Operative Technique in Plastic Surgery – Kevin C.Chung

■ In patients with thin skin, both sides of the edge of the implant are somet
more visible rather for a non–capsule-forming e-PTFE implant.
How to
manage
the
supratip
area
■ In an attempt to prevent supratip bulging, it is important to thinly carve th
implant tip and provide sufficient tip projection.
■ Additional cartilage or dermis graft may be necessary in some cases for t
sunken groove between the implant tip and cartilage onlay graft.
Carving
the
silicone
implant
■ Some surgeons make multiple partial-thickness cuts on the bottom of an
implant to improve accurate contact and adherence to the nasal bone in th
nasofrontal area (FIG 5A). This can cause an uneven thickness of the
posterior capsule and late spontaneous hematoma, however, as well as a
higher probability of infection secondary to increased surface area of an
implant, so this practice should be avoided as much as possible.
■ Occasionally, several holes are drilled into an implant to prevent implant
mobility (FIG 5B). This should also be avoided since it can cause dorsal
dimpling, secondary to capsular contracture formed within the hole, or ca
lead to late spontaneous hematoma following tearing of the thread-shape
capsule in the hole.
FIG 5 • A. Hatching on the undersurface of the silicone
implant is not recommended. B. Making several holes in
the implant is not also recommended.
POSTOPERATIVE CARE
■ An AquaSplint and paper dressing are removed 4 to 5 days after surgery.
■ Implant deviation should be frequently verified up to 2 weeks after surgery.
■ Detected implant deviation may be corrected by manual manipulation of the
implant within 2 weeks after surgery.
COMPLICATIONS

■ Immediate complications
■ Implant deviation
■ Hematoma
■ Infection
■ Delayed complications
■ Thinned dorsal skin with visible implant contour (FIG 6A)
■ Redness of the dorsal skin
■ Capsular contracture resulting in upturned nasal tip or visible implant contour
on both sides (FIG 6B)
■ Delayed spontaneous hematoma (FIG 6C)
■ Calcification on the surface of the implant or on the inner surface of capsule
■ Implant extrusion through the tip skin or vestibular mucosa (FIG 6D–I)
FIG 6 • A. Rib cartilage contour is visible through the
thinned skin, and there is dorsal irregularity because of
the focal partial resorption of the graft. B. Capsular
contracture at the thick implant tip results in a supratip
groove. C. Delayed spontaneous hematoma developed
3 years after dorsal augmentation with a silicone
implant that had been hatched. Complications of L-
shaped or long nasal implant include nasal tip skin
thinning (D,E), contracted nose with redness of the tip
skin (F,G), and exposure of the implant through the tip

skin (H,I).
REFERENCES
1. Tham C, Lai YL, Weng CJ, Chen YR. Silicone augmentation rhinoplasty in an
oriental population. Ann Plast Surg. 2005;54:1-5.
2. Deva AK, Merten S, Chang L. Silicone in nasal augmentation rhinoplasty: a
decade of clinical experience. Plast Reconstr Surg. 1998;102:1230-1237.
3. Godin MS, Walderman SR, Johnson CM. Nasal augmentation using Gore-
Tex: a 10-year experience. Arch Facial Plast Surg. 1999;1:118-121.
4. Jung YG, Kim HY, Dhong HJ, et al. Ultrasonographic monitoring of implant
thickness after augmentation rhinoplasty with expanded
polytetrafluoroethylene. Am J Rhinol Allergy. 2009;23:105-110.

67
CHAPTER
Diced Cartilage in Fascia
Graft for Dorsal
Augmentation in
Rhinoplasty
Aaron M. Kosins and Rollin K. Daniel
DEFINITION
■ Dorsal augmentation refers to augmentation of the nasal dorsum, which can be
done with alloplastic or autogenous materials.
■ Dorsal augmentation with a diced cartilage in fascia graft refers to
augmentation of the nasal dorsum using autogenous tissues—the patient’s
cartilage from the nasal septum, ear, and/or rib that is diced into small pieces
and wrapped in deep temporal fascia. The methods outlined herein include
refinements to the techniques initially proposed by Daniel and Calvert.1–3
ANATOMY
■ The normal or “ideal” dorsum exhibits a smooth transition from the nasal radix
to the nasal tip. In a male, this relationship is classically identified as a smooth
line, whereas in a Caucasian female, the ideal dorsum lies 2 mm behind this
line. Patients with deficiency of the nasal dorsum (low dorsum) lie behind this
line.
■ In non-Caucasian patients, the ideal dorsum may be different, and patient
preferences must be identified.
PATHOGENESIS
■ Dorsal deficiency can be congenital, genetic, traumatic, or a consequence of
previous surgery. Some patients are born with a low dorsum, and many
ethnicities have a naturally occurring low dorsum (eg, Asian ancestry).
■ Trauma to the nose can cause septal collapse resulting in a low dorsum or

“saddle deformity.”
■ Previous over-resection of the nasal dorsum and aggressive septal surgery are
the most common reasons for dorsal deficiency after rhinoplasty.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ In cases where no prior surgery has been performed, the diagnosis is clear and
based on physical examination. The patient is viewed on profile, and the ideal
radix and tip are visualized. The dorsum is designed to fit these ideals.
■ If previous surgery has been performed, the rhinoplasty surgeon should be
aware of the causes of a dorsal deficiency. Along with physical examination,
photographs should always be taken and, again, the ideal radix and tip overlaid
on the profile photograph. A complete internal speculum examination should
be done to assess the presence and integrity of the nasal septum. Previous
operative reports are desirable in diagnosis and should help guide the surgical
plan.
IMAGING
■ CT scans are rarely indicated except in the presence of severe trauma or
asymmetric developmental deviation of the nose (ADDN). CT scans are useful
to assess the nasal bones, nasal septum, heights of the maxillae, and the
presence of concha bullosa.
DIFFERENTIAL DIAGNOSIS
■ Differentiate the causes of dorsal height deficiency with physical examination,
speculum assessment, and previous operative reports.
NONOPERATIVE MANAGEMENT
■ Theoretically hyaluronic acid fillers can be used as a temporary solution;
however, the authors do not advocate this type of treatment. Results are
marginal at best, and injections require a high level of accuracy and experience.
Follow-up (repeat) treatments must be done at least twice per year.
SURGICAL MANAGEMENT
■ The authors perform diced cartilage in fascia as the mainstay for dorsal
augmentation whenever dorsal deficiency exists. Timing is dependent on
patient age (patients should be older than 14 years old) and timing of previous
operations. We advocate waiting at least 1 year from any prior nasal surgeries
to perform secondary surgery.

