Operative Technique in Plastic Surgery – Kevin C.Chung

■ Infection
REFERENCE
1. Cakır B, Oreroğlu AR, Daniel RK. Surface aesthetics in tip rhinoplasty: a
step-by-step guide. Aesthet Surg J. 2014;34(6):941-955.

53
CHAPTER
Indications and Technique
for Treating the Narrow
Midvault in Closed
Rhinoplasty
Shruti C. Tannan, Jeffrey R. Claiborne, and Mark B.
Constantian
DEFINITION
■ A narrow middle vault can be defined anatomically or functionally.
■ Anatomically, a narrow middle vault is defined as any part of the upper
cartilaginous vault that is at least 25% narrower than the upper or lower nasal
third.
■ Functionally, a narrow middle vault is defined as inadequate internal nasal
valve support.
ANATOMY
■ The middle vault is composed of the paired upper lateral cartilages (ULCs)
and the dorsal nasal septum.
■ The ULCs extend superiorly beneath the paired nasal bones approximately 5
mm, in a region known as the keystone area.
■ Laterally, the ULCs attach to the bony piriform aperture via the piriform
ligament.
■ Inferiorly, the ULCs are supported by their attachment to the lower lateral
cartilages in a region called the scroll area.
■ Aesthetically, the middle vault is the location of a smooth transition from the
narrower nasal bones superiorly to the wider nasal base inferiorly.
■ In the midline, the ULCs fuse with the septum to create a T in cross section, an
intersection that creates an angle known as the internal nasal valve (FIGS 1

and 2).
FIG 1 • Internal nasal valve.
■ The internal nasal valve is bounded medially by the septum, laterally by the
ULCs, and inferiorly by the inferior turbinate.
■ The internal nasal valve is the narrowest portion of the nasal airway and
therefore the site of highest airflow resistance.
■ The width and stability of the middle vault, the critical area of the internal
nasal valve, is determined by three factors:
■ Width of the nasal bony vault
■ Height and width of the middle vault roof
■ Soft tissue rigidity
PATHOGENESIS AND NATURAL HISTORY
■ As air enters the region of the narrow internal nasal valve, airflow speed

increases according to the Poiseuille law and the Venturi principle: when air
goes through a narrow passage, it speeds up and increases the transmural
pressure on the nasal sidewall, just as water running through a brook speeds up
as it passes between a narrow channel. Additionally, the Bernoulli principle
dictates that with increased flow speed, the intraluminal pressure decreases,
which places the valve at risk for collapse from the lower pressure.
FIG 2 • Nasal valves.

FIG 3 • Pathogenesis of iatrogenic middle vault
collapse.
■ Poiseuille law states that flow is proportional to the radius to the fourth power.
Thus, seemingly diminutive changes in middle vault size have dramatic
implications in nasal airflow.
■ A decrease in middle vault size or weakening of the structural integrity of the
nasal valve places the patient at risk for nasal airflow obstruction.
■ Any resection of the middle vault roof greater than 2 mm during hump
reduction destabilizes this most critical area, allowing the upper lateral
cartilages to fall medially and produce a characteristic “inverted V” deformity
and result in obstruction at the internal valves (FIG 3).
■ Reducing the dorsum and creating an open middle vault and interval valvular
incompetence will decrease the postoperative airway by 50%.
■ The middle vault and internal nasal valve are at risk in three specific
circumstances:
■ The midvault is congenitally narrow.
■ The nasal bones are short, therefore leaving a larger proportion of nasal
sidewall supported by the ULCs (internal valves) and the lateral crura
(external valves).
■ The surgeon reduces the dorsum by more than 2 mm, which in most patients
will open the cartilaginous roof.
■ The most common motivation for secondary rhinoplasty is an iatrogenic
deformity from the previous surgery.1
■ A narrow middle vault has been shown to be present preoperatively in 38% of
primary and 87% of secondary rhinoplasty patients.2
■ A study of 600 consecutive patients undergoing surgery for airway obstruction
between 1991 and 2008 with a mean follow-up of 27 months found the
following2:
■ Septal and valvular surgery corrected the airway obstruction in more than
95% of patients in a single operation, despite the fact that two-thirds of
patients were secondary rhinoplasty patients with more severe deformities.
■ Septoplasty improved airflow ipsilateral to an obstruction but made no
impact on total nasal airflow.
■ Internal valvular reconstruction with dorsal or spreader grafts doubled nasal

airflow.
■ Dorsal and spreader grafts were equally effective at improving nasal airflow.
■ External valvular reconstruction doubled nasal airflow.
■ The greatest improvement in nasal airflow was observed after both internal
and external valvular reconstruction (a fourfold improvement in airflow).
■ Septoplasty in addition to valvular surgery did not offer any clinical benefit
compared with valvular surgery alone.
■ In patients with lateralized symptoms, the septum was deviated away from
the obstructed side in 45% of cases, thus emphasizing the importance of
valvular obstruction in creating airway symptoms.
■ Of the 384 secondary rhinoplasty patients, 94% had previously undergone
adequate septoplasties but were still symptomatically obstructed. Within this
group, valvular reconstruction alone corrected the airway in 97% after one
operative procedure.
■ When primary and secondary rhinoplasty patients were stratified, the
improvement in primary patients equaled or exceeded the improvement
achieved in secondary rhinoplasty patients in six of the eight obstructed sites
examined.
■ Valvular obstruction was 4 times more common than pure septal obstruction
in primary rhinoplasty patients and 12 times more common than pure septal
obstruction in secondary rhinoplasty patients.
■ When the entire 600-patient group was stratified, the greatest improvement
was observed in those patients observed for more than 12 months, suggesting
that the airway continues to enlarge as postoperative edema resolves.
■ By measuring airflow during quiet and forced inspiration, sidewall stiffness
could be quantified and increased following valvular reconstruction by
dorsal, spreader, or alar wall grafts.
■ Based on this study indicating that reconstruction of the internal nasal valve
can double airflow, iatrogenic injury to the internal nasal valve can conversely
reduce airflow by 50%, and this assumption has been corroborated by recent
studies.3
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Four anatomic findings place patients at high risk for unfavorable results and
should be identified preoperatively.4
■ Low radix or low dorsum
■ Inadequate tip projection

■ Narrow middle vault
■ Alar cartilage malposition
■ Of these four, narrow middle vault and alar cartilage malposition (cephalic
rotation of the lateral crus) impact the airway because they indicate
preoperative threats to the internal and external nasal valves, respectively.
■ The exam findings of an obstructing septum or turbinate do not often correlate
well with patient symptoms.2
■ Patients frequently breathe better on the apparent “obstructed” side, indicating
that septal and turbinate obstruction do not explain the entire airway
dysfunction.
■ Eighty percent of nasal septa in the population are deviated, yet only a small
portion have clinical obstruction
■ Patients with straight septa or prior successful septoplasty and turbinectomy
frequently still have persistent symptoms of nasal obstruction.
■ History
■ Organized approach to obtaining history: first inquire about the airway and
subsequently discuss aesthetic concerns.
■ Many patients become accustomed to a poor nasal airflow and have forgotten
how much better their airway used to be prior to trauma or other surgeries—
thus, this part of the history requires that the physician guide the interview
with direct questions.
■ It is important to inquire about a history of prior trauma because unhealed
septal fracture lines may extend to the dorsal septal edge and therefore
threaten dorsal strut stability.
■ Recent trauma (within 3 months) is an indication to postpone the rhinoplasty
until any fractures have healed and until postoperative edema allows accurate
judgment of the aesthetic contours.
■ Ask about periodic or cyclic airway obstruction including which airway is
worse, any nasal trauma history, seasonal allergies, clear rhinitis and
suppurative sinusitis, snoring, epistaxis, sinus headache, frequent nose
blowing, and what nonsurgical remedies the patient has tried to date.
■ Often, secondary rhinoplasty patients with poor airways chronically self-
medicate with steroid or vasoconstrictive sprays that must be identified and
discontinued before surgery.
■ Also important are the patient’s work environment and a history of tobacco
or alcohol consumption (either of which may cause nasal congestion) and

