499
Postoperative care
Submucous turbinate resection has been advocated by
many. However, this does not eliminate the hypertrophic soft
tissues. Partial turbinectomy is likely the most versatile option,
as it addresses both the hypertrophic mucosa and underlying
bone while leaving a normal-sized turbinate behind. It also
portends less morbidity and greater success than complete
turbinectomy. Despite removing conchal bone and potentially
some mucosa, this procedure is designed to spare turbinate
mucosa and, thus, its important physiologic function of
warming, humidifying, and cleansing inspired air.13 Partial
turbinectomy should be done evenly across the full length of
the turbinate, rather than only anteriorly or posteriorly as
advocated by a few. Otherwise, the intact portion of the tur-
binate undergoes compensatory hypertrophy and requires
additional surgery. For the submucous resection, as described
by Mabry, a medial mucoperiosteal flap is created using Bovie
electrocautery, and the turbinate is outfractured with an eleva-
tor. Takahashi forceps are then carefully used to grasp, rotate,
and resect the exposed conchal bone. The remaining mucosal
flap, barring over-resection, naturally drapes over the resected
conchal bone. Judicious cauterization is then used for hemo-
stasis of the mucosal edges.73
Postoperative care
Following the completion of the procedure, a dorsal splint is
applied if a rhinoplasty is part of the plan. The dorsal splint
re-approximates the free tissue envelope to the corrected
framework. A combination of metal splints and Aquaplast
over Steri-Strips is preferred by the authors. The Aquaplast
provides stability, whereas the metal portion allows precise
molding of the Aquaplast splint. Doyle splints are also placed
within the nostrils in an extramucosal fashion. The use of the
Doyle splints allows further stabilization of the septum. The
external splint is left on for 8 days, while the internal Doyle
stent is removed in 3–4 days.
The simple extramucosal internal stents that are placed
after any septal correction surgery are kept in for 2 weeks.
The patient is kept on a first generation cephalosporin for
the duration that the Doyle internal splints are used. A
Medrol® dose-pack is also prescribed if a nasal bone osteot-
omy is part of the surgical plans, to minimize swelling and
turbinate hypertrophy is common with eventual relocation of
the turbinate back to its original position. In addition, simple
outfracture does not address the turbinate with hypertrophic
mucosa, which is either associated with, or even the primary
pathology responsible for, the enlarged turbinate.67 Thus, this
technique is often combined with other procedures.
Destructive procedures
Destructive procedures aim to reduce the bulk of the turbi-
nates by direct destruction and/or introducing scar. The first
method, electrocautery, can be done in a superficial or submu-
cous plane with monopolar or bipolar diathermy. It, too, has
the advantages of being technically facile and quick. However,
surface electrocautery can be associated with edema and
crusting for up to 3–6 weeks, as well as adhesions in 20–30
percent of cases.68,69 In addition, in submucous and bipolar
electrocautery, the conchal bone must be avoided to prevent
long-term edema, erythema, and sequestrum.67
Cryosurgery works by inducing mucosal injury by
causing intracellular crystal formation. Thus, its main affect
is seen in the water-laden goblet cells and therefore only
addresses hypertrophic mucosa.70 Prolonged crusting, late
hemorrhage, and the need for multiple treatments are reported
complications.
Laser turbinate reduction is not novel and has been in use
since the early 1970s in Europe.71 Many lasers have been used
including CO2, Nd:YAG, argon, and the potassium–titanyl–
phosphate laser. As with the previous techniques, lasers are
fast and easy with a relatively low complication profile (i.e.,
hemorrhage). Like electrocautery and cryotherapy, lasers only
address the mucosa and not the underlying bone.66
Turbinate resection procedures
Complete turbinectomy has largely fallen out of favor second-
ary to multiple reports citing severe complications, as well as
an increase in our knowledge and understanding of the
important physiologic role the turbinate plays. If too much
turbinate is removed, the excessively patent nasal airway can
lead to pharyngeal dryness, increased sensitivity to cold air,
ozena, and a paradoxical sensation of nasal obstruction.72
Thus, when approaching turbinectomy, most agree a conser-
vative approach is best.
Fig. 18.14 The proper placement of an alar batten graft is shown.
500
SECTION I
CHAPTER 18 • Airway issues and the deviated nose
Fig. 18.15 A patient before (A, C, E, G) and after (B, D, F, H) correction of a C-anteroposterior deviation of the septum and the nose.
A
B
C
D
E
F
G
H
bruising. However, corticosteroids are avoided in patients
with active acne. Heavy physical activity is curtailed for 3
weeks.
Outcomes/prognosis/complications
Without adequate preoperative and intraoperative assessment
of the deviated nose, an incomplete correction of the nasal
deformity and function is inevitable. Inadequate straighten-
ing of any one or combination of structures may contribute to
the recurrent or continued nasal deformity. One must address
the septum, bony framework, upper lateral cartilages, lower
lateral cartilages, internal valve, external valve, and turbi-
nates. Minor discrepancies may be corrected with taping or
continued splinting, but unfortunately, most will ultimately
need surgical revision. Other possible complications include
synechia, septal hematoma, septal perforation, infection,
bleeding, and atrophic rhinitis (Figs. 18.15, 18.16).
Secondary procedures
The prevailing goal of any rhinoplasty surgeon is to achieve
the best result with the first operation. However, even the
most skilled surgeon with the best intentions will care for
patients requiring secondary procedures to achieve improved
results. Each patient’s pathology is unique and should be
managed on a case-by-case basis. Specific techniques are
discussed within this chapter and throughout the text. Adher-
ence to these principles will minimize the need for secondary
procedures.
501
Secondary procedures
Fig. 18.16 A patient before (A, C, E, G) and 7 years after (B, D, F, H) correction of a left side nasal tilt.
A
B
C
D
E
F
G
H
2. Howard BK, Rohrich RJ. Understanding the nasal airway:
principles and practice. Plast Reconstr Surg. 2002;109:
1128–1146. The authors present a thorough review of the nasal
airway beginning with pertinent nasal anatomy and moving onto
physiology, pathology, and treatment. It is well cited and discusses in
detail the key concepts and principles in the practical management of the
nasal airway.
8. Courtiss EH, Gargan TJ, Courtiss GB. Nasal physiology. Ann Plast
Surg. 1984;13:214–223.
9. Constantian MB, Clardy RB. The relative importance of septal
and nasal valvular surgery in correcting airway obstruction in
primary and secondary rhinoplasty. Plast Reconstr Surg.
1996;98:38–54.
