Mastering Advanced Rhinoplasty

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7
7.2
Case Studies
7.2.1 Case 1: Augmentation with Cephalic
Portion of LLC
A 21-year-old male presented for cosmetic rhinoplasty
complaining of a large nasal tip and a weak nasal dorsum.
Examination revealed a wide and bulky nasal tip, thick nasal
skin, and a low nasal dorsum. Treatment included resection
of the LLC cephalic margin via a closed rhinoplasty
approach. Tip contour was further enhanced with vertical
dome division and contouring sutures. The resected por-
tions of the LLC were then used for dorsal augmentation
(. Fig. 7.14).
.
. Fig. 7.14  (a–c)
Augmentation with cephalic
portion of LLC
a
b

Chapter 7 · Primary Augmentation of the Dorsum

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7
c
.
. Fig. 7.14  (continued)
7.2 · Case Studies

346
7
7.2.2 Case 2: Dorsal Reconstruction
by Extracorporeal Septal
Reconstruction with PDS Foil
A 17-year-old female presented after severe nasal trauma in
childhood extreme saddling of the whole dorsum with block-
ing on both sides. The bony pyramid was very wide.
Using a closed approach with hemitransfixion incision,
we started to dissect both upper tunnels, but the scarring was
so bad that we switched to the open one and transected the
columella with a stair-step incision. After completing the dis-
section, the ULCs have been split from the septum, the per-
pendicular plate was fractured by pressing a 5-mm chisel,
and then the remnants of the septum could be removed in a
big block of scars. There was not enough cartilage for recon-
structing a neoseptum, so that we harvested the concha from
a posterior approach. We folded a double-layered sandwich
graft, sutured smaller plane cartilages to a PDS foil, and fixed
both together. After parasagittal oblique and low-to-high lat-
eral osteotomies from a sublabial access, the PDS foil with
the cartilages was replanted and fixed to the ULC and the
perforated ANS. The dorsum was covered with a full-length
cartilage graft from a septal spur together with a full-length
allogenic fascia lata graft. The medial crura have been fixed to
the sandwich graft and a transdomal suture narrowed the
domes (. Fig. 7.15).

Chapter 7 · Primary Augmentation of the Dorsum

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7
.
. Fig. 7.15  (a–c) Dorsal reconstruction by extracorporeal septal reconstruction with PDS foil. (d–f) Front view, profile view, base view
pre-op/post-op. (g–i) 9 years follow up
a
c
e
d
f
b
7.2 · Case Studies

348
7
g
i
h
.
. Fig. 7.15  (continued)

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7
7.2.3 Case 3: Dorsal Reconstruction
by Extracorporeal Septal
Reconstruction
A 27-year-old male presented with nasal airway obstruction
resulting from a post-traumatic septal deformity and saddle-­
nose collapse. Treatment included an extracorporeal septoplasty
in which the caudal septum was excised and the posterior
­portion of the quadrangular cartilage was used to create a new
L-strut. The deformed caudal septum was then used for spreader
grafts, and the newly created construct was then reimplanted
using drill holes in the nasal bones and nasal spine for suture
fixation. Additional stability was achieved with suture fixation to
the upper lateral cartilages. In this patient, the saddle-nose
deformity was corrected using only L-strut reconstruction via
the extracorporeal technique (. Fig. 7.16).
.
. Fig. 7.16  (a–b) Dorsal reconstruction by extracorporeal septal reconstruction. (c–e) Front view, profile view, base view pre-op/post-op
a
b
7.2 · Case Studies

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7
c
d
.
. Fig. 7.16  (continued)

Chapter 7 · Primary Augmentation of the Dorsum

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7
e
.
. Fig. 7.16  (continued)
7.2 · Case Studies