cocaine use.
■ Valve examination: Watch your patients breathe!
■ Sidewall collapse with inspiration is surprisingly common. If this occurs, it is
important to determine the etiology (prior surgery, intrinsic weakness,
cartilage malposition).
■ Perform a modified Cottle maneuver and compare airflow between sides.
This maneuver is not specific, because even with septal deviation, traction on
the sidewall will open the airway. Obstruction must be localized at the valves
before valvular surgery is undertaken.
• Support the collapsing area with a cotton-tipped applicator soaked in 1%
pontocaine hydrochloride for the patient’s comfort. Patients with valvular
incompetence will notice an obvious and gratifying increase in airway size;
thus, you can guarantee that valvular reconstruction will improve the airway
similarly.
■ It is important to assess whether a high septal deviation exists because hump
removal will unmask the curvature: in the middle of the operation, the nose
can suddenly look newly asymmetrical. When a high septal deviation exists,
the surgeon needs to be prepared to place unilateral or asymmetric spreader
grafts. The correction is straightforward, but the surgeon must be attentive to
new intraoperative deformities.
■ Turbinates
■ Obstructing turbinates are relatively low in the hierarchy of causes of nasal
obstruction.
■ Given their function to warm and humidify air, turbinate reductions should be
planned conservatively.
■ Because the majority of turbinate hypertrophy is due to bony (not mucosal)
overgrowth, most patients should be treated with turbinate crushing and
outfracture.5 If septal and valvular causes of airway obstruction have been
corrected, the turbinates will not become enlarged again, unless the patient is
atopic.
IMAGING
■ Accurate photographs are imperative for consultation, formulation of an
operative plan, and intraoperative guidance.
■ Views should include full head and close-up frontal views, both oblique views
(which often differ, particularly in patients with nasal asymmetry), both lateral
views, and an inferior view.

■ Photographs are best taken with a portrait focal length lens (90 to 105 mm)
against a medium–dark background, lit so that symmetries and contours will be
depicted accurately.
■ Camera-mounted flash units are inferior to studio systems with umbrella lights
or wall-mounted strobes to light the face evenly, provide backlighting, and
illuminate the face and hair.
SURGICAL MANAGEMENT
■ The great majority of functional nasal deformities can be corrected with only
one of two operative strategies: spreader or dorsal grafts for internal valvular
obstruction and alar wall grafts for external valvular obstruction. Each at least
doubles airflow in most patients. Done correctly, these three procedures always
work.
■ For the patients presenting with nasal obstruction and/or a narrow middle
vault, spreader grafts or dorsal grafts must be placed to support the lateral
walls.
■ Although some surgeons prefer autospreader grafts or spreader flaps where
redundant ULC is turned in medially, their effectiveness at treating internal
valve collapse has not shown promising results.6,7
■ Other options for middle vault support include spreader flaps, tension suturing
techniques,8 and butterfly grafts.7,9,10 Long-term functional outcome studies
supporting these alternative techniques are lacking at this time, and current
evidence indicates that tension sutures are ineffective. There is another
theoretical problem with tension sutures: creating a barrel effect in the middle
vault is not physiologic. The nasal airway needs variable resistance (which
means a movable sidewall) during both inspiration (so that the alveoli can
open) and exhalation (so that O2 and CO2 transfer can occur). The constant,
widely open middle vault eliminates that necessary movement. Spreader grafts,
however, have a solid foundation of literature supporting their long-term
efficacy in both preventing and correcting middle vault collapse.2
Preoperative Planning
■ Fallacies in planning: there are two common false assumptions that underlie
the logic of reduction rhinoplasty that lead to unsatisfactory results.
■ False assumption number one: The nasal soft tissue cover has the infinite
ability to contract to the shape of any underlying skeleton.
■ The nasal skin sleeve contracts according to its quality, thickness, and

preoperative distribution, and not necessarily to the shape of the surgically
reduced skeleton. The vectors of skin sleeve contraction are related to the
volume and contour of the underlying skeleton, and the end result of reduction
with a skin sleeve that cannot sufficiently contract to the reduced skeleton is
the supratip deformity.
■ False assumption number two: Alterations in the nasal skeleton produce purely
regional changes.
■ The classic application of this assumption is the common strategy in which the
surgeon plans to resect all nasal dorsum anterior to a straight line drawn from
the nasal radix to the point of the tip. Underlying this strategy is the assumption
that dorsal reduction affects bridge height alone. Changes in the nasal skeleton
are not independent, however, but rather have global effects outside their areas.
Resection of the nasal bridge affects nasal width and length, apparent nasal
base size, middle vault support, alar rim contour, and columellar position.
Similarly, alar cartilage reduction can affect tip support and projection, nasal
length, alar rim contour, and external valvular support. These structural
interdependencies are not just regional. Recognizing this interplay is essential
to effective preoperative planning, interpretation of intraoperative nasal
appearance, postoperative success, and predictable correction of secondary
deformities.
■ One of the most important preoperative unknowns is the condition and quality
of the cartilage graft material available. The appeal of alloplastic materials is
their predictability on the day of surgery. However, the consistent longevity
and intrinsic characteristics of autografts has not been duplicated with any
alloplastic materials currently commercially available.
■ The dorsum requires the straightest, smoothest graft—ideally septum, but
autologous rib works as well.
■ In planning graft placement, the surgeon should consider areas needing
augmentation based on preoperative assessment as well as areas that may need
grafts because of the surgical approach; for example, disequilibrium that the
surgeon has created during reduction (ie, spreader grafts to support the internal
valves after resection of the cartilaginous roof).
■ The augmentation phase of any rhinoplasty re-establishes the preoperative
nasal equilibrium and alters contours in ways that reduction alone cannot. The
nose that is equilibrated at the conclusion of the procedure is less likely to
change during healing and therefore gives the surgeon greater control over the
result.

Positioning
■ The operation is routinely performed under general anesthesia.
■ The patient is placed supine, and the table is positioned in 10 to 15 degrees
reverse Trendelenburg to minimize bleeding.
■ The nose is blocked with 1% Carbocaine with epinephrine 1:100 000
(Carbocaine has a longer analgesic effect and intrinsic vasoconstrictive
properties).
■ Nasal vibrissae are shaved and the nose is thoroughly cleaned, inside and out,
with povidone-iodine solution.
■ Cotton packs soaked in 4% cocaine solution are placed in each airway.
Approach
■ Endonasal rhinoplasty is an operation designed around changes in the skin
surface—the underlying framework is adjusted only as much as is necessary to
accomplish skin surface changes and functional airway changes.
■ The endonasal rhinoplasty surgeon exposes only those anatomical parts that
need correction and are directly related to changes that the patient wants. This
principle creates the unique advantage of not subjecting any other nasal areas
to possible iatrogenic deformities. Primum non nocere (first, do no harm)—if
you expose areas unnecessarily, you put them at risk for postoperative
problems.
■ Skin sleeve movement, nasal balance changes, and the effects of reduction and
augmentation all depend on an ability to see the undisturbed nasal surface
accurately. This is what the patient sees and what matters.
■ The nasal soft tissues create half the nasal shape: without being able to assess
the skin surface accurately, the surgeon forfeits half of the information that is
available to make the operation a success.
■ Making changes through limited incisions and judging progress by feeling the
surface simplifies some maneuvers and minimizes the need for graft fixation;
crushed grafts can be used in ways that would be tedious or impossible with
the open approach.
T E C H N I Q U E S