33. Guyuron B, Behmand RA. Caudal nasal deviation. Plast Reconstr
Surg. 2003;111:2449–2457. The authors begin by describing the anatomic
structures that define the caudal nose. They go on to discuss the specific
structures and their associated abnormalities as they relate to
abnormalities of the caudal nose and nasal airway. The discussion includes
a description of the surgical technique necessary to address each deformity.
In particular, six types of septal deviation are described in terms of
diagnosis and treatment.
34. Gunter JP, Rohrich RJ. Management of the deviated nose: the
importance of septal reconstruction. Clin Plast Surg. 1988;15:43–55.
35. Byrd HS, Salomon J, Flood J. Correction of the crooked nose. Plast
Reconstr Surg. 1998;102:2148–2157.
37. Constantian MB. The incompetent external nasal valve:
Pathophysiology and treatment in primary and secondary
rhinoplasty. Plast Reconstr Surg. 1994;93:919–931.
39. Chand MS, Toriumi DM, Landecker A. Surgical management of the
nasal airway. In: Gunter JP, Rohrich RJ, Adams WP Jr, eds. Dallas
Rhinoplasty. 2nd ed. St. Louis: Quality Medical; 2007:909. The authors
begin with a discussion on the preoperative assessment of a patient who
requires surgical management of the nasal airway. This includes the
history, physical examination, and appropriate diagnostic studies. This is
followed by a detailed discussion regarding the treatment strategies of the
various components making up the nasal airway.
58. Guyuron B. Nasal osteotomy and airway changes. Plast Reconstr
Surg. 1998;102:856–860. The author provides a prospective investigation
involving 48 consecutive patients who underwent various nasal bone
osteotomies during rhinoplasty procedures. The author concluded that the
nasal osteotomy does constrict the nasal airway in most incidences. The
length of the nasal bones, the degree of nasal bone repositioning, the
position of the inferior turbinates, and the type of osteotomy are definite
factors contributing to airway narrowing after nasal bone osteotomy.
66. Jackson LE. Management of the inferior turbinate hypertrophy. Plast
Reconstr Surg. 1999;104:1197–1198. The author provides a critical
appraisal in the medical and surgical management of the inferior turbinate.
Acknowledgement is made regarding the continued debate in the treatment
of inferior turbinate pathology. Advantages, disadvantages, complications,
and controversies of each form of treatment are reviewed and discussed. A
staged protocol of increasingly invasive interventions is proposed.
Access the complete reference list online at
501.e1
References
References
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authors present a thorough review of the nasal airway beginning with
pertinent nasal anatomy and moving onto physiology, pathology, and
treatment. It is well cited and discusses in detail the key concepts and
principles in the practical management of the nasal airway.
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32. Ferguson BJ, Mabry RL. Laboratory diagnosis. Otolaryngol Head
Neck Surg. 1997;117:S12.
33. Guyuron B, Behmand RA. Caudal nasal deviation. Plast Reconstr
Surg. 2003;111:2449–2457. The authors begin by describing the anatomic
structures that define the caudal nose. They go on to discuss the specific
structures and their associated abnormalities as they relate to
abnormalities of the caudal nose and nasal airway. The discussion includes
a description of the surgical technique necessary to address each deformity.
In particular, six types of septal deviation are described in terms of
diagnosis and treatment.
34. Gunter JP, Rohrich RJ. Management of the deviated nose: the
importance of septal reconstruction. Clin Plast Surg. 1988;15:43–55.
35. Byrd HS, Salomon J, Flood J. Correction of the crooked nose. Plast
Reconstr Surg. 1998;102:2148–2157.
36. Fancesconi G, Fenili O. Treatment of deflection of the anterocaudal
portion of the nasal septum. Plast Reconstr Surg. 1973;5:342–345.
37. Constantian MB. The incompetent external nasal valve:
Pathophysiology and treatment in primary and secondary
rhinoplasty. Plast Reconstr Surg. 1994;93:919–931.
38. Sheen JH. Spreader graft: A method of reconstructing the roof of the
middle nasal vault following rhinoplasty. Plast Reconstr Surg.
1984;73:230–239.
39. Chand MS, Toriumi DM, Landecker A. Surgical management of the
nasal airway. In: Gunter JP, Rohrich RJ, Adams WP Jr, eds. Dallas
Rhinoplasty. 2nd ed. St. Louis: Quality Medical; 2007:909. The authors
begin with a discussion on the preoperative assessment of a patient who
requires surgical management of the nasal airway. This includes the
history, physical examination, and appropriate diagnostic studies. This is
followed by a detailed discussion regarding the treatment strategies of the
various components making up the nasal airway.
40. Grymer LF, Hilberg O, Elbrond O, et al. Acoustic rhinometry:
evaluation of the nasal cavity with septal deviations, before and
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41. Hilberg O, Jackson AC, Swift DL, et al. Acoustic rhinometry:
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48. Portmann M, Guillen G, Chabrol A. Electrocoagulation of the
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49. Fernandes CM. Bilateral transnasal vidian neurectomy in the
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50. Kirtane MV, Prabhu VS, Karnik PP. Transnasal preganglionic vidian
nerve section. J Laryngol Otol. 1984;98:481–487.
51. Golding-Wood PH. Vidian neurectomy: its results and
complications. Laryngoscope. 1973;83:1673–1683.
52. Stucker FJ, Hoasjoe DK. Nasal reconstruction with conchal cartilage:
correcting valve and lateral nasal collapse. Arch Otolaryngol Head
Neck Surg. 1994;120:653–658.
53. Park SS. The flaring suture to augment the repair of the
dysfunctional nasal valve. Plast Reconstr Surg. 1998;101:1120–1122.
54. Sheen JH. Spreader graft revisited. Perspect Plast Surg. 1989;3:155.
55. Rohrich RJ, Hollier LH. Rhinoplasty-dorsal reduction and spreader
grafts. Dallas Rhinoplasty Symposium. 1998;15:179.
56. Oneal RM. Upper lateral cartilage spreader flaps in rhinoplasty.
Aesthet Surg J. 1998;18:370–371.
57. Gruber RP. The spreader flap in primary rhinoplasty. Plast Reconstr
Surg. 2007;117:1903–1910.
58. Guyuron B. Nasal osteotomy and airway changes. Plast Reconstr
Surg. 1998;102:856–860. The author provides a prospective investigation
involving 48 consecutive patients who underwent various nasal bone
osteotomies during rhinoplasty procedures. The author concluded that the
nasal osteotomy does constrict the nasal airway in most incidences. The
length of the nasal bones, the degree of nasal bone repositioning, the
position of the inferior turbinates, and the type of osteotomy are definite
factors contributing to airway narrowing after nasal bone osteotomy.
