Operative Technique in Plastic Surgery – Kevin C.Chung

and minimize swelling of the nasal tip. A nasal splint is also applied. Tape and
splint are discontinued at postoperative day 7 when the transcolumellar incision
sutures are removed. Patients are started on saline intranasal spray and topical
antibacterial ointment for the incision. Once the incision is healed, scar care is
initiated and continued for 6 to 12 months.
OUTCOMES
■ Reduction rhinoplasty to treat the long nose is an overall reliable operation.
The aesthetic result may be limited by a thick overlying soft tissue envelope.
Patients with thick skin should be made aware of this prior to surgery. Failure
to thoroughly recognize all instigating factors may result in a less than
desirable result.
COMPLICATIONS
■ Cartilage reduction must stop short of creating a secondary deformity.
Disruption of the upper lateral cartilage soft tissue connection with the nasal
bones and/or dorsal septum can result in middle vault collapse. Overzealous
resection of the lateral crura and failure to establish proper tip support can lead
to lower nose collapse and/or problems with the nasal ala. Any number of these
untoward outcomes can create aesthetic and functional problems.
REFERENCES
1. Lee MR, Geissler P, Cochran S, et al. Decreasing nasal tip projection in
rhinoplasty. Plast Reconstr Surg. 2014;134:41e.
2. Rohrich RJ, Hollier LH, Janis J, Kim J. Rhinoplasty with advancing age. Plast
Reconstr Surg. 2004;114:1936.
3. Lee MR, Malafa M, Roostaeian J, et al. Soft tissue composition of the
columella and potential relevance in rhinoplasty. Plast Reconstr Surg.
2014;134:621.
4. Lee MR, Tabbal G, Kurkjian J, et al. Classifying columellar deformities in
rhinoplasty. Plast Reconstr Surg. 2014;133:464e.
5. Rohrich RJ, Lee MR. External approach for secondary rhinoplasty—advances
over the last twenty-five years. Plast Reconstr Surg. 2013;131:404.
6. Rohrich RJ, Muzaffar AR, Janis J. Component dorsal hump reduction: the
importance of maintaining dorsal aesthetic lines in rhinoplasty. Plast Reconstr
Surg. 2004;114:1298.
7. Roostaeian J, Unger JG, Lee MR, et al. Reconstruction of the nasal dorsum
following component dorsal reduction in primary rhinoplasty. Plast Reconstr

Surg. 2014;133:509.

64
CHAPTERTreating the Short Nose
Nicholas Lahar and Jason Roostaeian
DEFINITION
The short nose is defined as a perceived excess upward tilt of the nasal tip that
results in a foreshortened appearance. Common defining features include a
decreased distance from nasofrontal angle to tip defining point, an over-rotated
tip, and an increased nasolabial angle. Other commonly associated features can
include decreased dorsal nasal length, increased nostril show, cephalic over-
rotation of tip, low/deep radix, and long upper lip.1 The perceived deficits of the
nose must be evaluated with respect to the other facial features, but there are
generally accepted measurements of facial harmony (see below).
ANATOMY
■ The structural nose is composed of the paired nasal bones, upper lateral
cartilages, and lower lateral cartilages. The midline septum also offers
significant support for dorsal height and projection.
PATHOGENESIS
■ Tip projection is highly dependent on support of the lower lateral cartilages. In
cases of poor lower lateral cartilage support, tip support becomes more
dependent on septal cartilage. Other supporting structures include
intercartilaginous ligament between the upper and lower lateral cartilages,
lateral crural complex extending from the piriform rim, interdomal ligaments,
and medial crural attachments to the septum.
■ Deformities are typically acquired or congenital.
■ Acquired causes: iatrogenic, trauma, chemical (eg, cocaine), autoimmune
disorders, and infections

■ Scar contracture from tumor resection or trauma involving the lower portion of
the nose may distort and retract the nasal tip.
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.2
■ A complete external and internal nasal examination should be conducted in all
patients.
■ Facial harmony is evaluated with particular attention to the relationships of the
facial thirds on the profile view, nasofrontal angle, tip defining point, nasal
length, nasolabial angle, and nostril show.
■ Via palpation and examination, identify typical findings such as lack of nasal
cartilage, weakened or fractured osseous/cartilaginous support, scar tissue, and
contracture of soft tissue.
■ Evaluate the nose with respect to the other facial features to assess facial
harmony.
■ There are generally accepted measurements for nasal length and nasolabial
angle that can be used to assess the appearance.
■ Nasal length is typically about two-thirds the height of the midface
(supraorbitale to subnasale).1
■ Ideal nasal length: nasal length/nasal projection ratio of 5:3.1
■ Ideal nasolabial angle:
■ Caucasian women: 95 to 105 degrees
■ Caucasian men: 90 to 95 degrees1
■ The columella protrudes 3 to 4 mm below the alar rim. The ideal ala-columella
relationship creates a symmetrical oval outline on profile view bisected by a
line connecting the most anterior to most posterior portion of the nostril.
■ Assess the nasal alae and soft tissues aesthetically and for skin quality.
■ A nasal speculum is used to evaluate the septum and the inferior turbinates for
abnormalities.
■ Standardized photographs including frontal, lateral oblique, and basal views
should be obtained in all patients.
■ Assess septal cartilage and other potential donor sites (ear and/or rib),
particularly if the patient has had nasal surgery previously.

■ Priority should be given to strong, straight pieces of cartilage for dorsal and
columellar strut grafts.
IMAGING
■ No specific imaging is required if attention is being paid specifically to a
shortened nose.
■ A nasal x-ray can be helpful in cases of prior trauma or asymmetric nasal
bones.
■ Computed tomography (CT) imaging can help evaluate nasal bones, septal
deviation, turbinate pathology, and the sinuses when the history warrants
further investigation.
SURGICAL MANAGEMENT
■ The primary objective in correction of the short nose is to increase overall
radix to tip length. This often requires a concomitant increase in tip projection
while reducing tip rotation and the nasolabial angle.2
■ Adjunctive procedures, eg, functional modifications, should also be
determined and made part of the operative plan accordingly.
Preoperative Planning
■ Risks, benefits, and expectations must be discussed with the patient prior to
surgery.
■ Consideration of the soft tissue envelope and its overall compliance, 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. In cases of severe
soft tissue contracture, preoperative discussion to set expectations accordingly
and/or attempts to increase compliance via mechanical means such as frequent
downward massaging should be considered.
■ Principles of nasal lengthening
■ Precise assessment of length deficiency
■ Accurate identification of deficient tissues
■ Adequate release of soft tissue envelope
■ Pertinent modification of skin, mucosa, and/or skeletal deformities to restore
length
■ Maintaining patency of the nasal airway