352
7
7.2.4 Case 4: Augmentation with Conchal
Cartilage and Allogenic Fascia
A 15-year-old female presented for rhinoplasty with a his-
tory of childhood nasal trauma complicated by septal
abscess formation. Examination revealed a short, under-
developed nose with a prominent saddle-nose deformity.
Endonasal examination revealed partial absence of the
quadrangular septum.
Treatment involved removal of the entire residual sep-
tum, rotating the specimen 180° so that the lower border
became the new nasal dorsum, and then reimplanting and
suturing the construct to both the nasal spine and the ULCs.
The septal construct was then augmented with residual pieces
of the septum and covered by a three-layered conchal carti-
lage graft concealed beneath allogenic fascia lata. A double-­
layered shield graft covered in soft tissue was also used for
nasal lengthening (. Fig. 7.17).
.
. Fig. 7.17  (a–b) After
extracorporeal septal
reconstruction the remaining
saddle was corrected with
residual parts of septal cartilage,
covered with allogenic fascia lata
lengthening by shield grafts.
(c–e) Front view, profile view,
base view pre-op/post-op
a
b

Chapter 7 · Primary Augmentation of the Dorsum

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7
d
c
.
. Fig. 7.17  (continued)
7.2 · Case Studies

354
7
e
.
. Fig. 7.17  (continued)

Chapter 7 · Primary Augmentation of the Dorsum

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7
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
A 17-year-old female presented with a post-traumatic nasal
deformity resulting from childhood trauma and a likely sep-
tal abscess. Examination revealed a largely absent caudal sep-
tum leading to columellar retraction and a saddle-nose
deformity with a widened and splayed nasal dorsum.
Surgical reconstruction of the anterior septal L-strut
involved placement of a double-layered conchal graft har-
vested from both ears and sutured to the ULCs and a nasal
spine drill hole. Severely buckled medial crura were
straightened by suture fixation to the leading edge of the
new caudal septum. Tip refinement was accomplished
using cephalic fold-under flaps (lateral crural underlay
technique), and the dorsum was augmented using a DC-F
graft fashioned from diced rib cartilage and allogenic fas-
cia lata (. Fig. 7.18).
7.2 · Case Studies

356
7
.
. Fig. 7.18  (a–c) Reconstruction of the anterior septum with double-layered conchal graft and augmentation with DC-F from allogenic fascia
and diced cartilage. (d–f) Front view, profile view, base view pre-op/post-op
a
b

Chapter 7 · Primary Augmentation of the Dorsum

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7
c
d
.
. Fig. 7.18  (continued)
7.2 · Case Studies

358
7
f
e
.
. Fig. 7.18  (continued)

Chapter 7 · Primary Augmentation of the Dorsum

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7
7.2.6 Case 6: Dorsal Reconstruction by Solid
Graft
A 19-year-old female presented with a severe post-traumatic
saddle-nose deformity resulting from childhood trauma fol-
lowed by septal surgery. Owing to soft-tissue scarring and con-
tracture, a solid framework of rib cartilage was required for
reconstruction. Two components were used: a large dorsal aug-
mentation graft with a groove cut in the distal end and a large
anterior septal replacement graft with a reciprocal “tongue”
carved into the upper cephalic border. Suture fixation was used
to secure the tongue-in-groove interdigitation of the two solid
rib grafts. High closing tension at the ­transcolumellar incision
was offset with a layered skin closure (. Fig. 7.19).
.
. Fig. 7.19  (a–b) Dorsal
reconstruction by solid rib graft
combined with solid septal
replacement graft. (c–e) Front
view, profile view, base view
pre-op/post-op
a
b
7.2 · Case Studies

360
7
c
d
.
. Fig. 7.19  (continued)

Chapter 7 · Primary Augmentation of the Dorsum

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7
e
.
. Fig. 7.19  (continued)
7.2 · Case Studies

362
7
7.2.7 Case 7: Dorsal Reconstruction
with DC-F
A 35-year-old male presented with a severe saddle-nose defor-
mity resulting from years of competitive boxing. Surgical explo-
ration revealed overlapping layers of septal cartilage and
thickening of the bony septum up to 5 mm in width. Treatment
involved extracorporeal reconstruction of the septum with thin-
ning of the bony segments. Fixation of the reimplanted con-
struct included drill hole fixation at the nasal spine and nasal
bones and suture fixation to the upper lateral cartilages. A dou-
ble-layered conchal graft was used to increase tip projection, and
left-over conchal cartilage was diced and combined with allo-
genic fascia lata to create a DC-F dorsal onlay graft (. Fig. 7.20).