59. Gunter JP, Friedman RM. Lateral crural strut graft: technique and
clinical applications in rhinoplasty. Plast Reconstr Surg.
1997;99:943–952.
60. Teichgraeber JF. Lateral crural spanning grafts for the treatment of
alar collapse. Laryngoscope. 1995;105:760–763.
61. McCollough EG, Fedok FG. The lateral crural turnover graft:
correction of the concave lateral crus. Laryngoscope. 1993;103:
463–469.
62. Guyuron B. Alar rim deformities. Plast Reconstr Surg. 2001;107:
856–863.
63. Sheen JH, Sheen AP. Aesthetic Rhinoplasty. 2nd ed. St. Louis: Mosby;
1987.
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revision. Arch Otolaryngol Head Neck Surg. 1987;113:943.
65. Constantian MB. An alar base flap to correct nostril and vestibular
stenosis and alar base malposition in rhinoplasty. Plast Reconstr
Surg. 1998;101:1666–1674.
66. Jackson LE. Management of the inferior turbinate hypertrophy.
Plast Reconstr Surg. 1999;104:1197–1198. The author provides a critical
appraisal in the medical and surgical management of the inferior
turbinate. Acknowledgement is made regarding the continued debate in
the treatment of inferior turbinate pathology. Advantages, disadvantages,
complications, and controversies of each form of treatment are reviewed
and discussed. A staged protocol of increasingly invasive interventions is
proposed.
67. Goode RL, Pribitkin E 2nd. Diagnosis and Treatment of Turbinate
Dysfunction. Alexandria: American Academy of Otolaryngology-
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68. Meredith GM Jr. Surgical reduction of hypertrophied inferior
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69. Muran AGD, Lund VJ. Clinical Rhinology. New York: Thieme
Medical; 1990:82–84.
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and Sinus Disorders. New York: Thieme Medical; 1993:94–118.
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72. Fanous N. Anterior turbinectomy – a new surgical approach to
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73. Mabry RL. Inferior turbinoplasty. Oper Tech Otolaryngol Head Neck
Surg. 1991;2:183–188.
SECTION I • Aesthetic Surgery of the Face
19
Secondary rhinoplasty
Ronald P. Gruber, Simeon H. Wall Jr., David L. Kaufman, and David M. Kahn
SYNOPSIS
■ Secondary rhinoplasty may be done to correct a complication, to
correct an untoward result, or simply to pursue further improvement.
■ Secondary rhinoplasty is more difficult than primary. All measures to
help the surgeon should be used, including preoperative imaging and
the intraoperative use of models.
■ Opening the nose is done by hyperinfiltration and patient dissection.
■ The nasal tip is “deconstructed” first by splitting it down the middle
and not trying to dissect away all the scar tissue, which risks harming
the structural integrity of the existing framework.
■ Suture techniques are attempted before cartilage grafting to restore
structural integrity and shape. Batten grafts are used more than ever
before to avoid the additional tissue trauma resulting from undermining
the framework from the vestibular skin.
■ Grafting of the surface of the lateral crus, upper lateral cartilage, or tip
is the main reconstruction method. Invisible grafts, e.g., columellar
struts and spreader grafts are also relied upon.
■ Airway compromise is a frequent problem that must be addressed in
secondary rhinoplasty. This includes septoplasty, internal valve
reconstruction, and external valve reconstruction.
Introduction
Definitions
Secondary rhinoplasty is a reoperation of a nose previously
operated upon by a prior surgeon. We distinguish this from a
“revision”, which is a reoperation by the same surgeon on
their own patient. Usually, the secondary operation is more
extensive than the revision. Secondary rhinoplasty and revi-
sion rhinoplasty are done for reasons that include complica-
tions of surgery, unsatisfactory results, or the need for further
improvement. For legal reasons, it is important to distinguish
between (1) a complication; (2) an untoward result; and (3)
the need for further improvement. A complication may or
may not be attributable to an action taken by the surgeon. For
example, a true saddle nose deformity is most likely the
responsibility of the surgeon. However, a supratip deformity
is usually an untoward result, even though more often than
not we think it can be prevented. Seeking “further improve-
ment” is done on a satisfactory result when both the surgeon
and patient feel that more can be done to obtain an even better
result.
Why secondaries are difficult
If rhinoplasty is the most difficult operation in aesthetic
surgery, secondary rhinoplasty is even more difficult.1 The
overall revision rate of 20% suggests that this is the case.
Whereas, the patient who needs a revision rhinoplasty is
willing to let the first surgeon perform it, they are is much less
likely to allow a third procedure by that surgeon if there is
dissatisfaction once again. It behooves the surgeon, therefore,
in a revision rhinoplasty, to do everything possible to avoid
an unhappy patient with its concomitant problems (lawsuit
and public complaining on the internet).2
Analysis
Dealing with the secondary rhinoplasty patient requires more
skill and patience than a primary case. The patients are often
unhappy, skeptical, and need more reassurance than they did
prior to their first surgery. The operation is often more com-
plicated, but not necessarily so. It is important to acknowledge
the patient’s complaints. However, one must always remem-
ber not to be judgmental of the first surgeon. Untoward and
unsatisfactory results are a part of rhinoplasty. The nose is an
unforgiving part of the anatomy. Unlike a breast augmenta-
tion, a 1-mm discrepancy can easily be noticeable and objec-
tionable. The very best rhinoplasty surgeons in the world
have had to contend with this fact.
J.P. Gunter3 has probably done more than any other surgeon
to emphasize analysis. Kim and Toriumi4 have a complete
review on this subject, and it is also covered in Chapter 15. In
Access video lecture content for this chapter online at expertconsult.com
503
Operative techniques
our practices, we consider digital imaging the most important
aspect of analysis. The surgeon should use imagers (Fig. 19.1)
for preoperative planning for each patient. Imagers are widely
available and economical. It is helpful to demonstrate to the
patient what you think should to be done and elicit their
feedback as to what they think should be done. The patient
needs to know what can and cannot be realistically achieved.
In the process of imaging, the surgeon learns what problems
may exist. Sometimes, the process of morphing can be enlight-
ening. Often, what may appear to be the problem when
judging the patient sitting in the examining chair is not the
problem as seen by the camera on the monitor. Furthermore,
some anatomic problems only become obvious when on the
monitor. Patients with unrealistic expectations can be weeded
out by this process. Morphing with an imager is a form of
mock surgery.
