Mastering Advanced Rhinoplasty

294
6
c
d
.
. Fig. 6.22  (continued)

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

295
6
.
. Fig. 6.22  (continued)
e
f
6.3 · Case Studies

296
6
g
.
. Fig. 6.22  (continued)

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

297
6
6.3.5 Case 5: Inverted-V Deformity
Combined with Polly-Beak Deformity
A 30-year-old female presented 10 years after primary septo-
rhinoplasty elsewhere with a polly-beak deformity, hanging
columella, inverted-V deformity, and asymmetrical nasal
bones. After degloving the nose using the external rhino-
plasty approach, the right lateral crus was found to be over-
resected, but the intermediate crus was still too large, creating
asymmetry of the lower lateral cartilages. To begin the recon-
struction, cartilage was harvested from the quadrangular
septum for extended spreader grafts, a columellar strut graft,
and an extended spreader graft. The left lower lateral carti-
lage was then trimmed, and the excised segment was used to
augment the overresected right LLC. Spanning sutures and
tip suspension sutures were used to refine and rotate the tip.
The extended shield graft was sutured into position and cov-
ered with allogenic fascia lata. The soft-tissue triangles were
augmented with small cartilage grafts, and the dorsum was
also covered with allogenic fascia lata (. Fig. 6.23).
.
. Fig. 6.23  (a–c) Reconstruction of the caudal framework. (d, e) Augmentation of the soft triangle. (f–h) Inverted-V deformity combined with
polly-beak deformity. Front view, profile view, base view pre-op/post-op
a
c
b
d
e
6.3 · Case Studies

298
6
g
f
.
. Fig. 6.23  (continued)

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

299
6
h
.
. Fig. 6.23  (continued)
6.3 · Case Studies

300
6
6.3.6 Case 6: Insufficient Tip Support
with Retracted Columella
A 35-year-old male presented for treatment of previous nasal
trauma after four unsuccessful attempts at surgical restora-
tion elsewhere. Examination revealed an overly wide nose
with a misshapen tip, a retracted columella, and asymmetri-
cal nostrils. Endonasal examination revealed an absent cau-
dal septum with severe deformity of the remaining
quadrangular septum, including unstructured remnants of a
previous rib graft.
Surgical exploration using the external rhinoplasty
approach revealed a previously placed strut graft fashioned
from rib cartilage. However, because the graft was misshapen,
malpositioned, and failing to support the tip, it was removed.
Additional misshapen fragments of rib were also encoun-
tered deeper in the septal partition contributing to airway
obstruction, and these were also removed. In order to
­reconstruct the missing L-strut, bilateral conchal grafts were
harvested and sewn together after placing the concavities
back-to-back. The cartilages were held with a modified Aiach
cartilage clamp while (parallel) running mattress-type
sutures were placed for fixation. This resulted in a flat,
straight, and rigid cartilaginous construct. After osteotomies
to narrow the bony vault, the newly created L-strut was
placed into the septal pocket and sutured to the upper lateral
cartilages and nasal spine for fixation. Additional support
was achieved by suturing the medial crura to the caudal bor-
der of the L-strut and by placement of a tip suspension suture.
Tip contouring was then achieved with spanning sutures.
Augmentation of the nasal dorsum was accomplished using a
DC-F graft. The DC-F graft was fashioned from a sleeve of
allogenic fascia lata filled with diced remnants of explanted
rib cartilage. This combined approach produced a well-­
supported tip with satisfactory columellar show and a straight
dorsum with improved dorsal aesthetic lines (. Fig. 6.24).

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

301
6
.
. Fig. 6.24  (a) Correction of insufficient tip support, retracted columella and low dorsum. (b–d) Front view, profile view, base view
pre-op/post-op
Septum reconstruction
from both conchae
Dorsum reconstruction
with DCF
a
b
6.3 · Case Studies

302
6
d
c
.
. Fig. 6.24  (continued)