Positioning
■ The patient is positioned supine with arms tucked. The head is placed at the
very end of the bed.
■ 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.
■ Oxymetazoline or 4% cocaine-soaked pledgets are placed in each nostril.
■ Local anesthetic consisting of 1% lidocaine with 1:100 000 epinephrine is
infiltrated into the nasal sidewalls, into the columella, and inside the nostril
along the lower lateral cartilages.
■ 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
■ An endonasal approach is indicated for simple refinements of the nasal tip.
Otherwise, an open approach is preferred particularly when there is poor
support for the nasal tip or when more complex nasal tip adjustments are
necessary.
T E C H N I Q U E S
■ Shield-Tip Graft
■ Indication: Mild shortening attributed to a deficient infratip lobule or
columella
■ Concept: Cartilage graft is placed at the tip of the lower lateral cartilages to
increase the length or manipulate contour.
■ A gull wing or stair-step transcolumellar incision is made at the narrowest
point of the columella (TECH FIG 1A).
■ An incision is made in the nostril margin at the caudal margin of the lower
lateral cartilages and extends to the transcolumellar incision medially (TECH
FIG 1B).

TECH FIG 1 • A. A transcolumellar incision is made
with care to avoid injuring the medial crus. B. An
infracartilaginous incision is made at the lower margin
of the lower lateral cartilages. C,D. The
transcolumellar incision is completed.
■ Fine curved iris or Converse scissors are used to complete the columellar
incision, with care taken to avoid injury to the medial crura (TECH FIG
1C,D).
■ A nasal skin flap is elevated from the columellar incision and lower lateral
cartilages using sharp double hooks for traction.
■ If the relationships of the lower lateral cartilages are to be preserved, a
Killian incision is performed approximately 1 to 1.5 cm cranially from the
caudal septal border through the mucoperichondrium using a no. 15 blade.
■ Submucoperichondrial dissection is performed using a Cottle elevator.
■ The septal cartilage can now be harvested using a no. 15 blade or swivel
knife, preserving an L strut of at least 1 cm dorsally and caudally.
■ The shield tip graft is shaped from the harvested cartilage.

■ The graft is laid in the desired location to augment tip projection and/or nasal
length. It is secured in place with 6-0 polyglactin (Vicryl) suture. Graft
position is adjusted to augment lengthening vs projection depending on the
needs of the patient.
■ Other preoperatively planned functional and aesthetic adjustments are made
as needed.
■ The nasal skin flap is laid back down and secured with 5-0 chromic sutures
intranasally and 6-0 polypropylene in the columella.
■ Tape strips are applied to the nasal dorsum to limit postoperative swelling
and to help shape and refine the tip.
■ 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.
■ An ice pack may be used on the midface to minimize swelling.
■ Septal Extension Graft
■ Indicated for moderate length deficiency.
■ Allows for a relatively stable construct and control of the length deficiency.
■ A gull wing or stair step incision is made at the narrowest point of the
columella.
■ An infracartilaginous incision is made in the nostril margin at the caudal
margin of the lower lateral cartilages and extends to the transcolumellar
incision medially.
■ Fine curved iris or Converse scissors are used to complete the columellar
incision, with care taken to avoid injury to the medial crura.
■ A nasal skin flap is elevated from the columellar incision using sharp iris or
Converse tip scissors. Care is taken to keep the perichondrium on the lower
lateral cartilages (TECH FIG 2A).
■ Intercartilaginous ligament attachments are divided sharply, allowing the
lower lateral cartilages to splay and to expose the septum (TECH FIG 2B).
■ The lower lateral cartilages are splayed open with sharp hooks, and an
incision is made on the dorsal septum.
■ Submucoperichondrial dissection of the septum is performed bilaterally
using a Cottle elevator.

TECH FIG 2 • A. The nasal soft tissues are elevated in
the subperichondrial plan, revealing the lower lateral
cartilages, the upper lateral cartilages, and nasal
dorsum. B. After separating the lower lateral cartilages
via the intercartilaginous ligament, the
mucoperichondrium is elevated off the nasal septum,
revealing the entire cartilaginous septum. C,D. A 1-cm
dorsal L strut is preserved while harvesting septal
cartilage for various grafts. E,F. The septal cartilage is
carefully crafted to create septal extension grafts,
spreader grafts, or tip grafts. G,H. The crafted
extension grafts are secured to the caudal septal
cartilage. I. The lower lateral cartilages are secured to

the extension graft.
■ The septum is incised anteroposteriorly with a no. 15 blade with care to
preserve a 1-cm dorsal and caudal strut for nasal support (TECH FIG 2C,D).
■ The septal extension graft is shaped from the harvested cartilage (TECH
FIG 2E,F).
■ Often two small septal grafts are needed if the septal extension graft need to
be placed midline; otherwise, inherent bend in septal cartilage graft and L
strut can be used to place graft on right or left side of septum to ensure the tip
is in the midline.
■ The septal extension graft is secured to the anterior septal angle/caudal
septum with multiple 5-0 PDS sutures (TECH FIG 2G,H).
■ The domes of the lower lateral cartilages are advanced and secured to the
septal extension graft as needed to increase tip projection (TECH FIG 2I).
■ Once structural lengthening has occurred, it must be verified that soft tissues
can cover the new length. Wide undermining of the dorsal and lateral nasal
soft tissues may be necessary to sufficiently advance the skin flap.
■ Mattress sutures of 4-0 plain gut are placed through the mucoperichondrial
flaps to close the dead space where septal cartilage was harvested.
■ The columellar skin is reapproximated with interrupted 6-0 Prolene, and the
infracartilaginous incisions are closed with interrupted 5-0 chromic sutures.
■ Internal nasal splints are placed in each nostril and sutured through the
septum with a single 3-0 Prolene mattress suture.
■ 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 mustache gauze dressing may be applied across the upper lip to absorb
any nasal drainage.
■ An ice pack may be used on the midface to minimize swelling.
■ Tongue-and-Groove Technique
■ Indication: Moderate to severe nasal length deficiency5–8
■ This technique allows for more stable construct and control of the length
deficiency.
■ A gull wing or stair-step incision is made at the narrowest point of the