Preoperative Planning
■ Discuss again risks, benefits, and expectations with patient at both the
preoperative visit and on the day of surgery. Risks include bleeding, infection,
septal perforation, dorsal asymmetry, prolonged swelling of the graft (6 weeks),
and cosmetic deformity. Harvest of the deep temporal fascia involves a
temporal incision, and risks include alopecia and poor scarring. Finally, if
auricular or rib cartilage must be taken, then these risks must be discussed as
well.
Positioning
■ The patient is positioned supine, and the hair, head, and neck are prepped and
draped in sterile fashion.
Approach
■ The temporal incision is planned. A line is drawn up from the most anterior
point of the tragus into the temporal hair. A V-shaped incision is drawn so that
the superficial temporal artery is avoided (FIG 1).
FIG 1 • A temporal V-shaped incision is used for access
to the deep temporal fascia.
T E C H N I Q U E S
■ Deep Temporal Fascia Harvest

■ The V-shaped incision is carefully planned and infiltrated subdermally with
5 cc of 1% lidocaine with epinephrine.
■ The incision is made clearly through the dermis, and careful cauterization is
used to avoid trauma to the hair follicles.
■ Dissection is carried down to the superficial temporal fascia, which is
identified and divided.
■ Scissors are used to spread the loose areolar layer until the glistening white
deep temporal fascia (superficial leaflet) is identified (TECH FIG 1).
■ Retractors are used to expose the operative site, and a 4 × 3 cm graft is taken
using a 15-blade scalpel. Care is taken to avoid trauma to the temporalis
muscle below. A distinct vessel is always present below the fascia at the 4 or
5 o’clock position.
■ The superficial temporal fascia is reapproximated as well as the skin with
staples.
TECH FIG 1 • After incision through the skin, the
superficial temporal fascia is divided, and scissor
dissection is carried out to the glistening layer of the
deep temporal fascia.
■ Diced Cartilage in Fascia Graft
■ The fascia graft is measured in length to approximate the dorsal
augmentation and 20 mm wide. The fascia is folded over on itself to fasten a
10-mm wide fascial sleeve. This is sewed on one side with a running 4-0
chromic suture. Two 4-0 plain gut sutures on straight needles are placed in

the proximal portion so that the graft may be guided up to the radix.
■ Cartilage from any donor site is prepared and diced into fine, less than 1 mm
cubes with 10-blade scalpels or dermatome blades.
■ The diced cartilage is placed in a tuberculin syringe for injection into the
fascial sleeve. It is important that the cartilage is finely diced so that the
cartilage is injected with minimal resistance. Excess fluid is removed before
injection.
■ Diced cartilage is injected into the fascial sleeve into the distal end. Once
injected, it is molded on the back table to the predetermined height.
■ Using the 4-0 plain gut sutures, the graft is guided into position up to the
nasal radix and secured distally with a 4-0 plain gut suture. If cartilage needs
to be removed, it can be done from the distal free end. Molding is then done
on the table.
■ After all incisions are closed, a Denver splint is placed for 6 to 7 days. The
graft can be molded postoperatively for up to 2 weeks. At times, a
percutaneous stitch is placed after graft insertion to prevent mobility.
■ See FIG 2 for a patient example.

FIG 2 • Frontal, oblique, lateral, and basal views of a
patient (A–D) preoperatively and 13 months
postoperatively (E–H). The patient requested dorsal
augmentation and required a diced cartilage in fascia
graft for dorsal augmentation. 0.6 cc of diced cartilage
was placed inside the fascial sleeve. I. A large piece of
septum and perpendicular plate of ethmoid bone were
harvested using Piezo instrumentation. After making the
cuts in the cartilage with a 15-blade scalpel, a Piezo
saw was used under direct vision to cut the bony
ethmoid. J. Tip projection was achieved by creating a
septocolumellar “tomahawk” graft that was placed on
the right side of the caudal septum for increased length
and projection as well as derotation. 15 cc of fat grafting
was also done to the forehead.

PEARLS AND PITFALLS
Do not overfill the graft. The
designer dorsum is created to
size.
■ Grafts made too high will maintain height
postoperatively.
Tapering grafts is very difficult
to do. Create a flat platform,
and place a uniform graft.
■ Trying to change the thickness of the graft
from proximal to distal does not work well
and results in dorsal irregularities.
Avoid excessive molding on
the table.
Make the fascial sleeve wider
than you think.
Create a narrow tunnel to
place the graft.
■ Excessive dissection allows for graft
migration. If it moves, hyaluronidase can be
used to help mobilize it versus revision
rhinoplasty.
POSTOPERATIVE CARE
■ Typically, the nose stays swollen for 3 weeks after open rhinoplasty, but the
full remodeling process takes 1 year. When a diced cartilage in fascia graft is
used, this swelling persists for 6 to 8 weeks.
■ Once the Denver splint is removed, taping is done at night for 3 weeks to help
with swelling.
■ No glasses are to be worn for 6 weeks.
■ Patients must be told not to mold his/her graft or massage it.
COMPLICATIONS
■ Infection occurs in less than 1% of patients and is treated with doxycycline
100 mg twice daily for 1 week. Any infection that appears to be getting worse
warrants an infectious disease consultation.
■ Displacement of the graft. Hyaluronidase can be attempted to mobilize the
graft, but operative intervention is often warranted.
■ Undercorrection
■ Overcorrection

■ Palpable, diced cartilage can occur if the cubes are not made as small as
possible.
REFERENCES
1. Daniel RK, Calvert JW. Diced cartilage grafts in rhinoplasty. Plast Reconstr
Surg. 2004;113(7):2156-2171.
2. Daniel RK. Diced cartilage grafts in rhinoplasty surgery. Plast Reconstr Surg.
2008;112(6):1883-1891.
3. Daniel RK, Sajadian A. Secondary rhinoplasty: management of the
overresected dorsum. Facial Plast Surg. 2012;28(4):417-426.

68
CHAPTER
Indication and Technique for
Diced Cartilage and Fascia
Grafting in Rhinoplasty
Ashkan Ghavami
DEFINITION
■ Augmentation of the nasal bridge and radix has historically been a highly
debated topic in rhinoplasty.
■ Techniques include alloplastic materials such as silicone implants, Gore-Tex,
and PTFE. Although these techniques continue to be popular worldwide,
particularly in Asian countries, there has been a paradigm shift toward
autogenous sources. Preferred cartilage grafts include septal, costal, and
conchal cartilage. Each of these in isolation is fraught with problems in
stability of shape and long-term contour.
■ Erol’s description of the “Turkish Delight,” which is diced cartilage wrapped
in Surgicel, provided a simple, less complicated option for dorsal
augmentation.1 Not long after, Daniel2,3 described wrapping with autogenous
temporal fascia (DCFG: diced cartilage fascia graft) as an alternative; this has
become many surgeons’ primary technique today. It should be noted that
temporoparietal grafting to the nose in isolation was described long ago by
Guerrerosantos in 1985.4
■ The author’s preferred material is conchal cartilage, but costal cartilage and/or
septal remnants can be used.
■ Fascial wrapping and/or overlay of the cartilage construct allows for
incorporation of the graft and smooth contour in surgical outcomes. Contour
irregularities from warping with other autogenous techniques have been a long-
standing problem that is avoided with DCFG when properly executed.
■ This technique can be particularly useful in secondary rhinoplasty.2

ANATOMY
■ Anatomical landmarks and technical execution of harvesting the cartilage
grafts to be diced/crushed are imperative to avoid injury or deformation of
donor sites at the expense of obtaining cartilage source.
■ Standard techniques for harvest of rib, septal, and conchal elements can be
used based on the surgeon’s personal preference.
■ For conchal grafts, a postauricular approach is performed. Rib graft typically
is taken from the sixth or seventh rib, and it is important to not harvest
calcified portions that are difficult to dice and/or morselize sufficiently. The
inframammary crease is used in both men and women.
■ Temporal, mastoid, and rectus fascia can all be used.
■ Goals are based on the desired contour and degree of
augmentation/camouflaging required. This begins at the radix and proceeds
caudally to the supratip and anterior septal angle region.
■ Blending with the osteotomy lines and the ascending process of the maxilla as
it transitions to the nasal bones is important to create a smooth nasal sidewall
contour and soft contour shadow/highlight.
■ “Spot” augmentation with DCFG can be done in radix alone or to fill specific
contour irregularities (particularly in secondary revision cases).
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Particularly in the modern era of social media and a “selfie-obsessed” culture,
it is absolutely critical to communicate the magnitude of augmentation desired
by the patient while setting realistic expectations.
■ Accounting for the somewhat unpredictable long-term absorption rates is also
important to communicate with the patient.
■ The author believes that the trade-off of minor to moderate long-term
absorbability of DCFG for complications associated with traditional
augmentation techniques (warping, extrusion, unnatural dorsal contour lines,
need for removal, and replacement/reconstruction) is highly acceptable in favor
of DCFG.
■ After the standard workup for rhinoplasty with imaging and planning, desired
dorsal contour is obtained during the consultation. Attention is given to the
width and height of desired dorsal augmentation. If specific camouflaging or
contour correction is planned, then these regions should be pointed out to the
patient with the end points described or shown via imaging, drawings, or