■ Endonasal Access
■ Unilateral or bilateral intercartilaginous incisions are preferred—the incision
runs from the lateral end of the caudal reflection of the upper lateral cartilage
around the septal angle. The surgeon making only functional corrections
needs a single intercartilaginous incision that exposes the septal angle
(TECH FIG 1).
■ Joseph scissors and then a broad Cottle periosteal elevator are used to
elevate the soft tissues off the bony and upper cartilaginous vaults if the
surgeon plans a rhinoplasty; if not, the dorsum is not skeletonized.
■ If no transfixion incision is necessary, the intercartilaginous incision stops at
the junction of the anterior and middle thirds of the membranous septum; if
the caudal septum requires shortening, the incision can be carried toward the
anterior nasal spine.
TECH FIG 1 • Endonasal access and creation of
spreader graft tunnels. It is important to leave an
adhesion between the mucoperichondrial edge and
the anterior edge of the septum to prevent graft
displacement.
■ Spreader Graft Tunnels
■ When needed, spreader graft tunnels are performed before septoplasty.
Spreader graft tunnels are facilitated by prior infiltration beneath the
mucoperichondrium with local anesthetic.
■ By identifying the septal angle, the surgeon can incise to cartilage beneath

each mucoperichondrial flap and develop the tunnels with the sharp end of a
Cottle perichondrial elevator (TECH FIG 1).
■ Each tunnel must follow the dorsal septal edge and should extend beneath
the caudal edge of the bony arch on each side, leaving a narrow
mucoperichondrial attachment along the anterior septal edge. This intact
adhesion creates a pocket that will hold the spreader graft precisely;
performed this way spreader grafts never rotate or displace. Done
technically properly, they improve the airway reliably and virtually never
require revision.
■ Septoplasty
■ For the septoplasty, the surgeon should perform the resection through a
Killian incision, not from the dorsal edge, and leave 15 to 20 mm of intact,
undissected cartilage along the nasal dorsum and 15 mm caudally to preserve
stability and to facilitate spreader graft placement (TECH FIG 2).
■ Do not perform a purely functional operation (septoplasty, crushing, and
outfracture the inferior turbinates, spreader grafts, or alar wall grafts) through
an open rhinoplasty approach because the risk of creating iatrogenic
deformities is much too high and because it is unnecessary to take the tip
apart to access the septum and internal valves. Spreader grafts are easily
placed through an intercartilaginous incision; septoplasty is done through a
Killian incision; and alar wall grafts are placed through short vestibular
incisions to brace the anatomically unstable areas.
■ Do not strip the mucoperichondrium from the dorsal or caudal struts, not
only for stability but because such stripping has been experimentally shown
to increase septal fibrosis and decrease chondrocytes in rabbits; we should
assume that the same applies in humans.11
■ If significant trauma has occurred, even in the distant past, the surgeon
should enter the septum very cautiously and check for old fractures, as
fractures through the anterior septal edge will destabilize the dorsal strut. It is
preferable to avoid simultaneous septoplasty and bilateral osteotomies or to
postpone osteotomy if the surgeon is not confident of septal support.
■ In practice, the need for bilateral osteotomies in the severely traumatized
nose is generally uncommon because a unilateral osteotomy on the
outfractured side achieves better symmetry than bilateral osteotomies.

■ For septoplasty access, the initial mucoperichondrial Killian incision is made
15 mm above (cephalad to) the caudal septal edge; and using first the sharp
and later the blunt end of a Freer elevator in one hand and a Frazier suction in
the other, dissection proceeds under the mucoperichondrial flap onto the
perpendicular plate of the ethmoid and over any posterior bony obstructions.
■ Once the first flap has been developed, the sharp end of the elevator can
score through the septal cartilage at the site of the opening incision;
dissection then proceeds on the second side.
■ Elevation of the perichondrium at the junction of septal cartilage and vomer
is particularly difficult because the periosteal and perichondrial fibers are
interlaced. The periosteal fibers are stronger, so mucosal tears are less likely
if the surgeon begins dissection beneath the maxillary and vomerine
mucoperiosteum and works cephalad.
■ The first septal cut is made 15 to 20 mm below the dorsal septal edge with
angled Knight septal scissors, which cut through septal cartilage and
ethmoid; make sure that both blades are within the mucoperichondrial flaps
before making the cut. A parallel cut is performed 8 to 10 mm inferiorly, and
using Killian septal forceps, the first graft, now free on three sides, can be
twisted so that the ethmoid fractures and allows removal in one piece. This
maneuver often provides an initial graft 25 to 30 mm long containing the
flattest, thickest, longest piece of septal cartilage, ideal for a dorsal graft.
TECH FIG 2 • Septoplasty technique.
■ Dissection continues posteriorly and caudally with the sharp end of a Cottle
perichondrial elevator. The septal cartilage in the vomerine groove can often
be dislodged by a bit of judicious wiggling with a narrow osteotome. With an
osteotome and septal forceps, additional pieces of vomer or perpendicular
plate of the ethmoid can be removed if obstructing or if additional graft
material is needed, always working under direct vision.

■ In areas of severe deflection, tears in the mucoperichondrial flaps may be
unavoidable, but the surgeon should nevertheless proceed cautiously and
repair any tears.
■ Spreader Graft Placement
■ Although septal cartilage provides the ideal spreader graft, strips of costal or
conchal cartilage, ethmoid, or vomer may be used instead.
■ Spreader grafts should provide confluence between the upper and lower
nasal thirds, and they must span middle vault length from the bony arch
almost to the septal angle.
■ After spreader grafts are placed, caudal slippage can be avoided by a single
4-0 plain catgut transfixing suture placed at the septal angle.
■ The width and contour of the middle vault should look and feel stable and
symmetric once spreader grafts have been placed. In this regard, the closed
approach provides significant advantages because the external surface
configuration will guide the surgeon.
PEARLS AND PITFALLS
Pathogenesis
■ The middle vault and internal nasal valve are at risk in three
circumstances: (1) when the midvault is congenitally narrow; (2)
when the nasal bones are short, therefore creating a larger portion
of the cartilaginous sidewall that is supported only by cartilage; (3)
when the surgeon reduces the dorsum by more than 2 mm.
Planning
■ All key planning decisions can be made preoperatively from the
nasal surface. Each anatomical point translates directly to a
diagnosis and then to a surgical step: the entire rhinoplasty strategy
can be set before surgery.
■ Reconstruct anatomically, never forgetting function and
considering the patient’s own aesthetic.
■ Reconstruction of internal valves doubles airflow in most patients.
Approach
■ The surgical outcome depends on the aesthetics and function of the
nose, which are determined by both the soft tissue and structural
support.