columella.
■ An infracartilaginous incision is made in the nostril margin at the caudal
margin of the lower lateral cartilages and extends to the transcolumellar
incision medially.
■ Fine curved iris or Converse scissors are used to complete the columellar
incision, with care taken to avoid injury to the medial crura.
■ A nasal skin flap is elevated from the columellar incision using sharp iris or
Converse tip scissors.
■ Intercartilaginous ligament attachments are divided sharply, allowing the
lower lateral cartilages to splay, exposing the septum.
■ The lower lateral cartilages are splayed open with sharp hooks, and an
incision is made through the perichondrium on the dorsal septum.
■ Submucoperichondrial dissection of the septum is performed bilaterally
using a Cottle elevator.
■ The septum is incised anteroposteriorly with a no. 15 blade with care to
preserve at least 1-cm dorsal and caudal strut for nasal support.
■ The cartilage is wedged off the bony septum and removed from the operative
field.
■ The dorsal septal extension grafts and columellar strut grafts are shaped from
the harvested cartilage.
■ Two septal grafts are cut to length in proportion to deficiency. For instance,
if the nose is deficient by 3 mm, the graft will extend beyond the septum by 3
mm.
■ These septal grafts will be placed along the dorsal septum with the
deficiency extending beyond the margins of the septum, projecting
anteriocaudally (TECH FIG 3).
■ The width of the septal grafts is dependent on the dorsal septum width. The
septal grafts can be thinned appropriately to make the total desired dorsal
width. Nasal bone osteotomies may be required to narrow the nasal dorsum
depending on the needs of the patient.
■ The dorsal grafts are secured to the dorsal septum bilaterally with 5-0 PDS
or Vicryl sutures.

TECH FIG 3 • A columellar strut is secured between
two extended spreader grafts to create a stable
construct for lengthening the nose.
■ A columellar strut is then prepared from the septal cartilage.
■ The width of the strut will be the width of the medial crus plus the desired
additional length (the deficiency).
■ The columellar strut is placed between the bilateral spreader grafts,
interdigitating. The strut is secured to both the caudal septum and the
extended spreader grafts into a position that helps to lengthen the nose and
increase projection.
■ The medial crura are advanced anteriorly and caudally on the columellar
strut as needed to increase tip projection. This medial crura are sewn and
secured to the columellar strut using 5-0 PDS or Vicryl suture.
■ Lower lateral cartilage tip refinements (eg, interdomal, transdomal, etc.) can
be made at this time.
■ Once structural lengthening has occurred, it must be verified that soft tissues
and lateral tissues can cover the new length. Wide undermining of the dorsal
and lateral nasal soft tissues may be necessary to sufficiently advance the
skin flap.
■ Mattress sutures of 4-0 plain gut are placed through the septal
mucoperichondrial flaps to close the dead space where septal cartilage was
harvested.
■ The columellar skin is reapproximated with interrupted 6-0 Prolene, and the
infracartilaginous incisions are closed with interrupted 5-0 chromic sutures.
■ Internal nasal splints are placed in each nostril and sutured through the
septum with a single 3-0 Prolene mattress suture.

■ 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 mustache gauze dressing may be applied across the upper lip to absorb
any nasal drainage.
■ An ice pack may be used on the midface to minimize swelling.
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
■ Wide undermining of the nasal skin is required to redrape the skin
over the cartilaginous framework.
■ Columellar strut grafts or septal extension grafts should not extend
past domes/tip defining points.
■ When there is insufficient septal strut cartilage, consider septal
extension graft given the minimal cartilage requirements. Lower
lateral cartilages can be strengthened with lateral crural strut grafts
or alar rim grafts if nasal lengthening causes excess alar retraction.
■ Be mindful of overwidening the nose with spreader grafts that are
too wide and high along the dorsal strut.
Postoperative
■ Have the patient avoid sleeping on a side as it will worsen edema
to one side and increase concern for deviation.
POSTOPERATIVE CARE
■ Surgery is usually 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.3,4 Optimal outcomes will be attained using the
technique with which the surgeon is most comfortable and able to achieve
consistent results.
COMPLICATIONS
■ Possible short-term and long-term complications include infection, hematoma,
nasal asymmetry, septal perforation, worsening of nasal obstruction, scarring,
nasal bleeding/crusting, cartilage exposure, and prolonged edema that may last
up to 1 year.
REFERENCES
1. Gunter JP, Rohrich RJ. Lengthening the aesthetically short nose. Plast
Reconstr Surg. 1989;83(5):793-800.
2. Katira K, Guyuron B. Contemporary techniques for effective nasal
lengthening. Facial Plast Surg Clin North Am. 2015;23:81-91.
3. Howard BK, Rohrich RJ. Understanding the nasal airway: principles and
practice. Plast Reconstr Surg. 2002;109(3):1128-1146.
4. Rohrich RJ, Ahmad J. A practical approach to rhinoplasty. Plast Reconstr
Surg. 2016;137(4):725e-746e.
5. Guyuron B, Varghai A. Lengthening the nose with a tongue-and-groove
technique. Plast Reconstr Surg. 2003;111(4):1533-1539.
6. Gruber RP. Lengthening the short nose. Plast Reconstr Surg.
1993;91(7):1252-1258.
7. Çakır B, Öreroğlu AR, Daniel RK. Surface aesthetics in tip rhinoplasty: a
step-by-step guide. Aesthet Surg J. 2014;34(6):941-955.
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.

65
CHAPTER
Technique for Dorsal
Augmentation Using Costal
Cartilage Graft
Dean M. Toriumi
DEFINITION
■ Low nasal dorsum is when the bridge of the nose demonstrates inadequate
height/projection.
■ A low dorsum can appear wide and flat on frontal view with inadequate lateral
wall shadowing.
■ Asian patients tend to have inadequate dorsal height and frequently are in need
of dorsal augmentation.
■ Inadequate dorsal height may be directly related to excessive nasal tip
projection. The relationship between dorsal height and tip projection frequently
requires creating balance between these two parameters.
ANATOMY
■ The anatomy of the low dorsum can vary from patient to patient.
■ In the Asian patient, the nasal dorsum can be low and wide (FIG 1).
■ Asian patients tend to have a low radix (low nasal starting point) as well.
■ Asian patients tend to have very small and thin septal cartilage that provides
insufficient stock for dorsal augmentation.
■ Some patients have a congenitally low dorsum.
■ Patients that suffered from trauma can present with a low dorsum or saddle
nose deformity.
■ Most patients with a saddle nose deformity have a deficiency in the middle
nasal vault usually with a normal bony nasal vault. Many of these patients may
actually have a dorsal convexity above the saddled area.

PATIENT HISTORY AND PHYSICAL FINDINGS
■ Any evidence of previous trauma or surgery should be elicited in the history.
■ Any prior placement of alloplastic implants should be elicited in the history.
■ Physical exam should reveal any septal deviations or fractures.
■ Asian patients who have a low dorsum also tend to have an underprojected
nasal tip.
■ All patients should be queried as to any previous injectable fillers placed into
their nose.
SURGICAL MANAGEMENT
Anesthesia
■ 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.