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

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6
6.3.7 Case 7: Underresected
and Overprojected Dorsal Septum
with Underprojected Tip (Sheep’s Nose
Deformity)
A 51-year-old female presented for revision surgery after two
previous failed surgeries elsewhere. Examination revealed a
deviated nose with overresected nasal bones and a severely
malpositioned central ethmoid complex. The cartilaginous
septum was overprojected, and the upper lateral cartilages
were both collapsed, resulting in internal valve obstruction.
Overprojection of the anterior septal angle in combination
with underprojection of the nasal tip resulted in a sheep’s
nose deformity on profile view.
Using the external rhinoplasty approach, the nose was
opened, revealing a severe deformity of the central septum
with dislocation of the caudal septum from the nasal spine.
However, the L-strut was otherwise normal. After ­detaching
the spine with an osteotomy and fixating it in the midline
with microplates and microscrews, the caudal septum was
sutured back to the nasal spine for secure fixation. Next,
the dorsum was lowered in a composite fashion, and the en
bloc specimen was reshaped using a cylindrical fraise.
Bilateral extended spreader grafts were sutured in place to
widen the pinched middle vault, open the collapsed inter-
nal valves, and buttress a columellar strut needed to
increase nasal length. The modified and slightly smaller
composite hump was then reinserted to produce a smooth
and straight dorsal profile. Using suture techniques, LLC
projection was increased, and a double-layered cap graft
was added for additional tip projection. The tip reconstruc-
tion was then covered with a single layer of allogenic fascia
lata. One year postrevision, the tip projection appeared
slightly too strong and prompted removal of the outermost
cap graft. A satisfactory profile was ultimately achieved
(. Fig. 6.25).
6.3 · Case Studies

304
6
.
. Fig. 6.25  (a) Correction of
Underresected and
overprojected dorsal septum
with underprojected tip
(sheep’s nose deformity). (b–d)
Front view, profile view, base
view pre-op/post-op. (e) Profile
view after revision
a
b

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

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6
c
d
.
. Fig. 6.25  (continued)
6.3 · Case Studies

306
6
e
.
. Fig. 6.25  (continued)

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

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6
6.3.8 Case 8: Irregular Overprojected
Dorsum with Overresected Septum
A 44-year-old female presented after two unsuccessful rhino-
plasties. Examination revealed a high radix with an irregular
and slightly overprojected dorsum and a round and amor-
phous nasal tip. The left nasal bone was depressed, and alar
retraction was present bilaterally.
Using the open rhinoplasty approach, the residual sep-
tum was found to be deformed, overresected, and embedded
in a dense mass of scar tissue. Correction was performed
using the extracorporeal approach in which the residual sep-
tum was removed and rotated by 90°, thereby creating a new
dorsum from the posterior bony septum. The bony neosep-
tum was then thinned and perforated with drill holes to facil-
itate suture fixation of spreader flaps fashioned from the
residual ULC.  The cephalic end of the newly fashioned
L-strut was secured to a small (dorsal) remnant of ethmoid
bone, and the base of the new caudal septum was sutured to
the perforated ANS. Residual portions of the quadrangular
septum were flattened with a cylindrical drill bit and used to
create a columellar strut and to splint the surgically weak-
ened caudal septum. The remnants of the right LLC were
reenforced with a thinned cartilage strip from the septum,
the weak right lateral crus was splinted with a septal batten
graft. Conchal cartilage was then used to create a shield graft,
and a spanning suture with combined posterior sling tip sus-
pension was used for tip contouring and stabilization. Free
diced cartilage created from the residual concha was used to
eliminate contour irregularities of the dorsum (. Fig. 6.26).
a
c
e
f
d
b
.
. Fig. 6.26  (a–i) Dorsal reconstruction with extracorporeal septal
reconstruction and tip reconstruction with septal cartilage in an irregular
overprojected dorsum with overresected septum and amorphous tip.
(j–l) Front view, profile view, base view pre-op/post-op
6.3 · Case Studies

308
6
j
g
h
i
.
. Fig. 6.26  (continued)

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

309
6
l
k
.
. Fig. 6.26  (continued)
6.3 · Case Studies

310
6
6.3.9 Case 9: C-Shaped Tension-Nose
Deformity with Long, Displaced
Septum
A 35-year-old male presented after previous rhinoplasty with
a tension-nose deformity, a narrow C-shaped dorsum, an
overly long nose, and a residual dorsal hump. Endonasal
examination revealed an overly long septum displaced to the
left of the anterior nasal spine.
Using the open approach, the caudal septum was trimmed
at its base and repositioned in the midline. After creation of
transverse drill holes in the anterior nasal spine, the caudal
septum was secured with nonabsorbable sutures. The dorsal
hump was then resected using the component technique, and
the overprojected LLCs were used for spreader flaps.
Paramedian osteotomies were created with a Lindemann drill
bit, and percutaneous transverse and low-to-low lateral oste-
otomies were used to reconfigure the bony pyramid. After
trimming the cephalic margin of the unusually thick LLCs, a
lateral crural overlap technique, combined with a medial cru-
ral setback, was used for deprojection of the nasal tip. Alar rim
grafts were placed for improved alar rim contour (. Fig. 6.27).
.
. Fig. 6.27  (a–b) Correction of
a C-shaped tension-nose
deformity with long, displaced
septum. (c–e) Front view, profile
view, base view pre-op/post-op
a
b

