Operative Technique in Plastic Surgery – Kevin C.Chung

• Correction of external valvular incompetence doubles mean nasal airflow in
most patients.4
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Patient history
■ Airway and aesthetic concerns
■ History of prior nasal trauma
■ Airway obstruction
■ Internal nasal exam
■ Valves
■ Septum
■ Turbinates
■ External nasal exam
■ Cartilage size and substance
■ Bony vault length
■ Nasal sidewall stiffness
■ Soft tissue thickness/distribution
• Soft tissue thickness determines the degree of reduction possible and the
character of augmenting or stabilizing grafts. Soft tissue distribution
determines ultimate nasal size and proportion.
■ Nasal shape overall: width, length, bridge contour, tip shape, nostril size,
columella and upper lip position, and any asymmetries.
IMAGING
■ Software imaging systems exist that allow improved communication between
surgeon and patient, although it represents a simulated, not guaranteed result.
Imaging is only useful if the surgeon can simulate those structural and contour
changes that the patient’s anatomy and biological principles will permit.
SURGICAL MANAGEMENT
■ The objectives of ethnic rhinoplasty are in keeping with the goals of as any
other rhinoplasty: to achieve the patient’s aesthetic and functional goals as
accurately as possible without introducing new deformities.
■ The closed approach to ethnic rhinoplasty offers many advantages.
■ Closed rhinoplasty requires less dissection, always allowing the surgeon an
undisturbed view of the nasal surface, which determines 50% of the final
outcome.

■ Closed rhinoplasty allows the surgeon the ability to control tip contours more
accurately because there is less intraoperative soft tissue manipulation and the
dorsal and tip skin never leave their preoperative positions.
■ Tip grafts are easier to place in precise pockets in closed rhinoplasty because
they do not have to be sutured into place. Multiple grafts of different thickness
and substance can be placed to create particular aesthetic goals because the
surgeon controls the soft tissue pocket. These techniques are not possible
through the open approach.
■ Columellar struts are never needed because the medial crura are not routinely
disrupted from the adherent columellar skin and tip projection is not routinely
lost through the closed approach access.
■ Fewer variables are introduced by the surgical approach, and this reduces
postoperative problems and greatly decreases the chance of new iatrogenic
deformities.
■ Closed rhinoplasty avoids problems that are almost unique to open
rhinoplasty: columellar widening or notching, significant alar rim, and alar
cartilage distortions.
■ There are no contraindications to the closed approach to rhinoplasty, as this
approach allows the surgeon to minimize morbidity in even the most difficult
of cases.
Preoperative Planning
■ The preoperative exam consisting of an internal and external nasal exam is
critical.
■ Specific attention should be paid to the valves, septum, turbinates, and basic
nasal aesthetics.
■ Always identify the four anatomical variants first so that their treatment can be
included in the surgical plan.
■ Preoperative photographs are imperative.
■ Setting goals with the patient and discussing potential complications and
revisions are vital.
■ Three soft tissue parameters are used to form the authors’ rhinoplasty plan:
skin thickness, skin distribution, and tip lobular contour.5
■ Virtually all primary and secondary nasal deformities can be solved by one of
two surgical strategies that follow the necessary reduction maneuvers: (1)
radix, spreader, and tip grafts or (2) dorsal grafts and tip grafts plus or minus

(3) alar wall grafts.
■ This means that the surgeon need master only four graft types (because
radix/dorsal grafts are the same graft in different lengths) to solve most nasal
problems.
■ Maxillary augmentation for retrusion, lateral wall grafts for asymmetries,
composite grafts for alar retraction, and other procedures are relative details.
■ The primary aesthetic and airway problems can be corrected using only the
four graft types mentioned, using the two strategies outlined. This gives the
surgeon much less to master.
Positioning
■ The patient is placed supine with the arms and legs padded and the knees
slightly flexed; the operating table is 10 to 15 degrees reverse Trendelenburg
position to minimize bleeding.
Approach
■ Closed rhinoplasty
■ Rhinoplasty offers the possibility of individualizing a result as much as or
more than any other aesthetic procedure, and the closed approach is often the
key to doing so.
T E C H N I Q U E S
■ The techniques for performing the closed approach to ethnic rhinoplasty are
the same as any closed rhinoplasty.
■ The key is addressing the patient’s desires and goals without creating
incongruity with a patient’s heritage or an awkward, “operated” appearance.
■ Skeletonization
■ Endonasal access via unilateral or bilateral intercartilaginous incisions is
preferred.
■ For details on closed rhinoplasty exposure, see Chapter 53, Indications and
Technique for Treating the Narrow Middle Vault in Closed Rhinoplasty.

■ Dorsal Resection
■ Bony vault reduction is performed under direct vision using a sharp rasp,
judging the result by assessing surface contours.
■ Next, resection of the dorsal border of the septum is accomplished with a no.
11 blade from which the tip has been broken to avoid lacerating the
contralateral dorsal skin (TECH FIG 1).
■ The dorsum should feel and appear perfectly smooth through the skin
surface after dorsal resection.
■ Watch for a depressed discontinuity in the mid-dorsum; this is a “mid-
dorsal notch” and signifies dorsal over-resection beyond the limits of soft
tissue contraction.
■ Treatment is placement of a thin dorsal graft under the notch, not more
skeletal resection.6
TECH FIG 1 • Resection of the dorsal border of the

septum is accomplished under direct vision with a no.
11 blade from which the tip has been broken to avoid
lacerating the contralateral dorsal skin.
■ Nasal Spine–Caudal Septum
■ Through a transfixion incision, the caudal septum and nasal spine can be
accessed and resected as necessary to change the relationship of the
columella to nostril rim, nasal length, subnasale contour, and upper lip
carriage (TECH FIG 2).
■ If the nasolabial angle and upper lip relationships are satisfactory, no
transfixion incision and no caudal septal or nasal spine modifications are
necessary.
■ Be cautious about over-resection; 1 or 2 mm makes the difference between
normal columellar position and retraction.
TECH FIG 2 • The specific maneuvers for the nasal
spine and caudal septum depend on the need.
■ Alar Cartilage Resection
■ Orthotopic or nondeforming cephalically rotated (malpositioned) lateral
crural cartilages are modified retrograde through the intercartilaginous

incisions; rarely, more than 2 to 3 mm is removed, leaving lateral crura of 8
to 10 mm in width.
■ The domes can be narrowed by vertical wedge resections performed at the
lateral genu.
■ Distorted or severely convex “boxy” or “ball” tips that must be significantly
modified are dissected free from their vestibular and overlying skin and (1)
resected and replaced after trimming to create the flattest segment, (2)
resected and replaced by septal or ear cartilage grafts, or (3) delivered as a
medially based flap and rotated into the alar rim, with care to ensure that
distortion or notching at the soft triangle or lateral genua does not occur.
■ Most “boxy” or “ball” tips are also malpositioned, so that a functional
problem accompanies the aesthetic deformity and should be corrected
simultaneously.7
■ Freeing of the lateral crura, dome resection, or division of the alar cartilage
arch reduces tip projection: thus, tip grafts are necessary to reconstruct the
lobule.
■ In order to avoid vestibular stenosis and iatrogenic airway obstruction, nasal
lining should never be resected.
■ Upper Lateral Cartilages and Shortening the Nose
■ A single hook is used to draw the caudal edge of the upper lateral cartilage
downward, exposing the caudal edge for submucosal resection with Joseph
scissors.
■ The posterior edges of the upper lateral cartilages should be left to abut the
lateral crura; mucosa should never be resected.
■ A variety of interventions shorten the nose. In descending order of their
effect, they are dorsal resection, caudal septal resection, resection of the
cephalic edges of the alar cartilages lateral crura, and resection of the
anterocaudal ends of the upper lateral cartilages (TECH FIG 3).
■ This final step is unnecessary unless substantial nasal shortening is
required.