FIG 1 • Asian patient with low dorsum showing lack of
lateral wall shadowing and flat appearance to nasal
dorsum.
T E C H N I Q U E S
■ Harvesting Costal Cartilage for Dorsal
Augmentation

■ Costal cartilage can be harvested from relatively small incisions with low
morbidity. Costal cartilage of adequate length and width can be harvested
through an 11-mm chest incision.1,2
■ When less experienced, a larger incision should be used to safely harvest
the costal cartilage.
■ Consider using a 3-cm incision until you are comfortable with the chest
wall anatomy and have significant experience harvesting costal cartilage.
■ Avoid cutting the muscle layer.
■ It is preferred to separate the muscle fibers bluntly.
■ This allows the muscle layer to be tightly resutured at the end of the
operation to provide good support to the area.
■ Costal perichondrium should be harvested from the surface of the rib. Costal
perichondrium can be used for camouflage or as a soft tissue graft.
■ The best rib to harvest for dorsal augmentation is typically the 7th rib. The
7th rib is longer and straighter and provides the best cartilage stock for major
dorsal augmentation3,4 (TECH FIG 1A,B).
■ The 5th rib is curved and not appropriate for large dorsal augmentations.
■ The 6th rib is relatively straight but has a genu that could shorten the
straight segment that can be used for the dorsal graft.
■ The 7th rib is also more superficial than the 6th rib, so it is easier to harvest
through a smaller incision.
■ The 7th rib cartilage is sharply dissected away from the 6th and 8th ribs
using a Freer elevator and lifted off of the underlying perichondrium.
■ Typically, a 3.5- to 4.5-cm segment of costal cartilage should be harvested.
■ Perform a Valsalva maneuver after the rib is harvested to see if there is a tear
in the pleura.
■ If so, a red rubber catheter can be placed during closure, and then the chest
can be expanded and the catheter removed after the closure is completed.
■ The 7th rib tends to lie below the level of the diaphragm and therefore
lessens the likelihood of a pneumothorax. As you move medially on the 7th
rib, it may move above the diaphragm.

TECH FIG 1 • A. Chest wall showing rib anatomy. The
7th rib is longer and straighter than the 5th and 6th
ribs. The 6th rib has a genu where the rib passes
below the breast. B. Harvested rib.
■ Preparing and Affixing the Dorsal Graft
■ The harvested costal cartilage should be initially carved into three separate
segments (TECH FIG 2A), which are then assessed for the most ideal
curvature.
■ If a very thick dorsal graft is needed, the rib should be carved differently
by taking thinner peripheral segments to provide a thicker dorsal graft
(TECH FIG 2B). In this case, the middle segment is typically used for the
dorsal graft.
■ If the central core of the costal cartilage has a soft (pearlike) texture, this
increases the likelihood of warping of the cartilage. In this case, it is
preferable to use the outer core of the rib for the dorsal graft.
■ If this cartilage must be used, it is recommended to laminate the cartilage
by suturing two thinner layers of cartilage together to create one dorsal

graft. The lamination acts to decrease the likelihood of warping.
TECH FIG 2 • A. Younger patient with the rib being
carved into three separate segments. Note the
bending of the cartilage. B. For larger dorsal grafts,
the central segment of the rib can be made thicker to
allow for a thicker dorsal graft.
■ The dorsal graft should be carved into a canoe shape that is narrower at both
ends (TECH FIG 3A).
■ It should be carved to provide appropriate dorsal height. Care should be
taken to avoid making it too narrow. It is carved so it is curved anterior to
posterior (TECH FIG 3B).
■ The graft is fashioned so the concave surface is facing inferior or toward
the nasal dorsum. This is critical to prevent the upward bending of the
cartilage graft creating a prominent radix and supratip.
■ The dorsal graft is carved slightly wider than what would be considered
ideal, as contracture over time will tend to make the dorsum look narrower.
■ If costal perichondrium is sutured to the sidewalls of the dorsal graft, it will
look a bit wider, and this should be accounted for when carving the graft.
Perichondrium that is so sutured acts to camouflage the graft and prevent
visibility of its lateral margins (TECH FIG 4A,B).
■ The perichondrium should overlap the junction between the lateral margins
of the dorsal graft and the nasal dorsum (TECH FIG 4C).
■ If the perichondrium is placed at the junction between dorsal graft and
nasal dorsum, the perichondrium will form bone and create an osseous
bridge between the dorsal graft and nasal dorsum.

■ A strip of costal perichondrium is sutured to the undersurface of the superior
aspect of the dorsal graft, where it would sit on top of the nasal bones (TECH
FIGS 4C and 5).
■ The perichondrium is sutured to the undersurface of the upper portion of
the dorsal graft with a running 5-0 PDS suture. Care is taken to make sure
the costal perichondrium is oriented so the surface that was initially against
the cartilage is oriented so it is facing the bone.
■ Costal perichondrium is at the bone/cartilage interface and will ossify,
creating a bony union between the dorsal graft and nasal dorsum. This
ossification and rigid fixation occur within the 1st month after surgery.
■ The nasal dorsum is rasped with a narrow rasp, or multiple perforations are
made in the bony nasal vault at the interface with the dorsal graft. Using a
narrow rasp decreases the likelihood that the dorsal pocket will be enlarged
(TECH FIG 6).
■ Multiple perforations are made in the bone using a 2-mm straight
osteotome. At least 8 to 10 perforations are made in the bone to expose
cancellous bone and allow more rapid ossification of the dorsal graft with
perichondrium interface to the underlying bony dorsum.
■ This ossification typically occurs within the first month after surgery. Once
the ossification is complete, the dorsal graft becomes immobile and cannot
be moved or shifted. This rigid fixation acts to prevent bending or warping
of the dorsal graft.
■ For the dorsal graft with costal perichondrium interface to ossify and fix to
the nasal dorsum, there must be a tight subperiosteal space that will force the
dorsal graft against the bone.
■ Thus, at the beginning of the operation, the surgeon should use a Joseph
periosteal elevator to raise the periosteum off the bone, leaving a relatively
narrow tunnel. This will ensure a tight fit when the dorsal graft is inserted
into the subperiosteal space.

TECH FIG 3 • Shape of dorsal graft. A. Dorsal graft is
typically canoe shaped tapering inferiorly. B. The
dorsal graft is curved with the concave surface facing
the nasal dorsum.

TECH FIG 4 • Dorsal graft with perichondrium. A.
Dorsal graft with perichondrium sutured to the sides of
the graft. B. Lateral view of the dorsal graft with
perichondrium. C. Dorsal graft with perichondrium
sutured to the undersurface of the dorsal graft and
placed into a tight subperiosteal pocket to force the
dorsal graft against the bone. Perichondrium is also
placed along the sides of the dorsal graft.