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

311
6
c
d
.
. Fig. 6.27  (continued)
6.3 · Case Studies

312
6
e
.
. Fig. 6.27  (continued)

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

313
6
6.3.10  Case 10: Polly-Beak Deformity
in a Short Nose
A 52-year-old female presented after two unsuccessful rhino-
plasties seeking revision surgery. According to the patient, a
silicone dorsal implant was placed during the first surgery
and was subsequently removed and replaced with conchal
cartilage. Profile examination revealed an overly short nose
with a severely obtuse nasolabial angle (130°) and a dorsal
hump that was unusually soft on palpation. From the front,
the nasal axis was C shaped and deviating to the patient’s
right side, and the bony pyramid was overly wide.
Additionally, the thick-skinned nasal tip was bulbous, and
the left alar rim was retracted. A conspicuous straight hori-
zontal columellar scar was also observed on basal view.
Using the open approach, we modified the columellar
incision to include a small inverted-V in order to prevent
retraction and visibility of the columellar scar. Upon explora-
tion of the dorsum, the hump was observed to be caused by
excessive soft-tissue scarring, and no conchal cartilage was
observed. Donor cartilage was then harvested from the sep-
tum with preservation of a 15-mm L-strut. The strong and
straight septal graft material was then subdivided into three
different grafts: a columellar strut graft and bilateral LLC
replacement grafts to replace missing tip cartilages. To recon-
struct the domes, the LLC replacement grafts were carefully
thinned using a cylindrical drill bit and then folded and
sutured to mimic natural dome cartilages. The grafts were
then sutured to the columellar strut graft medially and to the
scarred vestibular skin laterally. In addition to improving tip
contour, the LLC grafts also served to correct the left alar
retraction. Finally, after resecting the soft-tissue mass pro-
ducing the dorsal hump, the wide bony pyramid was nar-
rowed and straightened using (parasagittal) medial
osteotomies combined with percutaneous transverse and
(low-to-low) lateral osteotomies (. Fig. 6.28).
6.3 · Case Studies

314
6
a
b
c
d
e
.
. Fig. 6.28  (a–e) Correction of a polly-beak deformity in an overshorted nose. (f–h) Front view, profile view, base view pre-op/post-op

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

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6
g
f
.
. Fig. 6.28  (continued)
6.3 · Case Studies

316
6
6.3.11  Case 11: Polly-Beak Deformity
After Total Resection of the LLC
in a Thick-Skinned Patient with Bad
Scarring
The technique used was supratip excision. On rare occasions
a midline fusiform excision of supratip skin can be used to
help reduce skin envelope volume when there is a large
­discrepancy between the skeletal framework and an overly
large and thick skin envelope. By minimizing dead space in
the supratip, a well-defined supratip break point is created.
To avoid unsightly scarring of the supratip skin incision, clo-
sure is performed only in the subcuticular layer, and the
wound edges are approximated with adhesive strips.
A 20-year-old female presented for revision rhinoplasty
after previous cosmetic nasal surgery at age 15. Examination
revealed severe tip ptosis, a prominent polly-beak formation,
and deviation of the nasal axis to the patient’s left side. A con-
spicuous transcolumellar scar was also observed at the base
of the columella.
Using the malpositioned columellar scar for the open
approach, surgical exploration revealed near total resection
of both LLCs and replacement with fibrous scar tissue. Lack
of tip support resulted in severe tip ptosis. However, the
quadrangular septum was previously untouched, permitting
harvest of septal cartilage while preserving a 12-mm wide
L-strut. Donor septal cartilage was then used to create mul-
tiple cartilage grafts. The first graft was used to create a colu-
mellar strut graft, and both medial crural remnants were
sutured to the graft. Twin LLC replacement grafts were then
thinned using the cylindrical drill bit to facilitate folding and
suturing of the cartilage in order to create replacement domes
and lateral crura. The grafts were then sutured to the colu-
mellar strut graft centrally and to the vestibular skin laterally.
Intradomal sutures were then used for additional tip refine-
ment. Finally, the bony pyramid was narrowed and straight-
ened with medial, transverse, and lateral osteotomies.
After closure of the skin flap, the scarred and thickened
supratip skin failed to conform to the underlying skeletal
framework. Consequently, a full-thickness skin ellipse,
including the subcutaneous soft-tissue layer, was then
excised. Owing to the abundance of excess skin, the wound
edges approximated easily, necessitating only minimal suture
approximation of the subcutaneous layer (. Fig. 6.29).