■ These contributions are easily assessed by the endonasal approach
because the soft tissues, which determine 50% of the final result,
are largely undisturbed.
POSTOPERATIVE CARE
■ If septal or turbinate surgery has been performed, the nose is packed with
petroleum gauze impregnated with bacitracin/mupirocin ointment.
■ The packing should not overstuff the nose as it may dislodge the nasal bones
or grafts.
■ A no. 18 suction catheter is placed in the floor of each nasal airway to provide
some airway patency and help equalize middle ear pressure.
■ Oral antibiotics are prescribed for the first week while nasal packing is in
place.
■ A nasal splint is fashioned from layers of paper tape placed across the dorsum,
tip, and cheeks, and then cloth tape is layered over it. Several layers of
moistened 2-in. plaster are cut to fit and secured with another layer of cloth
tape. The splint must be applied precisely but not too tightly to prevent nasal
tip ischemia. Tip color should be checked frequently in the postoperative
period, and the tip sling cut and nasal packs or splint removed as necessary.
■ The nasal splint and any remaining packing are removed on postoperative day
6 to 7. By then, the nasal lining has healed, the nose is making mucus, and the
packing slides out painlessly. Upon splint removal, the airway should instantly
be excellent.
■ If only septal and valvular surgery has been performed, swelling is minimal. If
an entire rhinoplasty is performed, most patients are quite presentable at 7 days
and may easily return to work in 10 days except in unusual circumstances. The
nose will narrow after that for up to a year, but the dorsal line should be set.
■ Patients should be seen as needed during the first 2 weeks to clean the nose of
accumulated secretions, to ensure maintenance good alignment, and to educate
the patient of expected changes over time. Patients must not exert themselves
for at least 2 weeks following surgery to avoid hemorrhage and must slowly
increase their activity after that to full athletic function at 6 weeks.
OUTCOMES (FIG 4)
■ With good planning and technique, septal and valvular surgery can correct
airway obstruction in up to 95%.2
■ That percentage reflects a combination of primary and secondary patients,

some of whom required more than one surgery because of their preoperative
deformities.
■ In primary patients, spreader grafts will uniformly increase airflow and, with
experience, almost never require a second surgery.
■ The airway will continue to improve throughout the first year, indicating that
the airway enlarges as the edema resolves.2
FIG 4 • Patient before (A,B) and after (C,D) septoplasty.
COMPLICATIONS
■ Iatrogenic airway obstruction
■ More common than any complication and entirely preventable is iatrogenic
decrease in the postoperative airway size. That cannot occur with proper
preoperative septal, valvular, and turbinate diagnosis and treatment.
■ Most new postoperative obstructions are due to increased internal valvular
incompetence or an incomplete septoplasty with residual obstructions
posteriorly or along the floor. A new internal valvular incompetence will cut
the preoperative airway by 50%.
■ Inadequate turbinate resection, columellar widening, and nostril stenosis are
rare but do occur.
■ Skeletal
■ Visibility of the caudal edge of the bony vault is often mischaracterized as
inadequate reduction but is usually the result of middle vault collapse—the
bony arch stands out relative to the depressed and over-resected middle vault.
■ New frontal asymmetry can occur when dorsal resection uncovers a high
septal deviation. When recognized preoperatively or seen intraoperatively
after dorsal resection, the surgeon can correct the deviation with

asymmetrical spreader grafts and/or camouflage the deviation with a dorsal
graft.
■ Grafts
■ For those surgeons who augment often, graft imperfections are the most
common reason for secondary revision.
■ Spreader grafts may be too wide or too narrow
■ Septal perforation
■ Septal perforations can be minimized with careful dissection posteriorly and
inferiorly where the perichondrium is densely adherent by repairing any
mucosal tears and by placing silicone splints prior to nasal packing.
■ Even in the best of hands, the occasional small perforation will occur.
Fortunately, many of these remain asymptomatic.
■ Smaller perforations may present as whistling, while larger ones as crusting,
epistaxis, obstruction, or rhinitis.
■ Repair of perforations is difficult with a high recurrence rate. Repair involves
debriding the exposed septal tissue and coverage with a local
mucoperichondrial flap.
■ Rhinitis and empty nose syndrome
■ Temporary rhinitis may occur for several weeks after an obstructed airway
has been opened up.
■ An overaggressive turbinectomy can cause persistent rhinitis and is not
easily correctible.
■ Septal collapse
■ Loss of cartilaginous support has global ramifications for nasal support and
airway because the intact septal partition is necessary for normal bridge
contour, nasal length, base support, internal valvular competence, and upper
lip carriage.
■ Septal collapse can be avoided by identifying unhealed or unstable septal
fractures before surgery and by leaving a minimum 15 mm width of
undissected septal cartilage and mucoperichondrium along the dorsum to
avoid jeopardizing septal support if unexpected, unhealed fracture lines are
encountered.
■ It is safer to access the septum through a Killian incision rather than through
the dorsal edge. Leaving the mucoperichondrium undissected over the L-strut
protects against collapse, prevents exposure of potentially weakened
cartilage, and makes placement of spreader grafts easier.

■ Infection
■ Fortunately, bacterial infection with rhinoplasty is quite rare but has become
more common with the emergence and increasing prevalence of methicillin-
resistant Staphylococcus aureus as a community-acquired pathogen. Patients
should be routinely cultured for MRSA preoperatively and treated with
mupirocin if necessary.
■ Using systemic antibiotics while nasal packing is in place may minimize the
chance of maxillary sinusitis, although its necessity is unproven.
REFERENCES
1. Constantian MB. What motivates secondary rhinoplasty? A study of 150
consecutive patients. Plast Reconstr Surg. 2012;130:667.
2. Constantian MB, Clardy RB. The relative importance of septal and nasal
valvular surgery in correcting airway obstruction in primary and secondary
rhinoplasty. Plast Reconstr Surg. 1996;98:38.
3. Grymer LF. Reduction rhinoplasty and nasal patency: change in the cross-
sectional area of the nose evaluated by acoustic rhinometry. Laryngoscope.
1995;105(4 pt 1):429-431.
4. Constantian MB. Four common anatomic variants that predispose to
unfavorable rhinoplasty results: a study based on 150 consecutive secondary
rhinoplasties. Plast Reconstr Surg. 2000;105:316.
5. Berger G, Hammel I, Berger R, et al. Histopathology of the inferior turbinate
with compensatory hypertrophy in patients with deviated nasal septums.
Laryngoscope. 2000;110:2100-2105.
6. Saedi B, Amali A, Gharavis V, et al. Spreader flaps do not change early
functional outcomes in reduction rhinoplasty: a randomized control trial. Am J
Rhinol Allergy. 2014;28(10):70-74.
7. Eren SB, Tugrul S, Ozucer B, et al. Autospreading spring flap technique for
reconstruction of the middle vault. Plast Reconstr Surg. 2014;38(2):322-328.
8. Geissler PJ, Roostaeian J, Lee MR, et al. Role of upper lateral cartilage
tension spanning suture in restoring the dorsal aesthetic lines in rhinoplasty.
Plast Reconstr Surg. 2014;133(1):7e-11e.
9. Friedman O, Cook TA. Conchal cartilage butterfly graft in primary functional
rhinoplasty. Laryngoscope. 2009;119(2):255-262.
10. Jalali MM. Comparison of effects of spreader grafts and flaring sutures on
nasal airway resistance in rhinoplasty. Eur Arch Otorhinolaryngol.
2015;272(9):2299-2303.

11. Basaran K, Basat SO, Ozel A, et al. The effects of mucoperichondrial flap
elevation on septal L-strut cartilage: a biomechanical and histologic analysis in
a rabbit model. Plast Reconstr Surg. 2016;137(6):1784-1791.