TECH FIG 3 • The cephalic portion of the lateral crus
is resected.
■ Septoplasty and Spreader Graft Tunnels
■ Spreader graft tunnels should be performed prior to septoplasty.
■ For details on septoplasty and spreader grafts, see Chapter 63, Indications
and Technique for Treating the Narrow Middle Vault in Closed Rhinoplasty.
■ Turbinectomy
■ Turbinate crushing and outfracture suffice in most patients.
■ If resection is necessary, for example, in severely atopic patients, biopsy
forceps are used to trim the anterior edge sufficient to obtain 3 mm of
clearance to the septum or nasal floor.
■ Be conservative, as over-resection and its resulting physiologic disturbances
are not correctable.

■ Graft Placement and Wound Closure
■ Spreader grafts are sized to the dimensions of the tunnel and the length of
the upper lateral cartilages. They may be adjusted in width or configuration
to provide symmetry.
■ The skin of the nasal dorsum and radix is thinnest, and slight
imperfections/asymmetries may be easily noticed. Dorsal and radix grafts
must fit the configuration of the defect and suit the soft tissue cover. These
grafts should feel and look perfectly on the operating room table beneath the
soft tissue envelope.
■ Important principles of tip grafting include the following: graft length should
be suited to its purpose and graft substance/contour must match the soft tissue
cover.
■ Multiple softened grafts work well for patients who still have their alar
cartilages and only need improved definition.
■ For the patient with an undefined and unsupported tip, solid cartilage or
bone graft is placed to establish projection and define the angle of rotation.
By itself, a single tip graft looks too artificial and pointed. Accordingly,
softened cartilage grafts are placed anterior to the defining graft to re-create a
normal lobule.
■ As grafts are placed (in that order), 5-0 plain catgut sutures close each access
incision so that graft position will be easier to maintain.
■ Osteotomy
■ A single lateral osteotomy with a guarded osteotome, which begins
intranasally, low at the pyriform aperture, and ends higher toward the nasal
root, is sufficient to narrow the upper nasal third.
■ If the bony vault is low and broad and will be augmented, the nasal bones
are short, or if the upper nasal third is already sufficiently narrow,
osteotomy is not necessary (TECH FIG 4).
■ Gentle digital pressure is used to greenstick fracture the remaining cephalic
attachment and will reform the bony pyramid.

TECH FIG 4 • Intranasal osteotomies are performed
with a guarded, curved 4-mm osteotome beginning at
the base of the piriform and advancing toward the
medial canthus.
■ Alar Wedge Resection
■ When necessary, an external incision is made slightly outside the alar crease
in order to not destroy this important landmark.
■ Remember that the alar wall has two surfaces, external and vestibular, and
that they can be treated independently. In other words, the alar lobule can
be narrowed without reducing nostril size, or both alar lobule and nostril
can be reduced.
■ It is important to retain a small medial flap as the surgeon incises the nasal
floor to provide a smooth closure line and avoid notching. 6-0 nylon is used
for closure and sutures are removed at 5 days.

PEARLS AND PITFALLS
Ethnic
rhinoplasty
■ Ethnic rhinoplasty does not differ from any other type of rhinoplasty
from a technical standpoint: treatment of a low dorsum and large
nasal base under a thick soft tissue cover is the same whether the
patient’s ethnic background is Slavic or African American.
■ It is imperative that the surgeon and patient communicate about the
particular aspects of the appearance of the nose he or she wishes to
preserve and which ones he or she would like to address surgically.
■ Knowledge of common characteristics of each ethnic group provides
a starting basis for the preoperative discussion, but it is the patient’s
specific nasal contour and aesthetic goals that should dominate.
Individuals are too unique to make sweeping generalizations about
the characteristics of any ethnic groups.
Approach
■ Closed rhinoplasty does not mean blind rhinoplasty. Rather, the
mental exercise that distinguishes endonasal rhinoplasty from open
rhinoplasty is precisely the same thought process that distinguishes
liposuction from abdominoplasty.
■ The surgeon accepts limited access and makes intraoperative
judgments based on the appearance and “feel” of the surface because
doing so gives the surgeon more control and precision and therefore
benefits the patient.
■ The more difficult the deformity and the more difficult the case, the
stronger the argument can be made for limiting access, limiting
incisions, and minimizing morbidity by minimal disruption of the
nose.
FIG 1 • A young woman of Greek ancestry for whom it
was critically important to maintain ethnic identity, which

she defined as preserving her dorsal convexity. The
surgical procedure involved dorsal reduction, spreader
grafts to maintain valvular competence following
resection of the cartilaginous roof, tip grafts to increase
projection, and deliberate maintenance of dorsal height.
A,B. Preoperative views. C,D. Two-year postoperative
views.
POSTOPERATIVE CARE
■ Nasal packs are placed in all patients who undergo septoplasty or have had
grafts placed. Nasal packs, tape, and plaster splints immobilize the
reconstruction for 1 week, until the grafts and modified skeleton are stable and
packing can be removed without pain or bleeding.
■ See each patient frequently in the early postoperative period and for at least
the first postoperative year, documenting postoperative changes.
OUTCOMES
■ With a thorough informed discussion preoperatively, the surgeon can achieve
functional and aesthetically pleasing results that are in keeping with a patient’s
expectations about maintaining his or her ethnic identity (FIG 1).
■ Because only four graft types need to be mastered, with experience, the need
for revisions should not be common.
COMPLICATIONS
■ Skeletal problems
■ Soft tissue problems
■ Graft problems
■ Asymmetry
■ Using the surgical planning and techniques described, the following
complications virtually never occur.
■ Iatrogenic airway obstruction
■ Intraoperative and postoperative hemorrhage
■ Septal perforation
■ Rhinitis
■ Circulatory problems
■ Infection

■ Septal collapse
■ Red nose
■ Racial incongruity
■ Treatment of more common complications is straightforward. Because the
underlying anatomy has not been disturbed, and no sutures or struts have been
placed, not much can go wrong.
■ Dorsal grafts can move out of position but can be easily adjusted in a small
secondary procedure.
■ Spreader grafts virtually never require revision and can be expected to double
nasal airflow in most patients.
■ Alar wall grafts occasionally bow or are under corrected or overcorrected but
still double airflow if external valvular incompetence existed preoperatively.
■ Tip grafts can be placed insufficiently, or in excess, or heal asymmetrically.
■ In any of these occasions, local adjustments through limited incisions are
corrective.
REFERENCES
1. Constantian MB. What motivates secondary rhinoplasty? A study of 150
consecutive patients. Plast Reconstr Surg. 2012;130:667.
2. 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.
3. Constantian MD, Clardy RB. The relative importance of septal and nasal
valvular surgery in correcting airway obstruction in primary and secondary
rhinoplasty. Plast Reconstr Surg. 1996;98:38-54.
4. Constantian MB. Functional effects of alar cartilage malposition. Ann Plast
Surg. 1993;30:487.
5. Constantian MB. Experience with a three-point method for planning
rhinoplasty. Ann Plast Surg. 1993;30:1.
6. Constantian MB. The mid-dorsal notch: an intraoperative guide to
overresection in secondary rhinoplasty. Plast Reconstr Surg. 1993;91:477.
7. Constantian MB. The boxy nasal tip, the ball tip, and alar cartilage
malposition: variations on a theme, a study in 200 consecutive primary and
secondary rhinoplasty patients. Plast Reconstr Surg. 2005;116:268.

