Operative Technique in Plastic Surgery – Kevin C.Chung

patient. This will help ensure your aesthetic goals align with those of the
patient.
■ The linkage between lack of structural support and the large thick skin
envelope must be pointed out to the patient as well.
■ One of the key concepts in ethnic rhinoplasty (Black and Asian) is to realize
that it is usually necessary to augment the lateral view via dorsal augmentation,
place a caudal septal extension graft and possibly a shield-type tip graft to
stretch the thick skin, and create a narrowing effect on the lateral view. By
stretching the skin on the nose, particularly in the nasal tip area, definition can
be increased and narrowing can be achieved. This can be very difficult for both
the surgeon and patient to understand, but thick-skinned patients rarely look
better when the nose is reduced unless the skin is able to contract. Typically,
the thicker skin of the lower third of the nose will not contract significantly,
potentially leaving a polly beak deformity, a wider scarred nasal tip, and an
underprojected tip complex.
■ Expanding and augmenting the lateral view can also improve the lateral view
by lifting the upper nasal dorsum to match the projection of the prominent
thicker supratip skin by creating a straighter profile (FIG 3).

FIG 3 • By augmenting the lateral view, the upper nasal
dorsum can frequently be elevated to the level of the
prominent supratip skin creating a straighter dorsal line.
SURGICAL MANAGEMENT
■ It is preferable to perform these surgeries under general anesthesia. With the
patient intubated, the airway is protected from blood contacting the vocal cords
and potentially causing laryngospasm. A protected airway is particularly
important if any work is planned on the nasal septum or turbinates.
■ Local anesthetic agent (1% lidocaine with 1:100 000 epinephrine) is injected
into the nose to provide hemostasis. Injections are made along the septum,
along the marginal incisions, over the nasal dorsum and middle vault, and in
the nasal tip area. At least 10 minutes should pass before the procedure is
initiated to allow the full vasoconstrictive effect to set in.
T E C H N I Q U E S

■ Harvesting Cartilage for Grafting
■ Auricular cartilage can be harvested but is not ideal for grafting. The
auricular cartilage is softer and weaker than costal cartilage and usually not
adequate for augmentation cases. If auricular cartilage is harvested, the
posterior approach is preferred to minimize the chance of ear deformity or
change in position.
■ In most ethnic patients, a larger amount of cartilage is needed for grafting.
Costal cartilage is preferable and can be harvested from a smaller 11-mm
incision3 (TECH FIG 1A). It is recommended to use a larger incision when
less experienced because safety is most important when harvesting costal
cartilage.
■ The 6th or 7th ribs are ideal for cartilage grafting material in the ethnic
patient. If a longer dorsal graft is needed, it is preferable to use the seventh
rib as it is straighter and longer. The 6th rib tends to have a genu that will
shorten the straight segment that could be used for dorsal augmentation. If
both dorsal augmentation and premaxillary augmentation need be performed,
two costal cartilage grafts may be harvested.
■ Costal perichondrium should be harvested as well, because this material can
be used for camouflage and to aid in fixation of the dorsal graft to the
underlying dorsal nasal bone. In these cases, the costal perichondrium is
placed as an interpositional graft that is sutured to the undersurface of the
dorsal graft. The nasal dorsum is rasped or perforated with a 3-mm straight
osteotome, and then the dorsal graft with perichondrium is placed over the
nasal dorsum. The perichondrium will rigidly fix the dorsal graft to the
underlying nasal dorsum.

TECH FIG 1 • A 4.5-cm segment of costal cartilage
harvested through an 11-mm incision.
■ Open Approach
■ An inverted-V incision is made at the level of the midcolumella (TECH FIG
2A). The position of the incision can be varied depending on the goals of the
surgery. In most ethnic patients, the goal is to increase nasal tip projection.
■ The columellar incision is connected to bilateral marginal incisions made
along the caudal margin of the lateral crura.
■ The columellar flap is elevated off of the medial crura. Care is taken to avoid
damaging the columellar flap.
■ During flap elevation, dissection can be performed just below the subdermal
plexus leaving the fibrofatty tissue of the nasal tip and supratip on the
cartilages to then be excised (TECH FIG 2B,C).
TECH FIG 2 • A. Position of the inverted-V
midcolumellar incision marked out in yellow. B. A

Black patient with thick skin after flap elevated leaving
fibrofatty tissue on the lower lateral cartilages. C. After
fibrofatty tissue dissected from cartilages.
■ Exposing the Nasal Septum
■ Dissection is performed between the medial crura to access the caudal
septum. Typically, the caudal septum is further cranial than in most
Caucasian patients (TECH FIG 3). After identifying the caudal septum,
mucoperichondrial flaps are elevated.
■ Septal deviations can be corrected, and septal cartilage can be harvested for
grafting purposes. Most ethnic patients have small harvestable segments of
cartilage that are available.
TECH FIG 3 • Caudal septum exposed and bilateral
mucoperichondrial flaps elevated. Note how far cranial
the caudal septum is set back.
■ Managing the Nasal Dorsum
■ In most ethnic patients, the nasal dorsum needs augmentation. Major dorsal
augmentation with costal cartilage will be covered in another chapter.
■ Many ethnic patients will require radix augmentation to elevate a deep radix.
When placing a radix graft, smaller grafts can be fixated using a
transcutaneous suture (TECH FIG 4A–C).
■ If a modest degree of dorsal augmentation is required, septal cartilage can be

used. It is helpful to camouflage the lateral margins of the dorsal graft with
soft tissue (costal perichondrium, temporalis fascia, etc.) (TECH FIG 4D,E).
■ Larger dorsal grafts will be fixated to the nasal dorsum by suturing costal
perichondrium to the undersurface of the dorsal graft (TECH FIG 4F).3,4
The dorsal graft is then placed on the nasal dorsum after perforating the nasal
bones with a 3-mm straight osteotome. The perichondrium ossifies, resulting
in rigid fixation of the dorsal graft to the nasal dorsum. This method of
fixation is covered in Chapter 76.
TECH FIG 4 • A. Soft cartilage radix graft over radix
area. B. A 6-0 Monocryl suture placed
transcutaneously to fix radix graft into position. C.
Transcutaneous fixation suture in place over radix
area. D. For lesser degrees of dorsal augmentation,
septal cartilage can be used. Septal cartilage dorsal
graft with costal perichondrium sutured to the lateral
margins to camouflage the graft. E. Lateral view
showing the perichondrium draped over the edges of
the dorsal graft. F. For major dorsal augmentation,
costal perichondrium is sutured to the undersurface of
the dorsal graft and placed on top of the nasal bones
after they have been perforated with a 3-mm straight

osteotome. The perichondrium will act to ossify the
dorsal graft and fixate it to the bridge.
■ Middle Nasal Vault
■ Most ethnic patients do not require dorsal hump reduction. In this case, there
is no need to open the middle nasal vault unless deviated. The spreader grafts
can be placed into submucoperichondrial pockets to stabilize the dorsal
septum and extended caudally to stabilize the caudal septal extension graft.
■ Submucoperichondrial tunnels are dissected using a narrow Cottle elevator.
The elevator is advanced superiorly in a submucoperichondrial plane up to
the nasal bones (TECH FIG 5).
■ After the tunnels are created, spreader grafts are fashioned and placed into
the submucoperichondrial tunnels. The spreader grafts should fit rather
snugly into the pockets. The grafts are left to extend beyond the caudal
septum to stabilize the caudal septal extension graft.
■ The spreader grafts are fixated using a single 5-0 PDS suture that traverses
the spreader grafts and septum.