Operative techniques
Preparing to be a biological sculptor
It is not enough to have knowledge of nasal anatomy.5 Rhino-
plasty is sculpting with a biological medium (cartilage and
some bone). As such, we need to employ an artist’s principle:
copying. It is much easier to copy a beautiful structure than
it is to create it from memory. Commercial artists rely on this
concept. Unless you are a naturally gifted artist, you will find
this to be the case. Few of us can draw a decent picture of
a cat from memory, but even an artistically challenged
individual can copy a reasonable facsimile of a cat from a
photograph. Consequently, we recommend the use of an
intraoperative model of the ideal or prototype nasal frame-
work (Fig. 19.2
). Magnifiers and loupes make it difficult to
see the nose from a distance and get the proper perspective.
Therefore, it is also helpful to have a video camera in the
operating room (which gives a profile view of the patient –
from a distance – at all times). It is not surprising that some
surgeons are occasionally perplexed to see that the patient’s
nose has nostril exposure the next day or at the time of
splint removal. They may have neglected to judge that angle
Fig. 19.1 Imaging is a key to successful analysis and patient communication. It is
also a way to perform mock surgery.
accurately when the patient was in the supine position. Step-
ping back to evaluate the patient, or using a video camera,
gives a better perspective and helps avoid this problem.
Fig. 19.2 appears online only.
The open versus closed approach in
secondary rhinoplasty
The decision to open the nose or not in a secondary can be
more difficult than in the case for a primary rhinoplasty.6 If
there is little to do, e.g., rasping the dorsum or attaching a rim
graft, there is no question that a closed approach is ideal. And
if it appears that visualization will be beneficial to completing
the task, e.g., straightening the nose, or straightening out a
twisted tip, there will be little question that an open approach
will permit greater accuracy and therefore a better final
result.
The options for anesthesia are discussed online.
Opening the nose and tip deconstruction
The secondary nose may have a great deal of scar tissue that
obliterates much of the anatomy of the tip. Therefore, it is
important to appreciate the situation by (a) using a technique
that makes it easier to elevate the skin flap and (b) deal with
a mound of abnormal anatomy camouflaged by scar tissue.
We have found that hyperinfiltrating the tissues will minimize
perforation and allow the scissors to pass more easily in the
subcutaneous plane. Patience is imperative as one frequently
has to go slowly to elevate the flap with minimal trauma to
the soft tissues. Trauma to the cartilaginous frame is much less
of a concern because it can always be rectified with sutures
and grafts.
Once the flap is elevated, it is helpful to ignore the anatomy
momentarily and split the tip down the middle starting along
the dorsum (Fig. 19.3A). When cutting the dorsal tissues, one
usually finds the anterior septal cartilage by simple palpa-
tion. Any small perforation should be repaired with 5-0 plain
catgut suture. As the cut splits the dome region, the middle
crurae often come into view. Even if they do not appear, and
even if the splitting process results in a middle crus one side
that has extra cartilage on its surface and an opposite middle
crus that is devoid of some cartilage because the splitting
process did not precisely separate the two, it does not matter.
There will be enough integrity of the two sides, such that
when they are put together at the end of the tip-plasty, their
structural integrity will be restored. If necessary, a columellar
strut between them will restore that integrity and strength. Do
not try to dissect off the scar tissue of the tip cartilages hoping
to find a satisfactory framework. This typically damages the
cartilages. It is better to leave some scar tissue on the surface.
Trying to strip away scar tissue to see the cartilage should
be minimized if one wants to avoid damaging the structural
integrity. That is true when trying to visualize the lateral
crurae. It is reasonable to shave some scar tissue off the lateral
crus. However, as soon as some cartilage is seen, that process
should stop because continued dissection of the lateral crus
will only weaken it to the point where it collapses. The scar
tissue on a secondary lateral crus actually does provide some
structural integrity. Making it as thin as possible by shaving
scar off the surface is reasonable. Later, thin surface grafts (see
discussion of batten grafts
, below) can be applied if needed.
503.e1
Operative techniques
Fig. 19.2 (A) This autoclavable model of the prototype ideal framework for the nose makes it easy for the surgeon to perform their biological sculpting. Copying from a
model is much easier than memorizing the angles and relationships between various parts of the tip complex. (B) The deformed nasal tip should ideally look something like
the prototype model. (C,D) Appearance after suture techniques, excisional techniques, and grafts are complete.
A
B
C
D
Anesthesia
Most of our patients receive conscious intravenous sedation
because it is more affordable for the patient. The overall
benefits of conscious sedation are reviewed elsewhere.7
Unfortunately, many residency programs do not train sur-
geons to use it, forcing them to learn it following their formal
training. Patients are instructed to take flurazepam (Dalmane)
60 mg 1 h prior to arriving at the surgery center. On arrival,
the relaxed patient then receives intramuscular (IM) hydroxy-
zine (Vistaril) 100 mg and IM nalbuphine (Nubain) 10 mg.
Demerol 50 mg can be used as an alternative to nalbuphine.
In the operating room, the patient is sedated with incremental
1-mg doses of midazolam (Versed). When the patient has
difficulty counting backwards from 100, ketamine 30 mg is
given slowly over 30 s. For larger female patients and males,
50 mg is employed. Additional incremental doses of Versed
(1 mg) are used if the patient should not enter that desired
“dissociative state” that ketamine is known to produce, which
lasts for approximately 5 min.
Local anesthetic is injected into the nose during that time.
It consists of a solution containing a 50/50 mixture of xylo-
caine 1% and bupivacaine (Marcaine) 0.25% with an epineph-
rine concentration of 1/200 000. A total solution of 30–50 mL
is used in a hyperinfiltration technique. Injection of the dorsal
septum provides most of the anesthesia to the septum although
supplementary anesthesia is given to other areas. The inferior
turbinates are injected to provide anesthesia for a subsequent
lateral osteotomy and to be able to tolerate the pledgets that
are inserted to absorb blood that would otherwise run down
the patient’s nasopharynx and cause intermittent coughing.
Using the above approach has avoided the need for topical
anesthetics such as cocaine.
If one is going to undertake conscious anesthesia, it is
imperative that they be familiar with airway management. It
is a good idea to mask-ventilate the patient for a few breaths
during ketamine to appreciate what the patient’s potential
airway difficulty might be during the case. It is also important
to have an oral airway immediately available should it be
necessary to insert it if the oximeter indicates that the patient
is hypoventilating or their jaw has fallen back causing a partial
airway obstruction. In addition, it is important to have avail-
able reversal agents including naloxone (Narcan) for the
narcotics and flumazenil (Romazicon) for the benzodiazepines.
When general anesthesia is used, the epinephrine concentra-
tion is increased to 1/70 000. To avoid an adverse cardiac
reaction, a small dose is injected into the septum to observe
the cardiac response before proceeding with further injection
of the nose.