Chapter 7 · Primary Augmentation of the Dorsum

363
7
.
. Fig. 7.20  (a–b) Dorsal reconstruction with DC-F (c–e) Front view, profile view, base view pre-op/post-op
a
b
7.2 · Case Studies

364
7
c
d
.
. Fig. 7.20  (continued)

Chapter 7 · Primary Augmentation of the Dorsum

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7
e
.
. Fig. 7.20  (continued)
7.2 · Case Studies

366
7
7.2.8 Case 8: Dorsal Reconstruction
with DC-F
A 34-year-old male presented after a criminal attack severe
saddle-nose deformity. We planned a nose reconstruction
with a DC-F from allogenic fascia lata and autologous diced
rib cartilage. The fascia lata was soaked with gentamicin solu-
tion and sutured over a tuberculin syringe for tubing. The
tenth rib was harvested subperichondrially from a 4-cm inci-
sion. To reduce any pains, we put a catheter installing 10 cm
of 2 % ropivacaine as a local anesthetic. This was sucked out
after 30 min.
The rib cartilage was cut horizontally in 2-mm-thick
strips. One was used later on as a columellar strut; the residual
ones have been diced very finely for the DC-F.
Starting with an open approach technique, the epiperi-
chondrial/subperiosteal dissection of the dorsum was
extremely difficult because of severe scars.
The cephalic parts of the LLC have been trimmed, and a
columellar strut from the rib was placed. The medial crura have
been fixed to the strut; the domes have been contoured by a
transdomal suturing. To avoid later drooping, a tip suspension
suture with anterior sling has been placed. Then the DC-F was
put onto the dorsum with two guiding sutures. The fascia tube
was closed only cranially. After putting back the flap and closing
the columella incision with 6-0 nylon, the overfilled DC-F was
preciously molded by digital finger pressure, and the excess of
diced cartilage could be sucked out before closure of the infra-
cartilaginous incision. Then an elastic paper tape, a sticking plas-
ter, and a plaster of Paris were applied for 2 weeks (. Fig. 7.21).

Chapter 7 · Primary Augmentation of the Dorsum

367
7
.
. Fig. 7.21  (a) Dorsal
reconstruction with DC-F. (b–d)
Front view, profile view, base
view pre-op/post-op
a
b
7.2 · Case Studies

368
7
c
.
. Fig. 7.21  (continued)

Chapter 7 · Primary Augmentation of the Dorsum

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7
7.2.9 Case 9: Dorsal Reconstruction
with DC-F
A 19-year-old male presented with a short nose and low nasal
dorsum. There was no history of nasal trauma. Treatment
involved harvesting the central quadrangular cartilage to
­create a columellar strut graft which was positioned to
counter-­rotate the tip and lengthen the nose. To immobilize
the strut, extended spreader grafts were placed bilaterally. The
dorsum was augmented using a DC-F graft fashioned from
diced conchal cartilage and a sleeve of allogenic fascia lata
(. Fig. 7.22).
.
. Fig. 7.22  (a) Dorsal
reconstruction with DC-F. (b–d)
Front view, profile view, base view
pre-op/post-op
a
b
7.2 · Case Studies

370
7
d
c
.
. Fig. 7.22  (continued)

Chapter 7 · Primary Augmentation of the Dorsum

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7
7.2.10  Case 10: Dorsal Reconstruction
of Ethnically Low Dorsum
A 32-year-old colored female presented a long nose with flat
dorsum and deep radix. The tip and the nasal base have been
very wide. After harvesting the tenth rib from the right side,
an open approach technique was used. After extramucous
dissection of the dorsum and splitting the ULC from the sep-
tum, a cartilage graft from the central part of the septum has
been harvested for a columellar strut, but the cartilage was
too thin and weak and could be used only for a shield graft.
However, the tip of the rib graft was very straight and strong
and worked perfectly as a columellar strut. The nasal pyra-
mid was narrowed after parasagittal medial osteotomies and
percutaneous low-to-low lateral and transverse osteotomies.
The parasagittal osteotomy has been performed with a
Lindeman fraise in order not only to get a straight cut but to
remove some bone at the same time.
The tip was narrowed by transdomal sutures, and span-
ning sutures after the lateral crura have been strengthened by
a fold-under flap technique. That means that the cephalic
portion has been flipped under the lateral crus after dissect-
ing off the vestibular skin. So an iatrogenic concavity of the
lateral crura could be avoided. To rotate the tip upward and
keep it in position, a suspension suture with anterior sling
was fixed.
After these steps, a pattern of the dorsal defect was made
with some strongly rolled gauze, and according to that a
DC-F from allogenic fascia lata and finely diced cartilage
from the rib was build. It was brought in position with two
guiding sutures, but it seemed that we needed more volume.
Therefore, we put another layer of allogenic fascia on top of
the DC-F.
Originally, we had planned a sill and alar base resection,
but by increasing the projection, it was not necessary any-
more. After 1  year, we had to perform a minor revision,
because the DC-F had shifted to the right and seemed too
bulky. We sutured a new tube from allogenic fascia lata, diced
the solid mass of the previous DC-F again, and built a new
graft. The tip projection was reduced by columella shorten-
ing, and then it became necessary to reduce also the alar base
and to perform a sill resection. To improve the tip complex, a
conchal graft was placed for reconstruction of the infratip
lobule (. Fig. 7.23).
7.2 · Case Studies

