small needles before securing the grafts with 6-0 nylon
sutures.
Previously we used nylon sutures for permanent fixation
of all tissue grafts. However, we occasionally observed minor
suture abscess formation probably caused by foreign-body
reaction of the nonresorbable suture material. For that rea-
son, we have since switched to resorbable 5-0 or 6-0
polydioxanone (PDS) suture material and have subsequently
noticed a significant reduction in the incidence of suture
abscess formation, although without apparent change in
graft stability.
In thin-skinned patients, we cover the reconstructed
domes with onlay grafts of fascia or soft tissue to prevent vis-
ible contour irregularities (7 see Fig. 6.13). When the residual
LLC framework is missing large portions of both the lateral
and intermediate crura, we employ a graft bending technique
(. Fig. 6.7) in which the entire lateral crus, dome unit, and
intermediate crus are simultaneously reconstructed using a
single anatomically shaped replacement graft. To achieve
adequate bending at the nasal dome, autologous septal or rib
cartilage must be carefully thinned at the tip-defining point
using a cylinder-shaped, motorized diamond fraise
(. Fig. 6.8). Although thinning can also be performed with a
scalpel, it is difficult to achieve the uniform and precise

Chapter 6 · Secondary Correction of the Dorsum Including Polly-Beak Deformity

269
6
­thinning required to prevent fracture of the graft. In cases
where adequate bending cannot be achieved with thinning
alone, we use a scoring technique in which the domes are
also carefully scored to attain additional flexibility (. Fig. 6.9).
However, in some cases, such as partially calcified rib carti-
lage, the graft material is overly brittle, and through-and-
through fractures of the tip-defining point cannot be avoided.
In this situation, the fractured graft resembles a vertically
divided alar cartilage in which the lateral and intermediate
crura are divided at the tip-defining point. When such frac-
tures occur, we employ a dome division technique in which
the opposite dome is divided for symmetry, and the graft
edges are reapproximated with horizontal mattress sutures
(. Fig. 6.10). Alternatively, if a thick columellar strut graft is
available, we use a split graft technique in which a sagittal
split is created in the distal end of the strut to permit simulta-
neous reconstruction of the columella and infratip with only
a single strut graft (. Fig. 6.11). Finally, when tissue replace-
ment is confined to the lateral crus, we use a batten graft
technique to reconstruct deformed or missing segments of
the lateral crus (. Fig. 6.12). Alternatively, when the crus is
severely deformed or absent, we prefer lateral crural strut
grafts, which extend farther laterally than batten grafts to bet-
ter restore support and contour to the alae. Only when the
patient refuses the use of rib cartilage do we resort to conchal
cartilage. Our experience indicates that conchal cartilage is
the least desirable graft material owing to its predetermined
shape, which is often difficult to modify with sutures or other
techniques described earlier. After reconstruction of the car-
tilaginous tip framework, we may cover the cartilage with
soft-tissue grafts for camouflaging (. Fig. 6.13), but this tech-
nique has been mostly replaced recently by using free diced
cartilage (FDC).
In all cases of nasal tip reconstruction, it is essential to
reunite the newly reconstructed framework with the carti-
laginous dorsum using long-lasting but resorbable suture
material such as PDS fixation sutures. Two main types of sus-
pension suture are used for this purpose: a combination of
spanning and suspension suture (. Fig. 6.14) and a simple
sling-type suspension suture (. Figs. 6.15 and 6.16). Although
elimination of lateral crural flaring and tip suspension are
accomplished simultaneously with the combination suture,
this technique is contraindicated in weak cartilage, since an
unsightly concave lateral crural deformity usually results.
However, when the reconstructed crural cartilages have ade-
quate rigidity, as they most often do following skeletal recon-
struction, the combination suture technique is preferred.
Placement of the combination suture is a two-step process in
which the suture first is passed through both lateral crura in
the manner of a standard (bilateral) spanning suture to elim-
inate crural flaring and then is knotted to prevent further
crural movement. The suture is then passed through the dor-
sal septum, tightened until the desired degree of tip suspen-
sion is established, and then knotted a second time to
complete the suspension (7 see Fig. 6.14).
When the lateral crura do not require suture modifica-
tion, a simple (buried) suspension suture is preferred.