demonstration with saline (in-office).
IMAGING
■ Three-dimensional imaging software as well as 2D imaging or drawings are
helpful in communicating the amount of dorsal height and narrowing/widening
with patients.
■ The author currently prefers to demonstrate with description and reference to
other surgical case examples during consultation. Hand drawings on printed
out photographs are helpful, and only when necessary during repeat
consultation(s) or during the preoperative office visit is 3D imaging utilized.
■ X-rays or CT scans are not necessary unless there is history of recent or
remote trauma or if concomitant nasal airway correction or sinus surgery is
planned.
■ When costal cartilage is used, assessment of possible excess calcification of
the ribs should be done. This can include needle testing in the exam room using
minimal local anesthesia and/or CT scan evaluation when truly necessary.
FIG 1 • A. Anteroposterior view of proper DCFG
positioning on dorsum. B. Variation: radix-only DCFG.
C. Variation: radix-only DCG. No fascia necessary due
to thick nasal skin.
NONOPERATIVE MANAGEMENT
■ There is no substitution for DCFG that is nonoperative and long term that is

justified in the author’s opinion. However, as an adjunct to planning and only
when a patient is not ready for surgery for a year or more, temporary injectable
fillers can be a useful tool and “buys time.” Hyaluronic acid gel fillers are
preferred, and any other filler material is not recommended.
■ A major limitation of nonsurgical filler augmentation is that dorsal aesthetic
lines in the anteroposterior view are difficult to optimize because narrowing of
the nasal pyramid is not being simultaneously performed.
■ The one region that may warrant dorsal augmentation with temporary fillers
instead of DCFG is in the radix when all other aspects of the nasal shape are
accepted by the patient. Consultation should include surgical options and
informed consent of the temporary nature of injectable fillers for the radix or
for minor contour correction.
■ One of the best indications for injectable (nonoperative) dorsal augmentation
is for minor/subtle contour correction of dorsal and other irregularities
(primary and secondary rhinoplasty). Small molecule, highly cross-linked
hyaluronic acid gel is best and must be injected with respect of vascular dermal
capacitance.
SURGICAL MANAGEMENT
Preoperative Planning
■ Planning DCFG augmentation in rhinoplasty involves many of the methods
listed above:
■ Detailed consultation with the patient with regard to the desired goals in
dorsal augmentation is paramount. This includes dorsal height, dorsal
aesthetic contour width, and supratip/other tip transition points to the dorsum.
■ Imaging as discussed above can aid in this process.
■ Saline solution can be injected in the office to show an approximate effect of
dorsal augmentation on profile view if the surgeon and patient agree that this
step is necessary to finalize the decision-making process.
■ Standard rhinoplasty preoperative planning is performed including attention to
internal and external valve sufficiency, airway assessment, Cottle maneuver,
nasal endoscopy (when indicated), and evaluation of cartilage donor sites.
■ Note: augmentation of the dorsal height and/or narrowing of the bony
pyramid and midvault can worsen airway functional issues. Dorsal height
augmentation can mask these issues visually, while untreating the underlying
insufficiency and patency of the airway. Dorsal width changes with DCFG

must be reconciled with the need for spreader graft/flap techniques.
■ DCFG is not a substitute for proper osteotomies and correction of sidewall
irregularities and asymmetries. The platform for the DCFG construct must be
stable, symmetric, and structurally sound prior to using DCGF for
augmentation and/or contouring.
■ Marking of the topographical dimensions can be done both on the patient in
the holding area on day of surgery and on photographs.
■ FIGS 1 and 2 demonstrate typical positioning of the DCFG construct.
FIG 2 • A. Lateral view of typical DCFG seating and
suturing for dorsal augmentation. B. Lateral view
showing DCFG for radix-only augmentation. C. Lateral
view: variation of using two DCFG constructs. Note:
Cephalad fixation is done performed using sutures
through the dorsal skin. Caudal DCFG is to cartilages.
■ Donor sites:
■ Ear: The preferred sleeping side is avoided, and the contralateral ear is used
when possible. Concomitant correction of prominent ears allows for more
graft material, and discussion with the patient is indicated. If the patient has a
small conchal area, then the larger concha is used, or bilateral conchal graft is
planned.
■ Rib: The inframammary crease is marked in both men and women, and the
rib is accessed through the smallest incision the surgeon is comfortable with.
This is typically the sixth or seventh rib. Incision placement should be shown

to the patient preoperatively.
■ Fascia: The temporal, mastoid, or rectal fasciae are all options. When using
costal graft, the author prefers rectus fascia because it is thick and in the
same donor site. When this would be too thick and not indicated for a
particular nasal envelope, temporal fascia is then harvested. When using ear
cartilage, mastoid fascia is taken. If mastoid fascia is not large enough and
true wrapping is required, then ipsilateral temporal fascia is obtained through
a prehairline approach.
Positioning
■ Standard head positioning for rhinoplasty is used with the patient in the supine
position and the head of bed in reverse-Trendelenburg, as well as head
elevation, approximating a 30 to 45 degree angle.
■ Bilateral conchal cartilage grafts are typically consented for and prepped, so
access must be available with draping.
■ If rib graft is to be used, this harvest site is prepped and accessible during the
rhinoplasty.
Approach
■ The donor cartilage that is planned for harvest will determine the approach
taken to obtain it.
■ Incisions should be designed to be as small as possible and as inconspicuous
as possible.
■ Ear: retroauricular sulcus
■ Rib: inframammary crease
■ Septal: preferred septal approach (open vs Killian or transfixion incision)
■ Fascia: mastoid (posterior sulcus), temporal (posterior hairline), and rectus
abdominis (inframammary crease)
T E C H N I Q U E S
■ Cartilage Harvest (TECH FIG 1)
EAR
■ Prior to infiltration with local anesthesia, 7 mm of conchal height is marked

on the conchal surface anteriorly in multiple points using a caliper.
■ After infiltration, prepping, and draping, a posterior sulcus incision is made.
Cautery guided and sharp scissor dissection is performed to expose the
conchal donor in its entirety subperichondrially.
■ Two 25-gauge needles are then passed through the anterior marked points to
penetrate posteriorly. A line is marked connecting the two on the posterior
surface of the conchal cartilage. This avoids the sometimes messy tattooing
with methylene blue dye.
■ If mastoid fascia is to be used, then posterior exposure of the fascia is
accomplished by undermining in a posterosuperior direction to acquire both
the periosteum and mastoid fascia. Mastoid fascia often requires thinning and
can be placed as an onlay without wrapping. Care is taken to not injure and
transect posterior nerves. Meticulous hemostasis is necessary.
TECH FIG 1 • Components of DCFG: septal cartilage,
cephalic trim cartilage, deep temporal fascia (4 × 6
cm), and diced conchal cartilage.
■ Conchal harvest is then completed by excising all conchal cartilage posterior
to a line from needle to needle. This line should be curvilinear to avoid
deforming the superior crura. The graft and fascia are placed in saline.
■ Any rents in the skin should be repaired.
■ A layered closure should be performed, and Xeroform/antibiotic ointment
bolster is secured with a silk or nylon suture. This should be molded to
compress the conchal space.
RIB