54
CHAPTER
Indications and Techniques
for Increasing and
Decreasing Tip Projection in
Closed Rhinoplasty
Barış Çakır and Mithat Akan
DEFINITION
■ One of the reference points in the face is the vertical line intersecting the pupil,
or “midpupillary line.” The horizontal distance from the midpupillary line to
the highest point of the tip is called the tip projection (TP).
■ The horizontal distance from the midpupillary line to the apex of the nostril is
called the nostril apex projection (NAP).
■ The horizontal distance from the nostril apex to the tip’s highest point is called
the lobule projection (LP).
■ The NAP together with the LP constitutes the TP (FIG 1).
■ Examining the nose in this manner, element by element, will assist with the
treatment.
ANATOMY
■ The lower lateral cartilages consist of the footplate, the medial crus, the middle
crus, the domes and the lateral crus.
■ The lower lateral cartilages rest on the lip, the septum and the upper lateral
cartilages.
■ With its thickness of 2 to 4 mm, the Pitanguy midline ligament, which fills the
space between the septal angle and the domes, ensures an elastic projection
(FIG 2A,B).
PATHOGENESIS

■ Tip projection = nostril apex projection + lobule projection
■ High NAP: Hypertrophic anterior and caudal septum, hypertrophic maxillary
spine
■ High LP: Long medial and middle crus
■ Low NAP: Hypoplastic maxilla, footplate sitting posteriorly, hypoplastic
caudal septum, previous septoplasty surgery, aggressive resection of caudal
septum
FIG 1 • Tip projection (TP), lobule projection (LP), nostril
apex projection (NAP).
■ Low LP: Short middle crus, short medial crus
PATIENT HISTORY AND PHYSICAL FINDINGS
■ If the premaxillary support is weak, the nasolabial angle will be narrow, and
when pulling up the lips, one can see that the maxillary mucosa is deep.
■ Pressing on the nose tip will give us an idea about its support.
■ In patients with posteriorly located maxilla it is difficult to obtain enough nasal
projection. Patients who do not want a LeFort osteotomy may require a tongue
in groove, an aggressive augmentation in premaxilla, or a long, strong
columellar strut graft.

FIG 2 • A,B. With its thickness of 2 to 4 mm, the
Pitanguy midline ligament, which fills the space
between the septal angle and the domes, ensures an
elastic projection.

FIG 3 • One can easily plan changes to the TP, LP, and
NAP by superimposing the newly planned nose over
the old nose with a 50% contrast.
■ It is noteworthy that in patients with high projection, the caudal and dorsal
septa are hypertrophic.
■ A hypertrophic septum can cause a hanging columella, tense lips and a wide
footplate.
■ Because the septum pushes the footplates more anterior than normal, the
depressors are extremely tense. For this reason, the nasal tip may be more
active when speaking.
■ Skin thickness should be noted.
IMAGING
■ Front, base, top, lateral, and oblique photographs are standard. A lateral
smiling photograph can give clues about the dynamics of the nose tip.
■ Imaging programs facilitate better analysis of the problems and planning of
treatment.
■ One can easily plan changes to the TP, LP, and NAP by superimposing the
newly planned nose over the old nose with a 50% contrast (FIG 3).
SURGICAL MANAGEMENT
■ The treatment needs to directly address the problem.

FIG 4 • Although a patient’s LP may be normal, the high
TP can be linked to a high NAP. In this case, LP did not
change; TP decreased by decreasing NAP. Three
months post-op photo is similar with the simulation.
FIG 5 • A patient may have a normal TP, a high NAP,
and a low LP. In order to protect the TP, one has to
increase the LP in the same measure as one decreases
the NAP.
Preoperative Planning
■ It is important to observe how much the nasal tip contributes to the patient’s
facial expressions. One should observe the nose while the patient speaks. If the
depressors are very active, this should be noted.
■ Although a patient’s LP may be normal, the high TP can be linked to a high
NAP (FIG 4).

■ A patient may have a normal TP, a high NAP and a low LP. In order to protect
the TP, one has to increase the LP in the same measure as one decreases the
NAP (FIG 5).
■ A low TP may be linked to a low NAP as well as a low LP. Projection is the
horizontal axis of the tip cartilage length. Rotation of the droopy tip also
increases the projection (FIG 6).
■ In thick-skinned noses, the projection needs to receive stronger support.
Approach
■ A double-sided infracartilaginous incision and a single transfixion incision are
sufficient.
FIG 6 • A low TP may be linked to a low NAP as well as
a low LP. Projection is the horizontal axis of the tip
cartilage length. Rotation of the droopy tip also
increases the projection.
T E C H N I Q U E S
■ Reducing the Nostril Apex Projection
■ The surgical procedures outlined below all decrease the tip projection (TP).
The techniques below can be applied in succession, until the desired
projection is achieved.
■ Dissect the caudal septum bilaterally in a subperichondrial plane (TECH

FIG 1A).
■ If this is not sufficient, resect the excess caudal septum. This procedure is
recommended if the length of the nose needs to be shortened or if more
rotation is needed. Only these two procedures are enough to resolve most of
the excess TP (TECH FIG 1B).
■ If this is not sufficient, dissect the caudal periosteum of the maxillary spine.
■ If this is not sufficient, widen the dissection of the spine laterally.
■ If this is not sufficient, resect the maxillary spine. This resection results in a
dramatic deprojection (TECH FIG 1C).
■ In those rare cases where the above procedures are insufficient, resect more
bone from the maxillary spine and the surplus of periosteum an
perichondrium at the septum maxillary spine junction.
■ Even a deprojection of 3 to 5 mm greatly reduces the excursion of the
depressor nasi muscle. Therefore, in patients with an active depressor muscle,
an additional depressor resection may not be necessary if sufficient
deprojection is performed.
■ To decrease the NAP, shorten the lateral crura. If the lobule is short, we can
not only extend the lobule but also shorten the lateral crus by performing a
lateral crural steal.
■ If the lobule is beautiful, a long lateral crus can be treated with a dissection
and overlap in the region of the aperture.
■ In patients in whom not only the projection is decreased but also the length
shortened, there may exist an excess of mucosa in the membranous septum.
Here, a conservative elliptical mucosal resection can be performed (TECH
FIG 1D).

TECH FIG 1 • A. Dissect the caudal septum bilaterally
in a subperichondrial plane. B. If this is not sufficient,
resect the excess in the septum’s caudal. C.
Resection of the maxillary spine results in a dramatic
deprojection. D. In patients where not only the
projection is decreased but also the length shortened,
an excess of mucosa may occur in the membranous
septum. Here, a conservative elliptical mucosa
resection can be performed.
■ Reducing Lobule Projection
■ The most effective treatment for a long lobule is a medial crus overlap
(TECH FIG 2).
■ The most suitable location for this procedure is the break point of the
columella.
■ An oblique cut from the columella’s break point toward the caudal-posterior

direction increases the contact area.
■ For an overlap, dissect the cartilage 2 to 3 mm from the mucosa.
■ Tuck the medial crus underneath the middle crus, create an overlap of 2 to 3
mm, and suture it with a 6-0 PDS suture.
■ Rarely is an overlap of 7 to 8 mm necessary. In this case, a resection of 2 to
4 mm can be combined with an overlap of 3 to 4 mm. In cases of long lateral
crura shortened by lateral crural steal with high lobule projection (LP), an
overlap of more than 4 to 5 mm may be necessary.
■ A medial crus overlap is the most effective treatment for a hanging
columella.
TECH FIG 2 • A–C. The most effective treatment for a
long lobule is a medial crus overlap.
■ Increasing Lobule Projection
■ The best technique for extending the lobule is a lateral crural steal (TECH
FIG 3A–F). The LP increases at the same rate as the length of the lobular
polygon.1
■ A lateral crural steal will also increase rotation. Patients with a short lobule
generally tend to need greater rotation.
■ In closed rhinoplasty surgery where the Pitanguy and scroll ligaments are
protected, only 5% to 10% of patients require a tip graft (TECH FIG 3A).
Even though adequate rotation can be achieved by means of a steal, this may
not be sufficient for adequate LP. In this case, tip grafts are preferable.
■ If the ligaments are not protected, the cushioning underneath the domes
disappears and the domes collapse into the septum. The Pitanguy ligament
withdraws underneath the supratip skin and fills up the supratip area.
Depending on the increased height of the tip and supratip, the TP may appear

insufficient. The need for a tip graft generally occurs due to a loss of
projection of 3 to 4 mm, when the Pitanguy ligament has not been protected
(TECH FIG 3G–I).
■ If the lobule extends too much due to a lateral crural steal, this can be treated
with a medial crus overlap.
■ A lobule extended with the help of a steal should be supported by a strut
graft.
■ For an LP of 1 to 2 mm, minuscule free grafts to the tip are sufficient. After
the mucosa has been closed, these grafts can be placed on and in between the
dome cartilages.
■ An LP of 2 to 3 mm necessitates tip grafts. An onlay graft in the shape of a
boomerang facilitates the correct projection for tip highlights (TECH FIG
3J).