TECH FIG 5 • Spreader grafts placed into
submucoperichondrial tunnels. A. Cottle elevator used
to create the tunnels. B. Making the right tunnel. C.
Making the left tunnel. D. Left spreader graft ready to
be inserted into the tunnel. E. Left spreader graft
being positioned. F. Right spreader graft. G. Both
spreader grafts in place. H. Bilateral spreader grafts in
place.
■ Stabilizing the Nasal Base
■ The nasal base is stabilized using a caudal septal extension graft. Typically,
the extension graft is slightly wider along the anterior margin (TECH FIG
6A–D). The extension graft is stabilized anteriorly using the extended
spreader grafts and inferiorly using thin slivers of cartilage placed across the
caudal septum and the extension graft.5,6 The grafts are sutured in place with
5-0 PDS sutures.
■ After the extension graft is stabilized, the medial crura are fixed to the septal
extension graft using a 4-0 plain on an SC-1 needle. It is helpful to pull the
medial crura and columella anteriorly to open the nasolabial angle and
increase projection (TECH FIG 6E–G). This suture is followed up with a 5-
0 PDS suture that is placed between the medial crura catching the caudal
septum as well.

TECH FIG 6 • A. Rectangular-shaped caudal septal
extension graft ready to be sutured between the
spreader grafts. B. Caudal septal extension graft
being fixed to extended spreader grafts. C. Caudal
septal extension graft in place. D. Caudal septal
extension graft from the side. E. Caudal septal
extension graft from below. Note the position of the
medial crura. F. Medial crura are advanced anteriorly
to open nasolabial angle and increase tip projection.
G. Medial crura sutured to caudal septal extension
graft.
■ Managing the Nasal Tip
■ Nasal tip contour and definition are controlled by what is done at the tip
lobule. In most ethnic patients, a tip graft is placed over the domes to provide
additional tip projection and tip definition.7 There is rarely any need to
reduce the lateral crura as the tip grafting is what achieves the change in
lobular contour. Furthermore, the lateral crura tend to be very weak, and any
reduction can result in weakening of the tip structure.
■ An onlay-type tip graft can be sutured horizontally over the domes (TECH
FIG 7A,B). These tip grafts are typically softer cartilage and are sutured over

the domes using two 6-0 Monocryl sutures.
■ In most patients with thicker skin, a shield-type tip graft is used. In these
cases, if the shield-type tip graft extends more than 2 mm but less than 3 mm
above the existing domes, a buttress graft is used to stabilize the posterior
surface of the graft to prevent it from rotating cephalically (TECH FIG 7C–
E).9 This graft prevents over-rotation of the nasal tip lobule.
■ If shield-type tip graft projects more than 3 mm above the domes, lateral
crural grafts are used to stabilize the shield-type tip graft. These grafts are
angled at 45 degrees off of the midline and sutured to the posterior surface of
the shield graft to stabilize it and prevent it from rotating cephalically (TECH
FIG 7F–H). Lateral crural grafts are different from lateral crural strut grafts
that are placed under the lateral crura between lateral crus and the underlying
vestibular skin. Lateral crural grafts are placed on top of the lateral crura and
are used to stabilize the shield-type tip graft.3,7
Alar Rim Grafts
■ In some patients after placing the shield-type tip graft and stabilizing it with
a buttress graft or bilateral lateral crural grafts, additional camouflage is
needed to prevent visibility. In such cases, alar rim grafts can be placed. Alar
rim grafts are usually sutured to the lateral margin of the shield-type tip graft
with a 6-0 Monocryl suture (TECH FIG 8A–F). Then, the alar rim graft is
placed into pockets along the marginal incision. The alar rim graft is placed
into the pockets by suturing a guide suture to the end of the alar rim graft.
Then, the alar rim graft is advanced using the guide suture into the depth of
the pocket, and the suture is sutured over the mucosa with a loop and left
until the cast is removed. This helps to prevent the alar rim graft from
becoming displaced.
■ If additional camouflage is needed, soft tissue (scar tissue, fascia, or costal
perichondrium) can be sutured over the domes using a 6-0 Monocryl suture
(TECH FIG 8G,H).

TECH FIG 7 • A. Onlay-type tip graft sutured over the
domes. B. Onlay-type tip graft from side view. C.
Shield-type tip graft with buttress graft sutured to
posterior surface of the shield graft to stabilize it. D.
Side view. E. Note how the buttress graft extends
lateral to the shield tip graft. F. Shield-type tip graft
from above with lateral crural grafts extending off the
posterior surface of the tip graft to stabilize it. G. Side
view showing angulation of the graft. H. Note the
shield shape of the tip graft.
TECH FIG 8 • A. Alar rim grafts sutured to the lateral
margins of the shield-type tip graft. B. Guide suture
sutured to the end of alar rim graft. C. Alar rim graft

placed into pockets along marginal incision. D. Guide
suture pulled taught to pull alar rim graft into the depth
of the pocket. E. Tying guide suture over the vestibular
skin. F. Basal view at the end of the operation with
yellow arrows pointing to knots tied over vestibular
skin. G. Costal perichondrium sutured over leading
edge of the shield-type tip graft for camouflage. H.
Lateral view showing perichondrium over tip graft.
■ Managing the Alar Base
■ If necessary, alar base reduction can be performed to decrease the size of the
nostrils and to narrow the nasal base. In most ethnic patients, a lateral alar
base reduction can be used to decrease alar flare (TECH FIG 9A–C). In
patients with larger nostrils, a combination of internal and external alar base
reduction is performed (TECH FIG 9D–K). This type of resection involves
extending the excision into the nostril and onto the nostril sill. The design of
the excision depends on the size of the nostril and the amount of lateral alar
flare.

TECH FIG 9 • A. Planned lateral alar base reduction
to decrease alar flare. B. Note how the excision is
above the alar groove to allow some eversion of the
skin edge. C. After lateral alar base excisions are
completed. D. Preoperative frontal view showing wide
alar base. E. Planned combined internal and external
excisions to decrease nostril size and alar flare. F.
Excising skin. G. Alar base reduction completed. H.
Preoperative close-up frontal view. I. One-year

postoperative close-up frontal view (right). J.
Preoperative base view. K. Postoperative base view.
■ After making the skin excision, a subcutaneous 6-0 Monocryl suture is
placed to help with approximation of the nostrils. The skin edges are
approximated using 7-0 nylon vertical mattress sutures with some
interspersed 6-0 fast-absorbing gut sutures.
Nasal Base Bunching
■ In some ethnic patients, excision alone is not adequate to narrow the base of
the nose. In these cases, a nasal base bunching suture can be used to further
narrow the base of the nose (TECH FIG 10A). A 3-0 Mersilene suture is
passed from one alar base excision site to the other and cinched down to
narrow the nasal base (TECH FIG 10B–E). It is helpful to place some
fibrous tissue around the suture as it is passed through the skin to act a “stop”
to prevent the suture from tearing through the tissues.

TECH FIG 10 • A. Alar base bunching suture. A
nonresorbable multifilament suture is passed across
the base of the nose to create a narrowing effect. B.
Marked-out path of alar base bunching suture. C. 3-0
Mersilene suture on large needle. D. Suture passed to
the left side via alar base reduction incisions. E. After
alar base bunching suture placed. Note narrowing at
the end of the case.