57
CHAPTER
Indications and Technique
for Open Rhinoplasty in
Patients With Dorsal Hump
and Wide Tip
Charles H. Thorne and Sammy Sinno
DEFINITION
■ Dorsal hump refers to excess height in the upper third of the nose. When
examining a patient in the lateral view, ideally the nose should be in line with a
line drawn from the radix to the tip (or slightly behind this line in females); any
excess projection anterior to this line is a dorsal hump.
■ Wide tip refers to a variety of configurations of the lower lateral cartilages that
create the appearance of bulbous and poorly defined nasal tip.
ANATOMY
■ The anatomy of the dorsal hump is usually both cartilaginous and bony. The
nasal bones and the dorsal septum can both or independently be excessive. Any
of these situations can contribute to a dorsal hump.
■ A wide tip is primarily related to positioning and orientation of the lower
lateral cartilages. Dr. Rohrich and colleagues categorized three types of boxy
tip relating to a wide intercrural angle, a wide domal arch, or both.1 Wide or
bulbous tips can also result from bifidity of the nasal tip, excess or convex
lateral crura, or lower lateral cartilage malposition.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Dorsal hump and wide nasal tip are the two most commonly encountered
patient complaints regarding their nose.
■ On palpation of the dorsum, a dorsal hump can be bony or cartilaginous, or in
some instances both.

■ Palpation of the tip cartilages is important to give information regarding
integrity, positioning, and recoil of the lower lateral cartilages.
IMAGING
■ Although CT imaging can be useful in nasal surgery for airway abnormalities,
routine scans are not obtained for patients presenting for correction of dorsal
hump and wide nasal tips.
SURGICAL MANAGEMENT
■ A clear surgical plan should be outlined prior to any rhinoplasty procedure.
Preoperative Planning
■ The patient is counseled extensively in preoperative discussion regarding
surgical outcomes and recovery. Photographs are taken and will be used
intraoperatively. Currently, we do not use 3D imaging software.
Positioning
■ The patient is in the supine position with the head slightly extended.
Approach
■ The open approach is used for full visualization of deformities in the dorsum
and tip.
T E C H N I Q U E S
■ Correction of the Dorsal Hump
■ An inverted V or upright V incision is used to open the nose along with
bilateral infracartilaginous incisions (TECH FIG 1A).
■ Using converse tip scissors, the nasal skin and soft tissues are dissected
immediately on the surface of the nasal cartilages from caudal to cranial
(TECH FIG 1B). A Joseph periosteal elevator is used to elevate the
periosteum off the nasal bones in the midline (TECH FIG 1C).
■ Once full exposure is achieved, a no. 15 blade is used to separate the upper
lateral cartilages from the septum (TECH FIG 1D). An assessment is then
made regarding the anatomical features that contribute most to the dorsal

hump.
■ Separation of the upper lateral cartilages from the septum:
■ If primarily cartilaginous, the dorsal septum is scored with a no. 11 blade
and then excised with Swedish or Foman scissors.
■ If the hump is primarily bony, a bone rasp is used to bring down the
dorsum (TECH FIG 1E).
■ The nasal skin must be redraped and constantly reassessed by lateral
visualization and palpation to determine adequacy of reduction.
■ The dorsum is then restored by either suturing the upper lateral cartilages
back together with 5-0 PDS sutures or spreader grafts placed and secured
between the upper lateral cartilages and septum.

TECH FIG 1 • A. An inverted V or upright V incision
can be used. B. Nasal cartilages dissected free. C.
Nasal bones exposed. D. Separation of the upper
lateral cartilages from the septum. E. Rasping the
bony dorsum.
■ Correction of the Wide Tip
■ Correction of the wide tip has several components. A cephalic trim is often
performed first by marking, scoring, and then excising the cephalic aspect of
the lateral crura, making sure to leave an adequate width of residual lateral
crura (at least 5mm) (TECH FIG 2A).
■ Tip sutures can also be powerful in correcting a wide tip; these are placed
with 6-0 PDS:
■ Intradomal sutures can also be used to refine the tip and correctly orient
malpositioned lower lateral cartilages into the correct plane (TECH FIG
2B–D).
■ Interdomal sutures, placed from one dome to the other and tied, also can
have a drastic impact on refining the tip.
TECH FIG 2 • A. Marking of the cephalic aspect of the
lateral crura to be excised. B–D. Intradomal suture
placement.
PEARLS AND PITFALLS

Exposure
■ It is critical to expose the nasal architecture in a subperichondrial
and subperiosteal plane to avoid excess bleeding and leave maximal
soft tissue covering of framework modifications.
Dorsal
reduction
■ Reduce the dorsum in an incremental fashion to avoid over-
resection.
■ Avoid over-resection of the upper lateral cartilages.
■ If the patient has had a prior septoplasty, exercise caution in
reducing the hump as an 8- to 10-mm L strut is necessary.
Osteotomies
■ Perform the infracture as low as possible to avoid a step-off
deformity.
Wide tip
■ Use a graduated approach toward refining tip aesthetics: cephalic
trim, then intradomal sutures, and then interdomal suture.
POSTOPERATIVE CARE
■ The nose is taped, and an Aquaplast splint is applied.
■ The tape, splint, and sutures are removed in 5 days.
■ Patients are encouraged to sleep on their backs with head elevated for 2 weeks
following surgery.
■ All patients are encouraged to gently clean their nostrils with cotton swabs and
a mixture of water and peroxide.
OUTCOMES
■ Typically, correction of dorsal humps and wide tips yield very high patient
satisfaction in rhinoplasty procedures.
COMPLICATIONS
■ Undercorrection can occur and patients must be counseled extensively
preoperatively.
REFERENCE
1. Rohrich RJ, Adams WP Jr. The boxy nasal tip: classification and management
based on alar cartilage suturing techniques. Plast Reconstr Surg.
2001;107(7):1849-1863.