TECH FIG 5 • Dorsal graft with perichondrium. A.
Dorsal graft over the dorsum. B. Perichondrium
sutured to the undersurface of the dorsal graft. C.
Dorsal graft with concave surface facing the bony
dorsum.
TECH FIG 6 • Rasping the nasal dorsum. A. Narrow
rasp to roughen the nasal dorsum. B. Side view of the
low-profile rasp. C. After rasping bone dust on the
rasp.
■ Use of a Transosseous Suture or K-Wire
■ If a tight subperiosteal space is not possible as a result of removal of a
previous implant or deformity, a transosseous suture can be used to fix the
dorsal graft with interpositional costal perichondrium to the bony nasal vault
(TECH FIG 7).

■ In this case, small stab incisions are made along the side of the dorsum,
and holes are created across the nasal dorsum approximately 4 to 5 mm
below the leading edge of the dorsum just below the level of the medial
canthus (TECH FIG 8). This is done using multiple 16-gauge needles.
Care must be taken to make sure the holes are directly opposite each other
at the same level across the bridge of the nose.
■ The transdorsal path should be above the level of the intranasal mucosa.
This can be ensured by dissecting the intranasal mucosa to make room for
passage of the 16-gauge needle (see TECH FIG 7).
• Protect the eye when drilling the hole to avoid ocular damage.
■ Once the transdorsal hole is created, a 4-0 PDS suture can be passed
through the needle and passed back through the dorsum. The suture is then
passed back through the same skin incision and over the top of the upper
part of the dorsal graft. Then, the suture is passed back through the opposite
skin incision and tied tightly to force the upper segment of the dorsal graft
with intervening costal perichondrium tightly against the bony nasal
dorsum.
• This tight contact between costal cartilage dorsal graft, costal
perichondrium, and underlying perforated bone allows rigid fixation of the
dorsal graft to the bony dorsum.
TECH FIG 7 • Transosseous hole drilled across the
dorsum above the mucosa. The suture is passed
across the dorsum and then over the top of the dorsal
graft to hold it snugly against the bony dorsum.

TECH FIG 8 • Transosseous suture placement to hold
dorsal graft in position. A. A 16-gauge needle used to
drill hole across the dorsum. B. Needle is used to drill
a hole across the dorsum through small stab incisions
on the side of the dorsum. C. Needle passed across
the dorsum protecting the opposite eye. D. A 4-0 PDS
suture needle is placed into the core of the 16-gauge
needle to pass back across the dorsum. E. Suture
passed across the dorsum. F. Suture passed back
through stab incision and over the top of the dorsal
graft and through the opposite incision. G. Tying down
suture to force dorsal graft with interpositional costal
perichondrium against the perforated bony dorsum.
■ In some cases, in which a large dorsal pocket is created and a transosseous
suture is not possible (very low dorsum), a 0.45 threaded Kirschner wire can
be passed through a small upper dorsal skin incision, through the upper
dorsal graft, and into the bony dorsum (TECH FIG 9). The K-wire should
pass only 3 to 4 mm into the underlying bony dorsum.

■ It is left in place until the 7th postoperative day and then gently backed out
in the office using a hemostat or needle holder. The small stab incision will
close in a couple of days, leaving a small scar on the nasal dorsum.
■ In most patients, the dorsal graft with costal perichondrium interface is
ossified into position by the 21st day postoperative. At 1 month, the dorsal
graft is difficult to move.
TECH FIG 9 • Use of a Kirschner wire to fix the dorsal
graft. A. Canoe-shaped dorsal graft over the nasal
dorsum. B. Costal perichondrium sutured to the
undersurface of the upper aspect of the dorsal graft.
C. Dorsal graft in position and placement of 0.45
threaded Kirschner wire planned. D. Making a small
stab incision over the dorsal graft. E. Drilling the
threaded Kirschner wire through the dorsal graft and
then 4 mm into the underlying bony dorsum. F. Drilling
Kirschner wire into position. G. Cutting the Kirschner
wire with a wire cutter. H. Kirschner wire in place.
PEARLS AND PITFALLS

Choosing the grafting
material for dorsal
augmentation
■ Auricular cartilage is insufficient. Costal cartilage
provides larger cartilage stock and allows for carving of
larger dorsal grafts.
Harvesting costal
cartilage
■ Chose the proper rib to insure adequate cartilage. For
most larger dorsal grafts, the 7th rib is ideal as it is
longer and straighter.
Harvesting costal
perichondrium
■ Harvest costal perichondrium from the surface of the
rib.
Managing warping of
costal cartilage grafts
■ Observe for curvature as the dorsal graft is carved.
Splint cartilage grafts to prevent further bending.
Lamination is very effective.
Fixation of dorsal
grafts
■ Suture costal perichondrium to undersurface of the
dorsal graft and place on top of bony dorsum after
perforated with 2-mm osteotome.
Dorsal graft pocket
■ Make a tight narrow subperiosteal dorsal pocket to force
dorsal graft with interpositional costal perichondrium
tightly to the perforated bone.
Contour dorsal graft
■ Dorsal graft should be canoe shaped and should be
oriented with the concave surface facing the perforated
bone.
Other modes of
fixation of dorsal graft
■ If tight subperiosteal pocket is not possible, consider
transosseous suture fixation.

FIG 2 • Asian patient who underwent dorsal
augmentation using costal cartilage. A. Preoperative
frontal view. B. Postoperative frontal view. C.
Preoperative lateral view. D. Postoperative lateral view.
E. Preoperative oblique view. F. Postoperative oblique
view. G. Preoperative base view. H. Postoperative base
view.
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.
OUTCOMES
■ Most patients that undergo dorsal augmentation using costal cartilage with
dorsal graft fixation using the costal perichondrium interface do well over time.
The incidence of warping is relatively low, and the nasal dorsum looks very
natural (FIG 2).

COMPLICATIONS
■ Infection is rare but occurs when extensive cartilage grafting is performed.
■ Warping or displacement of the dorsal graft is possible but can be minimized if
preventive measures are taken.
■ Pneumothorax is a potential problem with harvesting of costal cartilage.
■ Resorption of the dorsal graft is rare.
■ Aesthetic problems such as undercorrection or overcorrection are possible if
appropriate sizing is not accomplished.
■ Potential visibility of the dorsal graft is possible as the dorsal nasal skin
contracts or thins.
REFERENCES
1. Toriumi DM, Pero CD. Asian rhinoplasty. Clin Plast Surg. 2010;37(2):335-
352.
2. Toriumi DM. Discussion: use of autologous costal cartilage in Asian
rhinoplasty. Plast Reconstr Surg. 2012;130(6):1349-1350.
3. Toriumi DM. Caudal septal extension graft for correction of the retracted
columella. Op Tech Otol Head Neck Surg. 1995;6(4):311-318.
4. Toriumi DM, Swartout B. Asian rhinoplasty. Facial Plast Surg Clin North
Am. 2007;15(3):293-307.