However, unlike the combination suture, which uses both
lateral crura as suspension points, the simple suture uses only
the columella for suspension. To prevent exposure of the
nonabsorbable suture material, the stitch must be buried
beneath the overlying vestibular skin and the medial crura
using a cannulation technique. In the first step, a permanent
suture is sewn to the caudal septum at the designated upper
suspension point. Next, a second suspension point is selected
along the infratip lobule that is oriented to produce the
desired profile configuration. A small hollow-bore needle is
then inserted at the columellar suspension point and passed
between the vestibular skin and medial crus to the desig-
nated fixation point on the dorsal septum. One end of the
suspension suture is then threaded retrograde through the
needle until it emerges from the opposite end. The needle is
then removed and reinserted at the equivalent point on the
opposite side of the columella to permit antegrade passage of
the suture back to the septal fixation point, where it is knot-
ted and tied. In this manner, the knot is buried internally
within the membranous septal pocket, where it is neither vis-
ible nor palpable. We refer to this configuration as a simple
suspension suture with posterior sling (7 see Fig.  6.15).
Alternatively, both ends of the suspension suture can be
passed anteriorly and tied over the columella—the so-called
tip suspension suture with an anterior sling. Although this
placement is easier, knot placement may result in a visible
and/or palpable irregularity of the columella in thin-skinned
patients (7 see Fig. 6.16). The advantage of this type of sus-
pension suture is the exact positioning of the tip after flipping
back the flap.
When revising the overresected nasal tip, skin thickness
often becomes an important factor in treatment planning. In
dealing with the thick-skinned nose, it is generally preferable
to enlarge the skeletal framework as much as cosmetic toler-
ance will allow, thereby stretching the overlying soft-tissue
envelope and maximizing tip definition. However, aggressive
skin stretching is sometimes contraindicated because it occa-
sionally results in an unacceptably large nose. On the other
hand, attempting to create a smaller skeletal framework often
results in soft-tissue polly-beak formation, since the supratip
skin may fail to contract and give rise to dead space, excessive
subcutaneous fibrosis, and unwanted skin thickening. In this
uncommon scenario, a direct vertically oriented fusiform
excision of the supratip skin can be used to eliminate the
polly-beak deformity by excising the scarred skin and reduc-
ing the overall skin volume, what we call a “supratip excision”
(. Fig. 6.17). To prevent conspicuous scar formation, closure
is accomplished only with subcutaneous sutures, and in our
series of 36 patients, only three developed significant scar-
ring.
Unsuccessful treatment of a nasal hump deformity can
result in either overresection or underresection of the nasal
dorsum. In the overresected dorsum, treatment requires
­augmentation to restore lost height. Options for dorsal aug-
mentation vary according to the location of the deformity
and to the extent of overresection. For minor deformities,
tragal cartilage or fascial grafts, either autologous or ­allogenic,
6.2 · Treatment of the Undersupported Nasal Tip

270
6
are suitable. Cartilage remnants from cephalic resection of
the LLCs cartilages are also well suited to this purpose, but in
recent years our workhorse for such a problem has been
FDC, which is diced so finely that it can be pressed easily
through the tip of a tuberculin syringe and then used like a
paste. However, for medium-sized defects, greater volume is
required, and layered fascial grafts or cartilage harvested
from the septum or auricle can be used for this purpose
(. Fig.  6.18). When using septal cartilage, a flat graft with
beveled edges or a lightly morselized graft is preferred.
Crushed septal cartilage is not recommended because chon-
drocyte survival is unpredictable. When using conchal carti-
lage, a soft malleable graft is obtained by cross-hatching the
cartilage while leaving the opposite perichondrium fully
intact; layered conchal grafts are preferred for the correction
of saddle deformities confined to the cartilaginous dorsum.
Finally, major defects involving the entire nasal dorsum are
best reconstructed with DC-F grafts to create a uniform and
natural-­appearing restoration of the nasal bridge. However,
in the complete absence of underlying skeletal support, a
solid rib cartilage construct is first used to rebuild the L-strut,
and the DC-F graft is used merely as an onlay graft to camou-
flage the underlying solid construct.
.
. Fig. 6.3  Sandwich graft from the concha
.
. Fig. 6.2  Planning of the grafts