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

317
6
a
b
c
d
.
. Fig. 6.29  (a–d) Correction of polly-beak deformity after total resection of the LLC in a thick-skinned patient with bad scarring 10 years follow
up. (e–g) Front view, profile view, base view pre-op/post-op 12 month. (f–j) Front view, profile view, base view one yr and 10 yr post-op
6.3 · Case Studies

318
6
e
f
.
. Fig. 6.29  (continued)

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

319
6
g
h
.
. Fig. 6.29  (continued)
6.3 · Case Studies

320
6
i
j
.
. Fig. 6.29  (continued)

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

321
6
6.3.12  Case 12: Irregular, Overprojected
Dorsum with Ptotic Nasal Tip
and Severe Septal Deformity
The technique consisted of extracorporeal septal reconstruc-
tion using a splinting graft created from ethmoid bone, dor-
sal augmentation with a DC-F graft, and lateral crural
contouring with horizontal mattress sutures.
A 43-year-old female presented for revision rhinoplasty.
Examination revealed an irregular and overprojected dor-
sum and a wide and ptotic nasal tip. Endonasal examination
revealed synechiae in the right nasal airway and a severe sep-
tal deformity.
Surgical exploration using the external rhinoplasty
approach revealed an irregular double-layered conchal graft
that had been removed from the nasal dorsum. The anterior
septum had been overresected, and the residual septum was
weak and misshapen. After parasagittal medial osteotomies
and fracturing of the ethmoid plate, the residual septum was
removed in its entirety. Previous lateral osteotomies had been
performed much too high on the bony side wall, necessitat-
ing narrowing of the bony pyramid with percutaneous
­transverse and (low-to-low) lateral osteotomies. A piece of
ethmoid bone was then thinned, perforated, and used to
splint the weak anterior septum after removing deformed
segments. A spreader graft was then applied on the opposite
side. After reimplanting the neoseptum, it was sutured to the
upper lateral cartilages (ULC). The base of the new caudal
septum was then trimmed to the desired height and sutured
to drill holes within the ANS. Tip support was augmented
using a columellar strut, and the concavity of the left lateral
crus was eliminated using horizontal mattress sutures. A
diced cartilage-fascia graft was constructed from deep tem-
poralis fascia and residual septal cartilage. The cephalic end
of the DC-F graft was sutured closed, and paired percutane-
ous guiding sutures were used to position the DC-F augmen-
tation graft on the nasal dorsum. After suturing the
columellar incision, the DC-F was molded to the desired
shape using digital pressure, and the excess diced cartilage
that was expressed from the DC-F graft was removed via suc-
tion through the marginal incisions. Finally, the dorsal con-
tour was stabilized with tape, the marginal incisions were
sutured closed, and quilting sutures were added to further
stabilize the neoseptum (. Fig. 6.30).
a
b
.
. Fig. 6.30  (a–b) Irregular,
overprojected dorsum with
ptotic nasal tip; severe septal
deformity with overresection of
the anterior border. (c–d)
Extracorporeal septal
reconstruction. (e) Tip
reconstruction and dorsal
augmentation with DC-F graft.
(f–h) Front view, profile view,
base view pre-op/post-op
6.3 · Case Studies

322
6
d
c
.
. Fig. 6.30  (continued)

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

323
6
f
e
.
. Fig. 6.30  (continued)
6.3 · Case Studies

324
6
h
g
.
. Fig. 6.30  (continued)

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

325
6
6.3.13  Case 13: Overresection of the Dorsum
with Saddle-Nose Deformity
Combined with Inverted-V
and Polly-Beak Deformity
The technique consisted of total reconstruction of the lower
nasal framework using rib cartilage and saddle-nose repair
using a DC-F graft.
A 52-year-old female presented after two unsuccessful
rhinoplasties for revision surgery. Examination of the dor-
sum revealed a severe saddle-nose deformity, deviation of the
nasal axis to the right side, and a depressed left nasal bone.
The tip was round with bilateral alar retraction (seagull
deformity). Endonasal examination revealed collapsed inter-
nal nasal valves.
Using the external rhinoplasty approach, exploration
revealed severe scarring and subtotal resection of both LLCs.
The anterior septum had been cut vertically, creating a sharp
angulated edge. The septal deformity was treated in situ by
shaving the deflection and splinting the residual cartilage
with a thin ethmoid splinting graft. Owing to depletion of
septal graft tissue, a 6-cm segment of the tenth rib was har-
vested for LLCs and dorsal reconstruction. Despite partial
calcification, the graft was cut vertically into multiple 1.5-­
mm thick strips. The widest strip of rib cartilage was then
used to create a columellar strut graft. The posterior edge of
the graft was sutured to the ANS in the midline. Two addi-
tional rib grafts were used as spreader grafts to straighten the
cartilaginous nasal axis, and the bony pyramid was straight-
ened with parasagittal medial osteotomies followed by per-
cutaneous transverse and low-to-low lateral osteotomies.
Additional narrow strips of rib cartilage were then thinned
using a cylindrical drill bit. However, upon attempting to fold
the partially calcified rib cartilage, a fracture occurred at the
neodome. Consequently, the contralateral graft was tran-
sected in the same location, and the corresponding segments
were then suture-approximated in the manner of a vertical
dome division. A shield graft was added for further
­stabilization and contour refinement. Finally, the remaining
cartilage was diced for creation of a DC-F graft fashioned
from allogenic fascia lata. After augmentation of the saddle
deformity with the DC-F graft, an additional layer of allo-
genic fascia lata was placed on the tip for additional augmen-
tation and smoothing (. Fig. 6.31).
6.3 · Case Studies