66
CHAPTER
Technique for Dorsal
Augmentation Using
Alloplastic Material
Man-Koon Suh and Nguyen Phan Tu Dung
DEFINITION
■ A low nasal dorsum is one of the main characteristics of Asian noses. Dorsal
augmentation is one of the most frequently performed procedures in Asian
rhinoplasty.
■ There is a distinctive difference in preferences of materials used for dorsal
augmentation between surgeons from Asia and other countries.
■ Autogenous tissues preferred by Western surgeons provide better safety but
have several disadvantages:
• Less satisfaction aesthetically
• Scars on the donor site
• Decreased height or irregularity of the nasal dorsum due to tissue resorption
• More complex surgical procedure compared with implants
■ Thus, use of an implant is still preferred for dorsal augmentation in Asia.
■ Owing to the thick and fibrotic soft tissue envelope of Asian noses, as opposed
to that of Westerners’ noses, implant visibility or an operated looking
appearance after dorsal augmentation with implant is considerably less likely.
The appropriate surgical technique complemented by a high-quality implant
surely minimizes the frequency of adverse effects.1–3
ANATOMY
■ The structure of an Asian nose is shown in FIG 1.
■ Use of an implant is limited to dorsal augmentation. Tip projection should be
carried out by various tip-plasty techniques including suture techniques and
cartilage grafting. It is safe to use an implant only from the radix to the supratip

area (FIG 2).
■ Application of an implant extending to the tip area should be avoided, since it
may cause thinning and redness of the tip skin or a rupture of the tip skin with
implant exposure.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ The following must be checked during the preoperative evaluation:
■ Presence of facial asymmetry
■ Presence of nasal axis deviation
■ Presence and underlying causes of tip and nostril asymmetry
■ Dorsal skin characteristics, including the texture, color, and any skin
problems such as visible veins or telangiectasias
■ The surgeon must decide the following during the preoperative consultation:
■ How high the nasal dorsum should be raised
■ Whether the profile should be straight or curved
■ The type of prosthesis to be used for dorsal augmentation
■ The type of cartilage to be used for tip projection
SURGICAL MANAGEMENT
■ Dorsal augmentation material for Asians is chosen from either autogenous
tissues or implants.
■ In cases in which the dorsal skin is too thin, autogenous tissues are
recommended.
■ Dermofat graft or diced cartilage wrapped with the temporal fascia is
preferred.
FIG 1 • A–D. Asian nose with a low and short nasal
dorsum. Nasal bone is flat and low, and alar cartilage is

small and weak as well. (D. Copyright Man Koon Suh,
MD.)
FIG 2 • Four types of dorsal and tip augmentation
strategies in Asian noses. A. L-shaped implant only for
dorsal and tip augmentation. B. L-shaped implant
combined with cartilage graft on the tip of the implant.
C. Long I-shaped implant combined with cartilage graft
on the tip of the implant. D. Short I-shaped implant with
cartilage graft on the alar cartilage. This is the most
recommended technique for the Asian rhinoplasty.
(Copyright Man Koon Suh, MD.)
■ A rib cartilage block used for dorsal augmentation for a patient with thin skin
may result in a visible contour of the rib cartilage graft, increasing the
possibility for revision surgery.
■ The implant can be relatively safe and bring aesthetically beautiful results for
Asians when the skin is not thin.
Preoperative Planning
Implant Selection
■ Each material has advantages and disadvantages. Silicone and e-PTFE
(expanded polytetrafluoroethylene) are used most commonly for dorsal
augmentation, but other products are available, such as Medpor.
■ Characteristics of silicone implants
• There is no change in the implant height as time progresses.

• Capsular formation.
• The frequency of calcification on the surface of the implant is higher than
that of an e-PTFE implant over a long period.
■ Characteristics of e-PTFE implants
• Micropores are present within implant, allowing tissue ingrowth. As a
result, there is less implant mobility and no capsular formation.
• Calcification occurs less in e-PTFE implants than in silicone implants.
• Delayed spontaneous hematoma also occurs less in e-PTFE implants.
• The height of an e-PTFE implant decreases to about 5% to 20%.4
Accordingly, the height predictability decreases, and tissue ingrowth makes
it difficult to remove an e-PTFE implant as opposed to a silicone implant.
■ The answer to which type of implant is better between silicone and e-PTFE
implant depends largely on the experience and preference of the surgeon.
Silicone implants are generally used because there is no morphologic change
over time and height predictability is excellent. Nevertheless, an e-PTFE
implant may be considered for the following cases:
■ A contracted nose due to capsular contracture
■ Wide dorsum due to hypertrophied capsule
■ Weak periosteum (cases with fragile periosteum are prone to implant
mobility; e-PTFE implants have higher adherence to the nasal bones or
adjacent tissues, so that implants are less mobile)
■ Calcification on the surface of a silicone implant
■ Foreign body reaction to silicone
■ Late spontaneous hematoma inside the capsule of a silicone implant
■ Thin dorsal skin is not an indication for an e-PTFE implant.
■ An e-PTFE implant inserted into a patient’s nose with thin dorsal skin may
force the thin skin to adhere closely to the implant without capsular formation.
Thus, the implant edges may be more conspicuous.
■ There are I-shaped (boat shape) and L-shaped silicone implants (FIG 3).
■ An I shape is mainly used for dorsal augmentation, whereas an L shape is
used to simultaneously raise both the dorsum and the tip.
■ An L shape is not recommended because it has a risk of the nasal tip
becoming too hard, tip skin thinning, and implant exposure through the nasal
tip skin.
Implant Design

■ The patient is asked to look straight ahead, and the starting and end points of
an implant are marked on the nose (FIG 4A,B).
■ The starting point of an implant would coincide with the double eyelid line
for Westerners. However, it looks natural to have the implant starting point
coincide with the eyelash line for Asians.
FIG 3 • I- and L-shaped silicone implants.