58
CHAPTER
Treating the Narrow
Midvault
Eric J. Culbertson and Jason Roostaeian
DEFINITION
■ The brow-tip dorsal aesthetic lines on frontal view are paired gentle
curvilinear lines starting at the medial brow curving medially along the nasal
bridge before transitioning laterally to the tip. This line can be disrupted by
bony irregularities of the upper third of the nose, middle vault contour
deformities in the middle third, and deviations of the tip or asymmetry of the
lower lateral cartilages in the lower third. Restoration of this and other nasal
aesthetic contours is key to achieving an optimal result following rhinoplasty
(FIG 1A).1
■ Narrowing of the midvault can cause both aesthetic deformity, commonly
appearing as an “inverted V,” and functional airway obstruction due to
narrowing of the internal nasal valve (FIG 1B).2
ANATOMY
■ The middle vault is composed of the paired upper lateral cartilages, overlying
soft tissue and skin, and underlying attached mucosa. Superiorly, the keystone
area (also referred to as the K area) is the junction of the upper lateral cartilages
with the nasal bones. Inferiorly in the scroll area, the upper and lower lateral
cartilages are connected by loose areolar and fibrous attachments (FIG 2).
■ The internal nasal valve is defined by the caudal border of the upper lateral
cartilage, the septum, the head of the inferior turbinate, and the piriform
aperture. Nasal airway resistance accounts for more than 50% of total airway
resistance during nasal breathing, and the internal nasal valve has the smallest
cross-sectional area of the nasal airway. The normal angle between the septum
and upper lateral cartilage is 10 to 15 degrees (FIG 3A). An angle below this

range can contribute to nasal obstruction (FIG 3B).3
PATHOGENESIS
■ Midvault narrowing is a common sequela of rhinoplasty, particularly following
dorsal hump reduction. Reduction of the cartilaginous component frequently
disrupts the relation and attachments of the septum with the upper lateral
cartilages, which form a single entity. Cartilage resection can result in an open
roof deformity and allow collapse of the upper lateral cartilages, narrowing the
internal valve angle and resulting in an inverted-V deformity and nasal
obstruction. Often, this may not become apparent for months or years after
surgery.
■ Patients at particular risk are those with short nasal bones, thin skin, weak
cartilages, or a combination thereof.2
■ Scar contracture from tumor resection or trauma involving the lower portion of
the nose may distort the internal nasal valve.
■ Facial paralysis may cause internal and external valve collapse through ptosis
of the lateral nasal soft tissues and loss of muscle tone that normally prevents
valve collapse, particularly on inspiration.
■ Weakening of the attachments between the upper and lower lateral cartilages
with age may lead to senile tip ptosis that can also cause internal valve
narrowing.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ A detailed nasal history should be obtained, in particular to include a history of
symptoms related to nasal obstruction, nasal allergies, prior nasal trauma, and
nasal surgeries. Any patient aesthetic concerns and goals should be elicited and
clearly defined.3,4
■ A complete external and internal nasal examination should be conducted in all
patients.
■ Evaluate symmetry of the upper lateral cartilages. An inverted-V deformity
may be present as a result of collapse of the upper lateral cartilages.

FIG 1 • Normal brow-tip aesthetics form paired
curvilinear lines from the medial brow to the tip (A).
Midvault narrowing can disrupt these lines and distort
the aesthetics of the nose, with a visible inverted-V
deformity (B).
FIG 2 • A,B. Normal nasal anatomy.
■ Perform a Cottle maneuver, where the cheek immediately adjacent to the nasal

sidewall is displaced laterally to assess for improvement in nasal airway
obstruction with widening of the internal nasal valves. Gentle internal elevation
of the upper lateral cartilages using a cotton-tipped applicator will also improve
breathing in patients with midvault narrowing. Patency of the internal nasal
valve during inspiration should also be assessed.
■ A nasal speculum is used to evaluate the septum for deformities and the
inferior turbinates for hypertrophy.
■ Standardized photographs including frontal, lateral oblique, and basal views
should be obtained in all patients.
IMAGING
■ Imaging is seldom required for diagnosis or treatment; however, supplemental
testing can be performed to assess airway dynamics. Rhinomanometry
measures pressure and flow during inspiration and expiration and provides a
measure of airflow resistance and nasal patency. Acoustic rhinometry analyzes
reflected sound waves directed through the nostrils and can be used to measure
cross-sectional area and nasal volume to quantify nasal obstruction.5
SURGICAL MANAGEMENT
■ The primary objective is to correct any functional airway obstruction caused
by narrowing of the internal nasal valve.
■ Aesthetic concerns and goals for treatment discussed with the patient may also
be addressed, particularly to restore symmetric and pleasing dorsal aesthetic
lines.
■ The use of spreader grafts to reconstruct the roof of the middle nasal vault and
open the internal nasal valve was first described by Jack Sheen, originally
through an endonasal approach.2 Either an open or endonasal approach may be
used for spreader graft placement. The use of the upper lateral cartilages as
autospreader grafts or flaps, reducing the need to harvest cartilage grafts, was
subsequently described.
Preoperative Planning
■ In planning the operative approach, it is important to carefully review the
preoperative photos and establish clear goals of treatment with the patient.
Consideration of previous operations, extent of previous nasal trauma, and
involved structures and available septal and other potential cartilage grafts (ear,
rib) should be taken into account. The patient should be informed of the

possible need to harvest cartilage from these other donor sites such as the ear or
rib.
Positioning
■ The patient is positioned supine on the operating table with arms tucked at the
side.
■ An oral right angle endotracheal tube is used for intubation, and should extend
inferiorly in the midline away from the nose, and secured without distorting the
upper lip and nose.
■ Nasal hairs may be trimmed, if desired.
FIG 3 • Normal middle nasal vault anatomy is
demonstrated. The normal angle between the septum
and upper lateral cartilages is 10 to 15 degrees (A). A
more acute angle may narrow the midvault and cause
obstruction of the internal nasal valve (B).

FIG 4 • Local anesthetic is injected into the nasal
sidewalls, columella, and inside the nostril along the
lower lateral cartilages.
■ Local anesthetic consisting of 1% lidocaine with 1:100 000 epinephrine is
infiltrated into the nasal sidewalls and columella and inside the nostril along
the lower lateral cartilages (FIG 4).
■ Oxymetazoline or 4% cocaine-soaked pledgets are placed in each nostril.
■ A throat pack is placed to prevent gastric accumulation of blood.
■ The face is prepped with dilute Betadine.
■ A sterile head wrap is placed followed by surgical drapes.
Approach
■ The open or closed (endonasal) approach to rhinoplasty may be used to correct
the narrow midvault, depending on the technique used, extent of prior surgery
or trauma, and other treatment goals.
■ Spreader graft placement, using either cartilage or autospreader flaps, corrects
the lack of dorsal support and helps restore a normal dorsal profile. If
additional cartilage is needed, this may be harvested from the rib or ear.
T E C H N I Q U E S
■ Open Spreader Graft Placement
■ After prepping and draping, the nasal pledgets are removed.

■ A gull wing or stair-step incision is marked on the columella at the narrowest
point, approximately at the midpoint, and extending along the side of the
columella just into the nostril.
■ This is incised with a no. 15 blade just through the dermis.
■ Infracartilaginous incisions are made laterally on each side (TECH FIG 1A).
■ The columella and alar incisions are connected.
■ Fine curved iris or converse scissors are used to complete the columellar
incision, with care taken to avoid injury to the medial crura.
■ The nasal tip is elevated from the lower lateral cartilages with scissors, and
dissection continued over the upper lateral cartilages up to the bony dorsum
(TECH FIG 1B).
■ The upper lateral cartilages are separated from the septum at the anterior
septal angle using fine iris scissors or a no. 15 blade, and the
mucoperichondrium on either side of the septum is incised onto the septal
cartilage (TECH FIG 1C).
■ Mucoperichondrial flaps are raised on either side of the septum using a
Cottle elevator (TECH FIG 1D).
■ The more proximal portion of the upper lateral cartilages is then separated
from the septum after complete release of the mucoperichondrium using a no.
15 blade to upstroke from distal to proximal. A converse retractor should be
used to protect the nasal skin.
■ Adequate septal cartilage is removed for spreader and any other needed
grafts as well as to correct any significant septal deviation, preserving 1 to
1.5 mm dorsal and caudal septal struts (TECH FIG 1E).
■ Spreader grafts are designed, typically measuring 1 to 3 mm in thickness, 3
to 5 mm in width, and 15 to 30 mm in length, depending on the patient’s
anatomy and degree of correction needed (TECH FIG 1F–H).
■ The spreader grafts are placed on each side of the septum, just below the
level of the upper lateral cartilages, extending from above the bony-
cartilaginous junction beneath the nasal bone to the caudal end of the upper
lateral cartilages (TECH FIG 1I).
■ The spreader grafts are secured in place with 2 to 3 interrupted 5-0 PDS
sutures passing through the spreader graft on one side, the septum, and then
the other graft (TECH FIG 1J).
■ The upper lateral cartilages are then reapproximated to the septum at the
midline over the spreader grafts using 2 to 3 interrupted 5-0 PDS sutures.