PEARLS AND PITFALLS
Approach
■ Avoid making columellar incision too high or too low. Keep
incision away from the soft tissue triangle.
Grafting
material
■ Harvest adequate cartilage for grafting to avoid suboptimal
outcomes.
Nasal dorsum
■ Avoid excessively narrowing the nasal bones and potentially
creating imbalance between upper and lower third of the nose.
Approach to
managing the
ethnic nose
■ Avoid reducing the Black or Asian nose as most of these
patients require expansion of the skin envelope using cartilage
grafts and stabilization of the nasal base.
Stabilizing
nasal base
■ Make sure the nasal base is adequately stabilized. In most cases,
a columellar strut may be inadequate.
Managing
nasal tip
■ If a shield-type tip graft is placed, make sure it is adequately
stabilized using a buttress graft, lateral crural grafts, or alar rim
grafts.
Managing the
alar base
■ When performing alar base reduction, avoid excessive excision.
FIG 4 • A Black patient with wide nasal nose and

underprojected nasal tip. A. Preoperative frontal view
(left). Two-year postoperative frontal view (right). B.
Preoperative lateral view (left). Postoperative lateral
view (right). C. Preoperative oblique view (left).
Postoperative oblique view (right). D. Preoperative base
view (left). Postoperative base view (right).
POSTOPERATIVE CARE
■ No nasal packing is used in the rhinoplasty patients. A running quilting 4-0
plain gut suture is used to approximate the septal flaps.
■ Cast is removed on the 7th postoperative day.
■ Patients should avoid salty foods postoperatively to minimize edema.
■ Kenalog (10 mg/mL) can be injected deep into the tissues of the nasal tip to
decrease edema and help to prevent scarring. These injections can be started at
1 month postoperatively and repeated every 3 months.
OUTCOMES
■ Improved nasal tip definition and stronger profile can be expected after
augmenting the nose using structural grafting (FIG 4).
COMPLICATIONS
■ Infection is rare but can occur when extensive cartilage grafting is performed.
■ Potential complications include asymmetries, deviation, and irregularities.
■ If costal cartilage is used, warping of the cartilage can occur.
■ Postoperative polly beak deformity can occur if there is a loss on tip projection
or if there is prolonged supratip edema.
■ Postoperative loss of nasal tip projection can be seen if the nasal base is not
adequately stabilized.
■ Potential visibility of the shield-type tip graft over time.
REFERENCES
1. Gunter JP, Rohrich RJ, Friedman RM. Classification and correction of alar-
columellar discrepancies in rhinoplasty. Plast Reconstr Surg. 1996;97(3):643-
648.
2. Toriumi DM. Caudal septal extension graft for correction of the retracted
columella. Oper Tech Otolaryngol Head Neck Surg. 1995;6(4):311-318.

3. Toriumi DM, Pero CD. Asian rhinoplasty. Clin Plast Surg. 2010;37(2):335-
352.
4. Toriumi DM. Discussion: use of autologous costal cartilage in Asian
rhinoplasty. Plast Reconstr Surg. 2012;130(6):1349-1350.
5. Bahman Guyuron MD, Amin Varghai BS. Lengthening the nose with a
tongue-and-groove technique. Plast Reconstr Surg. 2003;111(4):1533-1539.
6. Toriumi DM. Structure approach in rhinoplasty. Facial Plast Surg Clin North
Am. 2002;10(1):1-22.
7. Toriumi DM. New concepts in nasal tip contouring. Arch Facial Plast Surg.
2006;8:156-185.

62
CHAPTER
Technique for Treating the
Crooked Nose
Ali Totonchi, Navid Pourtaheri, and Bahman Guyuron
DEFINITION
■ A crooked nose is a nose with a portion of its midline structures deviating
away from the facial midline along any extent of its cranial to caudal or
anterior to posterior dimension.
ANATOMY
■ The crooked nose involves deviation or asymmetry of one or more structural
components of the nose, including nasal bones, upper lateral cartilages, lower
lateral cartilages, septum, and nasal spine.
PATHOGENESIS
■ The crooked nose may be a result of trauma, collapse or cicatrix after surgery,
cocaine abuse, infection, mass effect from tumor, congenital defects, or
improper development.
■ The crooked nose can affect nasal airway patency and sinus drainage in
causing sinus or migraine headaches.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ A complete patient history, including prior nasal and facial reconstructive or
aesthetic procedures, should be reviewed.
■ It is essential to collect a history of nasal trauma, airway complaints, allergies,
sinus symptoms, and headaches.
■ A crooked nose can be associated with sinus infections, sinus headaches and
migraines, or nasal airway obstruction. Assessing for these factors and
postoperatively tracking these symptoms aid in gauging the benefits of
surgery beyond its aesthetic outcome.

■ Unilateral nasal airway obstruction that is persistent or obstructive symptoms
during quiet and deep inspiration is a reliable indicator of mechanical airway
compromise, such as an enlarged turbinate, septal or nasal deviation, or
incompetent internal or external nasal valve that should be addressed during
surgery. Cyclical nose obstruction is a physiological or occasionally
pathological change that may not improve with surgery.
■ It is crucial to obtain a history of medications that can lead to bleeding (ie,
aspirin and NSAIDs) and behaviors that may affect wound healing (ie,
smoking, poor diet, steroid use). Discussion of these deleterious factors and
their potential impact on postoperative outcomes with the patient may improve
patient compliance.
■ Patient expectations should be assessed and managed, and the patient’s role
in facilitating a successful outcome should be emphasized.
■ Physical examination should include facial analysis to assess for overall
symmetry, canting of the occlusal plane, alignment of the nose with the rest of
the face, and chin position in relation to the upper and the lower incisor
midlines, lips, and upper face midline.
■ The nasal midline should be at the intercanthal midline rather than the
intereyebrow midline, because patients often pluck their eyebrows
differentially to align the midline of the deviated nose with the altered
eyebrow.
■ Nasal analysis should assess each structural component and their degree of
deviation. This should include observation of asymmetric nasal bones, a
deviated caudal dorsum (septum and upper lateral cartilages), or a deviated
nasal base (septum and lower lateral cartilages).
■ Midvault deviation always involves anterior septal deviation and is
commonly associated with mid- and posterior septal deviation.
■ By tilting the patient’s head up for an examination of the basilar view, one
can assess the deviation or asymmetry of the columella, tip, footplates,
nostrils, and alar bases. An overhead view may detect the external nasal
deviation more clearly. The most powerful view for observation of nose
deviation is a full-smile frontal view.
■ Palpation to assess the three-dimensional frame of the nose could prove
helpful:
■ One can palpate the nasal bones, upper lateral, and lower lateral cartilages, as
well as the membranous septum, tip support, the caudal cartilaginous septum,
and the anterior nasal spine. The latter is done by placing this structure