326
6
.
. Fig. 6.31  (a) Correction of
the overresected dorsum with
saddle-nose deformity,
combined with inverted-V and
polly-beak deformity. (b–d) Front
view, profile view, base view
pre-op/post-op
a
b

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

327
6
.
. Fig. 6.31  (continued)
c
d
6.3 · Case Studies

328
6
6.3.14  Case 14: Overresected Dorsum
Combined with Polly-Beak Deformity
A 27-year-old male presented after previous rhinoplasty with
an overresected dorsum and polly-beak deformity. Alar
depressions were present bilaterally from concave LLCs.
Endonasal examination also revealed a severe residual septal
deformity contributing to nasal obstruction.
Using the open approach, dissection was complicated by
severe surgical scarring and by a compound septal defor-
mity involving all three anatomic planes. Owing to severe
­deformity of the septum, an extracorporeal septal recon-
struction was required for correction. Straightening of the
dorsal L-strut was accomplished by scoring the deformed
cartilage and applying spreader grafts harvested from rib
cartilage. The caudal septum was reinforced with a batten
graft also fashioned from rib. After straightening the bony
pyramid with parasagittal medial and percutaneous low-to-
low lateral and transverse osteotomies, the neoseptum was
reimplanted and sutured to the ULC as well as to the nasal
bones after creating paired osseous drill holes. Similarly, the
caudal septum was also sutured to drill holes created within
the ANS, and the medial crura were sutured to the caudal
septum using a tongue-in-groove type fixation. After cor-
recting the lateral crural concavities with bilateral cephalic
fold-under flaps using the cephalic margin, a tip suspension
suture with an anterior sling was used to keep the infratip
lobule in position and thereby prevent tip ptosis. The dor-
sum was reconstructed using a DC-F constructed from
allogenic fascia lata filled with finely diced residual rib car-
tilage. Rim grafts were also placed to improve alar contour
(. Fig. 6.32).
a
b
c
.
. Fig. 6.32  (a–c) Correction of the overresected dorsum combined with polly-beak deformity by extracorporeal septal reconstruction. (d–f) Front
view, profile view, base view pre-op/post-op

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

329
6
d
e
.
. Fig. 6.32  (continued)
6.3 · Case Studies

330
6
f
.
. Fig. 6.32  (continued)

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

331
6
6.3.15  Case 15: Overresected and Deviated
Dorsum
A 38-year-old female presented with a deviated nose and an
overresected bony and cartilaginous dorsum after previous
rhinoplasty. The nostrils were asymmetrical owing to asym-
metry of the alae following a unilateral (right-sided) alar base
resection. Both alar rims were retracted, and endonasal
examination revealed a badly deformed nasal septum.
After opening the nose via the external approach, severe
scars were found covering a deformity and malposition of the
right lateral crus. Septal dissection revealed a weak caudal sep-
tum and deviation of the central septum. The deformed septal
segments were then harvested, including the adjacent perpen-
dicular plate. An 8.0-cm segment of the left tenth rib was also
harvested and split vertically into 1.5-mm thick strips. Two
strips were used as extended spreader grafts and sutured to the
residual dorsal septum for straightening and widening of the
internal nasal valve. A straight piece of septal cartilage was
used as a columellar strut graft, which was sutured to the
extended spreader grafts and to the ANS. After dissecting the
lateral crus from the vestibular skin, it was transposed to a
symmetrical position and contoured with a batten graft for
correction of the right alar retraction. The tip was contoured
using a transdomal suture and then covered with a soft-tissue
graft. On the left side, the alar retraction was treated with a
large alar rim graft. After partially closing the skin flap, free
diced cartilage (FDC) was used for smoothing and augment-
ing the dorsum. A V-to-Y plasty was performed on the right
side to further improve nostril symmetry (. Fig. 6.33).
6.3 · Case Studies