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6
.
. Fig. 6.4  Modified Aiach clamp creating a sandwich graft
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6
.
. Fig. 6.5  Septum reconstruction from both conchae

Chapter 6 · Secondary Correction of the Dorsum Including Polly-Beak Deformity

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6
.
. Fig. 6.6  Tongue-in-groove technique
.
. Fig. 6.7  Bending technique
.
. Fig. 6.8  Thinning the cartilage by a motor fraise
6.2 · Treatment of the Undersupported Nasal Tip

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6
.
. Fig. 6.9  Scoring technique
.
. Fig. 6.10  Dome division technique
.
. Fig. 6.11  Split technique
.
. Fig. 6.12  Batten graft technique

Chapter 6 · Secondary Correction of the Dorsum Including Polly-Beak Deformity

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6
a
b
.
. Fig. 6.13  (a, b) Covering the reconstructed framework with soft-tissue graft
.
. Fig. 6.14  Spanning suture combined with tip suspension suture
.
. Fig. 6.15  Posterior sling suspension suture
6.2 · Treatment of the Undersupported Nasal Tip

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6
a
b
.
. Fig. 6.16  (a, b) Anterior sling suspension suture
.
. Fig. 6.17  Supratip excision

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6
.
. Fig. 6.18  Material for augmentation
6.2 · Treatment of the Undersupported Nasal Tip

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6
6.3
Case Studies
6.3.1 Case 1: Polly-Beak Deformity with Tip
Ptosis and Deviated Nose in a
Thin-Skinned Patient
A 40-year-old female presents after an unsuccessful rhino-
plasty for possible revision surgery. Examination revealed
a polly-beak deformity with an asymmetric tip and left alar
pinching. The columella was oblique and the nostrils were also
asymmetric. The dorsum revealed an S-shaped deviation of
the nasal axis, irregular aesthetic dorsal lines, and numerous
skeletal irregularities visible through thin overlying nasal skin.
Using the external rhinoplasty approach, the tip carti-
lages were exposed leaving the subcutaneous scar attached
to the tip framework. After removal of the scar tissue,
overresected and deformed LLCs were observed. The ante-
rior septum was also overresected leaving only a weakened
­6 mm-wide septal framework that was displaced into the
left nasal vestibule.
The ninth rib was harvested and cut into long 10 mm
wide strips. The strips were then carefully thinned to a uni-
form thickness of 1.5 mm using a sculpture board (MediconR).
Bilateral strips were then sewn to the dorsal septum as extended
spreader grafts. The caudal septum was also reconstructed
using two additional strips as splinting grafts. The tip frame-
work was reconstructed using batten grafts and lateral crural
strut grafts to contour and strengthen the weak and overre-
sected LLCs. The LLCs were then sutured to the reinforced
double-layered rib graft which represented the new anterior
septal border. The tip was also contoured with intradomal and
interdomal sutures. Following partial closure of the skin flap,
free diced cartilage (FDC) was used as a malleable onlay to
obtain a smooth and even surface contour (. Fig. 6.19).
.
. Fig. 6.19  (a) Overresected and scarred LLCs. (b, c) Overresected and deformed anterior septum. (d) Dorsal reconstruction with extended
spreader grafts from rib. (e–g) Front view, profile view, base view pre-op/post-op
a
c
d
b