■ The inframammary crease is marked at approximately 4 cm. Surgeons
should not hesitate to make this incision as big as they need based on
experience and comfort. Visualization is necessary for preventing
complications.
■ An incision is made and dissection carried down to the perichondrium of the
rib. The rib is palpated and needle prick examination performed to assess for
softness and suitability. The fascial and rectus abdominis fibers are vertically
spread bluntly to expose the rib. If rectus fascia is to be used, see below for
details regarding harvest.
■ A midline incision is made through the perichondrium parallel to the
orientation of the costal cartilage. Gentle elevation is performed to preserve a
perichondrial sleeve around the removed rib segment that is later closed
along with fascia and muscle forming a functionally rigid construct and
prevents postoperative pain from any sensation of instability during deep
respiration.
■ Using direct visualization and staying subperichondrial, the posterior aspect
of the rib is freed from the perichondrium with a blunt elevator. Curved
endoscopic brow elevators and Cottle elevators are an excellent combination
for this technique.
■ Once the rib is removed using a 10 blade, it is placed in saline. If strut grafts
and other grafts are needed, it is allowed to sit for at least 10 minutes after
symmetrical carving; the remaining cartilage will be used to dice/crush.
■ Long-acting local anesthetic is infiltrated into the deep subcutaneous tissues
and in the rib dead space. The author prefers to place an angiocath in this
space, followed by reinjection and removal of the angiocath prior to
extubation. Some surgeons prefer a pain pump, which I have found to be
unnecessary. The site is then closed in a layered fashion with absorbable
sutures, from deep to skin: perichondrium, rectus fascia (if fascia is
harvested, then closure is still possible, or spanning sutures can be used, and
remaining muscle fibers and fascia can be approximated), Scarpa fascia, deep
dermal, and subcuticular closure.
■ Commonly, if the rib is used for DCFG, the costal cartilage is needed for
other elements such as strut grafts, spreader grafts, etc. Rib cartilage simply
for DCFG is sufficient without obtaining the conchal cartilage. However,
there are circumstances when rib cartilage and ear are both required for
different purposes particularly in very deficient dorsum or in complex
revision rhinoplasty.

■ Dicing of Cartilage
■ The cartilage to be diced or crushed is placed on a silicone block. A 10 or 11
blade is used to dice the pieces as small as possible so that they can pass
through a “slip tip” (non-Luer locking) tuberculin syringe. Alternatively,
sterilized razor blade can also be used. The size of the pieces is determined
by the augmentative goals, the rigidity/memory of the cartilage donor, and
the thickness of the dorsal skin envelope (TECH FIG 2).
■ For radix augmentation in thicker-skinned patients, finely diced cartilage
can be used without fascial onlay or wrapping. Excessive crushing is not
necessary and may increase absorption. However, fascial onlay or
wrapping will help reduce the chance of untoward cartilage edge visibility
long term and can also have a subtle augmentative benefit too, depending
on the thickness of the fascia (rectus or mastoid vs temporal).
TECH FIG 2 • Dicing of cartilage graft.
■ If finer pieces are needed, a handheld (Ruben) morselizer is very useful and
preferred over the classic morselizer which requires a mallet and is less
refined in giving the exact degree of softening or morselizing of diced pieces.
Once again, excessive morselization is not indicated.
■ Temporal Fascia Harvest
■ If ear cartilage is harvested, the ipsilateral temporal region is approached.

■ A 3-cm incision is made several centimeters posterior to the temporal
hairline. If the hair is thin, the incision is placed further posteriorly (TECH
FIG 3).
■ Respect of hair follicles and the anterior beveled approach is used to limit
injury and transection of hair roots.
■ If proper preinfiltration of local anesthetic with epinephrine is used, then
cautery can be minimized, which also aids in prevention of iatrogenic
alopecia.
■ After the incision is made, the subgaleal, supratemporal bloodless plane is
entered. Blunt undermining superficial to the white fibers of the deep
temporal fascia is visualized and exposure from the temporal crest cephalad
from the supraorbital ridge toward the sentinel vein, and 3 to 5 cm posterior
to the incision point is performed.
■ Marking pen can be used to delineate the rectangular piece for harvest.
Typically a 5 × 7 cm piece can be obtained. Using an 11 or 15 blade, the
temporal fascia is scored, muscle is exposed along the marked lines, and then
fascia is grasped and pulled off the muscle with the aid of angled scissors.
TECH FIG 3 • Temporal fascial harvest.
■ Inadvertent muscle fibers and any fatty tissue carried over should be
trimmed off the fascia.
■ Occasionally vessels deep to the fascia are injured, especially in the
inferoposterior region and temporal crest caudally. These should be
cauterized precisely without inadvertent heat injury of the fascial harvest.
■ The incision is closed after irrigation of the pocket and confirmation of

hemostasis. Three-point layered closure helps close the dead space. Staples or
a running small caliber quick absorbing suture of the skin layer can be used.
A drain is rarely used, but if it is, a round 7-French drain to bulb suction is
preferred. No compressive wraps are necessary.
■ Fascial Wrapping
■ There are two methods for wrapping:
■ Syringe method (TECH FIG 4):
• Diced/crushed pieces are placed into a non–Luer-Lok (“slip tip”) 1 cc
tuberculin syringe. The plunger is used to squeeze pieces into a confluent
mass within the syringe without gaps or air. The syringe is placed on top
of the fascia, and the fascia is needle-fixed at two corners to the silicone
block.
• A running absorbable suture is used from proximal to distal and needles
removed for circumferential closure of the fascial sleeve around the
syringe. The contents are injected into the sleeve, and final suture is
placed to close the proximal open end of the sleeve. This suture can be cut
with needle attached for placement and securing to the radix skin.
■ Onlay technique:
• No syringe is required, and the diced cartilage is placed onto the fascia
directly in the middle (similar to how a burrito is made), and the fascia is
then wrapped around it and sutured in similar fashion as above. This
technique is best for when the DCFG does not need to be as rigid and is
best for lesser degree of augmentation, radix augmentation, and/or
contour/camouflage grafting purposes.

TECH FIG 4 • A. Syringe fascial sleeve wrapping. B.
Syringe and sleeve near complete. Cartilage will now
be pushed into fascial tubular sleeve and final sutures
placed at open end to close the DCFG construct. It is
important to not leave openings so that diced cartilage
cannot extrude and create irregular contours. C.
DCFG construct completed. Sutures left long on either
end to allow for immediate fixation.
■ Placement of DCFG
■ DCFG can be placed through an open or “closed” endonasal approach. A
closed approach requires passing through an infra or intra-cartilaginous
access incision.
■ The needle that is left attached to the DCFG construct is used to pass
through the radix region at the cephalad end point of the desired
augmentative footprint. This is done after osteotomies to narrow the nasal
bony vault (if indicated). The DCFG is slid into a pocket that was previously
undermined from the tip complex to the takeoff of the frontal bone in the

nasofrontal angle/radix region. The needle is brought through the skin and
grasped, and after the DCFG is positioned, it is tied to the skin and to itself as
a loop. This can be removed upon splint removal on day 6 or 7 (TECH FIG
5).
■ The lateral dimensions of the DCFG tunnel should not be overly released
and undermined because this can result in inadvertent excessive blunting of
the lateral dorsal aesthetic contour lines. In addition, if more height is needed,
a tighter “wrap” of the DCFG and narrower tunnel will aid in driving the
volumizing effect of the DCFG dorsally rather than laterally.
■ If only radix augmentation is indicated, then the DCFG will be shorter, but
skin securing with suture is still recommended.
■ It is imperative that the caudal aspect of the DCFG is secured with at least
two sutures to the anterior septal angle region. Typically the upper lateral
cartilage and septum are great anchor points.
■ The DCFG should be massaged in place to desired contour, width, and
height.
■ Note: After the remaining sequence of the primary or revision rhinoplasty is
complete, it is important to create a balance between the dorsal augmentation
and tip height as well as supratip transition. The caudal aspect of the fascial
(DCFG) can extend to the lower lateral cartilages and/or domes depending on
the desired aesthetic goals in this region.
■ Splinting should take into account precise molding effects of the splint on
the height and width of the DCFG. The author prefers an elastic splint
(Aquaplast), but any splinting choice is acceptable as long as excessive
narrowing is not created. Lastly, it is important to not have any irregularity or
deviation in the splinting process because this may alter the shape and
centralization of the DCFG.