■ Mattress sutures of 4-0 plain gut are placed through the mucoperichondrial
flaps to close the dead space where septal cartilage was harvested.
■ The nose is thoroughly irrigated, hemostasis is achieved, and the nasal skin
is redraped.
TECH FIG 1 • A. The columella incision is made,
followed by infracartilaginous incisions laterally on
each side. The columella and alar incisions are then
connected. B. The nasal tip is elevated from the lower
lateral cartilages and dissection continued over the
upper lateral cartilages up to the bony dorsum. C. The

upper lateral cartilages are separated from the
septum, and the mucoperichondrium on either side of
the septum is incised onto the septal cartilage. D.
Mucoperichondrial flaps are raised on either side of
the septum. E. Septal cartilage is harvested with
preservation of 1 to 1.5 mm dorsal and caudal septal
struts. Spreader graft are designed (F), typically
measuring 1 to 3 mm in thickness, 3 to 5 mm in width
(G), and 15 to 30 mm in length (H). I. The spreader
grafts are placed on each side of the septum, just
below the level of the upper lateral cartilages. J. The
spreader grafts are secured in place with interrupted
sutures passing through the spreader graft on one
side, the septum, and then the other graft. K. The
columellar skin is reapproximated with interrupted 6-0
Prolene, and the infracartilaginous incisions are
closed with interrupted 5-0 chromic.
■ The columellar skin is reapproximated with interrupted 6-0 Prolene, and the
infracartilaginous incisions are closed with interrupted 5-0 chromic (TECH
FIG 1K).
■ Internal nasal splints are placed in each nostril and sutured through the
septum with a single 3-0 Prolene mattress suture.
■ Tape strips are applied to the nasal dorsum to limit postoperative swelling.
■ The throat pack is removed prior to extubation. A nasogastric tube may be
used to suction gastric contents to remove accumulated blood.
■ A mustache gauze dressing is applied across the upper lip to absorb any
nasal drainage.
■ Endonasal Spreader Graft Placement
■ The patient is positioned and prepared as previously described.
■ The nasal pledgets are removed after prepping and draping.
■ A Killian incision, approximately 1 to 1.5 cm cranially from the caudal

septal border, or a hemitransfixion incision at the caudal septal border is
performed through the mucoperichondrium using a no. 15 blade (TECH FIG
2A).
■ Submucoperichondrial dissection is performed using a Cottle elevator,
preserving the attachments to the septum dorsally for approximately 1 cm for
later spreader graft pocket creation (TECH FIG 2B).
■ The septum is incised vertically with a no. 15 blade or Freer knife with care
to preserve the contralateral mucoperichondrium.
■ Submucoperichondrial dissection is performed on the contralateral side,
again preserving attachments dorsally (TECH FIG 2C).
■ The septal cartilage can now be harvested using a no. 15 blade or Freer
knife, preserving an L strut of at least 1 cm dorsally and caudally.

TECH FIG 2 • A. A Killian incision is made
approximately 1 to 1.5 cm cranially from the caudal
septal border through the mucoperichondrium. B.
Submucoperichondrial dissection is performed,
preserving the attachments to the septum dorsally for
approximately 1 cm for later spreader graft pocket
creation. C. Submucoperichondrial dissection is
performed on the contralateral side, again preserving
attachments dorsally for later spreader graft
placement. D. The mucosa at the internal nasal valve
is incised, and a submucoperichondrial pocket is

developed on each side between the septum and
upper lateral cartilages. E. An approximately 5-mm-
wide pocket for spreader graft placement is developed
along the dorsal septum beneath the upper lateral
cartilages to the level of the nasal bones. F. This is
repeated on the other side. G. The spreader grafts are
inserted into each pocket, and the caudal aspects are
secured to the septum in a horizontal mattress fashion
(H). I. The mucosa is closed over the spreader grafts.
J. Mattress sutures are placed through the
mucoperichondrial flaps to close the dead space
where septal cartilage was harvested. K. Internal
nasal splints are placed in each nostril and sutured
through the septum.
■ Spreader grafts are shaped from the harvested cartilage, one or two
depending on whether unilateral or bilateral placement is desired.
■ Spreader grafts typically measure 1 to 3 mm in thickness, 3 to 5 mm in
width, and 15 to 30 mm in length, depending on the patient’s anatomy and
degree of correction needed.
■ The mucosa at the internal nasal valve is incised with a no. 15 blade, and a
submucoperichondrial pocket is developed on each side between the septum
and upper lateral cartilages (TECH FIG 2D).
■ Mucoperichondrial attachments to the septum between this plane and the
previous septal dissection are left intact for support along the floor of the
pocket.
■ An approximately 3 to 5 mm wide pocket for spreader graft placement is
developed along the dorsal septum beneath the upper lateral cartilages to the
level of the nasal bones using fine iris scissors. This is then repeated on the
other side (TECH FIG 2E,F).
■ The spreader grafts are inserted into each pocket, and the caudal aspects are
secured to the septum with a 4-0 chromic suture in a horizontal mattress
fashion (TECH FIG 2G,H).
■ The mucosa is closed over the grafts using 5-0 chromic suture (TECH FIG
2I).

■ Mattress sutures of 4-0 plain gut are placed through the mucoperichondrial
flaps to close the dead space where septal cartilage was harvested (TECH
FIG 2J).
■ Internal nasal splints are placed in each nostril and sutured through the
septum with a single 3-0 Prolene mattress suture (TECH FIG 2K).
■ The throat pack is removed prior to extubation. If necessary, a nasogastric
tube may be used to suction gastric contents to remove accumulated blood.
■ A moustache gauze dressing may be applied across the upper lip to absorb
any nasal drainage.
■ Autospreader Flaps
■ Positioning and prepping proceed as previously described.
■ The open approach is used to elevate the skin of the nasal tip and dorsum
and expose the upper and lower lateral cartilages and dorsal septum.
■ The upper lateral cartilages are separated from the septum using a no. 15
blade, and the mucoperichondrium on either side of the septum is incised
onto the septal cartilage.
■ Mucoperichondrial flaps are raised on either side of the septum using a
Cottle elevator.
■ 5-0 PDS sutures are placed caudal to the upper edge of the upper lateral
cartilages, thereby infolding the superior edge of the upper lateral cartilages,
serving a spreader-type function (TECH FIG 3).
■ The nose is thoroughly irrigated, hemostasis is achieved, and the nasal skin
is redraped.
■ The columellar skin is reapproximated with interrupted 6-0 Prolene, and the
infracartilaginous incisions are closed with interrupted 5-0 chromic.
■ Tape strips are applied to the nasal dorsum to limit postoperative swelling.
■ The throat pack is removed prior to extubation. A nasogastric tube may be
used to suction gastric contents to remove accumulated blood.
■ A mustache gauze dressing is applied across the upper lip to absorb any
nasal drainage.