372
7
.
. Fig. 7.23  (a–d) Dorsal reconstruction of ethnic saddle nose. (a) Cleaning the allogenic fascia from adherent soft tissue and manufacturing a
DCF graft. (b–d) Front view, profile view, base view pre-op/post-op
a
b

Chapter 7 · Primary Augmentation of the Dorsum

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7
c
d
.
. Fig. 7.23  (continued)
7.2 · Case Studies

374
7
Technique: Fabrication of a Double-Layered
“Sandwich” Graft from Conchal Cartilage
When septal cartilage is unavailable, a double-layered colu-
mellar strut graft fashioned from conchal cartilage offers a
suitable alternative. The double-layered “sandwich” graft is
both rigid and straight, making an ideal columellar strut
graft, and a satisfactory amount of donor cartilage can be
harvested from the ear without alteration in auricular shape.
The cymba concha is used for “sandwich” graft ­fabrication
and is harvested with the posterior perichondrium still
attached. The fusiform-shaped cymba concha is then divided
lengthwise, leaving the perichondrium intact, so that recip-
rocal halves remain joined by perichondrium. Irregularities
in cartilage thickness are then eliminated, and the cartilages
are then sutured “back to back” using a modified Aiach clamp
and 4-0 Prolene on a small Keith needle to create a strong,
straight, and flat “sandwich” graft.
7.2.11  Case 11: Dorsal Reconstruction
of Ethnic Saddle Nose and Narrowing
of Alar Base
A 25-year-old female presented with a congenitally low nasal
dorsum, a poorly supported and underprojected nasal tip,
and overly wide nostrils. Treatment included placement of a
double-layered columellar strut graft fashioned from conchal
cartilage, supported by two small extended spreader grafts
created from septal cartilage. The remaining conchal carti-
lage was combined with conchal cartilage harvested from the
contralateral ear and a sleeve of allogenic fascia lata to create
a DC-F graft for dorsal augmentation. The DC-F graft was
then covered with two additional layers of allogenic fascia
lata. A nasal base resection with partial excision of the nostril
sills completed the procedure (. Fig. 7.24).

Chapter 7 · Primary Augmentation of the Dorsum

375
7
a
b
.
. Fig. 7.24  (a–d) Dorsal
reconstruction of ethnic saddle
nose combined with lengthening
the nose by a columellar strut,
kept in position by two extended
spreader grafts. (e–g) Front view,
profile view, base view pre-op/
post-op
7.2 · Case Studies

376
7
c
d
.
. Fig. 7.24  (continued)

Chapter 7 · Primary Augmentation of the Dorsum

377
7
f
e
.
. Fig. 7.24  (continued)
7.2 · Case Studies

378
7
g
.
. Fig. 7.24  (continued)