504
SECTION I
CHAPTER 19 • Secondary rhinoplasty
to the primary rhinoplasty and involve all the principles of
primary rhinoplasty. The surgeon will also be in a position
to do a septoplasty starting at the anterior septal angle,
which has now been exposed as a result of the tip-splitting
process.
Suture techniques and grafts (reconstruction)
Suture techniques – general principles
The universal horizontal mattress suture8,9 is a suture that
can be applied to any unwanted convex or concave carti-
laginous structure of the nose in a secondary rhinoplasty
(Fig. 19.4). A short learning curve is necessary, because if
the gap between purchases is too little, no effect results, but
if the gap between purchases is too large, the cartilage will
buckle. Our studies have shown that one suture can increase
the strength (biplanar modulus in engineering terms) of the
cartilage by approximately 35%, whereas scoring the carti-
lage to achieve the same degree of correction can weaken
the cartilage by as much as 50% (Fig. 19.5
). The lateral
crural mattress suture is the most obvious example. However,
the universal horizontal mattress suture is also useful for
unwanted curvatures of the septal L-shaped struts. Similarly,
ear cartilage is much more usable when it is straightened and
stiffened with this particular suture. When the concha cymba
is removed from behind the ear, it is split down the middle,
pinned to a silicone block, concave side down. A 5-0 Vicryl
Following splitting the tip down the middle and some
superficial shaving of scar tissue from the lateral crus, the
tip complex should be separated from the middle vault
(upper lateral cartilages). The tip will become a mobile unit
if this is done properly. One should try to find the junction
between upper lateral cartilages (ULC) and lateral crus by
simply moving the tip complex with a pair of forceps. Usually,
the lateral crus folds onto the ULC when this is done. If
that is not seen, one should arbitrarily draw a line with a
marking pencil at least 6 mm from caudal border of the mar-
ginal incision. That line will arbitrarily become the border
between lateral crus and ULC. The tissues of the vestibule
are hyperinfiltrated (Fig. 19.3B), and an incision is arbitrarily
made where marked (Fig. 19.3C). There may or may not be
sufficient cartilage in the region that is now indicated as the
lateral crus. If it is not stable, it will need grafting. More
often than not it is stable because most surgeons these days
do not resect most of the lateral crus, as was done years ago
to reduce tip bulbosity. The incision between the ULC and
lateral crus should not penetrate the vestibular lining. The
gap is widened with scissors. Surprisingly, that gap can be
as much as 4–8 mm. It results in a tip mobility that allows
the surgeon to derotate or rotate the tip to a new position
without tension. When the splitting process is complete, when
some shaving of scar tissue has been done, and when the tip
complex is mobile, deconstruction will have been completed
and the surgeon will now be in a position to reconstruct the tip.
That reconstruction process will, in essence, be very similar
Fig. 19.3 (A) The best way to get control of a fibrotic amorphous tip is to first split
it down the middle beginning with the dorsum. The anterior septal angle will become
exposed, and then one can split the middle crurae apart. So doing avoids losing
structural integrity, which occurs when trying to dissect the entire scar in an attempt
to find the cartilaginous framework. (B) Hyperinfiltration with local anesthesia helps.
(C) If the junction between the upper lateral cartilages (ULC) and lateral crus is not
visible because of scarring, the tip complex is separated from the ULC by arbitrarily
making an incision at least 6 mm from the marginal incision. By spreading in that
incision, the tip complex becomes separated from the ULC and mobile for rotation or
derotation.
A
Splitting the tip
B
Local hyperfiltration
C
Incise at least 6 mm
from caudal border of
lateral crus
505
Operative techniques
Fig. 19.4 (A) The horizontal mattress suture corrects convexities of any cartilages. When the spacing between bites is approximately 5 mm, most of the convexity is
removed. Adjacent mattress sutures may be necessary along the course of the convexity to flatten he cartilage. (B) Convexity is readily apparent here. (C) The mattress
suture is in place. (D,E) Now the cartilage is devoid of most convexity. (F) If the mattress suture is pulled too tight a concavity will result.
A
3 mm
B
C
D
E
F
or polydioxanone (PDS) horizontal mattress suture is applied
at each end of the cymba to straighten it and stiffen it (Fig.
19.6
). Such a suture reinforced graft makes a good columel-
lar strut and can even replace the entire lateral crus if it is
missing.
Figs. 19.5 & 19.6 appear online only.
Grafts – general principles
Most secondary rhinoplasties demand grafts to either replace
missing cartilage that has been excessively removed or to
provide support for weak structures. Septal cartilage is pre-
ferred. However, it is usually unavailable in sufficient
505.e1
Operative techniques
Fig. 19.5 A single universal horizontal mattress suture can increase the strength of
cartilage by 35%. Scoring the cartilage to achieve the same degree of straightness
can reduce the cartilage strength by 50%.
Biplanar Modulus (Map)
0
7
6
5
4
3
2
1
No Suture
Suture
Score
A fundamental principle of reconstruction is the use of grafts
when nothing further can be done with suture techniques.
Every conceivable graft has been described for the nose, e.g.,
lateral crural strut to support the lateral wall, columellar strut
to support the middle/medial crus tip projection, spreader
grafts to support the attachment of ULC to dorsal septum,
batten grafts to the ULC to give it structural integrity, batten
grafts on the surface of the lateral crurae to give them integrity,
and tip grafts to provide structural support and shape to the
actual tip. In recent years it has been our experience that it is
not necessary to dissect beneath the vestibular lining to insert
a graft beneath the existing tip framework. So doing may
cause more damage to the lining of the nose. Therefore, our
use of onlay grafts for either the ULC region or the lateral crus
region has increased. The caveat is that these grafts must be
thin (no more than 1 mm in thickness) if a bulkiness of the
nose is to be avoided.
505.e2
SECTION I
CHAPTER 19 • Secondary rhinoplasty
Fig. 19.6 (A–E) The ear is a great source of donor cartilage. This concha cavum/cymba graft is applied
to a silicone block where it will be divided into two units: cymba and cavum. As individual units, they
are easily straightened with horizontal mattress sutures and made into usable units of cartilage to
reconstruct various parts of the secondary nose.
A
B
C
D
E
505.e3
Operative techniques
Fig. 19.7 (A) Rib is relatively easily obtained by making an inframammary incision and exposing the nearest available cartilaginous rib (usually the fifth rib). (B,C) Often,
only the anterior surface of the rib need be removed with the aid of a slightly curved osteotome or septal knife. (D) The rib is sliced into pieces 1 mm thick and 3-4 cm
long for surface graft reconstruction. When a structural L-strut unit is needed, thicker segments are carved to make it. The structural support remains deep to the surface
grafts.