TECH FIG 3 • Sutures are placed through the upper
lateral cartilages caudal to their upper edges, thus
infolding the superior edges against the septum and
serving an autospreader flap function.
PEARLS AND PITFALLS
Preoperative
■ A thorough discussion of the planned goals and risks should be
conducted with the patient to ensure appropriate expectations are
met.
Technique
■ The open technique provides greater control of spreader graft
placement and facilitates other alterations to the nasal structure,
particularly tip refinement.
■ The endonasal technique is especially useful in patients with long,
thin noses that are straight.
■ To minimize widening of the nasal dorsum and potential
palpability, place the spreader grafts just below the level of the
upper lateral cartilages.
■ Autospreader grafts may not be adequate to straighten the deviated

dorsum, and spreader grafts are preferred.
Postoperative
■ Have the patient avoid sleeping on a side as it will worsen edema
to one side and increase concern for deviation.
Prevention
■ Spreader grafts may be beneficial prophylactically following
dorsal hump reduction, particularly in patients with a high bony-
cartilaginous junction or weak upper lateral cartilages, in which
closure of the open roof with nasal bone infracturing alone may be
inadequate.
■ Preservation of the upper lateral cartilages during dorsal hump
reduction and reapproximation along the dorsal septum with
tension spanning sutures will frequently restore the midvault
without the need for spreader grafts.6
POSTOPERATIVE CARE
■ Surgery is performed on an outpatient basis.
■ Usual postrhinoplasty precautions are followed.
■ Keep the intranasal mucosa moist with frequent application of ointment and
saline nasal spray.
■ Any internal and/or external nasal splints are removed at 1 week.
■ Prolonged edema may occur and in some cases can take up to 1 year to fully
resolve.
OUTCOMES
■ The goals of functional and aesthetic improvement can be accomplished with
any of the described techniques.7,8 Optimal outcomes will be attained using the
technique with which the surgeon is most comfortable and able to achieve
consistent results.
COMPLICATIONS
■ Spreader grafts may widen the nasal midvault and/or tip, which may or may
not be desired. This is more likely with autospreader flaps.
■ Other possible short-term and long-term complications include infection,
hematoma, nasal asymmetry, septal perforation, worsening of nasal
obstruction, scarring, nasal bleeding/crusting, empty nose syndrome, and
prolonged edema that may last up to 1 year.
REFERENCES
1. Rohrich RJ, Muzaffar AR, Janis JE. Component dorsal hump reduction: the

importance of maintaining dorsal aesthetic lines in rhinoplasty. Plast Reconstr
Surg. 2004;114(5 suppl):1298-1308.
2. Sheen JH. Spreader graft: a method of reconstructing the roof of the middle
nasal vault following rhinoplasty. Plast Reconstr Surg. 1984;73(2 suppl):230-
239.
3. Howard BK, Rohrich RJ. Understanding the nasal airway: principles and
practice. Plast Reconstr Surg. 2002;109(3 suppl):1128-1146; quiz 1145-1126.
4. Rohrich RJ, Ahmad J. A practical approach to rhinoplasty. Plast Reconstr
Surg. 2016;137(4 suppl):725e-746e.
5. Aziz T, Biron VL, Ansari K, Flores-Mir C. Measurement tools for the
diagnosis of nasal septal deviation: a systematic review. J Otolaryngol Head
Neck Surg. 2014;43:11.
6. Roostaeian J, Unger JG, Lee MR, et al. Reconstitution of the nasal dorsum
following component dorsal reduction in primary rhinoplasty. Plast Reconstr
Surg. 2014;133(3 suppl):509-518.
7. Hassanpour SE, Heidari A, Moosavizadeh SM, et al. Comparison of aesthetic
and functional outcomes of spreader graft and autospreader flap in rhinoplasty.
World J Plast Surg. 2016;5(2 suppl):133-138.
8. Erickson B, Hurowitz R, Jeffery C, et al. Acoustic rhinometry and video
endoscopic scoring to evaluate postoperative outcomes in endonasal spreader
graft surgery with septoplasty and turbinoplasty for nasal valve collapse. J
Otolaryngol Head Neck Surg. 2016;45:2.

59
CHAPTER
Indications and Technique
for Increasing and
Decreasing Tip Projection in
Open Rhinoplasty
David A. Sieber and C. Spencer Cochran
DEFINITION
■ Proper tip projection can be determined through multiple methods.
■ The authors’ preferred method is to have a tip projection that is equal to the
length of the upper lip as measured from the white roll to the base of the
columella. This line should equal the distance from the base of the columella
to the tip-defining point. This method assumes that the upper lip is of normal
length and may not be applicable in all patients (FIG 1A).
■ Another method places a line from the alar crease to the tip-defining points
(lines A to B). A perpendicular line is then drawn from the upper lip through
lines A to B. Ideal tip projection is when A, 50% to 60% of AB (FIG 1B).
■ Goode method: a triangle is formed from a line drawn from the nasion
through the alar crease (A). The other sides are composed of a line from the
nasion to the tip-defining point (B) and another line from the alar crease to
the tip-defining point (C). An ideal tip has a B:C ratio of 0.55 to 0.6 (FIG
1C).
ANATOMY
■ Tip projection is dependent on numerous interrelated nasal structures:
■ Length and strength of lateral crura
■ Length and strength of medial crura
■ Septal angle
■ Fibrous attachments from the feet of the medial crura to the caudal septum

■ Attachments between the upper lateral and lower lateral cartilages at the
scroll area
■ Interdomal ligaments connecting the cephalic margins of the domes
■ Nasal skin and soft tissue envelope (this is the limiting factor in tip
projection)
PATHOGENESIS
■ Overprojection of the tip may be the result of one or many abnormalities in
nasal anatomy such as a prominent septal angle or excessively long and/or
strong medial or lateral crura.1
■ Likewise, underdevelopment or underprojection of the nasal tip may be due to
a weak septal angle or short and weak medial or lateral crura.2
■ More commonly, underprojection is the result of a poorly planned primary
rhinoplasty in which proper support either through the use of a columellar strut
or tip suturing was not employed, resulting in loss of tip support as the soft
tissue envelope contracts.3,4
FIG 1 • A–C. Common methods for determining proper
tip projection.

■ The tripod method for understanding tip projection is both relevant and
important to comprehend (FIG 2). As each leg of the tripod is modified to re-
establish proper tip projection, there is a resulting effect on tip rotation.
■ Proper support of each leg of the tripod is critical in maintaining tip projection
over time through the use of:
■ Columellar strut graft: forms foundation of the tip, maintains projection, and
prevents distortion
■ Extended alar contour grafts
■ Dorsal spreader grafts
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Patients presenting for primary rhinoplasty will complain of a nose that “sticks
out too far” or will state that they do not like the appearance of their nose on
profile view.