332
6
a
b
.
. Fig. 6.33  (a–d) Reconstruction
of overresected and deviated
dorsum. (e–g) Front view, profile
view, base view pre-op/post-op

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

333
6
c
d
.
. Fig. 6.33  (continued)
6.3 · Case Studies

334
6
e
f
.
. Fig. 6.33  (continued)

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

335
6
g
.
. Fig. 6.33  (continued)
6.3 · Case Studies

336
6
Suggested Reading
Aiach G. Atlas of rhinoplasty: open and endonasal approaches, vol. 2. St.
Louis: Quality Medical Publishing; 2003.
Daniel RK.  Secondary rhinoplasty following open rhinoplasty. Plast
Reconstr Surg. 1995;96:1539–46.
Daniel RK, Sajadian A. Secondary rhinoplasty: management of the over-
resected dorsum. Facial Plast Surg. 2012;28(4):417–26.
Davis RE, Bublik M. Common technical causes of the failed rhinoplasty.
Facial Plast Surg. 2012;28(4):380–8.
Foda HMT. Rhinoplasty for the multiply revised nose. Am J Otolaryngol.
2005;26(1):28–34.
Foda HMT. The caudal septum replacement graft. Arch Facial Plast Surg
J. 2008;10(3):152–7.
Grotting JC. Secondary rhinoplasty and nasal reconstruction. St. Louis:
Quality Medical Publishing; 1996.
Gunter JP, Rohrich R. External approach for secondary rhinoplasty. Plast
Reconstr Surg. 1987;80:161–74.
Kim DW, Toriumi DM. Nasal analysis for secondary rhinoplasty. Facial Plast
Surg Clin North Am. 2003;11:399.
Meyer R.  Secondary and functional rhinoplasty: the difficult nose.
Orlando: Grune & Stratton; 1988.
Rohrich RJ, Hoxworth RE, Kurkjian TJ. The role of the columellar strut in
rhinoplasty: indications and rationale. Plast Reconstr Surg.
2011;129(1):118e–25.
Sheen JH. Spreader graft method of reconstructing the roof of the middle
nasal vault following rhinoplasty. Plast Reconstr Surg. 1984;73:230–9.
Sheen JH, Sheen A. Aesthetic rhinoplasty. 2nd ed. St. Louis: Mosby; 1987.
Sykes JM. Management of the middle nasal third in revision rhinoplasty.
Facial Plast Surg. 2008;24:339–47.

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

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© Springer International Publishing AG 2018
W. Gubisch, Mastering Advanced Rhinoplasty,
7
Primary Augmentation
of the Dorsum
7.1
Surgical Principles in Primary Saddle-Nose Deformity – 338
7.2
Case Studies – 344
7.2.1
Case 1: Augmentation with Cephalic Portion of LLC – 344
7.2.2
Case 2: Dorsal Reconstruction by Extracorporeal
Septal Reconstruction with PDS Foil – 346
7.2.3
Case 3: Dorsal Reconstruction by Extracorporeal
Septal Reconstruction – 349
7.2.4
Case 4: Augmentation with Conchal Cartilage
and Allogenic Fascia – 352
7.2.5
Case 5: Reconstruction of the Anterior Septum
with Double-Layered Conchal Graft and Augmentation
with DC-F from Allogenic Fascia and Diced Cartilage – 355
7.2.6
Case 6: Dorsal Reconstruction by Solid Graft – 359
7.2.7
Case 7: Dorsal Reconstruction with DC-F – 362
7.2.8
Case 8: Dorsal Reconstruction with DC-F – 366
7.2.9
Case 9: Dorsal Reconstruction with DC-F – 369
7.2.10
Case 10: Dorsal Reconstruction of Ethnically Low Dorsum – 371
7.2.11
Case 11: Dorsal Reconstruction of Ethnic Saddle Nose
and Narrowing of Alar Base – 374
7.2.12
Case 12: Dorsal Reconstruction with DC-F After Septal
Abscess in Childhood – 379
7.2.13
Case 13: Complex Dorsal Reconstruction of Binder
Syndrome Deformity – 383
7.2.14
Case 14: Augmentation of a Severe Congenital Saddle Nose
with Simultaneous Bulbous Tip Correction – 387
7.2.15
Case 15: Augmentation of a Severe Idiopathic Saddle Nose
and Simultaneous Tip Correction – 391