A
B
C
D
506
SECTION I
CHAPTER 19 • Secondary rhinoplasty
Fig. 19.7 appears online only.
Diced cartilage has a vital role, especially if it is wrapped
in a substance like fascia to give it shape. This technique was
developed primarily for dorsal augmentation by Daniel.12
Erol13 demonstrated that diced cartilage in a Surgicel wrap-
ping could be useful. However, we prefer fascia to avoid the
possibility of absorption due to the slight inflammatory effect
of Surgicel. The cartilage is cut into small bits approximately
1 mm in size and placed in a blanket of fascia (on a silicone
block). The fascia is simply folded over and secured with 5-0
plain catgut suture. It is helpful to have applied a silicone sizer
in the patient’s dorsum, to get an idea as to how long and
thick to make the DCIF graft (Fig. 19.8). When soft-tissue
padding only is required for the dorsum (such as in the thin-
skinned patient) fascia alone (see Fig. 19.8) or even dermafat
grafts (taken from behind the ear) are used.
We seldom consider irradiated allograft rib cartilage.
Although this can be useful when the patient is resistant
to harvesting autogenous material, the main problem with
allograft is the potential for absorption. Although some
reports of long-term survival exist,14 one must be prepared for
absorption within a few years. An option we never consider
for secondary rhinoplasty is the use of implants of any mate-
rial. We recognize that many surgeons have found them
quantities. Therefore, either ear or rib is required. For small
amounts of cartilage, we prefer ear cartilage. Since it can be
straightened and stiffened as described above, it is useful for
almost every situation where septal cartilage would ordinarily
be used. However, when large amounts of cartilage are
required, we prefer rib.10,11 In particular, we prefer the fifth rib
that is accessible from an inframammary incision (Fig. 19.7
).
The entire rib cartilage need not be removed. The anterior half
(or two-thirds) is relatively easily removed with a septal knife.
The specimen is taken early in the case to allow time ( 12 h) for
warpage to show itself. It is carefully sliced into multiple 1-mm
thick segments that are about 3–4 cm in length and 6 mm in
width with a large scalpel. Units of cartilage grafts of this size
are the building blocks (the “bricks”) for reconstructing the
nose (see Fig. 19.7). However, when there is a major structural
problem, such as in a cocaine nose, larger, thicker, longer units
are carved for the underlying main framework. This involves
a single robust horizontal component and a single robust verti-
cal component (similar to, but much thicker than, the conven-
tional columellar strut) to make an L-frame. That frame is the
understructure for more surface grafts such as diced cartilage
in fascia (DCIF), or fascia only, or single 1-mm grafts. It is a
framework only and does not have to be carved to any particu-
lar shape. The surface grafts do that job.
A
B
C
D
E
F
Fig. 19.8 (A) Deep temporalis fascia is harvested using a vertical incision beginning at the root of the ear. (B) Silicone dorsal nasal sizers are helpful to sculpt a dorsal
graft when doing secondary rhinoplasty. (C) The silicone sizer is applied to the dorsum to see if it is the appropriate size. It is then applied internally to see if it is the
proper size. (D) Cartilage of any type is diced into 1 mm sizes and placed in the deep temporalis fascia. It is easiest to work on the cartilage on a silicone block with pins
to stabilize the fascia. (E) The fascia is rolled over like make a cigarette and sutured down one side with 5-0 plain catgut. The sizer acts as a model to determine the width
and length of the graft. (F) The diced cartilage graft is lying on the dorsal surface of the nose.
507
Common secondary problems
Gi
Gii
Hi
Hii
Ii
Iii
J
K
(G) Preoperative/postoperative frontal view of patient who required an L-shaped strut rib cartilage along with a tip graft and columellar strut. A thin dorsal
graft was required also. (H) Side view. (I) Basal view. (J,K) Fascia (deep temporalis) is often needed to pad and slightly augment the dorsal region.
Fig. 19.8, cont’d
helpful because they are easy to employ and economical for
the patient. However, occasional failures (risk of skin necrosis
and implant exposure), although unlikely, can be exceedingly
difficult to correct when they happen.
Common secondary problems
Broad, bulbous, round tip
One of the most common frustrations in secondary rhinoplasty
is the broad, or bulbous, or round tip.15 Patients vigorously
complain about this the most. Fortunately, there are some
good solutions. It is important to decide whether to use the
open or closed approach for the reasons mentioned above.
Most of the time, the cephalic part of the lateral crus has
been resected at the first surgery. In fact, often too much
has been removed. The first goal is getting to the abnormal
tip anatomy. In the open approach, careful elevation of the
flap is necessary. In the closed approach, it may be neces-
sary to deliver the tip cartilages with an intercartilaginous
and marginal incision. The second goal is to establish a
lateral crus that is approximately 5–6 mm wide and render
it straight. Usually, suture techniques will convert the exist-
ing tip framework into something that is more normal and
stronger.
508
SECTION I
CHAPTER 19 • Secondary rhinoplasty
on the surface (ear acting as donor) and small rim grafts were
also required.
Fig. 19.10 appears online only.
Collapsed middle third of nose
One of the more frequent problems requiring secondary or
revision rhinoplasty is middle vault collapse. All too often,
when a humpectomy is performed in a primary rhinoplasty,
some surgeons neglect to reconstruct the middle third (inter-
nal valve) of the nose with either spreader flaps26,27 or spreader
grafts.28 Failing to do so results in an inverted-V deformity
that is not only unaesthetic but is a functional problem in
terms of airway obstruction. The patient in Fig. 19.11 demon-
strates not only tip deficiency but a collapse of the middle
third of the nose and an inverted-V deformity. She required
spreader grafts, as well as reconstruction of the tip with
sutures and a tip graft.
Quite often, the collapsed middle third is not improved by
spreader grafts alone. That is because the walls of the ULC
themselves may be weak and flaccid. In those cases, onlay
batten grafts provide additional support. One should look for
that type of weakness in the secondary patient preoperatively
by simply asking them to inspire deeply. If the walls appear
as if they have no structural integrity, appear to collapse
quickly upon inspiration as if there is no cartilage in them, the
patient is a candidate for onlay batten grafts. Finally, suture
techniques to reinforce the walls of the ULC can be very
helpful. We are referring to suspension sutures that go from
the flaccid part of the wall to the dorsal septum region where
there is some rigidity. Alternatively one can use a single large
mattress suture that goes up and over the dorsum from one
side to the other (Fig. 19.12
). They are typically non-
absorbable 5-0 or even 4-0 nylon sutures if necessary. Other
suspension techniques have been described. Davidson and
Murakami29 and that of Lieberman and Most30 secure the
lateral crus to the nasal bone with a screw.