between the dominant index finger and the thumb and confirming the midline
positioning of this structure precisely.
■ Percussion over the frontal, ethmoid, and maxillary sinuses can elicit
tenderness. This may be indicative of inflammation of the underlying sinuses.
■ To assess nasal valve competence or airway patency, one can occlude the
patient’s nostril one side at a time and ask the patient to inhale normally and
then deeply.
■ During the modified Cottle test, the examinee asks the patient to breathe
quietly while supporting the nostril open at the level of the external and then
internal nasal valve with a cotton-tip applicator or the speculum. If breathing
is improved, this represents a positive test and indicates internal and/or
external nasal valve incompetence.
■ An internal nasal exam using a speculum can detect septal deviation, enlarged
turbinates, synechiae, perforation, spurs, and contact between the turbinates
and the septum:
■ Septal deformities observed may include septal tilt, C- or S-shaped deviation
in the anteroposterior or cephalocaudal dimensions, or localized deviation
with septal spurs. When there is a septal tilt, usually there is no curve to the
septum, and the caudal septum is dislocated to one side of the vomer bone.
This is the most common class of septal deviation, followed by C-shaped
anteroposterior septal deviation.
■ Crusting, purulence, ulceration, or presence of polyps should also be noted.
■ It is important to observe and document the color and size of the turbinates—
pale boggy turbinate mucosa may indicate allergic rhinitis, whereas
erythematous mucosa may indicate infection or inflammatory rhinitis.
■ Analysis of the turbinates may reveal hypertrophy that typically occurs on
the side ipsilateral to the external deviation or a paradoxical curl, which can
misdirect the air and increase turbulence of airflow through the nose.
■ Analysis of the nasal valves and internal nose should be repeated before and
after vasoconstriction of the nasal mucosa using 0.25% phenylephrine or 1%
ephedrine sulfate delivered via an aerosolized misting system or topically with
cottonoid pledgets:
■ Posterior rhinoscopy is often helpful in patients with nasal airway obstructive
symptoms.
■ Visualization of the posterior nasal airway is best achieved using a 0- or 30-
degree nasal endoscope.

IMAGING
■ Life-sized photographic and cephalometric analysis should be performed to
confirm the findings of the physical examination and allow for measurements
used to plan for surgical correction, particularly on patients who are expecting
aesthetic improvement.
■ Computed tomographic (CT) imaging of the nose and perinasal sinuses is not
obtained routinely but can provide valuable information in the following cases
(FIG 1):
■ Patients with frequent sinus headaches, sinus infections, or migraine
headaches
■ Patients for whom the extent of deviated structures are not clear after
physical examination
■ Imaging provides clear visualization of the nasal bones, septum, turbinates,
or a mass that may have contributed to the nasal deviation.
■ The CT may reveal many conditions such as septal deviation, large posterior
spur sinusitis, concha bullosa, septal bullosa, Haller cell, and contact points.
FIG 1 • Coronal CT image illustrating a deviated nasal
septum and asymmetric turbinates. (Reprinted from
Guyuron B. Correcting deviated noses, septoplasty, and
turbinectomy. In: Rhinoplasty. Philadelphia, PA:
Elsevier; 2012:306, with permission from Elsevier.)
SURGICAL MANAGEMENT
■ The crooked nose usually presents with multiple deviated substructures, and

successful surgical correction requires complete elimination of deviation from
all substructures.
■ Surgical techniques for correction of the crooked nose will be discussed for
each substructure of the nose that may be involved.
Preoperative Planning
■ Analysis of life-sized photographs and measurements of the deviation from the
midline for each component of the nose can be valuable in correcting the
deviation and discussing the surgical plan with the patient preoperatively.
“Morphed” or simulated preoperative photos demonstrating the intended
surgical changes can help the patient understand the surgical goals and manage
the patient’s expectations prior to obtaining final written consent for the
procedure. It is crucial to clearly indicate to the patient that there cannot be any
guarantee that the simulated or intended results may not be achieved.
■ If there is a need for cartilage grafts, the first choice is septal cartilage as long
as there is enough cartilage present. It is important to discuss with the patient
the potential need for cartilage from a second site such as a conchal or costal
graft if the septal cartilage is too deformed, absent, or insufficient to correct the
nasal deformities planned.
Positioning
■ The patient is placed in supine position with the arms tucked by their sides.
■ After induction of general anesthesia, the airway is secured with dental floss or
dental wire to the first premolar.
■ The table is turned 90 degrees away from anesthesia to optimize access to the
face and nose.
■ The internal nasal hairs are trimmed with a pair of curved iris scissors, and the
internal nose is cleansed with cotton swabs.
■ The entire face is prepped with Betadine solution. After 1 to 2 minutes, the
Betadine is wiped away with sterile saline solution.
■ A split drape is placed sterilely around the face to expose the forehead up to
the hairline and down to the chin.
■ This exposure allows for continual assessment of the nasal midline with
respect to the facial midline and the effect of surgery on the upper lip position.
Approach
■ An open approach is the authors’ preferred method for correcting significant

deviation or if other concomitant rhinoplasty maneuvers are planned.
■ Deviation of the upper nasal third or bony vault involves the nasal bones and
will require osteotomies for correction.
■ Deviation of the midvault involves the septum and in most cases the upper
lateral cartilages, which have to be separated from the septum and differentially
trimmed after septoplasty and completion of nasal bone osteotomies. Other
techniques, such as spreader grafts and/or septal rotational sutures, may be
indicated.
■ Deviation of the lower nasal third or nasal base involves the lower lateral
cartilages, and successful correction may require elongation of the short side,
shortening of the long side, reshaping, and/or the use of cartilage grafts.
T E C H N I Q U E S
■ Administration of Local Anesthesia
■ It is important to achieve long-lasting and profound local anesthesia and
vasoconstriction using the double-injection method:
■ Initial injection includes approximately 10 cc of 1% Xylocaine with 1:200
000 epinephrine solution.
■ If a turbinectomy is indicated, inject the turbinates using a 25-gauge spinal
needle.
■ Cottonoid gauze saturated in oxymetazoline hydrochloride or
phenylephrine solution is inserted deep in the nose as far cephalically and
posteriorly as possible to produce vasoconstriction of the lining of areas
that are difficult to reach with injection.
■ The injection should be performed with precision and in an organized
manner, starting from the radix into soft tissues along the lateral and medial
surface of the nasal bones profusely, along the medial surface of the nasal
bones, followed by injection along the nasal base and columella, the dorsal
septum on either side of the nasal roof, and the lining on either side of the
vomer as far posteriorly as possible.
■ After a few minutes, the injection is repeated in the same order of initial
injection using approximately 10 cc of 0.5% ropivacaine with 1:100 000
epinephrine.

■ This double-injection method starting with 1:200 000 solution reduces
systemic uptake of the higher epinephrine concentration in the second
injection that may otherwise cause hypertension, tachycardia, or
arrhythmia. Ropivacaine in the second injection is longer lasting, which
minimizes discomfort and the need for analgesics in the early postoperative
period. Additionally, the initial injection by virtue of vasoconstriction
renders the effects of the second injection more intense and produces
protracted anesthesia.
■ Nasal Bone Correction
Unilateral Nasal Bone Correction
■ Unilateral nasal bone deviation not affecting the internal nasal valve patency
can be corrected with an onlay graft:
■ Septal cartilage (provides the most predictable outcome), conchal cartilage
(gently crushed as a single or double layer), diced cartilage, soft tissue such
as dermis, fascia graft, or fat injection may be used for this purpose.
■ An intercartilaginous incision is made to expose the target nasal bone.
• A limited pocket is created by elevation of the periosteum using a Joseph
periosteal elevator.
■ The graft is positioned in the subperiosteal plane and molded into place.
■ The incision is loosely approximated to allow for drainage.
■ If the nasal bone shift is associated with medial transposition of the upper
lateral cartilages, this may compromise ipsilateral internal valve function and
requires correction by unilateral out-fracture.
■ A small vestibular incision at the pyriform aperture is made, and the
periosteum is elevated using a Joseph periosteal elevator.
■ A low-to-low osteotomy and out-fracture of the nasal bone can be used to
reposition the bone.
■ A spreader graft may be placed to avoid return of the nasal bone to its
previous position as follows:
• Make a 3-mm-long incision in the mucoperichondrium immediately
caudal to the junction of the upper lateral cartilage and the septum as
anteriorly as possible.
• A septal elevator is used to create a pocket only large enough to
accommodate the spreader graft between the septum and the upper lateral