Suggested Reading – 394

338
7
7.1
Surgical Principles in Primary
Saddle-Nose Deformity
Although saddle-nose deformities are present in approxi-
mately 20 % of all rhinoplasties, the extent of saddle collapse
varies widely. Hence, a wide variety of techniques are neces-
sary to correct saddle noses. Because all saddle-nose defects
arise from skeletal deficiency, augmentation is the primary
means of surgical treatment. We prefer to use autologous
augmentation materials for this purpose, with one exception:
Tutogen (allogenic) fascia lata (Tutoplast® Inc., Neunkirchen
am Brand, Germany). Tutoplast fascia lata is a gamma radia-
tion processed human allograft which we have used success-
fully in over 3000 patients during the past 8 years (. Fig. 7.1).
Soaking the graft in antibiotic solution is necessary to rehy-
drate the graft and reduce infection risk. In addition to the
avoidance of a donor site scar, fascia lata offers an ideal struc-
ture and stiffness for use in augmentation rhinoplasty.
Conversely, autologous fascia lata lacks adequate stiffness,
necessitating the use of percutaneous stay sutures to guide
graft positioning and to prevent graft displacement.
As an alternative to allogenic fascia lata, we also use
autologous temporalis fascia for dorsal augmentation
(. Fig. 7.2). However, autologous temporalis fascia has differ-
ent biomechanical properties when compared to Tutoplast
fascia lata. Since temporalis fascia is much thinner, the cam-
ouflage effect is reduced, and the comparative lack of graft
stiffness necessitates the use of stay sutures or subcutaneous
fixation sutures to maintain proper positioning. When used
for radix augmentation, temporalis fascia can be compressed
and suture sculpted to achieve the desired shape, and when
placed over the nasion, the thick overlying skin of the radix
serves to conceal irregularities in graft contour. In addition to
soft-tissue augmentation, we also commonly perform dorsal
augmentation using autologous cartilage harvested from a
variety of donor sources including the tragus (. Fig.  7.3),
concha (. Fig. 7.4), septum (. Fig. 7.5), and rib (. Fig. 7.6).
For some time, we have been using free diced cartilage
(FDC) not only for dorsal refinements but also for augmenta-
tion, specifically if there is a minor contour deficiency.
Cartilage harvested from the ear or rib—we avoid septal car-
tilage since its unique properties make it better suited to
other ­purposes—is diced finely until it has a paste-like con-
sistency and can be placed through the tip of a tuberculin
syringe. The primary advantage of this material is its excel-
lent malleability and reliable durability (. Fig. 7.7).
We do not feel that autologous bone has a role in dorsal
augmentation, and we have no clinical experience with bone
grafting.
Prior to surgery, it must be decided if a full-length dorsal
augmentation is preferable to a focal dorsal augmentation.
Because a full-length augmentation avoids visible separations
between the dorsum and the adjacent graft material, we often
prefer to resect portions of the dorsum in order to facilitate a
full-length (and thus far more uniform) dorsal restoration.
Full-length grafts have the added advantage of creating more
uniform and natural-appearing brow-tip aesthetic lines.
Although full-length augmentation is often preferable for
comparatively large defects of the nasal dorsum, minor sad-
dle indentations involving only a small portion of the dor-
sum are best managed with small precision-fabricated grafts
custom-tailored to the defect. For this purpose, we prefer
Tutoplast fascia lata, cephalic portions of the lower lateral
cartilage (. Fig. 7.8), tragal cartilage grafts (. Fig. 7.3), or sep-
tal cartilage (. Fig. 7.9) when available. Tragal cartilage is a
particularly well-suited graft material for small-sized defects
since we can easily harvest a 12–16-mm-wide, flat, and uni-
formly thick cartilage specimen with minimal donor site
morbidity. When harvesting tragal cartilage, we also rou-
tinely leave behind a small outer rim of cartilage to preserve
the tragal contour. Tutoplast allogenic fascia lata is available
in large quantities and is well suited to virtually any sized
defect. It can also be used as a single layer or as multiple lay-
ers. We have previously used as many as six layers of Tutoplast
with good results, and Tutoplast can also be used to camou-
flage irregularities in underlying autologous cartilage grafts.
Another effective method for focal dorsal augmentation is
the excised cephalic remnants of the lower lateral cartilages
or free diced cartilage. Noses with overly wide and bulky
nasal tips often provide adequate amounts of suitable aug-
mentation material following the cephalic trim procedure
(. Fig. 7.8). Morselized septal cartilage is another potential
source of augmentation material (. Fig. 7.9). However, the
limited supply of septal cartilage must often be prioritized for
other needs, and care must be taken to avoid crushing septal
cartilage since unwanted chondrogenesis and/or chondro-
cyte mortality may lead to unacceptable long-term results.
If the saddle-nose deformity requires significantly more
volume, a larger graft is required, and we often use conchal
cartilage for these defects. In order to adapt the conchal graft
to the appropriate shape, we incise the concave conchal sur-
face in a grid-like pattern, leaving the outer perichondrium
intact to maintain graft integrity (. Fig. 7.10). When required,
a double-layered graft can be used for additional graft thick-
ness. Stability of the two-layered “sandwich” graft is enhanced
by suturing the grafts in a reciprocal orientation.
When even greater volume replacement is required, our
workhorse technique is the diced cartilage-fascia (DC-F)
graft. Originally introduced under the moniker “Turkish
delight” by Erol Onur, oxidized cellulose polymer was ini-
tially used to envelop the diced cartilage, but long-term
results suffered from substantial cartilage resorption.
However, the modified technique introduced by Rollin
K. Daniel, which uses temporalis fascia to encase finely diced
cubes of autologous cartilage measuring no more than 0.2–
0.4 mm3, has virtually eliminated the problem of cartilage
resorption. In order to create a uniform fascial sleeve, we use
a tuberculin syringe with its tip amputated to serve as an
assembly scaffold. The fascia is first wrapped around the
syringe and temporarily held in position with short hub nee-
dles (. Fig. 7.11). Once secured, the fascia is trimmed and
sewn lengthwise to create a single longitudinal seam. After
sewing the distal (cephalic) end of the sleeve shut, the syringe
is then loaded with the desired amount of diced cartilage,