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6
e
f
.
. Fig. 6.19  (continued)
6.3 · Case Studies

280
6
g
.
. Fig. 6.19  (continued)

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6
6.3.2 Case 2: Complex Deformity
with Polly-Beak Parrot Beak
from Incomplete Hump Reduction
A 37-year-old male presented for revision rhinoplasty.
Examination revealed tip ptosis with a polly-beak deformity
and C-shaped deviation of the nose to the patient’s left side.
The bony pyramid remained overly wide, and palpation
revealed a depressed right nasal bone. In conjunction with a
severe anterior septal deviation, extracorporeal septal recon-
struction was deemed necessary to straighten the nose.
Using the external rhinoplasty approach, the nasal frame-
work was surgically degloved. After freeing the upper lateral
cartilages, C-shaped curvature of the anterior septum was
confirmed. Parasagittal medial osteotomies were performed,
and the entire septal partition was then removed. Owing to
flat segments of the posterior septum, the specimen could be
rotated 90° to create a flat septal L-strut for reinsertion.
Spreader grafts were added to the neo-L-strut in order to
reinforce the dorsal segment, and a batten graft was used to
straighten the caudal segment. The newly reconstructed
L-strut was then returned to the septal pocket for suture fixa-
tion. Cephalically the neoseptum was sutured to both the
nasal bone after placing drill holes and to the upper lateral
cartilages for dorsal fixation. Caudally, the spine was deb-
ulked on the left side to restore midline symmetry, and a
transverse drill hole was placed to allow suture fixation of the
caudal septum to the nasal spine.
Tip reconstruction was performed by resecting the
cephalic border of the left lateral crus and using the specimen
to augment the right lateral crus. A columellar strut graft was
added for tip support, and both transdomal and lateral crural
spanning sutures were used for tip refinement. A cap graft
was also used to increase tip projection, and the cap graft was
covered with allogenic fascia lata to prevent delayed graft vis-
ibility. Alar rim grafts fashioned from autologous (right) tra-
gal cartilage were also placed bilaterally. Tip support was
further enhanced using a tip suspension suture with a poste-
rior sling, and dorsal augmentation was achieved using four
layers of allogenic fascia lata (. Fig. 6.20).
.
. Fig. 6.20  (a–j) Reconstruction
after complex nasal deformity
with polly-beak from incomplete
hump reduction. (k–m) Front view,
profile view, base view
pre-op/post-op
a
c
e
f
d
b
6.3 · Case Studies

282
6
g
h
i
j
.
. Fig. 6.20  (continued)

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6
k
l
.
. Fig. 6.20  (continued)
6.3 · Case Studies

284
6
m
.
. Fig. 6.20  (continued)