FIG 4 • A. Start and end point of the implant. B.
Markings. C. The implant tip should be shortened and
adjusted to fit to its ending point, which is 3 to 5 mm
above the tip defining point. The dorsal line should be
slightly curved and have a higher nasal tip and supratip
break in women (D) but be straight in men (E). (A,D,E.
Copyright Man Koon Suh, MD.)
■ The starting point of an implant would be somewhat higher for patients with
a protruding forehead. The more protruding the forehead, the higher the
position of the implant starting point. The flatter the forehead of a patient, the
lower the implant starting point.
■ The distal end of an implant should not extend to the nasal tip but to the area
just above the nasal tip. Hence, the length of an implant would be
approximately 35 to 45 mm.
■ No part of an implant should enter into the nasal tip under any circumstance,
and the nasal tip must be projected with cartilage graft (FIG 4C).
■ Raising the radix area high like that of the Westerner creates a fierce-looking
face for Asians. It is pertinent for Asians to have the line extending from the
forehead to the radix to be natural.
■ The nasal tip of a female should be slightly higher than the dorsal line so as to
form the natural supratip break. Accordingly, the nasal tip should also be
projected by a cartilage graft. The side view line from dorsum to the nasal tip
should be a straight line in males (FIG 4D,E).
Approach
■ Dorsal augmentation can be done through an intranasal or an open approach.
■ An open approach is needed in cases requiring tip plasty, whereas the
intranasal approach is adequate for dorsal augmentation using a simple
implant. In these cases, an inframarginal incision is recommended.
T E C H N I Q U E S

■ Implant Carving
■ The operator must be equipped with implants of various shapes and heights
provided by the manufacturer (TECH FIG 1A).
■ Until recently, an e-PTFE block was carved into nasal implant shape (TECH
FIG 1B). Now, however, ready-made products that are precarved in various
shapes facilitate ease of carving (TECH FIG 1C). The carving process for an
e-PTFE prosthesis is similar to that for a silicone implant.
Carving Process
■ The operator selects the most appropriate implant in consideration of nasal
profile and the desired nasal shape of a patient.
■ The proximal beginning part of the implant is placed on the starting point
marked on the nose, and then distal ending point of the implant is marked
(TECH FIG 2A,B).
■ The marked distal end of the implant is cut, and then the thick distal end is
thinly carved (TECH FIG 2C,D).
■ The bottom of the implant is carved and trimmed to the curvature of the
dorsum (TECH FIG 2E,F).
■ With respect to carving of an implant, various techniques exist depending on
the surgeon. However, it is convenient to use a no. 11 scalpel blade for a
novice surgeon. A number of blades must be prepared so that a slightly dull
blade can be replaced with a new one.
Carving Precautions
■ Implants are available with a variety of width profiles, ranging from 8 to 12
mm. While the most common implant width for Asians is 10 mm, the width
is individually determined depending on the width of the nasal bone.
■ With respect to the hardness of the silicone implant, the soft type has
advantages of better adherence to the nasal bone and less mobility as opposed
to the hard type.

TECH FIG 1 • A. Various silicone implant shapes. B.
e-PTFE implant block that would be carved into
shape. C. Preshaped e-PTFE implant.

TECH FIG 2 • Silicone implant carving. A,B. Placing
the company-supplied implant on the designed
marking. C. Shortening the implant. D. Thinning the
thickness of the tip. E. Carving the implant body
according to the patient’s dorsal irregularity. F. Final
shape after carving.
■ The shape of the bottom side of an implant should be curved or concave, so
that the surface adheres to the nasal skeleton. Thus, implant mobility is less
likely to occur.
■ The end of an implant should be carved very thin.
■ A thick terminal end of an implant may lead to capsular contracture, which
can occasionally cause skin indentation.
■ The author avoids both hatching and making holes in silicone implants.
■ Incision
■ The endonasal approach would be sufficient for cases desiring a simple
augmentation of the dorsum and tip. In such a case, an infracartilaginous

incisional approach is recommended (TECH FIG 3A).
■ An incision begins initially along the inferior margin of the medial crus, at 2
to 3 mm inward from the columella border of the midpoint of the columella
(TECH FIG 3B).
■ Once the incision is made to the dome area, it changes direction and moves
laterally along the inferior border of the medial crus (TECH FIG 3C).
■ The inferior margin of the lateral crus can be visualized by turning over the
alar rim inside out.
■ The incision lies deep medial to the alar rim (TECH FIG 3D). Incisions
made along the lines of the alar rim must not be performed because they
cause a nostril deformity.
TECH FIG 3 • A–D. Inframarginal incision. (Copyright
Man Koon Suh, MD.)

■ In cases requiring an additional operation, such as tip plasty, open
rhinoplasty incisions are used.
■ Implant deviation occurs in the process of making a pocket for an implant.
When an operation creates a pocket by making incisions in the right side, a
pocket in the radix may easily deviate toward the left side. Therefore, it is
safe to create a symmetrical pocket by making incisions bilaterally.
■ Dissection for the Pocket
■ A space for inserting an implant is referred to as a pocket. A dissection to
form a straight and symmetrical pocket is the most significant part of dorsal
augmentation.
■ The dissection plane is supraperichondrial and subperiosteal, which means
that dissections are performed above the perichondrium in the lower lateral
and upper lateral cartilages and under the periosteum in the nasal bone area.
■ Metzenbaum scissors are used for the dissections over the lower and upper
lateral cartilages while making sure a maximum amount of the soft tissues
is included in the skin envelope.
■ Implants should be inserted into the subperiosteal pocket to prevent mobility
and shifting of the implant and to reduce visibility of the implant through the
skin.
■ A Joseph knife is used to cut the periosteum transversely about 1 mm
above the inferior margin of the nasal bone. Then, a Joseph elevator is used

to lift the periosteum.
■ At that time, lifting the periosteum a little bit at a time, step by step, can
avoid periosteal damages, rather than lifting a large portion of the
periosteum all at once. Once the operator is acquainted with this procedure,
he or she may proceed by using only a Joseph elevator without the knife.
■ Dissection and pocket formation mentioned above are performed through the
opposite side incision to form a symmetric pocket (TECH FIG 4).
■ Some surgeons prefer that the implant pocket be exactly the same size as the
implant, but this author recommends a slightly larger pocket size.
■ Theoretically, fitting snugly and precisely to the width of a pocket prevents
shifting of an implant. In reality, there is no assurance of having accurate
identical left and right dimensions of a pocket. Thus, having a pocket width
slightly wider than that of the implant allows room for prompt manual
correction of implant shifting externally in the event of a development of
implant deviation later on.