cartilage. The dissection is extended under the nasal bone.
• A piece of folded Surgicel saturated in bacitracin ointment is placed
between the nasal bone and septum and is left in position until it dissolves
while the patient is maintained on oral antibiotics.
Bilateral Nasal Bone Deviation
■ Bilateral nasal bone deviation is corrected with bilateral osteotomies and
repositioning of the deviated nasal bones:
■ An onlay graft may be placed instead of osteotomy for mild deviation with
no midvault deviation or compromise of internal nasal valve function.
■ If the nasal bone deviation also involves midvault deviation, a septoplasty
is also needed, along with separation of the upper lateral cartilages from the
septum.
■ The bilateral independent controlled osteotomy technique begins with
medial osteotomy of the nasal bones (TECH FIG 1):
• A 4- or 6-mm osteotome is placed medial to the nasal bones and is driven
cephalically with gentle tapping of a mallet.
• A wedge of bone is resected medially, unilaterally, or bilaterally, to
reposition the nasal bones if the bones are too widely spaced from the
septum.
■ Percutaneous anteroposterior vertical osteotomy of the nasal bones is
performed next:
• It is important to palpate the cephaloanterior border of the nasal bones to
identify their point of divergence from the midline. This is where the
osteotomy will begin.
• A 2-mm osteotome is passed through the skin and muscle at this point,
and osteotomy is performed through this small incision by sliding the
osteotomy over the bone to avoid injury to the angular artery.
• The osteotomy is advanced in the subperiosteal plane to make several
interrupted puncture osteotomies in a linear fashion from anterior to
posterior.

TECH FIG 1 • Nasal bone osteotomies. A. Medial
wedge osteotomy is carried out using a 4- to 6-mm
osteotome. B. Vertical osteotomy performed anterior
to posterior percutaneously using a 2-mm osteotome.
C. Low-to-low osteotomy is performed at the nose-
face junction using a guarded osteotome to complete
the nasal bone osteotomies. (Reprinted from Guyuron
B. Correcting deviated noses, septoplasty, and
turbinectomy. In: Rhinoplasty. Philadelphia, PA:
Elsevier; 2012:117-119, with permission from
Elsevier.)
■ Finally, perform a low-to-low lateral osteotomy:
• A no. 15 blade is used to make an incision in the vestibular lining close to
the piriformis aperture.
• A Joseph periosteal elevator is used to elevate the periosteum in a
protected manner (it provides a barrier to reduce diffusion of blood that
may otherwise cause periorbital ecchymosis).
• A guarded osteotome is placed at the nasofacial junction. A low-to-low
osteotomy is completed to avoid a step deformity with gentle tapping of a
mallet.

■ The osteotomies are repeated on the contralateral side.
■ Reposition the nasal bones with direct pressure.
■ Septoplasty
■ Correction of the deviated septum can be accomplished using an open
approach or closed technique through a left-sided L-shaped (Killian) incision.
■ Open approach
■ After separation of the upper lateral cartilages from the septum, the
mucoperichondrium on the left side of the septum is elevated, starting from
the caudal septal angle. A small incision in the mucoperichondrium
anteriorly may be needed to facilitate opening into the correct
subperichondrial plane.
■ Once in the correct plane, the glistening cartilage will be in view. The blunt
end of a periosteal elevator is used to raise a mucoperichondrial flap.
■ Continue dissection posteriorly, cephalically, and caudally until the
junction of the quadrangle cartilage and the vomer bone is reached. It is
often easier and safer to start the dissection from the posterocaudal septum
anteriorly to facilitate dissection of the firm anterocaudal fibrous
attachments.
■ Closed approach:
■ An L-shaped (Killian) incision is used on the left mucoperichondrium (for
the right-handed surgeon) to enter the subperichondrial plane and to elevate
the mucoperichondrium on the left side.
■ From this point on, the septoplasty technique is the same, regardless of
whether an open approach or closed Killian incision was used.
■ Using the sharp end of the septal elevator, one can continue an L incision
through the quadrangular cartilage, leaving an L strut at least 20 mm wide
anteriorly and 10 mm wide caudally:
■ This L strut helps maintain long-term dorsal and columellar support,
particularly if the operative plan includes repositioning of the nasal bones
or manipulation of the upper lateral cartilages.
■ Beyond the L strut, only the deviated portion of the septum that cannot be
straightened with scoring needs to be resected. If more cartilage is needed to
serve as a graft in other parts of the nose, then the remainder may be
harvested. In other words, only the deviated portion of the posterocaudal

septum is removed.
■ The mucoperichondrium is elevated posterior and cephalad to the L incision
only. Gentle separation of the caudal portion of the septal cartilage from the
maxillary crest of the vomer bone is performed using the sharp end of the
septal elevator.
■ The sharp end of the septal elevator is also used to separate the cartilage
from the perpendicular plate of the ethmoid bone.
■ Once the septal cartilage is freed, it is removed using cartilage forceps
(Adson-Brown).
■ Correction of bony septal deviation and spurs
■ Septal deviation and spurs are often corrected by posterocaudal resection
of the septal cartilage. Spurs, if present, are usually at the junction of the
vomer bone, quadrangle cartilage, and perpendicular plate of the ethmoid
bone.
■ If the maxillary crest or any portion of the vomer bone is deviated or if
there is a bony spur on one side of the septum, it is important to remove
this portion of bone using a rongeur.
■ It is imperative to dissect the mucoperichondrium and the periosteum on
the concave side of the septum first to prevent a tear in the
mucoperichondrium. If a tear occurs, it can be addressed after septoplasty
is complete (see below).
■ Deviation or protrusion of the anterior nasal spine (ANS)
■ By palpating the ANS with the thumb and index finger of the dominant
hand, the position of and size of the ANS is assessed. If the ANS is
deviated or protruding, it can be reduced. If it is deviated, it can be
repositioned with a greenstick fracture using a 2-mm osteotome.
■ When the posterocaudal portion of the remaining septal cartilage is
dislodged to one side of the maxillary crest, it is paramount to correct this
septal tilt (see below).
■ The caudal septum is affixed to the ANS spine using a figure-of-8 5-0 PDS
suture placed from the septal cartilage to the periosteum of the ANS.
■ The deviated portion of the vomer bone and the perpendicular plate are
removed as thoroughly as possible to completely eliminate any internal septal
deviation posteriorly.
■ The remaining portion of the septoplasty technique depends upon the type of
septal deviation observed.