TECH FIG 5 • A. Passing DCFG with 5-0 chromic
suture to secure at radix skin and B. two sutures
placed to caudal upper lateral cartilage (approximately
7 o’clock and 5 o’clock positions).
■ Combined Techniques
■ Case no. 1 demonstrates the benefits of combining DCFG with traditional
costal cartilage dorsal augmentation (see FIG 3).
■ It is important to secure the cephalad portion of the costal graft to the nasal
bones and to adhere to classic carving and shaping principles. This avoids
lateral migration and cantilevering of the costal graft.
■ The DCFG is sutured on top of the rib graft. Skin securing as described
above is also necessary, as is passing the threaded K-wire through the DCFG
and costal graft chimera construct. The wire is trimmed at skin level and
removed during splint removal (TECH FIG 6).
■ This combination gives a large degree of augmentation and utilizes the
benefits of lateral contour and camouflage.
TECH FIG 6 • Variation of rib graft to the dorsum
(wired to radix bone) and DCFG on top for warping
prevention, contour blending, and further
augmentation. K-wire has already been placed
through the DCFG and Rib graft. Caudal suture left
long and will be on two sutures to secure DCFG to the

upper lateral cartilages. A third suture can also be
placed if necessary so that the DCFG can drape and
contour properly over the caudal dorsal structures.
Patient is Case 1.
PEARLS AND PITFALLS
Obtaining
proper dorsal
height
■ Preoperative photographs and/or 3D imaging
■ Thorough discussion with the patient preoperatively on setting
realistic goals with dorsal height
■ Saline test if necessary
Optimizing
DCFG
dimensions
■ Tighter wrapping and maximal filling provide more rigid and
larger construct
■ Avoid overdissection of lateral dorsal tunnel dissection
■ Larger pieces can be used in thicker skin envelopes
Fixation
■ Cephalic DCFG suturing at radix skin
■ Three-point caudal fixation (one central and two lateral)
Early contour
irregularity
■ Can be molded up to 3 wk in office
■ If necessary, no earlier than 9 mo, minor dorsal ridges if present
or spicules can be rasped under local anesthesia in office
Radix-only
augmentation
■ May not require fascia, but pieces should be small enough for
camouflage
POSTOPERATIVE CARE
■ Postoperatively, the DCFG has the great advantage of being malleable and
able to be further shaped/molded for 3 weeks.
■ If deviations or irregularities are seen, they can be softened and improved with
gentle steady yet firm pressure much like clay. Occasionally local anesthesia
may be required for patient comfort.
■ The splint is removed at day 6 or 7.
■ Retaping is preferred to help with edema and is a routine technique of the
author in all primary and secondary rhinoplasties. The patient is instructed on

how to tape and is encouraged to tape as shown nightly for 7 to 21 days,
depending on the amount of edema present at splint removal.
FIG 3 • Case 1: primary Asian rhinoplasty. Rib graft
augmentation of the dorsum with overlying DCFG.
Note: DCFG and rib graft are both K-wire fixed to the
radix bone. Wire removed at 7 days with splint. A.
Lateral view shows preop, 1.5 years postoperatively
(B), and 5 years postoperatively (C). Notice the integrity
of dorsal volume. Rib graft was relatively small in
height. D. AP view. E. 5-year result. F. Oblique view. G.
5-year result.
■ The DCFG effects and solidification occur at approximately week 3 and
continue to be complete by 3 months where its effects can be seen.
■ In the author’s experience, desired outcomes can be assessed accurately as
with most rhinoplasty aesthetic endpoints at 1 year postoperatively.
■ Much like all rhinoplasty outcomes, aesthetic results will still continue to
evolve even past a year, and patients should be informed about the process.
OUTCOMES

■ Patient satisfaction is high and is likely dependent on thorough preoperative
assessment, and proper informed consent of dorsal dimension end goals.
■ Realistic expectations are important in the preoperative discussion and
planning. It should be stressed to the patient that absorption and dorsal height
long term have been shown to be acceptable and revision rates are low.
■ Discussion of alternative techniques and their limitations should also be done
preoperatively.
■ Typical dorsal aesthetic contour lines and height are shown a year or more in
these case examples (FIG 3).
COMPLICATIONS
■ In general, the adverse events that can occur from the DCFG technique are
rare and when present can be addressed via closed surgical approach.
■ Loss of unacceptable DCFG volume has not been in issue in the author’s
practice and, if present to a small degree, has not driven any patient to seek
revision.
■ Excess dorsal height can be present and is addressed through a closed
approach with sharp trimming or rasping. If other revisions are indicated and
opening of the nose is indicated, then direct excision of regions of the DCFG
can be accomplished.
■ Irregular contour is managed by simple rasping via a closed approach.
■ DCFG contour can appear edematous and irregular for a few months, and
patience from both surgeon and patient is required. Once the subtle height and
width dimensions plateau and no longer change after a few months, discussion
of any undesirable contours and/or dimensions can proceed, and possible
revision is planned.
■ Infection is rare and has not been experienced by the author but should be
addressed early with oral antibiotics, irrigation (if indicated), and removal if
necessary. There are no reports of DCFG removal for infection. However,
meticulous sterility of grafted cartilage during acquisition and creation of the
DCFG construct is important.
■ “Redness” of the skin overlying the DCFG has been witnessed by the author
and has typically subsided without intervention.
REFERENCES
1. Erol OO. The Turkish delight: a pliable graft for rhinoplasty. Plast Reconstr
Surg. 2000;105:2229-2241.

2. Daniel RK. Rhinoplasty: septal saddle nose deformity and composite
reconstruction. Plast Reconstr Surg. 2007;119: 1029-1043.
3. Daniel RK, Calvert JC. Diced cartilage in rhinoplasty surgery. Plast Reconstr
Surg. 2004;113:2156-2171.
4. Guerrerosantos J Temporoparietal free fascial grafts to the nose. Plast
Reconstr Surg. 1985;76:328-329.