FIG 2 • Tip support is dependent on three independent
structures much like the legs of a tripod. The paired
lateral crura and the columella/medial crura form the
three legs of support.
■ Secondary rhinoplasty patients may complain of a “short” nose, stating that
their nose has become smaller over time.
■ Confirmation of nasal over- or underprojection should be confirmed using the
aforementioned methods.
IMAGING
■ Imaging may be performed using Vectra (Canfield, Parsippany, NJ) or
standard photographs and should be employed to establish preoperative
anatomy as well as to help determine surgical goals with the patient.
NONOPERATIVE MANAGEMENT
■ Although soft tissue fillers such as hyaluronic acid are used by some surgeons
as a nonsurgical option to change nasal contour, we do not advocate the use of

fillers in the tip to increase tip projection; the risk of vascular occlusion or
embolization that can result in injury to the remaining nasal vascular network
may lead to irreversible skin loss.
SURGICAL MANAGEMENT
■ Surgical management of tip projection should follow an organized and
incremental approach including the following:
■ Determine the cause of tip over- or underprojection.
■ Incrementally address each of the aforementioned factors.
■ Reset the desired tip projection based on preoperative planning and
intraoperative results.
■ Re-establish proper support in each leg of the tripod.
Preoperative Planning
■ Preoperative imaging should be reviewed with the patient to ensure that the
patient has realistic goals for surgery and that the desired surgical result can be
achieved.
Positioning
■ Patient is placed in the flat supine position.
■ General anesthesia and endotracheal intubation are preferred for this
procedure.
■ Approximately 5 cc of 1% lidocaine with 1:100 000 epinephrine is injected
into the planned columellar and marginal incisions.
■ The nose is packed with oxymetazoline-soaked gauze to assist with
hemostasis.
■ The patient is then prepped and draped in a sterile fashion.
Approach
■ Any change in tip projection should be performed through an open approach
for maximal control of tip positioning and support.
■ Tip projection is typically a result of a combination of factors and therefore
requires a stepwise approach for correction.
■ After each aforementioned factor is addressed, tip projection should be
reassessed by redraping the soft tissue envelope.

T E C H N I Q U E S
■ Opening the Nose
■ A transcolumellar incision is made as an inverted V or chevron shape across
the narrowest portion of the columella and extends around the columellar roll
to terminate on the midportion of the medial crura.
■ The soft tissue envelope is elevated from the tip and nasal dorsum to expose
the osteocartilaginous framework.
■ The soft tissue envelope should be widely undermined from the lateral crura
toward the piriform aperture. The destabilization of the nasal tip that occurs
when the soft tissue envelope is elevated in the open approach establishes a
modest amount of deprojection.
■ Any additional dorsal refinement is then preformed at this time prior to tip
modification.
■ Separation of Lower Lateral Cartilages
■ Divide the ligamentous attachments between the lateral crura and the upper
lateral cartilages. Also divide the suspensory ligaments traversing the septal
angle connecting the cephalic margins of the domes.
■ After the suspensory ligament has been divided, patients with a prominent
septal angle may require judicious trimming of the lower portion of the
cartilaginous dorsal septum. This can help prevent a “polly beak” deformity
resulting from excess dorsal septum in the supratip area.
■ If additional deprojection is required, the fibroelastic attachments between
the feet of the medial crura and the caudal septum should be released.
■ This is accomplished by dividing the lower lateral cartilages in the midline
to elevate mucoperichondrial flaps on either side of the caudal septum
beginning at the septal angle and extending to the nasal spine area.
■ These maneuvers will cause a deprojection of approximately 2 to 3 mm.
■ When all other factors have been addressed and the desired decrease in tip
projection still has not been achieved, the length and strength of the medial
and/or lateral crura must be altered.

■ Isolation of Lower Lateral Cartilages
■ Approximately 1.5 cc of 1% lidocaine with epinephrine is infiltrated into
each dome, lateral, and medial crura to hydrodissect the vestibular mucosa
off of the underside of the lower lateral cartilages.
■ If indicated, a cephalic trim is then performed using a no. 15 blade to remove
the cephalic excess from the lateral crura, making sure to leave at least 6 mm
of cartilage in place.
■ Using angled converse scissors, a spreading motion is used to separate the
vestibular mucosa from the cartilage.
■ Care must be taken not to tear the mucosa when developing the correct plane
of dissection.
■ Both the cephalic and caudal borders of the lower lateral cartilages must be
completely free from mucosal attachments.
■ The nasal mucosa needs to be freed from the lateral third of the lower lateral
crura down to the lower third of the medial crura. The medial and lateral
portions need to maintain some attachments to the mucosa so as to not avulse
the cartilage completely.
■ Once these maneuvers have been performed, the lower lateral cartilages
should be present as a single, continuous ribbon of cartilage (TECH FIG 1).
TECH FIG 1 • Appearance of lower lateral cartilages
with vestibular mucosa dissected off of cartilage.
Lower lateral cartilage should be present as a single
continuous “ribbon” of cartilage.

■ Determination of Tip Projection
■ This ribbon of lower lateral cartilage may then be reformed into the
appropriate segments composed of the lateral, middle, and medial crura.
■ The first step is to determine where the new dome should be located.
■ The location of the new dome will determine three interrelated factors:
■ Nasal length
■ Tip rotation
■ Tip projection
■ As the dome is moved from a more medial (caudal) to a lateral (cephalic)
position on the lower lateral cartilage, there will be a resultant decrease in
nasal length and projection with an increase in tip rotation (TECH FIG 2).
■ The caveat is that because you are creating a new dome, increasing tip
rotation, and causing tip deprojection, there will be an excess of cartilage in
the new medial crura.
■ Using these same concepts, additional tip projection can be created through
formation of a new dome in a more medial (caudal) position along the lateral
crura. This will in turn result in a decrease in tip rotation and an increase in
nasal length.
TECH FIG 2 • Location of new domes has been
established, causing deprojection and rotation of the
tip. Excess cartilage is now present in the area of the
medial crura.

■ Resupporting the Tip
■ It is the senior author’s (CSC) preferred technique to routinely use a
columellar strut for all rhinoplasties.
■ Using angled converse scissors, a pocket is created in the midline within the
soft tissue caudal to the edge of the septum. Some soft tissue needs to be left
between the columellar strut and septum to prevent “clicking” of the cartilage
postoperatively (TECH FIG 3A).
■ The length of the columellar strut helps to determine tip projection, and the
angle at which the soft tissue pocket is created helps to determine final tip
rotation (TECH FIG 3B).
■ A horizontal mattress using 5-0 PDS is made to secure the medial crura to
the columellar strut. This suture knot should be tied between the medial crura
and the columellar strut so as to prevent a palpable knot from forming
postoperatively.
■ Once the appropriate location for the dome has been determined, a simple 5-
0 PDS is passed through the new dome and into the columellar strut. The
position of this suture into the caudal vs cephalic portion of the dome will
also determine the degree of dome divergence. Typically, the suture is placed
in the cephalic third of the dome.
■ An identical suture is placed on the contralateral side.