■ Correction of septal tilt (TECH FIG 2):
■ Disengaging the dislodged caudal and posterior portion of the retained L
strut from the vomerine groove and ANS is accomplished using a periosteal
elevator.
■ Removal of the overlapping redundant caudal portion of the septal
cartilage with a no. 15 blade scalpel provides a “swinging-door”-type free
movement of the cartilage.
■ Repositioning and fixation of the septum at midline to the periosteum of
the anterior nasal spine are performed by placing a 5-0 PDS figure-of-8
suture.
TECH FIG 2 • Septal tilt correction. The overlapping
and displaced caudal portion of the deviated septal L
strut is resected, moved into position at midline, and
sutured into place. Deviated nasal spine correction
may be needed prior to medializing the septum.
(Reprinted from Guyuron B. Correcting deviated
noses, septoplasty, and turbinectomy. In: Rhinoplasty.
Philadelphia, PA: Elsevier; 2012:316.)
■ Prior to repositioning the septum, it is important to ensure that the ANS is
in the midline or correct its position as discussed earlier.
■ Correction of C- or S-shaped septal deviation
■ The posterocephalic portion of the septum is resected as described above.
■ Using a 2-mm osteotome, the ANS is greenstick fractured to reposition it
in the midline as needed.
■ The perpendicular plate of the ethmoid and remaining portion of the
quadrangular cartilage beyond the L strut is may be partially resected only
if needed to correct deviation in the anterior and cephalic third of the
septum.
■ Typically, removal of the posterior and caudal portion of the cartilage and
creation of a swinging-door-type movement will release enough tension
from the cartilage to eliminate the curvature.
■ If still deviated, one can score the L-shaped frame on its concave surface

using a scalpel.
■ Specific differences in septal cartilage scoring based on the type of C- or S-
shaped deviation are as follows:
• Anteroposterior C-shaped deviation—the cartilage is scored in a
cephalocaudal direction on the concave surface of the septal cartilage.
• Cephalocaudal C-shaped deviation—the cartilage is scored in an
anteroposterior direction on the concave surface of the septal cartilage.
• Anteroposterior S-shaped deviation—the cartilage is scored in a
cephalocaudal direction on both surfaces.
• Cephalocaudal S-shaped deviation—the cartilage is scored in an
anteroposterior direction on both surfaces.
■ Because the final outcome of scoring is not predictable, it is mandatory to
place bilateral extramucosal stents (Simple Stent, Supramed) which are
fixed into position using a through-and-through suture (TECH FIG 3).
This will mold the septal cartilage while it is healing to further remove the
deviation.
TECH FIG 3 • Septal stents. To control the effects of
the scoring and eliminate dead space, simple stents
are applied on both sides and sutured in position.

(Reprinted from Guyuron B. Correcting deviated
noses, septoplasty, and turbinectomy. In: Rhinoplasty.
Philadelphia, PA: Elsevier; 2012:322.)
■ Correction of mucoperichondrial perforation
■ Inadvertent tears in the mucoperichondrium if unilateral or bilateral
without apposing perforations may be managed with nasal stents (Doyle or
Simple) to prevent synechiae.
■ A bilateral tear with apposing perforations should be corrected by replacing
a straight piece of septal cartilage, perpendicular plate of the ethmoid bone,
or a PDS synthetic plate between the mucoperichondrial flaps, spanning the
full width of the perforation.
■ Correction of the deviated caudal dorsum
■ Despite a thorough septoplasty, if the caudal portion of the dorsal L-shaped
strut remains deviated to one side along the caudal third of the anterior
septum, one has to place spreader grafts and possibly a septal rotation
suture as follows.
■ The spreader grafts are cut to size from the harvested septal cartilage or
secondary donor site such as rib cartilage and are sutured along the dorsum
of the septum after septal scoring using 5.0 PDS horizontal mattress sutures
(TECH FIG 4).
■ After placement of the spreader grafts, a septal rotation suture is placed
(TECH FIG 5). On the side that the anterior septum needs to be shifted
toward, a 5-0 PDS suture is passed through the caudal portion of the upper
lateral cartilage and then through the spreader grafts and the septum and
further caudal through the upper lateral cartilage on the side where the
septum needs to be shifted away. The suture is then returned through the
upper lateral cartilage, spreader grafts, septum, and upper lateral in mattress
fashion.
■ As the suture is tied, the composite layers, including the spreader grafts
and the septum, are pulled toward the somewhat fixed upper lateral
cartilage on the side where the suture was placed more cephalically.
■ The suture is tied incrementally until the septum becomes perfectly aligned
with a line bisecting the intercanthal line and the upper incisor midline (as
long as these structures are positioned centrally).
■ A second suture may be required to avoid bowing of the upper lateral

cartilage on the side toward the septum that is being rotated.
■ Turbinate reduction:
■ Repositioning the septum requires reduction of the turbinates for optimal
correction of the septal position and to prevent nasal airway obstruction
after correction of the deviated septum.
■ Partial turbinectomy is more versatile and predictable than submucous
resection, because it addresses both the hypertrophic mucosa and the
underlying bone while leaving a normal-sized turbinate behind, which
leads to less morbidity and greater success than complete turbinectomy.
■ Excising medial aspects of the turbinate evenly across the full length of the
turbinate using a pair of turbinate scissors will produce a reliable outcome.
Submucous resection with a microdebrider (XPS blade) combined with
out-fracture of the turbinate is another reasonable option.
■ One can out-fracture the middle turbinate or partially or completely
remove the middle turbinate if there is hindered sinus drainage or other
indications, such as migraine headaches.
■ Concha bullosa can be treated by removal of the medial wall or on rare
occasions, resection of most of the turbinate.
■ Use of septal stents
■ After completion of septoplasty, a Doyle stent or a Simple Stent is placed
on either side of the septum and fixed in position using a through-and-
through 4-0 polypropylene suture (see TECH FIG 3).

TECH FIG 4 • A–D. Spreader graft placement.
Bilateral spreader grafts are placed and sutured into
position along the dorsal septum to correct septal
curvature after septal scoring. (Reprinted from
Guyuron B. Correcting deviated noses, septoplasty,
and turbinectomy. In: Rhinoplasty. Philadelphia, PA:
Elsevier; 2012:322, with permission from Elsevier.)

TECH FIG 5 • Septal rotation sutures. A–D. Technique
for placement of septal rotation mattress suture. E.
Septal rotation suture. F. An additional septal rotation
suture may be placed cranially to control bowing of the
upper lateral cartilage on the side toward which the
septum is being rotated. (Reprinted from Guyuron B.
Correcting deviated noses, septoplasty, and
turbinectomy. In: Rhinoplasty. Philadelphia, PA:
Elsevier; 2012:336-337, with permission from
Elsevier.)
■ Upper Lateral Cartilage Correction
■ For a deviated midvault dorsum, an open approach is preferred.
■ It is important to separate the upper lateral cartilages from the septum and
assess for symmetry after the septum is pushed to midline and nasal bones

have been repositioned (TECH FIG 6).
■ Repositioning of the septum may require differential trimming of the upper
lateral cartilages using a Joseph scalpel and then sutured along the septum
with spreader grafts (see TECH FIG 4) if indicated using 5.0 PDS horizontal
mattress sutures or a septal rotation suture (see TECH FIG 5) as discussed in
the sections above.
TECH FIG 6 • Importance of differential trim of the
upper lateral cartilages after septoplasty and nasal
bone repositioning. A. Deviated septum and upper
lateral cartilages. B,C. Trimmed upper lateral
cartilages prior to nasal bone osteotomies and septal
repositioning may result in residual excess or shortage
of the upper lateral cartilages on either side.
(Reprinted from Guyuron B. Correcting deviated
noses, septoplasty, and turbinectomy. In: Rhinoplasty.
Philadelphia, PA: Elsevier; 2012:314, with permission
from Elsevier.)

■ Lower Lateral Cartilage Correction
■ The lower lateral cartilages may be accessed for correction using an open
rhinoplasty approach.
■ If the caudal septum is displaced, straighten it prior to adjusting the length of
the lower lateral cartilages.
■ The tripod concept is used to determine the appropriate length that each side
of the lower lateral cartilages must be matched in order to correct the
deviation and nasal projection. For example, a nasal base that is deviated to
the left will require lengthening of the lateral crus of the left lower lateral
cartilage or shortening of the lateral crus of the right lower lateral cartilage,
depending on what the appropriate tip projection would be. In the
underprojected nose, the lateral crus on the side the base is deviated toward is
lengthened, whereas in the overprojected nose, the lateral crus on the side the
base is deviated away from is shortened.