69
CHAPTER
Technique for Surgical
Management of the
Depressor Septi Nasi
Muscle
Michael R. Lee, Sammy Sinno, and Rod J. Rohrich
DEFINITION
■ Depressor septi nasi (DSN) muscle is a paired structure occasionally
responsible for deformity of the nasal tip and/or columella.1
■ Animation deformity of the nasal tip and/or columella may result from action
of the DSN. Such deformities typically include drooping of the nasal tip and/or
columella on animation.
■ Basal aesthetic lines (BALs) are created by the lateral borders of the
columella. Excess soft tissue of the columella which includes the DSN muscle
may cause distortion of the BALs.2
■ Medial crura footplate approximation is a described multistep process
designed to improve symmetry and architecture of the medial nasal base,
thereby improving the BALs.3
ANATOMY
■ Variations of DSN anatomy have been reported in the literature, particularly
with ethnicity.4
■ Muscular fibers of the DSN may originate from the maxillary periosteum
and/or orbicularis oris muscle. Fibers may be diminutive in some patients.
■ Muscle fibers of the DSN course through the columella and insert on the
medial crura and nasal septum.
■ Columella composition includes cartilage (caudal nasal septum and medial
crura) and soft tissue (muscle fibers, fibroblast, collagen fibers, elastin fibers,

adipocytes, and neurovascular structures).5 Muscle fibers traversing the
columella are from the DSN and orbicularis oris muscle.
■ The caudal septum is firmly seated on the maxillary crest and does not move
with contraction of the DSN. Flanking the caudal septum is the medial crura.
These more mobile medial crura may descend with contraction of the DSN.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Patients may report (1) tip descent on animation, (2) short upper lip on
animation, (3) transverse crease in the mid-philtral area, (4) infratip/columellar
decent on animation, and (5) columellar fullness and nostril deformity on basal
view.
■ Exam includes inspection of the nose in all classic rhinoplasty views.
Inspection is initially performed in repose and then again with animation.
Animation includes smiling and speaking.
■ Frontal view is used to evaluate tip position both in repose and with animation.
The tip is inspected to determine if descent is occurring or if the misconception
of tip descent is occurring. Tip position in relation to the ala and cheek during
animation helps to differentiate between the two deformities. The tip is
inspected both in isolation and in comparison to the nasal ala and cheek
mound. It is important to determine if the tip is truly descending or if elevation
of the ala/cheek mound with subnasale repositioning are responsible for the
deformity. The latter is an illusion of tip descent.6 The infratip lobule is also
studied to identity fullness and/or asymmetry.7 Inspection of the upper lip for
shortening and/or a transverse crease is also done.
■ The lateral view is studied in repose and animation to study tip position,
infratip architecture, and the alar-columellar relationship. Inspection of the
nasal ala and check mound in relation to tip position is studied on animation.
This lateral view allows a more focused inspection on the tip alone with
animation. The alar-columella relationship is also assessed to identify the
presence of alar retraction or a hanging columella. Fibers of the DSN attach to
the mobile medial crura, and animation may distort the columella on
animation.
■ Basal view evaluation focuses on identifying and classifying columellar
deformity. Four types of deformity exist all based on the underlying anatomy.2
Excess or malpositioned cartilage and/or soft tissue can create a deformity in
this area and distort the BALs.2 Comprehensive evaluation of the nasal base
and in particular the medial nasal base (columella) is important when treating

the DSN.
IMAGING
■ Imaging is typically not utilized for diagnosis of animation deformities.
■ 3D imaging is used to discuss existing static deformities and illustrate
anticipated surgical results. Many patients with the aforementioned complaints
will receive increased tip rotation and placement of a columella strut to
stabilize the nasal tip. These potential changes can be illustrated using an
imaging system.
■ Changes in alar-columellar relationships are also illustrated using the imaging
system.
SURGICAL MANAGEMENT
■ Proper diagnosis is essential for effective surgical treatment. Treatment of the
DSN can be perceived as a static problem, dynamic problem, or both.2,4
■ Excess muscle volume can disrupt aesthetic ideals of the medial nasal base
creating a static lateralization of the BALs. Surgical management focuses on
reduction of the DSN and adjacent soft tissue.
■ Treatment of dynamic problems is deformity specific. Tip descent is managed
with disruption of the DSN and stabilization. Illusion of tip descent is treated
with increased rotation and stabilization. A shortened upper lip and/or
transverse crease is addressed with treatment of the muscle and mucosal
rearrangement.1
Preoperative Planning
■ A focused discussion is undertaken with the patient to determine concerns.
Patients should be educated in regard to limitations of deformity correction.
Although all maneuvers are executed to maximize the aesthetic and functional
outcome, the face and nose are dynamic, and perfection is rarely achievable.
■ Examination of the nose under anesthesia is performed prior to local injection
and prepping of the patient. Both visual and tactile examinations of the tip and
columella are completed. Palpation of the tip helps to determine support and
cartilage integrity. Gentle manipulation of the columella from side to side can
help determine caudal septal position and soft tissue volume. The BALs are
also inspected (FIG 1).

FIG 1 • Illustration of ideal basal aesthetic lines (BALs;
dashed lines). The BALs should be smooth and exhibit
a slight convexity, harmoniously transitioning the upper
lip to the nasal tip. Excess soft tissue or cartilage
malposition can disrupt this nasal harmony.
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. The
stretcher may be placed head up to 15 degrees to minimize venous pooling in
the operative field. A throat pack is gently placed and removed at surgery end.
Local anesthetic with epinephrine is injected into the planned incision sites
(FIG 2).
Approach
■ Though treatment of the DSN can be accomplished through intranasal
incisions, the authors prefer an open surgical approach. The transcolumellar
incision allows direct visualization and access to the tip and columella tissue.
When the operative plan includes lengthening the upper lip and or treating a
transverse crease, a transoral incision is also used. Techniques are dependent on
the problem being treated as outlined below.

FIG 2 • Photographic example of patient position and
exam under anesthesia.
T E C H N I Q U E S
■ Tip Descent
■ A transcolumellar incision is made and connected to bilateral
infracartilaginous incisions. As the nasal envelope is elevated, soft tissue is
detached from the underlying cartilage of the lower lateral cartilages (TECH
FIG 1). Muscle fibers are directly resected to release any attachment to the
medial or domal crura.5 The tip is well supported with columella strut and tip
suturing. Collectively, these maneuvers stabilize the tip and correct the
animation deformity. Patients with short upper lip or philtral crease may
undergo treatment with transoral incision. When a transoral incision is used,
the muscle may be transposed and sutured together with a 4-0 chromic. Alar
contour grafts are also commonly used to provide additional support to the
ala.

TECH FIG 1 • Demonstration of the transcolumellar
incision with direct exposure of the medial crura
cartilage.
■ Tip Descent Illusion
■ An open surgical approach is performed as described above. Surgical
maneuvers to increase tip rotation are often needed in these patients. Release
of the scroll ligament and possible cephalic trim is used with placement of a
columella strut to reposition and strengthen the nasal tip (TECH FIG 2A,B).
TECH FIG 2 • A. Photograph showing release of the
scroll ligament. Release of the scroll ligament allows
for upward rotation of the nasal tip. B. Illustration of

nasal tip mechanics. With disruption of the scroll
ligament (in isolation or with cephalic trim), the nasal
tip can be rotated upward and stabilized with a
columellar strut.
■ Short Upper Lip/Transverse Crease
■ A 1-cm horizontal incision is made in the upper labial sulcus centered on the
frenulum (TECH FIG 3A). Incision is made with pinpoint electrocautery,
and dissection is continued until the DSN is identified. The DSN is released
near the point of origin (either orbicularis or periosteum). The fibers are then
transposed and sutured1 together with 4-0 chromic (TECH FIG 3B).
TECH FIG 3 • A. Transoral horizontal incision
centered on the frenulum. This incision allows access
to the DSN and orbicularis fibers. B. Illustration of
release of the depressor septi nasi muscle and suture
fixation.