TECH FIG 3 • A–F. Lateral crural steal procedure. G–I.
If the ligaments are not protected, the cushioning
underneath the domes disappears, and the domes
collapse into the septum. The Pitanguy ligament
withdraws underneath the supratip skin and fills up the
supratip area. Depending on the increased height of
the tip and supratip, the TP may appear insufficient.
The need for a tip graft generally occurs due to a loss
of projection of 3 to 4 mm, when the Pitanguy ligament
has not been protected. J. An LP of 2 to 3 mm
necessitates tip grafts. An onlay graft in the shape of a
boomerang facilitates the correct projection for tip
highlights.
■ Increasing Nostril Apex Projection

■ If the footplates are wide, narrowing them with sutures will facilitate a TP of
1 to 2 mm (TECH FIG 4A–G).
■ If the front of the maxilla is empty, perform a subperiosteal dissection to the
front of the maxilla and fill it with cartilage pieces (TECH FIG 4H,I).
■ In patients with a recurrent droopy tip, an aggressive augmentation in front
of the maxilla is an effective technique.
■ A long strut graft that extends to the maxilla and fixes the interdomal gap is
the most effective technique for tip projection (TECH FIG 4J–M).
■ Fixing the strut graft while the assistant pulls the dome cartilages anteriorly
makes this technique easier.
■ Increasing NAP also increases the rotation.

TECH FIG 4 • A–G. If the footplates are wide,
narrowing them with sutures will facilitate a tip
projection of 1 to 2 mm. H,I. If the front of the maxilla
is empty, perform a subperiosteal dissection to the
front of the maxilla and fill it with cartilage pieces. J–
M. A long columellar strut graft that extends to the
maxilla and fixes the interdomal gap is the most
effective technique for tip projection.

PEARLS AND PITFALLS
Lateral crural steal
■ Every steal of 1 mm results in a rotation of about 6 to 8
degrees. The amount of the rotation obtained by means of a
steal decreases logarithmically.
Lower lateral
cartilage division
■ In big noses, it is generally necessary to cut the lower lateral
cartilage at some point. The safest region for this cut is the
middle crus.
Relationship
between
projection and
rotation
■ Deprojection techniques will also reduce tip rotation. For
this reason, it is necessary to equally shorten the lateral crus.
Tip projection
analysis
■ Analyzing the TP in NAP and LP makes treatment more
accurate.
FIG 7 • A–D. Case examples.
POSTOPERATIVE CARE

■ Carefully tape the nose without squeezing the tip. If the tape pinches the nose
tip caudally, the positioning of the tip cartilages can be damaged.
■ Because thermoplastic plaster is water resistant, the patient may shower every
day.
■ Applying tape underneath the eyes decreases swelling and bruising.
■ The patient can be discharged after 3 to 4 hours.
■ In case of swelling, a cold compress can be applied. Cold compresses are not
routinely used after wide dissection and insertion of a drain.
■ The patient rests in bed with the head elevated.
■ Paracetamol with codeine is sufficient for pain management.
■ Against bone edema, diclofenac potassium can be prescribed from day 5 to 10.
■ After the preoperative prophylaxis, there is no need for antibiotics.
■ Saltwater irrigation can be done for 10 days.
■ Internal silicone dolly splints can be removed after 2 to 4 days.
■ After 10 days, the cast is removed. Generally, no more tape is used.
OUTCOMES
■ Sample preoperative photographs can be seen in FIG 7.
COMPLICATIONS
■ Loss of rotation
■ Loss of projection
■ Tip asymmetry
■ Bleeding
■ Infection
REFERENCE
1. Cakır B, Oreroğlu AR, Daniel RK. Surface aesthetics in tip rhinoplasty: a
step-by-step guide. Aesthet Surg J. 2014;34(6):941-955.

55
CHAPTER
Techniques for Controlling
Tip Rotation in Closed
Rhinoplasty and Rhinoplasty
Anesthesia
Barış Çakır and Mustafa Özgön
DEFINITION
■ A droopy nasal tip is one of the most frequently encountered indications for
rhinoplasty.
ANATOMY
■ The following anatomical features impact nasal tip rotation:
■ Maxilla
■ Columella
■ Lateral crus
■ Caudal septum
■ Upper lateral caudal
■ Pitanguy, scroll and interdomal ligaments
■ All these anatomical structures have to be of the right dimension in order to
ensure the desired nasal tip position (FIG 1).
PATHOGENESIS
■ The most frequent problem causing a droopy nasal tip is the “tension nasal.”
Septum that extends too far caudally shapes the domes by bending the nasal tip
cartilages from the middle crura.
■ Septum pushes the footplates forward.
■ Because the depressor and orbicularis muscles are under tension, an
excessively droopy nasal occurs when laughing.

■ Because the domes emerge from the middle crura, we encounter a long, wide
and generally convex cartilage.
■ Also, trauma or a resection of the caudal septum creates projection and loss of
rotation.
FIG 1 • Anatomy.
NATURAL HISTORY
■ The nasal tip has an elastic rotation and projection.
■ The nasal tip contributes to minimal facial expressions. A nasal tip that
remains stiff when speaking is one of the last remaining stigmata of
rhinoplasty.
■ It is important for the nasal tip to be mobile, so that the patient is able to
comfortably lie face down and to kiss.
■ Techniques such as septal extension graft and tongue in groove are proven
solutions for rotation and projection; however, the nasal tip loses its softness.
■ The nasal ligaments, and most importantly the Pitanguy ligament, ensure an
elastic rotation and projection (FIG 2).

PATIENT HISTORY AND PHYSICAL FINDINGS
■ The patient complains about a “droopy nasal tip.”
■ The nasolabial angle is narrow.
■ The patient’s skin type is of significance. Patients with thick skin and a nasal
tip that droops excessively when laughing are more likely to experience loss of
rotation.
IMAGING
■ Front, base, top, lateral, and oblique photographs are standard. A lateral
smiling photograph gives clues about the dynamics of the nasal tip. Taking a
photograph of a beautiful nose, rotating it by 90 degrees, and looking at it in
this way will facilitate the decision-making process concerning rotation during
the surgery.
NONOPERATIVE MANAGEMENT
■ Filler and Botox can be applied to the nasal base. This cannot substitute for
rhinoplasty, however.
SURGICAL MANAGEMENT
■ Suggested treatments for rotation control consist of different ways of attaching
the medial crura to the septum.
FIG 2 • Pitanguy and scroll anatomy.
■ The medial crura can be sutured to the septum named tongue-in-groove
technique
■ Permanent sutures can be applied from the medial crura to the septum named