TECH FIG 7 • Lower lateral cartilage trim after septal
tilt correction. A,B. Lower lateral cartilage exposed
and mobilized after septal tilt correction, a portion of
the medial crus portion is resected or overlapped as
needed. C. Lateral crus is overlapped depending on
the orientation of the lower lateral cartilage and taking
into consideration the tripod concept. (Reprinted from
Guyuron B. Correcting deviated noses, septoplasty,
and turbinectomy. In: Rhinoplasty. Philadelphia, PA:
Elsevier; 2012:341, with permission from Elsevier.)
■ If correction requires shortening of the lower lateral cartilage on one side,
one can mobilize the lower lateral cartilage, transect and overlap it laterally
and if necessary medially, and then repair it preferably after placement of a
Gunter lateral crus strut with 5.0 PDS sutures (TECH FIG 7).
■ If correction requires lengthening of the lower lateral cartilage on one side,
the lateral crus is dissected, transected, and elongated, and the cut ends are
secured to a Gunter lateral strut using 5.0 PDS sutures (TECH FIG 8). A
lateral crus strut, if used, should be placed bilaterally for symmetry.
■ After correction, the lower lateral cartilages are secured to a columellar strut
graft to provide long-term stability.
■ A perfect alignment of the nasal domes and the midline of the dorsum is
checked repeatedly.

TECH FIG 8 • Lower lateral cartilage extension after
septal tilt correction. A,B. Mobilization of the lower
lateral cartilage and anterior advancement after septal
tilt correction. C. Segments fixed in position with a
columella and lateral crus strut. (Reprinted from
Guyuron B. Correcting deviated noses, septoplasty,
and turbinectomy. In: Rhinoplasty. Philadelphia, PA:
Elsevier; 2012:342, with permission from Elsevier.)
PEARLS AND PITFALLS

Preoperative
examination
■ Careful preoperative analysis of the face, nasal framework,
and internal structures allows for thorough correction,
including important observation of eyebrow alteration. A
full-smile frontal view will best elucidate nasal deviation.
■ Failure to do so may result in residual deviation.
Mucoperichondrial
tears
■ It is important to identify any mucoperichondrial tears
before repair of the incisions.
■ Bilateral apposing tears can result in a persistent septal
perforation if not addressed.
Turbinate
reduction
■ Turbinates must be conservatively reduced intraoperatively
before or after the septoplasty.
■ Failure to reduce the turbinates on the side toward which the
septum was corrected may result in relapse of the septal
deviation.
Trim the upper
lateral cartilages
last
■ Trimming these structures prior to repositioning the septum
and nasal bones may result in upper lateral cartilage excess
on one side and shortage on the opposite side.
Protect the
periosteum during
lateral osteotomy
■ The periosteum provides a barrier to limit diffusion of blood
into the periorbital tissues.
■ If disrupted, this can result in significant periorbital
ecchymosis.
POSTOPERATIVE CARE
■ Stents:
■ If a septoplasty was performed, at the end of the procedure, Doyle stents are
placed on either side of the septum and fixed to the membranous septum using
a through-and-through mattress 4-0 polypropylene suture. Doyle stents allow
further stabilization of the septum and eliminate dead space. These stents are
removed after 3 to 8 days, depending on the condition and the amount of
dissection or manipulation of the septum.
■ Extramucosal internal stents (Simple Stents) that are placed for septal scoring
or stents placed for bilateral apposing perforations of septal
mucoperichondrium should be removed after 2 to 3 weeks.
■ The patient is kept on oral antibiotics throughout the period that any internal
stents are in position to prevent toxic shock syndrome. An oral first-
generation cephalosporin is preferable.
■ Dressing:

■ Place Steri-Strips transversely across the nasal dorsum and sidewall touching
down onto the midface on either side as well as one vertically along either
sidewall connecting beneath the tip to help maintain the new shape of the nose
and facilitate collapse of the dead space.
■ Splint:
■ If nasal bone osteotomy was performed, a dorsal nasal splint (aluminum and
thermoplastic) is applied over the Steri-Strips.
■ The dorsal splint is removed after 7 to 8 days and after Doyle stent removal
to prevent nasal bone shift.
■ A Medrol dose-pack may be prescribed postoperatively to minimize swelling
and bruising from osteotomies. Corticosteroids are to be avoided in patients
with active acne or a propensity for severe acne.
■ The patient should avoid wearing glasses for 5 weeks after nasal bone
osteotomy.
■ The patient can bathe on postoperative day 1 but is instructed to not get the
nasal dressings wet.
■ Patients are prevented from strenuous activity for 3 weeks to avoid intranasal
bleeding.
OUTCOMES
■ Although the goal is correction of all of the nasal deviation in a single surgery,
secondary procedures may become necessary to achieve optimal results even
for the most skilled surgeon.
■ It is important to discuss this possibility with patients who undergo rhinoplasty
for any reason, especially those with a significantly crooked nose.
COMPLICATIONS
■ Hematoma
■ Persistent epistaxis
■ Infection
■ Graft loss
■ Dorsal nasal collapse—from L-strut fracture or collapse
■ Synechiae—can be avoided by use of Doyle stents
■ Empty nose syndrome—from over-resection of the inferior turbinate

63
CHAPTER
Technique for Treating the
Long Nose
Michael R. Lee and Rod J. Rohrich
DEFINITION
■ Long nose is a term used to describe a nose that extends beyond the ideal nasal
length. Multiple subsites may be responsible for creating a long nose and will
be discussed.
■ Nasal length is measured from the root of the nose to the most projected part
of the nasal tip. Ideally, nasal length should measure 0.67 of the midfacial
height (eyebrow to subnasale).
■ Nasal projection is measured from the alar groove to the most projected part of
the nasal tip. Ideally, nasal projection should measure 0.67 of the ideal nasal
length.1
■ Nasal rotation is determined by using the nasolabial angle. On lateral view, a
line is drawn bisecting the long axis of the nostril, whereas a second vertical
line is drawn through the anterior most aspect of the upper lip. The angle
created should fall between 90 and 110 degrees in women and between 90 and
95 degrees in men. A more obtuse angle is associated with over-rotation of the
tip, whereas a more acute angle is associated with a decreased tip rotation. The
latter is often seen with the long nose.
ANATOMY
■ Increased nasal length may result from multiple anatomic subsites including
the radix and nasal bones, dorsal and caudal nasal septum, and/or excess paired
nasal cartilages. These structures may be solely responsible for the long nose,
but more often it is a combination of subsites (FIG 1).
■ The nasal skin and musculature envelop the underlying bone and cartilage.
Soft tissue attachments work to keep proper relationships between nasal bone

and cartilage. These attachments provide support for the nasal tip.
■ Nasal tip support structures can be divided into major and minor. Major tip
support structures include the fibrous attachments between the upper and lower
lateral cartilages (scroll ligament), lateral crura and pyriform aperture, medial
crura and caudal septum, and the interdomal tip ligament. Minor tip support
structures include fibrous attachments of alar cartilage to the cartilaginous
dorsum, alar cartilage attachments to overlying skin, and the membranous
septum.1
PATHOGENESIS
■ A long nose may occur as the result of congenital development, traumatic
injury, iatrogenic injury, and/or aging.2,3 Congenital overgrowth may lead to
volume excess. Traumatic injury may displace or activate growth of bone or
cartilage. Iatrogenic injury may create a long nose when tip support is not
properly established. Aging results in loss of tip projection and midface volume
loss, both of which contribute to a long nose.
■ The illusion of a long nose may occur in patients with subnasale malposition,
periapical hypoplasia, short midface, or inadequate chin projection.
■ A true increase in nasal length may occur with a high radix, excess volume of
the upper lateral cartilages, lower lateral cartilages, nasal septum, and/or loss of
tip projection.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Aesthetically, patients may feel their nose is simply too large for their face. As
the focal point of the face, a long nose often disrupts nasofacial balance.
■ Patients may point out a large hump caused by excess bony or cartilaginous
dorsum. They may complain of a prominent or hanging columella that results
from excess of the caudal septum. Patients may also report a drooping tip from
inadequate support.