Chapter 7 · Primary Augmentation of the Dorsum

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7
7.2.12  Case 12: Dorsal Reconstruction
with DC-F After Septal Abscess
in Childhood
A 19-year-old female presented with a saddle-nose defor-
mity, a wide and bulbous nasal tip, and a damaged septum
from a childhood septal abscess. The bony pyramid was also
very wide.
After harvesting an 8.0 cm cartilaginous segment of the
eighth rib, we placed a percutaneous catheter into the rib
donor site to permit infusion of 10.0  cc of ropivacaine as
needed for pain control. Twenty minutes after injection of
the anesthetic, the residual anesthetic is suctioned from the
donor site, and the process is repeated over the next 48 h
whenever the patient complains of donor site pain.
Using an open rhinoplasty approach, surgical explora-
tion revealed severe deformities of the LLCs and septum.
The septum was removed completely for extracorporeal
reconstruction. From the septal specimen, a 25.0 × 20.0 mm
straight segment was thinned using a cylindrical drill bit.
This was then used like a septal extension graft and sutured
to the ANS via a transosseous drill holes. To further stabilize
the graft, two firm 10.0-mm-wide extended spreader grafts
fashioned from rib cartilage were sutured to the neoseptum
and to the nasal bones via osseous drill holes placed within
the nasal bones. The ULCs were then sutured to the neosep-
tum for further support and to widen the internal nasal
valves. Prior to placement of the septal construct, the bony
pyramid was narrowed using parasagittal medial osteoto-
mies created with a 1.0 mm Lindemann (electric) drill bit.
This allowed removal of bone along the osteotomy line for
better narrowing of the bony vault with percutaneous low-
to-low lateral and transverse osteotomies. The deformed lat-
eral crura were flattened by cephalic fold-under flaps (lateral
crural underlay technique), and the acute left dome was cor-
rected using an extended under batten graft, where the tip of
the graft was pushing and rounding the dome. Then the
residual rib was then diced to a very fine consistency and
used to create a DC-F graft from a tube of allogenic fascia
lata. The DC-F graft was sutured shut at the cranial end and
left open at the distal end. The DC-F graft was then posi-
tioned in the subcutaneous pocket over the dorsum using
two guiding sutures sewn to the cranial end and passed
through the lower glabella. After closing the skin flap at the
columella, the dorsum was molded using finger pressure,
and the extruded (excess) diced cartilage was removed from
beneath the skin flap with suction. The marginal incisions
were then closed (. Fig. 7.25).
7.2 · Case Studies

380
7
.
. Fig. 7.25  (a–c) Dorsal reconstruction with extracorporeal septal reconstruction and DC-F graft after septal abscess in childhood. (d–f) Front
view, profile view, base view pre-op/post-op
a
b

Chapter 7 · Primary Augmentation of the Dorsum

381
7
c
d
.
. Fig. 7.25  (continued)
7.2 · Case Studies

382
7
e
f
.
. Fig. 7.25  (continued)

Chapter 7 · Primary Augmentation of the Dorsum

383
7
7.2.13  Case 13: Complex Dorsal
Reconstruction of Binder Syndrome
Deformity
An 18-year-old female with Binder syndrome presented
for augmentation rhinoplasty. Examination revealed a
wide, flat nose with partial atresia of the premaxilla and
nasal dorsum. Treatment initially involved construction of
a structural neo-­framework from solid rib cartilage to
increase nasal base projection. A notched premaxillary
augmentation graft fashioned from solid rib cartilage was
used as a platform to support a large columellar strut graft
also fashioned from solid rib cartilage. The alar cartilages
were also reconstructed from rib cartilage using the “graft-
bending” technique (see Chap. 4: Treatment of the Under-
Supported Nasal Tip). Augmentation of the dorsum was
achieved using a large DC-F graft fashioned from diced
rib cartilage and allogenic fascia lata. Owing to the dra-
matic increase in tip projection, unusually high closing
tension resulted in focal but temporary underperfusion of
the nasal tip skin. However, the problem fully resolved
after only 2 weeks (. Fig. 7.26).
7.2 · Case Studies

384
7
.
. Fig. 7.26  (a–c) Complex dorsal reconstruction of Binder syndrome deformity. (d–f) Front view, profile view, base view pre-op/post-op
a
b

Chapter 7 · Primary Augmentation of the Dorsum

385
7
c
d
.
. Fig. 7.26  (continued)
7.2 · Case Studies

386
7
e
f
.
. Fig. 7.26  (continued)