Fig. 19.12 appears online only.
Collapsed or concave rims (external valves)
Many secondary noses exhibit a problem of concave rim,
airway obstruction as a consequence, and retracted alae, all of
which are generally due to failure to obtain a normal lateral
crus (normal in width, and normally oriented). It is largely a
preventable problem. Excising too much lateral crus to reduce
a broad tip is the typical trap for the novice surgeon – a situ-
ation we have all found ourselves in during the early years of
our profession. Correction is to return strength and shape to
the lateral crus. One solution to the problem is the use of a
rim graft as pioneered by Troell et al.,31 Rohrich et al.,32 and
Guyuron33 (Fig. 19.13). Typically, the graft is the size of a
matchstick and is placed either from the medial side (in the
open approach) or through a separate incision posteriorly in
the closed approach.
Another approach that we more commonly employ today
is an onlay rim graft to the caudal aspect of the lateral crus to
restore the integrity. The marginal incision for opening the
nose, therefore, is placed where the caudal border of the lateral
crus is desired. The graft should not be cephalically oriented
as Constantian34 has pointed out. Daniel35 noted that the inci-
sion should be where the caudel border of the lateral crus is
Suture techniques (Fig. 19.9
) are the first means by which
the framework is modified.15–20 The many types of suture tech-
niques that apply to the primary rhinoplasty apply equally
to the secondary rhinoplasty, although fewer are necessary
because some of them have usually been applied at the first
surgery. Guyuron and Behman et al.15,16 have reviewed most
of the common techniques. Daniel17 has a useful algorithm,
and we have one that deals with most problems. Our own
suture algorithm for tip-plasty involves four basic sutures:
(1) hemi-transdomal or transdomal suture; (2) lateral crus
suture; (3) interdomal suture; and (4) septal–crus suture. The
hemi-transdomal suture21 is a variation of the transdomal
suture that narrows the dome. It is placed at the cephalic end
of the dome so that it everts the caudal rim and prevents rim
collapse or concave rims. It minimizes the need to use rim
grafts, which are often used to maintain a straight nostril
rim or prevent concave rims. Daniel17 and Toriumi22 were
aware of the importance of having a suture at the cephalic
end of the dome. The lateral crural mattress suture removes
any residual convexity of the lateral crus. One, two, or even
three such sutures will flatten out the lateral crus and make
it strong. This is especially useful in secondary cases because
the lateral crurae are often weak from the first surgery, with
residual convexity. The interdomal suture brings the domes
together and provides a small amount of tip rigidity and
symmetry. The septal–crus suture secures the tip complex
to the septum much as the original lateral crural-spanning
suture of Tebbetts. One can adjust the height to some degree
with this suture, although it is not a substitute for the
columellar strut. All of these suture techniques require either
5-0 Vicryl or PDS. If one is certain there is good soft-tissue
coverage, a permanent suture such as nylon is a reasonable
choice.
Fig. 19.9 appears online only.
The tip can be deficient (underprojected) either because the
infratip lobule is small, the columella is short, or both. When
the tip is deficient, a tip graft is in order; when the columella
is short, a columellar strut is in order; if both are deficient,
both grafts are used. Deficient tips benefit enormously from
a tip graft because the tip graft provides structure and defini-
tion. We prefer the “anatomic tip graft”,23 similar to the classic
Sheen shield graft24 and Daniel’s golf tee graft,25 whether via
the open or closed approach. The graft has a shape that simu-
lates the normal surface anatomy of the middle crus and
domes (Fig. 19.10
). Septal cartilage is ideal, although it
needs to be scored slightly to avoid a tombstone effect. Concha
cavum makes an excellent tip graft because it has just the right
amount of curvature and requires no scoring, and is almost
always available. More often than not, additional tip projec-
tion is needed and is provided by a “support graft” (cap
graft), which is a two- or three-layered graft that is placed
deep to the tip graft for three purposes: (1) to provide more
projection; (2) to immobilize the tip graft; and (3) to fill the
dead space deep to the tip graft. Suturing tip grafts in place
is not necessary in the closed approach. Additional bruised
grafts on the side of the tip graft may be necessary to provide
a smoother transition to the facets of the nasal tip. The patient
in Fig. 19.10 is a good example of a deficient tip problem. The
patient exhibited a narrow over-resected tip, inverted-V
deformity, and alar retraction. At surgery, through an open
approach, the tip cartilages had to be separated and an inter-
domal graft put between them. An anatomic tip graft was laid
508.e1
Common secondary problems
Fig. 19.9
is an example of a patient who had multiple
prior surgeries and grafts. She required sculpting of the tip
cartilages with suture techniques. In addition to the four-
suture algorithm described above, she required a humpectomy
and osteotomies.
A
B
C
D
Fig. 19.9 (A,B) The suture algorithm for secondary rhinoplasty is
identical to that for primary rhinoplasty. It begins with a hemi-
transdomal suture (a variant of the transdomal suture). It is a single
suture that narrows the cephalic side of the dome and everts the rim
of the lateral crus to minimize rim deformities. (C) A lateral crural
mattress suture reduces convexity of the lateral crus and thereby
removes unwanted bulbosity or increased width of the tip. Often two
to three such sutures are needed to do the job. (D) Intraoperative
view of a lateral crural mattress suture. Note how it converts a convex
lateral crus to a straight one and gives it additional strength. Two or
three such sutures are often necessary. Typically 5-0 Vicryl is a good
suture for this purpose.
Continued
508.e2
SECTION I
CHAPTER 19 • Secondary rhinoplasty
F
G
H
E
This next patient
exhibited a broad tip, supratip deformity
and radix deficiency. Because of the very
thick skin, it was decided to use a closed
approach. The tip cartilages were delivered.
The patient received cephalic trim of the
lateral crus along with interdomal and
lateral crus sutures (5-0 PDS). A radix graft
from the septum was used and the caudal
septum was shortened. A lateral osteotomy
was also performed. At 14 months
postoperatively, considerable improvement
was obtained as seen on front view (E,F),
side view (G,H), and basal views (I,J).
Fig. 19.9, cont’d
508.e3
Common secondary problems
I
J
Fig. 19.9, cont’d
A
B
Fig. 19.10 (A,B) This schematic illustration demonstrates the
shape of an “anatomic tip graft”, which simulates the surface of
the middle crurae and domes. Usually, a support graft
(appearing as a block of cartilage) is placed deep to the tip graft
in order to enhance the effect of tip augmentation. Sometimes
bruised grafts are placed adjacent to the tip graft to soften the
facet region.