FIG 1 • Illustration depicting the nasal substructure.
Increased nasal length may result from multiple
anatomic subsites including the radix and nasal bones,
dorsal and caudal nasal septum, and/or excess paired
nasal cartilages.
■ Examination begins with assessment of facial widths and vertical heights. This
is important as the overall surgical goal is to create improved balance between
the face and nose. If the facial proportions grossly deviate from aesthetic
ideals, this is taken into consideration when creating the operative plan.
■ The nose is evaluated in all classic rhinoplasty views with attention focused on
areas responsible for creating a long nose. The patient is examined in repose,
animation, and respiration as the nose is a dynamic structure.
■ Anterior inspection is useful to determine symmetry and straightness, both of
which contribute to the dorsal aesthetic lines (DALs). A large dorsal hump may
distort the DALs.
■ Tip definition and position are also noted.

■ Lateral and oblique views are useful in the long nose. Evaluation begins with
critique of the radix or nasal root. A high radix may be responsible for creating
a long nose, whereas a low radix may give the nose an overprojected
appearance. Next, the dorsum is inspected for the presence of a convexity
(hump) or irregularities. Overgrowth of the upper lateral cartilages and/or
dorsal septum is typically responsible for dorsal convexity. Distally,
overgrowth of the caudal septum can downwardly displace the lower lateral
cartilages. Overgrowth of the lower lateral cartilages can further contribute to
caudal tip position. Caudal septal excess may also distort the alar-columellar
relationship and create excess columella show.
■ Basal view analysis provides additional information in the long nose patient.
Excess lower lateral cartilage volume may create domal fullness and disrupt
the ideal columellar:tip ratio of 2:1. The basal aesthetic lines (BALs)4 are
studied as they may be distorted by excess lower lateral cartilage volume and
malposition of the medial crura.
IMAGING
■ 3D imaging is extremely helpful in the long nose and improves
communication between the surgeon and patient. Modern-day imaging
software can readily display the anticipated changes of hump reduction,
increased nasal rotation, and decreased nasal projection.
■ Imaging can also be useful to illustrate to patients the difference chin surgery
or midface volume restoration can make in overall nasofacial harmony.
SURGICAL MANAGEMENT
■ Surgical management is best accomplished with an open surgical approach.
This provides direct visualization of the radix, upper lateral cartilages, nasal
septum, and lower lateral cartilages. Direct visualization and inspection of
these structures optimize the ability to correctly diagnose and treat the
problem(s).5
Preoperative Planning
■ A comprehensive consultation is required as with all patients seeking
rhinoplasty. Communication is an essential component of a successful
outcome. This communication allows the patients to voice their desired
changes and the surgeon to determine if expectations are obtainable.
Furthermore, patients may not want all aspects of their long nose addressed,

and each anticipated change should be discussed. The result of this discussion
helps establish an ideal operative plan.
Positioning
■ Once in the operating room, the patient is intubated and positioned on the
table. The most cephalic portion of the head extends just beyond the table (FIG
2). The patient’s head may be elevated 15 degrees to minimize venous pooling
in the operative field. A throat pack is gently placed and removed at the end of
the surgery. Local anesthetic with epinephrine is injected into the planned
incision sites.
Approach
■ Overall treatment of the long nose involves reduction of oversized nasal
structures and establishment of adequate tip support. With the nasal skin
envelope elevated, nasal bone and cartilages are easily inspected. Direct
visualization and palpation help to determine cartilage size and integrity.
■ The relationships between these structures are also studied. Excess dorsal
septum may be associated with excess or normal upper lateral cartilage
volume. Excess upper lateral cartilages may caudally displace excess or
normal-sized lower lateral cartilages. Excess caudal septum may also caudally
displace excess or normal-sized lower lateral cartilages. The open surgical
approach allows an exact inspection of each structure to determine the
appropriate surgical technique(s) to be implemented.
FIG 2 • Photograph depicting proper positioning of

patient undergoing rhinoplasty.
T E C H N I Q U E S
■ Component Dorsal Hump Reduction
■ The component dorsal hump reduction6 may be used to address multiple
causes of a long nose. Such causes include a high radix, dorsal septum
excess, and/or upper lateral cartilage excess.
■ Dissection continues to the anterior septal angle.
■ Once identified, bilateral mucosal flaps are elevated to expose the
cartilaginous septum.
■ The elevator is used to dissect away the mucosa from the medial portion of
the upper lateral cartilages (TECH FIG 1A).
■ This move facilitates separation of the upper laterals from dorsal septum
while minimizing mucosal trauma. Next, the upper lateral cartilages are
separated from the dorsal septum with scalpel or scissors.
■ Subsequently, short-angle scissors are used to remove excess of the
cartilaginous dorsal septum.
■ The rasp can be used to lower a high radix and smooth out any bony humps
that exists. If excess upper lateral cartilage volume is present, it is trimmed
with scissors.
■ Reconstitution of the dorsum is completed with upper lateral crura tension
spanning sutures7 (TECH FIG 1B).
TECH FIG 1 • A. Component dorsal hump reduction.

Mucosa is freed from the medial upper lateral
cartilages and nasal septum to minimize trauma
during separation of these structures. B. Upper lateral
cartilage tension spanning suture. Suture is used to
advance the upper lateral cartilages anteriorly and
fixate them to nasal septum. This reconstructs the
middle vault and smoothens the dorsum.
■ Caudal Septal Reduction
■ The caudal septum is easily exposed with further dissection of the septal
mucosal flaps (TECH FIG 2A).
■ Once exposed, scissors are used to excise the excess caudal septum.
■ Often in the long nose, an angulated excision is performed for increased tip
rotation (TECH FIG 2B).
TECH FIG 2 • A. Caudal septal exposure provided
with open approach rhinoplasty. B. Geometry of the
caudal septal resection is designed to increase
rotation of the nasal tip.
■ Excess Lower Lateral Cartilages

■ Excess volume of lower lateral cartilages can be improved with a cephalic
trim (TECH FIG 3A).
■ This disrupts the scroll ligament (major tip support) and permits upward
rotation of the nasal tip often needed in the long nose (TECH FIG 3B).
TECH FIG 3 • A. Cephalic trim to reduce lower lateral
cartilage volume and increase tip rotation. B.
Disruption of the scroll ligament is often required to
allow cephalic rotation of the lower lateral cartilages.
■ Optimizing Tip Support
■ Once the dorsum is established at the appropriate level, ideal tip position is
determined and secured. This is most commonly accomplished with the use
of a columella strut and tip sutures (TECH FIG 4A).
■ Alar contour grafts may also be used to provide additional support to the
lower third (TECH FIG 4B).