TECH FIG 3 • A. A precise pocket is created for the
columellar strut which will act to re-establish and
support the new nasal tip location. B. The orientation
and height of the columellar strut help to determine tip
rotation and projection. C. Appearance of the lower
lateral cartilages once the new domes have been
secured to the columellar strut. With tip deprojection
and cephalic rotation, excess lower lateral cartilage is
forced into the medial crura as depicted here. D.
Excess cartilage has been excised and is secured to
the columellar strut. Cut edges of cartilage should be
placed within the soft triangle so as to not create
visible ridges postoperatively.
■ A third simple suture is then placed through the cephalic portion of one
dome, then through the cephalic portion of the columellar strut, and through
the contralateral dome.
■ At this point, the excess cartilage that has been forced into the medial crura
must be assessed (TECH FIG 3C).
■ A small amount of cartilaginous excess in the medial crura with a minimal
convexity may be plicated to the columellar strut using a 5-0 PDS as a
horizontal mattress.
■ If too much excess cartilage exists in the medial crura so that it creates a
visible convexity not correctable with a suture, then this excess will need to
be excised.
■ The segment of medial crural cartilage should be cut in a way so that the cut
edges of the cartilage lie within the soft triangle. This can either be in an end-
to-end fashion or with the proximal segment overlapping on top of the distal
segment. Leaving the ends of the cartilage too far posteriorly will create a
visible ridge on the columella postoperatively.
■ Two to three horizontal mattress sutures are then used to tie down the
cephalic, caudal, distal, and proximal edges of the cartilage to the columellar
strut (TECH FIG 3D). Failure to do so will again result in a visible ridge.
■ These techniques help incremental manipulation of tip projection, which

when properly supported, should provide the patient with a lasting result.
■ The soft tissue is then redraped, and the vestibular and columellar incisions
are closed.
PEARLS AND PITFALLS
Pitfall
■ Skin thickness is often the limiting factor in the amount of possible tip
deprojection because the skin must be able shrink around the
osteocartilaginous framework for the nose to have sufficient tip definition.
Pitfall
■ Changing the length of the lateral crura or medial crura can have the
potential to affect rotation.
Pitfall
■ The surgeon should be cognizant of the possibility of alar base flaring and
be prepared to correct the flaring with an alar base resection.
Pearl
■ Multiple factors contribute to tip projection. Incrementally eliminating these
factors will allow the surgeon to decrease tip projection in a controlled
manner.
Pearl
■ When the ligamentous attachments and fibroelastic attachments are
eliminated, the main support to the tip comes from the length and strength of
the lower lateral crura, especially in an open rhinoplasty where the support
from the skin has been eliminated.
POSTOPERATIVE CARE
■ Steri-Strips are applied to the dorsum with one in the infratip region to support
the new tip position.
■ A Denver Splint is placed onto the dorsum.
■ The Denver Splint and Steri-Strips are removed 7 days postoperatively.
OUTCOMES
■ FIGS 3 and 4 demonstrate representative examples of successful tip
modification using the described techniques.
COMPLICATIONS
■ Because of the destructive nature of tip refinement, the most common
complication requiring reoperation is a distortion or twisting of the nasal tip
due to abnormal scarring. This is typically resolved by releasing the soft tissue

envelope and the cartilaginous interfaces causing the distortion. The tip must
then be resupported as described.
■ The strength of the lateral crura needs to be evaluated intraoperatively. If they
are weak and are not resupported, then external nasal valve collapse may occur
postoperative. Support is best maintained through the use of a lateral crural
strut graft or extended alar contour graft.
FIG 3 • A,B. Frontal view of a 27-year-old female pre-
and 1-year postoperative from open primary rhinoplasty
with tip deprojection. C,D. Lateral view of a 27-year-old
female pre- and 1-year postoperative from open primary
rhinoplasty with tip deprojection.
FIG 4 • A,B. Frontal view of a 48-year-old female pre-
and 1-year postoperative from primary open rhinoplasty
with tip deprojection. C,D. Lateral view of a 48-year-old
female pre- and 1-year postoperative from primary open
rhinoplasty with tip deprojection.
■ After deprojection of the tip, the patient may have excess flaring of the alar

bases. This needs to be evaluated preoperatively with the patient as there may
be a need for an alar base resection to restore proportional nasal aesthetics.
REFERENCES
1. Johnson CM Jr, Godin MS. The tension nose: open structure rhinoplasty
approach. Plast Reconstr Surg. 1995;95:43.
2. Petroff MA, McCollough EG, Hom D, Anderson JR. Nasal tip projection:
quantitative changes following rhinoplasty. Arch Otolaryngol Head Neck Surg.
1995;117:783.
3. Rich JS, Friedman WH, Pearlman SJ. The effects of lower lateral cartilage
excision on nasal tip projection. Arch Otolaryngol Head Neck Surg.
1991;117:56.
4. Tardy ME Jr, Walter MA, Patt BS. The overprojecting nose: anatomic
component analysis and repair. Facial Plast Surg. 1993;9:306.

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61
CHAPTER
Technique for Ethnic
Rhinoplasty Using the Open
Approach
Dean M. Toriumi and Jeffrey T. Steitz
DEFINITION
■ The ethnic nose is very diverse and can encompass many different nasal
contours and anatomic variations. It is outside the scope of this chapter to cover
all of these anatomic variations. For this chapter, I will cover the Black and
Asian nose and how I use the open approach to perform structural grafting to
augment the nose.
■ When I use the term “ethnic” in this chapter, I will be referring to primarily
Black and Asian patients. These techniques may also prove to be effective in
the thick-skinned “Mestizo” nose. This is with the understanding that there are
many other forms of ethnic noses that have significantly different anatomy but
will not be emphasized in this chapter.
■ Many ethnic patients have an underprojected nose with a wide alar base and
poorly defined nasal tip. These patients also tend to have thicker skin. They can
have a low wide dorsum lacking definition on frontal view. Some ethnic
patients may have a dorsal hump with a low radix. All of these different
configurations require different management.
■ In general, most Black and Asian patients require augmenting their nose to
stretch the thick skin envelope to create improved contour. This requires
cartilage grafting to push out and stretch the thick skin envelope making the
lateral view larger to enhance the appearance of the frontal view.
ANATOMY
■ The anatomy of the Black and Asian nose can vary significantly from patient
to patient. Most ethnic patients will tend to have thicker sebaceous skin that is

much thicker in the lower half of the nose. They tend to have weak lower
lateral cartilages that can make controlling and preserving tip projection very
difficult.
FIG 1 • The normal relationship between the infratip
lobule and ala demonstrates a “gull in flight”
appearance on the frontal view. This translates to a 2-
to 3-mm columellar show on the lateral view.
■ Ethnic patients tend to have a short weak nasal septum that lacks caudal
projection leaving a deficiency in tip support. For this reason, adding structural
support is critical to providing a good aesthetic and functional outcome.
■ Ethnic patients may demonstrate a reversal of the normal “gull in flight”
appearance of the transition from alar margin to infratip lobule (FIG 1).1 Many
of these patients will demonstrate a reversal of normal with retraction of the
columella in relation to the hanging alar lobule (FIG 2). Correction of the
retracted columella requires a large caudal septal extension graft that can push
the columella and infratip lobule inferiorly to create a more normal “gull in
flight” appearance to the alar lobular transition to the infratip lobular
projection.2 This graft will act to move the columella/infratip lobule or central
compartment inferiorly to create a more favorable relationship between the ala
and infratip lobule.
■ Ethnic patients also tend to have a wide alar base that creates a discrepancy
between the width of the upper third of the nose and the width of the lower
third of the nose. It is preferable to avoid overnarrowing the upper third of the