Chapter 7 · Primary Augmentation of the Dorsum

387
7
7.2.14  Case 14: Augmentation of a Severe
Congenital Saddle Nose
with Simultaneous Bulbous Tip
Correction
A 22-year-old female presented with congenital hypoplasia
of the nasal dorsum and a “ski slope” nasal profile. In addi-
tion, the tip was overrotated, slightly overprojected, and bul-
bous.
Using the open rhinoplasty approach, dysmorphic LLCs,
characterized by bulbous lateral crura, abnormally narrow
intermediate crura, and buckling at the lateral crural junction
were observed. Treatment began with excision of the inter-
domal soft tissues. Following degloving of the anterior septal
angle, submucosal tunnels were created on both sides of the
dorsal septum, and the upper lateral cartilages were then
sharply divided. Next, a large piece of quadrangular cartilage
was harvested for use as a septal extension graft. The graft was
sutured to the left side of the caudal septum using a side-to-
side fixation technique. The overly wide but underprojected
bony pyramid was then narrowed using parasagittal medial
osteotomies followed by bilateral percutaneous transverse and
lateral (low-to-low) osteotomies. Using a sliding medial crural
overlap technique, the tip cartilages were simultaneously
counter-rotated and deprojected. Tip narrowing was then
accomplished using bilateral cephalic fold-under flaps, fol-
lowed by placement of dome-unit and transdomal tip sutures.
Additional nasal lengthening was achieved with shield graft
placement. Finally, dorsal augmentation was restored using a
diced cartilage and fascia (DC-F) graft fabricated from autolo-
gous rib cartilage and allogenic fascia lata. After fabricating
the fascial sheath, the proximal end was sutured closed and
intentionally overfilled with diced cartilage. Paired percutane-
ous guiding sutures, placed at the cephalic end, were then
used to position the graft and were retained to stabilize the
graft for the first week. To establish the final graft contour, the
transcolumellar incision was sutured closed, and the over-
filled graft was then molded using digital pressure. Excess
material produced by digital molding was then removed with
suction via the marginal incisions. Using a needleless tubercu-
lin syringe, ultrafine diced cartilage was then injected along
the dorsal sidewalls for final smoothing (. Fig. 7.27).
7.2 · Case Studies

388
7
a
b
.
. Fig. 7.27  (a–b) Dorsal augmentation in a congenital saddle nose and simultaneous correction of a bulbous tip. (c–e) Front view, profile view,
base view pre-op/post-op

Chapter 7 · Primary Augmentation of the Dorsum

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7
c
d
.
. Fig. 7.27  (continued)
7.2 · Case Studies

390
7
e
.
. Fig. 7.27  (continued)

Chapter 7 · Primary Augmentation of the Dorsum

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7
7.2.15  Case 15: Augmentation of a Severe
Idiopathic Saddle Nose and
Simultaneous Tip Correction
A 22-year-old female presented idiopathic severe saddle nose
with very wide nasal pyramid. The nose was very short, the
tip was bulbous and overprojected, so that in the profile a
skilooped nose resulted. Intraoperatively, we found badly
deformed LLC with a lot of irregularities (. Fig. 7.28).
Using an open approach technique, we removed a large inter-
crural fat pad. We harvested a large piece of straight septal carti-
lage, fixing it side to side as septal extension graft. So we could
lengthen the nose. The circumference of the LLC was too large,
creating also the bulbosity of the tip. This cartilage excess was
corrected by a medial sliding technique (medial overlay tech-
nique) because the side effect of this maneuver is a down rota-
tion, which leads to a further lengthening. The third technique to
lengthen the nose was fixation of a strong shield graft. Before that
maneuver, the cephalic portion was fold under to strengthen the
lateral crus. This enabled us to contour the tip with spanning
sutures. The residual rib cartilage was diced very fine and used
together with allogenic fascia lata for fabrication of a DC-F.
It was overfilled and only the cranial end was closed.
After fixing it in position with two guiding sutures, the nasal
skin was sutured back, and by manual massaging an ideal
contour got achieved.
.
. Fig. 7.28  (a–c) Augmentation of a severe saddle nose with DC-F from allogenic fascia lata, which first had be cleaned from adherent fibrous
tissue. Simultaneous ­correction of a bulbous tip. (d–f) Front view, profile view, base view pre-op/post-op
a
b
c
7.2 · Case Studies

392
7
e
d
.
. Fig. 7.28  (continued)

Chapter 7 · Primary Augmentation of the Dorsum