■ Animation Deformity of the Columella
■ An open surgical approach is performed as described above. The DSN fibers
(both superficial to and between the medial crura are resected away from the
medial crura (TECH FIG 4). It is important to resect at least 2 to 3 mm so
that the muscle does not scar back together. If posterior columella animation
deformity is present, then any fibers inserting on the footplates are also
removed. A columella strut is often placed to fortify tip position and stabilize
the columella.
TECH FIG 4 • Photograph illustrating soft tissue that
includes DSN fibers traversing the columella. At least
2 to 3 mm of muscle resection is needed to avoid
recurrent animation deformity.
■ Columellar Base Deformity
■ Excess DSN volume requires resection to recreate the ideal medial nostril
and BALs. Through an open approach, this tissue is easily reduced as needed.
If footplate flare is abnormal, then a MCFA3 is also performed (TECH FIG
5). This may displace excess soft tissue inferiorly subsequently distorting the
alar-columellar relationship. Resection of excess soft tissue avoids this
complication.

TECH FIG 5 • A. Premature flare of the medial crura
footplates causes distortion of the basal aesthetic
lines. B. Any excess soft tissue should be resected to
prevent inferior displacement during the medial crura
footplate approximation. C. A combination of gut and
PDS sutures is used to approximate the tissue.
PEARLS AND PITFALLS
Patient
communication
■ Of utmost importance is communication between the patient and
surgeon. An understanding of patient goals is essential for
successful rhinoplasty.
Proper
diagnosis
■ Proper diagnosis provides the basis for operative planning. This
requires a comprehensive evaluation of the face and nose during
repose and animation.
Knowledge of
relevant
anatomy
■ An understanding of the anatomy responsible for existing
deformities is crucial. Anatomically based classification systems
are particularly useful.
Technique
■ Once the problem has been identified and diagnosed, surgical
correction is planned. Understanding the problem is fundamental
to correction as all DSN deformities are not treated the same.
POSTOPERATIVE CARE
■ Nasal dressing is placed at surgery end. Taping is done to support 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
■ Resolution of tip deformity with DSN treatment has been well documented in
the existing literature.4 Outcomes regarding nasal base aesthetics are limited.
Composite outcomes reported included increased nasolabial angle, lengthened
upper lip, improvement of lip crease, narrowed wide nasal base, and
improvement in perceived tip descent/animation deformity.
COMPLICATIONS
■ Described complications of DSN treatment are uncommon but include
transient central upper lip paresthesia and upper lip asymmetry.4 These
typically resolve in 2 to 3 months.1,4 One might also expect recurrence of
deformity if the muscle is not adequately treated.
REFERENCES
1. Rohrich RJ, Huynh B, Muzaffar AR, et al. Importance of the depressor septi
nasi muscle in rhinoplasty: anatomic study and clinical application. Plast
Reconstr Surg. 2000;105:375-383.
2. Lee MR, Tabbal G, Kurkjian J, et al. Classifying columellar deformities in
rhinoplasty. Plast Reconstr Surg. 2014;133:464e-470e.
3. Geissler P, Lee MR, Unger J, et al. Reshaping the Medial Nostril and
Columellar Base: Five-Step Medial Crural Footplate Approximation. Plast
Reconstr Surg. 2013;132:553-557.
4. Sinno S, Chang JB, Chaudhry A, et al. Anatomy and management of the
depressor septi nasi muscle: a systematic review. Plast Reconstr Surg.
2014;134:134-135.
5. Lee MR, Malafa M, Roostaeian J, et al. Soft tissue composition of the
columella and potential relevance in rhinoplasty. Plast Reconstr Surg.
2014;134:621-625.
6. Kosins AM, Lambros V, Daniel R. The plunging tip: analysis and surgical
treatment. Aesthet Surg J. 2015;35:367-377.
7. Rohrich RJ, Liu RJ. Defining the infratip lobule in rhinoplasty: anatomy,
pathogenesis of abnormalities, and correction using an algorithmic approach.

Plast Reconstr Surg. 2012;130:1148-1158.

70
CHAPTERAlar Contour Grafts
Jacob Unger and Rod J. Rohrich
DEFINITION
■ The alar contour graft (ACG) is a cartilaginous strut utilized in rhinoplasty to
strengthen and reinforce the alar rim placed along the alar margin1 (FIG 1).
■ ACG is synonymous with alar rim graft.
■ Alar retraction is excessive elevation of the alar rim as evidenced from an AP
or lateral view with >2 mm of elevation from the long axis of the nostril.2
■ Alar collapse is a malformation of the rim on basal view that can occur when
the lower lateral cartilage (LLC) is congenitally cephalically oriented, resulting
in a loss of support along the anterior portion of the alar rim with a subsequent
concavity. This deformity may be static, dynamic, or both.
■ Alar notching is defined as a sharp angle within the ovular lateral contour. This
can extend cephalically and sometimes be referred to as a “parenthesis
deformity” or “ball tip.”3,4
ANATOMY
■ ACGs are intimately related to the aesthetics of the alar rim. The ideal alar rim
is defined on lateral view by a smooth contour with a slight arch, peaking
vertically between the level of the tip defining points and the columellar-
lobular angle. Further, the height of the alae should be no higher than 2 mm
above or 2 mm below the long axis of the nostril.
■ The alar rim is largely composed of thick, lower nasal skin superficially and
mucosa internally.
■ The lateral crus of the LLC normally runs parallel to the alar rim. The LLC
may be cephalically oriented, which predisposes to alar deformity. The
orientation of the LLC helps determine the shape of the ala anteriorly in the

area of the soft triangle.
■ The posterior half of the alar rim encompasses the alar lobule and is composed
entirely of fibrofatty tissue and thick skin.1,2
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Visual inspection and manual palpation of the nose will indicate if any alar rim
deformities are present in the preoperative state. Standard rhinoplasty imaging
should be undertaken with AP, lateral, basal, and ¾ views of the nose.
Visualization of the lateral crura of the LLC through the skin envelope can help
diagnose a more vertical orientation, which may portend a higher risk of future
alar deformities.
■ Forced inspiration through the nares will uncover any dynamic external nasal
valve collapse or evidence of alar collapse.
IMAGING
■ No imaging is necessary or indicated to prepare for alar rim deformity
correction with ACG.
■ Three-dimensional imaging may be useful as a preoperative planning and
patient communication tool. Caution is advised not to “lower” the alar position
with a computer program if one does not feel that this is a consistently
reproducible surgical outcome in his or her hands. However, this imaging may
help educate patients how reinforcement of alar retraction or collapse with
ACG may be very useful, as well as indicating changes in alar-columellar
relationships.

FIG 1 • Alar contour grafts.
SURGICAL MANAGEMENT
■ It is crucial that the correct diagnosis is made to ensure the most accurate
surgical treatment. Most crucially, if the patient has had severe mucosal loss
and shortening due to previous surgery, this must be disseminated to the
patient. This is a much more difficult problem to correct and may require
mucosal grafts or other interventions beyond placing ACGs.
■ In a virgin nose, alar retraction, notching, and collapse, both static and
dynamic, can be treated with operative placement of ACGs. It is important to
note the position of the LLCs as well. If they are cephalically oriented, some
inferior repositioning may be indicated as well using lateral crural strut grafts
or other techniques.
PREOPERATIVE PLANNING
■ A discussion regarding the patients’ concerns of lower nasal shape and alar
position should be undertaken. The patient must understand that although this
maneuver has a powerful impact on alar position and deformity correction,
there is a definite possibility of only partial correction or asymmetry.
■ Examination under anesthesia is performed prior to local injection and
intranasal oxymetazoline-soaked pledget placement. This examination will
help ensure that there is no internal mucosal shortage or scarring that can add
to any alar deformity.