rotation control suture.
■ The rotation can be stabilized with a septal extension graft.
■ However, these techniques may lead to a stiff nasal tip.
■ When deprojection is performed, the footplates, which are connected to the
depressor muscles, change place posteriorly. This procedure decreases the
muscle’s excursion and weakens its function. For deprojection, it is generally
sufficient to dissect the caudal septum in the subperichondrial plane.
■ For proper rotation, it is necessary to shorten the lateral crural cartilage, the
upper lateral cartilage and caudal septum.
■ Shortening the lateral crus by means of the lateral crus steal technique
increases lobule projection.
■ Without performing deprojection, a steal does not guarantee projection. The
steal procedure re-establishes the projection lost due to deprojection.1
■ The basic effect of the lateral crus steal technique is an increase in rotation.
■ A strut graft is important to strengthen the support of the columella. In patients
with weak columella support, 2 to 3 struts can be placed. Loss of projection
causes loss of rotation.
■ In patients with an insufficient maxilla support, it is difficult to obtain rotation
and projection. In these patients, the front of the maxilla should be filled with
cartilage and bone (FIG 3).
■ In thick-skinned patients, it is necessary to select a strong and long cartilage as
a strut graft and to use septocolumellar suture with 5-0 Prolene passing
through the medial crus or the strut graft.
Positioning
■ The patient is positioned in the Trendelenburg position and lumbar flexion,
with the neck in an extension of 20 to 30 degrees and parallel to the floor. In
this position, intracranial blood pressure and surgical bleeding decrease.
Keeping the head always parallel to the floor makes it less likely for errors to
occur in rotation.
■ The patient is positioned on the back, with a pillow under the head, the arms
on belly, and supported by a silicone cushion placed under their legs in such a
way that their heels do not touch the operating table. The arms are secured by
wrapping them with a sheet so that the chest is left either exposed or covered.
■ In the operating room, the anesthesia device is placed at a 45-degree angle
next to the patient’s head, to their right side. Thus, the surgeon can access the

patient’s head and check for symmetry (FIG 4). If the surgeon is right handed,
the anesthesia device is placed to the left side.
FIG 3 • Augmentation of premaxilla with bone and
cartilage grafts.
FIG 4 • Position of patient.
Anesthesia
■ Goal: Anesthesia aims to ensure the patient’s safety and a bloodless surgical
field during rhinoplasty and to prevent pain, nausea, and shivering, especially
in the postoperative phase.
■ Application: On the day of the surgery, the patients, generally young adult
outpatients whose anesthesia exam and workout (complete blood count,
coagulation parameters, hepatitis markers, and ECG) have been completed 1
day earlier, are taken to the preop assessment room. The patient is monitored

(ECG, SpO2, NIBP), the tympanic temperature is measured, and the baseline
values are recorded. An intravenous line is started, and 250 mL 0.9% isotonic
NaCl with 1 g metamizole + 100 mg tramadol + 45.5 mg pheniramine maleate
is administered.
■ A first-generation cephalosporin is used for surgical prophylaxis.
■ Pseudoephedrine nasal spray is used for septal mucosa vasoconstriction.
■ As premedication, an IV bolus of 1 mg midazolam + 10 mg metoclopramide +
50 mg ranitidine + 40 mg methylprednisolone is administered.
Dexmedetomidine is administered with an infusion pump at a rate of 40 mcg/h.
■ Once these preparations are completed, the patient can be taken into the
operating room and will be monitored again.
■ Infusions of propofol 50 mg/h and remifentanil 250 mcg/h are administered.
Over the IV—after an infusion of 60 mg 2% lidocaine + 50 mcg fentanyl—5
mg rocuronium is given for the purpose of priming, and the timer is started.
Following 150 mg of propofol, another 25 mg of rocuronium is administered.
Fentanyl 50 mcg and another 50 mg of propofol are administered.
■ Once the eyelash reflex has disappeared, the eyes are covered with a line of
polymyxin B eye cream and 1 cm of transparent tape. After 3 minutes, the
patient is endotracheally intubated with a 7.0 spiral tube. The cuff is inflated
with a cuff pressure of 25 cm H2O, and during the operation, the cuff pressure
is constantly measured, having been connected to a manometer with an 850 psi
120-cm extension, so that small adjustments can be made to keep it at 25 ± 5
cm H2O.
■ The endotracheal tube is fixed at 21 to 23 cm to the right side (for left-handed
surgeon) of the mouth, at a distance of 1 cm and such that the upper lip is not
pulled askew, with 2 cm of Hypafix tape in the shape of an omega around the
tube. Then the tube is connected to the anesthesia device in a semiclosed
circuit with the help of an extension tube. In the volume control mode,
breathing support is secured with 44% oxygen + 50% nitrous oxide and 6%
desflurane at ET CO2: 30 mm Hg (VT 8 to 10 mL/kg, f: 10 to 12/min, rate of
fresh gas flow 2 L/min).
■ The mouth and stomach are checked with a 16 G orange aspirator cannula.
Then the surgery is started.
■ Over 30 minutes, 1 g paracetamol is given.
■ After the first hour, the dexmedetomidine infusion will be adjusted to 20
mcg/h, and in each half hour thereafter, the dose will be decreased by half,

until it reaches zero after the 2nd hour.
Administering Local Anesthesia
■ Local anesthesia is performed with 3-cc solution 1/80 000 (5 cc bupivacaine +
5 cc 2% lidocaine + 9 cc 0.9% NaCl + 1 cc 1/4 adrenaline) nasally, 2 cc 1/160
000 (2 cc 0.9% NaCl + 2 cc 1/80 000 lidocain-adrenaline solution. Jetokain®)
solution for septal mucosa in 10 minutes. Generally, this should not lead to any
significant lengthening of the QT interval or any other arrhythmia, and the
increase in ETCO2 should not exceed 10%. (Based on the adrenaline contained
in the local anesthesia, the increase in ETCO2 and the lengthening of the QT
interval in the ECG are accepted as early warning signs to suspend the
administration of local anesthesia, and normocapnia is ensured by increasing
the minute volume on the ventilator.)
■ Wait until the systolic blood pressure decreases below 90 mmHg for the local
solution injection. If the local solution infiltration to nasal increases the blood
pressure over 100 to 110 mm Hg, optimal adrenaline vasoconstriction cannot
be achieved.
■ During the surgery, generally, no further intervention is necessary. Rather than
focusing on the same fixed numerical values in terms of the hemodynamic
parameters for all patients during the surgical procedure, one should ensure the
individual patient’s regular pulse and blood pressure in such a way that they
facilitate a surgical field without bleeding (FIG 5).
FIG 5 • Patient’s parameters stabilization during the
surgery.
■ Based on the surgeon’s feedback and the patient’s hemodynamic parameters,

the infusion dosages can be decreased in a controlled manner after the first
hour.
■ Toward the end of the surgery, while the silicone doyle splints are being
placed, the nitrous oxide and desflurane are turned off. After a washout with
100% oxygen, 44% oxygen and 56% air are administered.
■ Dexamethasone 8 mg and 4 mg ondansetron are administered intravenously.
■ Upon completion of the surgery and before applying the bandages, the mouth
and stomach are aspirated with an 18 G green aspirator cannula. Infusions of
propofol are discontinued.
■ While applying the bandages, the patient may sometimes open the eyes when
coming into contact with cold water; if the patient can follow verbal directions,
he or she can be extubated and given oxygen with a simple mask at 5 to 6
L/min. If the patient has not woken up at this stage, the team waits until the
patient spontaneously does so, which generally occurs within 20 minutes. A
conscious patient with sufficient spontaneous breathing is kept on the
operating table for 5 more minutes and then transferred to the postoperative
recovery room.
T E C H N I Q U E S
■ Securing an Elastic Rotation by Protecting the
Pitanguy Ligament
■ With the posterior transfixion incision, the perichondrium of the caudal
septum is left attached to the Pitanguy ligament.
■ Leaving 1 mm of cartilage from the caudal septum attached to the
perichondrium makes it easier to suture it back.
■ The surgeon delivers the caudal septum, then determines the excess caudal
septum by forcing the tip rotation, and removes that excess (TECH FIG 1A).
■ In the area of the membranous septum, the perichondrium and 1-mm
cartilage flap that has been left attached to the Pitanguy ligament are fixed to
the septum with 3 to 5 sutures with 5/0 PDS in the desired projection and
rotation (TECH FIG 1B).