TECH FIG 4 • A–C. Dissection around the nasal tip
and over the upper lateral cartilage. D–F. Periosteal
elevation. (Copyright Man Koon Suh, MD.)
■ The time it takes for an implant in a pocket to be fixed by capsular
formation is 10 to 14 days after surgery. A deviated implant may be
properly positioned by moving it by hand during the time.
■ In cases in which the nasal dorsum is not straight or uniform (eg, the nasal
dorsum is skewed to one side of the nose), an inserted implant may easily be
deviated if the gradient difference of the slope of the nasal dorsum has not
been properly compensated by carving the implant properly before inserting
it.
■ Pretreatment of e-PTFE Implant
■ Unlike a silicone implant, an e-PTFE implant has internal pores of 25 to 40
μm in size. The size of bacterium is smaller than that of the pore. Bacteria
may enter through these pores and reside within an e-PTFE implant, whereas
a macrophage is larger than the pore, which makes it impossible to enter and
combat these bacteria through the pores within an e-PTFE implant.
Accordingly, a pretreatment is required for infection prevention.
■ For the prevention of infection, a thorough aseptic technique and removal of
the powders in the gloves are necessary.
■ A liquid mixture of povidone-iodine and antibiotics is used for implant

washing. Simply soaking an e-PTFE implant within a bowl of antibiotic does
not allow infiltration of an antiseptic solution within the pores. Thus, the
antiseptic solution should be forced to flow through these pores by using
negative pressure.
■ The author inserts an e-PTFE implant within a syringe and draws into the
syringe a 10-cc antiseptic solution, for which an antibiotic is reconstituted
with a povidone-iodine solution. Then, in an attempt to fill these pores with
the antiseptic solution, negative pressure is applied by pulling the syringe
plunger (along with the piston in the syringe) (TECH FIG 5).
TECH FIG 5 • Pretreatment of the e-PTFE using the
negative pressure.
■ Implant Insertion
■ Washing the inner pocket with a povidone-iodine solution mixed with an
antibiotic before implant insertion is helpful for the prevention of infection.
■ When the implant is inserted into the pocket through an incisional opening,
make sure it is positioned in the center of the pocket without deviation to one
side (TECH FIG 6A).
■ Insertion of a silicone implant is not that difficult, but an operator needs to

take precautions for insertion of e-PTFE implant.
■ If a soft type e-PTFE implant is being used, the implant may be pressed or
wrinkled or may produce a dead space during insertion, which can increase
the possibility of infection. An e-PTFE implant should not be pushed to be
inserted. Rather, it is pulled into place with thread (TECH FIG 6B). This
technique also facilitates proper positioning of the implant in the midline.
■ There is no need to fix the distal end of an implant. A prospect of implant
shifting may require suturing of the distal implant to the septal angle or alar
cartilage (TECH FIG 6C).
TECH FIG 6 • A. Silicone implant insertion. B. Pullout
technique for the e-PTFE insertion. C. Fixation of the
silicone implant tip to the alar cartilage. (A. Copyright
Man Koon Suh, MD.)
■ Management of Supratip Area

■ Theoretically, female patients should have a break point in the supratip area,
so that there is a slight curvature, from the dorsum to the nasal tip.
■ A formation of a natural-looking supratip break requires two elements:
■ Adequate tip projection
■ Prevention of supratip bulging
■ The thickness of the terminal end of a prosthesis should be thinly carved for
the prevention of supratip bulging.
■ Supratip bulging may occur in cases where a tip projection is inadequate,
thick supratip soft tissues that existed before surgery have not been corrected,
or the distal end of an implant is thick. Thus, these issues need to be solved.
■ A supratip groove occurs due to a height discrepancy at the area where the
thinly carved distal end of an implant meets the cartilage onlay graft of the tip
(TECH FIG 7A).
■ The groove is largely inconspicuous in cases with thick skin. Nevertheless,
the existence of a groove should be verified by palpating it by hand before
wound closure.
■ If the surgeon is concerned with an unsightly groove on the nose, it can be
resolved by using dermis or cartilage graft in the area (TECH FIG 7B–E). A
graft should be placed between the skin envelop and the distal end of an
implant.

TECH FIG 7 • A. Visible groove between the implant
tip and grafted cartilage on the tip. B. Cartilage or
dermis graft is placed at the visible groove between
the implant tip and cartilage onlay graft. C. Groove on
the supratip area. D. Cartilage graft on the groove. E.
Groove disappears after the cartilage graft. (A,B.
Copyright Man Koon Suh, MD.)
■ Implant Wrapped With Temporal Fascia or
Allograft Dermis
■ If an implant is needed in patients with thin dorsal skin, covering it with
temporal fascia or allograft dermis can reduce the issue of an implant
visibility.
■ The temporal fascia does not leave visible scar in the donor area, while
donor harvesting is easy. Both superficial and deep temporal fascia may be
used, but this author uses the latter.
■ Temporal fascia may be easily harvested under local anesthesia and is
performed from the area between the temporal crest and the superior root of
the ear helix (TECH FIG 8A).
■ An incision of a 3 cm in length is made, 1 cm anterior and 3 cm superior to
the superior root of the helix. The surgeon should take precaution not to
injure the superficial temporal vessels.

■ The glittering and lustrous deep temporal fascia can be seen after retracting
the superficial temporal fascia. This fascia is appropriately incised and
carefully removed from the temporal muscle (TECH FIG 8B) and the
wound is closed (TECH FIG 8C).
■ An implant is carved to coincide with the curvature of the nasal dorsum.
Then, all sides of the implant, except for the bottom, are covered with the
harvested temporal fascia.
■ After the fascia is trimmed along the margin of the implant, the fascia is
fixed to the implant by using an absorbable suture material (TECH FIG
8D).
■ An identical effect may be obtained from allograft acellular dermis used in
place of a fascia.
TECH FIG 8 • A. Donor site for the harvest of temporal
fascia. B. Harvest of the deep temporal fascia. C. The
temporal wound is closed with glue and staples. D.
Silicone implant covered with temporal fascia. (A.
Copyright Man Koon Suh, MD.)

■ Completion
■ An absorbable suture material is used to repair the intranasal wound.
■ Joseph dressing is done using paper tape (TECH FIG 9A). The paper tape is
applied starting from the radix and proceeding caudally.
■ This author applies compression by implementing an AquaSplint as well as a
Joseph dressing. They both serve to minimize postoperative swelling (TECH
FIG 9B,C).
TECH FIG 9 • A. Joseph dressing. B,C. AquaSplint.
■ Correction of Implant Deviation
■ In the event that prosthetic deviation is detected after 2 to 3 weeks of
surgery, making it difficult to manipulate manually, a surgical revision is
made as follows.
■ Deviated silicone implant
■ A small inframarginal incision is made on the contralateral side of implant
deviation.
■ Unilateral capsulotomy is performed along the lateral margin of the
posterior capsule by using a D knife or a pair of scissors (TECH FIG 10).
■ A small additional pocket is made for movement of an implant in the area
slightly lateral to the capsulotomy site.
■ After moving the implant manually, the implant is fixed by using a paper
tape and AquaSplint.
■ Deviated e-PTFE implant