Chapter 7 · Primary Augmentation of the Dorsum

339
7
and the cartilage is injected into the fascial sleeve
(. Fig. 7.12). After placement of the assembled DC-F graft
into the subcutaneous pocket, we close the (open rhino-
plasty) transcolumellar incision before assessing the final
nasal contour. To facilitate adjustments in graft size, the prox-
imal end of the sleeve is left open so that excess cartilage can
be “milked” from the graft and removed via the marginal
incision as needed. We have observed equivalent long-term
results using both autologous temporalis fascia and allogenic
fascia lata for sleeve construction, and diced cartilage can be
constructed from septal, conchal, and rib cartilage (or com-
binations therein) with equal reliability.
In patients with severe dorsal defects, the solitary use of
malleable augmentation materials is ill-advised since a struc-
turally sound skeletal framework is missing. In these cases, a
structural framework of solid costal cartilage must first be
created to provide the necessary foundation for surface con-
tour grafting (. Fig. 7.13). Because solid rib cartilage grafts
are notoriously prone to warping, special precautions must
be taken when using rib cartilage. Perhaps the most impor-
tant precaution is the concept of “balanced carving,” in which
the graft is symmetrically harvested from the central core of
the costal cartilage. In this manner the intrinsic stresses of the
inner and outer cartilage components are balanced. Next, the
graft is submerged in saline for a long as possible to identify
any intrinsic warping tendencies not addressed by concentric
carving. When identified prior to placement, warped grafts
can sometimes be carved asymmetrically to balance out
asymmetric stresses. Although some surgeons use a Kirschner
wire to skewer the graft longitudinally for added support, we
have no experience with this technique. Instead, we prefer a
thick, and therefore strong, segment of solid rib cartilage,
coupled with a DC-F overlay graft, for total dorsal recon-
struction. As an alternative to the solid rib graft, for a while
we have been using cartilaginous beam grafts consisting of
two or three layers of 2–3-mm-thick stripes from rib carti-
lage fixed against each other.
Further stabilization is first achieved by attaching a colu-
mellar strut graft using the tongue-in-groove configuration
for secure unification (. Fig. 7.13). If a straight segment of rib
cartilage is unavailable, the columellar strut can also be fash-
ioned from a double-layered conchal cartilage graft.
a
c
b
.
. Fig. 7.1  (a) Allogenic fascia lata after rehydration. (b) Histology of explanted graft 12 months after initial placement. (c) Histology of explanted
graft 14 months after initial placement
7.1 · Surgical Principles in Primary Saddle-Nose Deformity

340
7
.
. Fig. 7.2  Autologous temporalis fascia
.
. Fig. 7.3  Tragal cartilage

Chapter 7 · Primary Augmentation of the Dorsum

341
7
.
. Fig. 7.4  Conchal cartilage
.
. Fig. 7.5  Septal cartilage
.
. Fig. 7.6  Solid rib cartilage
7.1 · Surgical Principles in Primary Saddle-Nose Deformity

342
7
.
. Fig. 7.7  Finely diced cartilage for using as free graft (FDC)
.
. Fig. 7.8  Cephalic portion of the lower lateral cartilages for
augmentation
.
. Fig. 7.9  Morselized septal cartilage

Chapter 7 · Primary Augmentation of the Dorsum