TECH FIG 1 • A. Resection for rotation. B. Resection
of caudal septum and suturing caudal septal
perichondrium and 1-mm cartilage flap to septum.
■ Shortening a Long Lateral Crus
■ The surgeon delivers the tip cartilages and completes the surgery on the tip.
■ The lateral crus must absolutely be shortened to the correct length.
■ In patients with a short lobule and weak domes, the best technique to shorten
the lateral crus is the lateral crus steal (TECH FIG 2).
■ Cephalic resection also increases rotation but not as much as shortening the
lateral crura.
TECH FIG 2 • Lateral crura steal (because of long
lobule after lateral crura steal, medial crura overlap
performed).

■ Shortening a Long Upper Lateral
■ After the desired tip position has been achieved, the caudal part of the upper
lateral cartilages should be double-checked. Any kind of surplus should be
resected (see TECH FIGS 1A and 3).
■ While repairing the scroll ligament, the surgeon can pass one suture through
the upper lateral.
TECH FIG 3 • Caudal resection of upper lateral
cartilage.
■ Projection is Important for the Nasal Tip Rotation
■ The rigidity of the nasal tip needs to be double-checked. The nasal tip should
be mobile but should still have adequate support when pressed with a finger.
If support is not adequate, an additional strut should be placed.
■ In secondary patients and patients with recurrent tip rotation and loss of
projection, one should consider an augmentation in front of the maxilla.
PEARLS AND PITFALLS
Projection
■ Loss of projection causes loss of rotation. Therefore, the support for
the tip should be double-checked at the end of the surgery.
Skin
■ Thick-skinned noses are more likely to experience loss of rotation.
Projection should be well supported, and for that purpose, the surgeon

may want to perform an over-rotation of 1 to 2 mm.
Loss of
rotation
■ The most frequent reason for loss of rotation is a long lateral crus, a
long upper lateral, and insufficient support of the nasal tip.
Impact of
anesthesia
■ The patient is our main priority.
■ A harmonious collaboration between the anesthesia and surgical teams
impacts the surgical outcome.
■ Nasal spray 20 min before surgery supply bloodless septal surgery.
■ We applied pre-emptive multimodal analgesia, multimodal nausea
prophylaxis, combined H1 + H2 receptor blockage, and a balanced
general anesthesia supported by nitrous oxide. (Noah pudding
anesthesia*.)
■ We supported the premedication with an alpha 2 agonist
(dexmedetomidine).
■ We used neither beta-blockers nor nitroglycerin.
■ We administered the local anesthesia-adrenaline solution in fractions
and over a span of more than 10 min. Rather than waiting for suitable
conditions to occur, the surgeon should create them.
■ We continuously monitored the pressure in the balloon of the
intubation tube and kept it at a level that would not damage the
trachea’s mucosa.
■ At the end of the surgery, oral and pharyngeal suction as well as
gastric emptying were performed when the patient was still under
general anesthesia.
■ The patient was awakened at the position and the conditions that the
anesthesia induction was started.
■ During the surgery, easy listening type of music was listened.

FIG 6 • A,B. A case example for rotation frontal view (3
months result). C,D. Smiling frontal view. E,F. Lateral
view. G,H. Smiling lateral view. I,J. Oblique view. K,L.
Base view.
POSTOPERATIVE CARE
■ The patient is on bed rest for the first hour. After 1 hour, the patient may drink
water. If the patient does not complain about nausea, he or she is allowed to eat
a sandwich and drink fruit juice, followed by another hour of bed rest. If the
patients have no further complaints, they may sit up and be mobilized. If their
general condition is satisfactory, the intravenous line can be removed. The
patient should be advised not to drink alcohol or operate a vehicle in the first
24 hours. Patients should be transferred by wheelchair to the vehicle taking
them home.
OUTCOMES
■ A case example for nasal tip rotation can be seen in FIG 6.
COMPLICATIONS
■ Loss of rotation
■ Over-rotation
REFERENCE
1. Cakır B, Oreroğlu AR, Daniel RK. Surface aesthetics in tip rhinoplasty: a
step-by-step guide. Aesthet Surg J. 2014;34(6):941-955.

56
CHAPTER
Technique for Ethnic
Rhinoplasty by the Closed
Technique
Shruti C. Tannan, J. Clayton Crantford, and Mark B.
Constantian
DEFINITION
■ Closed rhinoplasty allows the surgeon to achieve the patient’s aesthetic and
functional goals as accurately as possible without introducing new deformities
with the surgical approach.
■ Ethnic rhinoplasty refers to surgery of the non–Northern European nose that
respects the aesthetics and particular challenges associated with a patient’s
unique ethnic background. However, in practice, the distinction is somewhat
artificial because each patient, regardless of his or her ethnic background,
deserves a result that matches, as much as possible, the patient’s aesthetic goals
and that takes into account the degree of change (or preservation) of ethnic,
familial, or personal characteristics that the patient desires.
■ Specifically, some patients with distinctive familial, ethnic, or personal
characteristics may wish to retain them, whereas others may want a type
change. It is critical that the surgeon be aware of these expectations to prevent
patient dissatisfaction with the surgical result.
■ As with all preoperative discussions, a conversation with the patient about his
or her goals and expected outcomes should be a critical part of every
rhinoplasty, ethnic or not.
■ The principles of forming and then performing the surgical plan do not differ;
thus, ethnic rhinoplasty in many ways does not differ from any other
rhinoplasty.
■ The surgeon must consider the technique that allows him or her to deliver
what the patient wants while also maintaining his or her personal identity.

■ One of the most common motivations for secondary rhinoplasty is the loss of a
familial, ethnic, or personal nasal characteristic.1 For example, the surgeon
may assume the dorsal hump is to be taken down, but the patient may prefer
that the dorsal hump remain as a distinctive feature; this and all areas to be
addressed during rhinoplasty should be discussed together preoperatively.
■ A detailed discussion of specific aesthetic goals with the patient is imperative.
The closed approach offers the surgeon the ability to see the result on the table;
therefore, it is possible to set goals and deliver.
■ Some patients intend to maintain some of the characteristics of their noses that
are a part of their shared heritage, whereas others wish to alter them; it is up to
the surgeon to initiate this discussion for a thorough understanding of the
operative plan.
ANATOMY
■ Although there is a large spectrum of variability in the so-called ethnic nose,
there are common characteristics and features. It is important to recognize
these findings in advance so that a preoperative discussion is complete and so
the operative plan addresses the concerns the patient wishes to alter while
maintaining the characteristics the patient wishes to preserve.
■ Four anatomic findings place all patients at high risk for unfavorable results
and should be identified preoperatively.2
■ Low radix or low dorsum
• Dorsal length and height, balanced against lower nasal size, determine the
attractiveness of nasal proportion. A low radix or low dorsum begins caudal
to the level of the upper lash margin with the patient’s eyes in primary gaze.
• When the radix begins low, nasal length is shorter and the nasal base size
therefore appears larger. The surgeon must raise the dorsum segmentally or
entirely to balance the patient’s nasal base. In thicker-skinned patients, the
strategy is particularly attractive because it requires less soft tissue
contraction.
• However, dorsal length must also be balanced against nasal base size. In
patients with a very short nasal base (eg, some Asian noses), the radix
should begin lower than the upper lash margin. Ethnicity and patient
preference is one aspect; good nasal proportion is another.
■ Inadequate tip projection
• Tip projection reflects cartilage strength, not skin volume, specifically the