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6.3.3 Case 3: Polly-Beak Deformity
Following Septal Overresection
and Increased Scarring
A 52-year-old female was seen for revision nasal surgery
20 years after primary rhinoplasty. Examination revealed an
asymmetrical nose with an overresected and pinched tip,
weak tip cartilages, a concave and overresected dorsum, and
leftward deviation of the septum.
After exploring the nose using the external rhinoplasty
approach, copious soft-tissue scarring was found covering
both tip cartilages. Upon removal of the scar tissue, a badly
damaged right lateral crus was revealed, and the left lateral
crus, while largely intact, was severely concave. The interme-
diate crura and medial crural footpods were also absent from
both sides. This patient with rhinoplasty 20 years ago had
destruction of the caudal framework, septal deviation to the
left, overresection of the dorsum with irregularities, a devi-
ated nose, and missing tip contouring with depressed alae.
After opening up the nose, we found large severe scars, and
after removing the scars, the right LLC was found to be
almost totally destroyed. On the left side, large parts had
been preserved, but there the shape was concave. The inter-
mediate crus was missing on both sides. Both foot plates
were absent.
In addition to the aforementioned alar cartilage deformi-
ties, a severe residual deformity of the nasal septum necessi-
tated extracorporeal septal reconstruction. Using the external
approach, the entire septal partition was removed. After
rotating the septal specimen by 90°, we obtained a straight
neo-L-strut that was reinforced with bilateral spreader grafts
along the dorsal margin and a batten graft along the caudal
septum. The bony pyramid was then mobilized with parasag-
ittal medial osteotomies and low-to-high lateral osteotomies.
The septal construct was then reinserted into the septal
pocket and sutured to the upper lateral cartilages and nasal
spine.
Tip reconstruction was then initiated by replacing the
absent intermediate crura using a split cartilage technique.
By cleaving a thick segment of septal cartilage, thin interme-
diate crural replacement grafts were created, bent, and inte-
grated into the residual LLC framework using a columellar
strut graft for support. Next, the concave left lateral crus was
flattened using a lateral crural strut graft, and the severely
damaged right lateral crus was reconstructed with an onlay
(batten-type) replacement graft. The rebuilt alar cartilages
were then further refined by a combination of transdomal
sutures, lateral crural spanning sutures, and tip suspension
sutures. After placement of an additional cartilage augmenta-
tion graft to the supratip, cartilage grafts to both soft trian-
gles, and bilateral alar rim grafts, the entire tip framework
was camouflaged with a soft-tissue onlay graft. The dorsum
was then covered with an allogenic fascia lata graft
(. Fig. 6.21).
6.3 · Case Studies

286
6
.
. Fig. 6.21  (a–b) Polly-beak
deformity following septal
overresection and increased
scarring. (c–d) Extracorporeal
septal reconstruction. (e–i) Tip
reconstruction. (j–l) Front view,
profile view, base view
pre-op/post-op
a
b

Chapter 6 · Secondary Correction of the Dorsum Including Polly-Beak Deformity

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6
c
d
.
. Fig. 6.21  (continued)
6.3 · Case Studies

288
6
e
f
.
. Fig. 6.21  (continued)

Chapter 6 · Secondary Correction of the Dorsum Including Polly-Beak Deformity

289
6
g
h
.
. Fig. 6.21  (continued)
6.3 · Case Studies

290
6
i
j
.
. Fig. 6.21  (continued)

Chapter 6 · Secondary Correction of the Dorsum Including Polly-Beak Deformity

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6
k
l
.
. Fig. 6.21  (continued)
6.3 · Case Studies

292
6
6.3.4 Case 4: Inverted-V Deformity Combined
with Underresected Dorsum
A 25-year-old female presented for revision rhinoplasty with
an oversized nose and a residual hump deformity. The nasal
tip was both overprojected and overrotated, producing an
obtuse nasolabial angle. From the front, the nose was canted
to the right with an inverted-V deformity and a pinched mid-
dle vault. In the profile a hump was seen, but the whole nose
seemed too big. That means that the tip was also overpro-
jected but at the same time overrotated, with a resulting
obtuse nasolabial angle. In the front view, the asymmetry and
irregularities of the dorsum became obvious related to an
inverted-V deformity as well as a collapsed cartilaginous
dorsum.
Using the external rhinoplasty approach, the residual
hump was lowered using the composite technique, and donor
septal cartilage was harvested from the quadrangular sep-
tum. Bilateral spreader grafts were placed to widen the
pinched upper lateral cartilages, eliminate the inverted-V
deformity, and straighten the nasal bridge. The tip was depro-
jected and counterrotated using a medial crura overlap tech-
nique combined with placement of a shield graft with
carefully beveled edges. Spanning sutures were used for fur-
ther refinement, and counterrotation was stabilized using a
tip suspension suture placed more caudally in an upside-­
down manner to pull the tip downward and in. Finally, the
dorsum was augmented with a full-length morselized septal
cartilage graft covered with an allogenic fascia lata onlay graft
(. Fig. 6.22).

Chapter 6 · Secondary Correction of the Dorsum Including Polly-Beak Deformity