Positioning
■ The patient is intubated and positioned on the table supine. The most cephalic
portion of the head extends just beyond the table. One may choose to place the
patient slightly asymmetrically on the table with the head and body closer to
the edge of the bed to the surgeon’s dominant hand side. If needed or desired,
one may utilize a “head-up” position to 15 degrees to minimize venous pooling
in the operative field.
Approach
■ Although placement of ACG can be accomplished through medial or lateral
approach, the authors prefer an open, medial approach. The transcolumellar,
infracartilaginous incisions allow direct visualization and access to the desired
location of the grafts. A laterally based approach through a radial incision
within the base of the lobule on the mucosal side can be utilized but has the
added difficulty of challenging angles of dissection and placement, as well as
confirmation of the depth of placement.
T E C H N I Q U E S
■ Open, Medial Placement (Preferred Technique)
■ A stair-step transcolumellar incision with bilateral infracartilaginous
incisions is used to open the soft tissue envelope.
■ The placement of the ACGs is performed at the end of the procedure,
immediately prior to closing, because these grafts are delicate and can tend to
become misplaced or fracture during soft tissue envelope manipulation.
■ First choice cartilage is septal cartilage because it can be harvested within
the primary surgical field, but an ear or rib cartilage graft may be used if
septum is unavailable. A double hook is utilized to place traction on the soft
triangle/columellar region to create tension for accurate dissection.
■ The ACG pocket is carefully dissected between the vestibular and nasal skin
below the infracartilaginous incision by using long, sharp Stevens scissors.
■ The pocket should be carried down into the alar lobule and ideally to the
level of the alar base.
■ This dissection will secure the pocket for graft placement.

■ Once the grafts are placed into their pockets, the nasal skin is redraped for
closure.
■ Any excess cartilage extruding medially from the pocket is resected1,2
(TECH FIG 1; Video 1).
Video p1-c070
TECH FIG 1 • A. Planned location for placement of
ACG. B. Dissection of pocket for ACG placement.
■ Lateral Placement—Open Approach
■ This technique helps placing the ACG via a radial incision within the alar
base/alar lobule.
■ A no. 15 blade is used to create a 0.5-cm incision in the base mucosa.
00:00 / 00:00

■ Use a double hook to extend the alar rim laterally and create tension for
dissection of a pocket.
■ Carefully place Stevens scissors into the incision and spread, aiming toward
the soft triangle until the tips are visible within the space at the edge of the
infracartilaginous incision at the level of the soft triangle.
■ Place the grafts from lateral to medial and excise the excess cartilage at the
lateral margin of the incision.
■ Closed Approach
■ This is a blind technique that requires extensive experience in rhinoplasty
prior to attempt and has high risk for misplacement or asymmetric placement.
■ Once the domes of the LLC have been delivered and there is a medial pocket
rostral to the soft triangle, careful dissection with Stevens or Converse
scissors is used to create a pocket along the alar margin between the mucosal
and skin envelope.
■ This requires bimanual palpation and constant checking to ensure accurate
pocket dissection.
■ Ensure dissection laterally to the same position bilaterally with palpation of
scissor tips at the same position on each side.
■ Place the grafts in the same manner and excise the excess medially.
PEARLS AND PITFALLS
Asymmetry
■ It is important to note that although alar contour grafts are not large
(measuring on average 2 to 3 mm in width and 1.5 cm in length), they
must be of equivalent size, strength, and design. If the grafts are not
nearly identical in both dimension and strength, these powerful grafts
can cause tip deviation toward the weak side or asymmetric alar
contour upon healing.
Avoid
nasal skin
buttonhole
■ Use curved Stevens scissors with tips pointing toward the mucosal
side at all times. This provides an anatomic dissection and ensures
that if a rent is created in the soft tissue envelope, it is on the more
forgiving mucosal side.
Difficulty
■ Cut the leading edge of the graft on an angle of 30 to 45 degrees for

of
placement
an atraumatic advancement of the graft into the pocket. Undue force
on the graft upon placement can result in fracture of this delicate
graft.
POSTOPERATIVE CARE
■ Nasal dressing is placed at surgery end.
■ Bacitracin-soaked 1 × 1 cm surgical squares are used to support the soft
triangle where no suture is placed to avoid a teardrop nostril apex.
■ Taping is done to support and minimize swelling of the nasal tip.
■ A Denver nasal splint is also applied. Doyle splints are also commonly
applied after septoplasty.
■ Tape and splints are removed 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.
■ Patients are encouraged to keep head of bed elevated while sleeping for the
first 2 weeks to improve edema.
■ No nose blowing for 2 weeks postoperatively
■ Exercise is reintroduced on a graduated scale, beginning with light exercise at
2 weeks, heavy exercise (ie, jogging) at 4 weeks, and heavy lifting allowed and
inverted maneuvers (ie, yoga head stands, etc.) at 6 weeks.
OUTCOMES
■ Outcomes are well documented in the literature showing improvement in alar
position, external nasal valve function, as well as prevention of postoperative
alar complications such as collapse, notching, and retraction.2,5,6
COMPLICATIONS
■ Complications related to ACG are minimal. It is a low-risk maneuver used to
improve alar aesthetics and prevent complications. One must be cautious to
avoid placing asymmetric grafts because this could influence tip position and
cause asymmetry of tip position.
REFERENCES
1. Rohrich RJ, Raniere J Jr, Ha RY. The alar contour graft: correction and
prevention of alar rim deformities in rhinoplasty. Plast Reconstr Surg.
2002;109(7):2495-2505.

2. Unger JG et al. Alar contour grafts in rhinoplasty: a safe and reproducible way
to refine alar contour aesthetics. Plast Reconstr Surg. 2016;137(1):52-61.
3. Constantian MB. The boxy nasal tip, the ball tip, and alar cartilage
malposition: variations on a theme—a study in 200 consecutive primary and
secondary rhinoplasty patients. Plast Reconstr Surg. 2005;116(1):268-281.
4. Toriumi DM. New concepts in nasal tip contouring. Arch Facial Plast Surg.
2006;8(3):156-185.
5. Guyuron B. Alar rim deformities. Plast Reconstr Surg. 2001;107(3):856-863.
6. Guyuron B, Bigdeli Y, and Sajjadian A, Dynamics of the alar rim graft. Plast
Reconstr Surg. 2015;135(4):981-986.

71
CHAPTER
Techniques for Treating
Nasal Airway Obstruction
Michael R. Lee
DEFINITION
■ Nasal airway obstruction (NAO) is a clinical diagnosis established through a
focused history and physical examination. All patients undergoing rhinoplasty
should be assessed for NAO.
■ The external nasal valve is located at the nostril. Nasal ala forms the lateral
aspect of the valve, whereas the columella makes up the medial portion.
Collectively, these structures with the soft triangle create the external valve.
■ The internal nasal valve is formed by the junction of the caudal portion of the
upper lateral cartilage with the dorsal nasal septum.
■ Nasal septum is the anatomic structure that divides the nasal cavity. Made of
bone and cartilage, the septum provides support for the nasal dorsum and tip.
■ Inferior turbinates are paired bones that extend medial into that nasal cavity
from the lateral nasal wall. Turbinates regulate nasal airflow characteristics and
provide mucociliary clearance.
ANATOMY
■ NAO typically occurs at one of four areas:
■ External nasal valves
■ Internal nasal valves
■ Nasal septum
■ Inferior turbinates
■ Understanding the anatomy of these structures is fundamental to treating NAO
in rhinoplasty.
■ The external nasal valve relies on structural support of the lower lateral
cartilages and adjacent soft tissue.