Continued
508.e4
SECTION I
CHAPTER 19 • Secondary rhinoplasty
C
Small
Medium
Large
D
E
F
(C) Tip graft sizers are made of
silicone. They come in three sizes. (D,E) Note that the
sizer covers the middle crus and domes of the
anatomic model. (F) The sizer is held in place to the
existing tip complex with a needle. When the
appropriate size is chosen, it is placed on the donor
cartilage and used as a cookie cutter-like device to
carve a tip graft.
Fig. 19.10, cont’d
508.e5
Common secondary problems
Fig. 19.12 (A,B) Suspension sutures reinforce the internal valve when spreader grafts cannot do it. This is particularly true when the walls of the upper lateral cartilages
(ULC) are flaccid. The suspension suture is basically a large mattress suture from the most flaccid part of the lateral wall to the dorsal septum region where there is some
rigidity.
A
B
509
Common secondary problems
ideally located. Therefore, we place the marginal incision such
that it is approximately 6 mm from the nasal rim at the level of
the posterior aspect of the nostril. The result is a flap of vestibu-
lar skin to which a graft may be directly applied and sutured
to whatever lateral crus exists. It is typically triangular in shape
(see Fig. 19.13).36 If little lateral crus exists from prior over-
resection, the lateral crus is simply replaced with a 6-mm wide
graft and whatever length is necessary to cover the area from
just lateral to the dome cartilages to where the accessory
cartilages are expected to be located. By placing it up against
the marginal edge, it will have the proper orientation to avoid
aesthetic and functional problems. A case example is seen in
Fig. 19.13.
Isolated collapse of the lateral external valve
If the posterior (lateral) aspect of the lateral crus is col-
lapsed, the patient may complain of feeling it and seeing it
A
B
C
D
Fig. 19.11 (A,C,E) This patient is a good
example of a deficient tip problem. She
exhibited a narrow over-resected tip,
inverted-V deformity, and alar retraction. At
surgery, through an open approach, the tip
cartilages had to be separated and an
interdomal graft put between them. An
anatomic tip graft was laid on the surface
(ear acting as donor) and spreader grafts
were inserted. Small rim grafts were also
required. She also received a dermis graft
to augment the lips. (B,D,E) The
postoperative result at 22 months shows
considerable improvement.
Continued
510
SECTION I
CHAPTER 19 • Secondary rhinoplasty
E
F
Fig. 19.11, cont’d
A
B
Fig. 19.13 (A) Alar rim deformities are best corrected with rim grafts. The Guntergram indicates the non-anatomic position of this graft along the alar rim. (B,C) A method
preferred now is to make the marginal incision where the caudal border of the rim graft is to be located. That is usually about 6 mm from the rim at the level of the posterior
aspect of the nostril.
511
Common secondary problems
E
F
G
D
C
(D,E) The resultant vestibular skin in that area can then be covered with a cartilaginous graft that fills in the entire gap that exists. Typically such a graft
will be triangular in shape. If portions of the lateral crus are weak or missing, the triangular rim graft can be made larger to accommodate that lateral crus deficiency as
well. (F,G,H) Intraoperative views shows a triangular-shaped graft covering the entire void that results when placing the marginal incision in this manner.
Fig. 19.13, cont’d
Continued
512
SECTION I
CHAPTER 19 • Secondary rhinoplasty
H
I
J
K
L
(I,J) Pre- and postoperative frontal view of a patient who exhibited a collapse alar rim, corrected by a rim graft; (K,L) basal view also shows the
improvement.
Fig. 19.13, cont’d
in their nostril. It may even be a cause of airway obstruction
(Fig. 19.14). Fortunately, the treatment is relatively simple.
Part of much of the lateral crus can be delivered through
the nostril by making a U-shaped incision. A medially
based composite flap is elevated; one or more horizontal
mattress sutures are placed on the convex cartilage defor-
mity. These sutures will straighten and stiffen the lateral
crus and, in most cases, avoid the need for a graft in this
region, which is often thick and annoyingly palpable to the
patient.
Short nose
The short nose (Fig. 19.15) used to be one of the most difficult
cases to correct.37–43 Here, too, modern techniques have made
this problem much less formidable. The algorithm we employ
today is the one introduced over a decade ago and has not
changed in any significant way. Through an open approach
(which is almost a must) the upper lateral cartilages are
released from the dorsal septum. Any available septal carti-
lage is harvested for a septal extension graft. If none is avail-
able, concha cavum will work but is somewhat thick. A double
hook is placed on the tip cartilages and pulled caudally. After
infiltrating the vestibular skin of the lateral crus, a releasing
incision is made between the upper lateral cartilage and
lateral crus. Small scissors are used to expand the gap between
these two cartilages, which lengthens the side wall of the nose.
The septal extension graft is applied either on the horizontal
or vertical component of the L-shaped strut to maintain the
tip cartilages in a caudally displaced location. If the gap
between the upper lateral cartilage and lateral crus is signifi-
cant, an intercartilaginous graft44 is placed between the two
513
Common secondary problems
Fig. 19.14 (A) On occasion, the posterior (lateral) aspect of the lateral crus will be seen to curl into the vestibule causing a mild aesthetic and functional (airway)
problem. However, correction can be achieved by creating a medially based U-shaped composite flap. One or more universal horizontal mattress sutures are then applied to
the undersurface of the flap to remove that curvature. (B,C) Pre- and postoperative basal views of a patient who had such a deformity of the lateral (posterior) aspect of the
lateral crus corrected by mattress sutures applied to the undersurface of a composite lateral crus flap.
Ai
Aii
B
C
A
Septum
B
ULC
LLC
C
Fig. 19.15 (A) Schematic of elevation of the mucoperichondrium as a first step to correcting the short nose. (B) A gap is created between the upper lateral cartilage (ULC)
and lateral crus (LLC), keeping the lining in tact. This maneuver lengthens the side wall of the nose and may require an intercartilaginous graft to fill the gap. (C) A
horizontally oriented batten (septal extension graft) is applied to the dorsal septum to lengthen the nose.
Continued
D
E
F
G
H
(D) Schematic of vertically oriented batten applied to caudal septum will work also. (E) An intraoperative view of vertically oriented septal extension
graft applied to the vertical component of the L-shaped strut. (F) When necessary, an intercartilaginous graft is applied to the gap created between the upper lateral cartilage
and lateral crus to maintain the length of the side wall of the nose. (G,H) Preoperative views of a patient with a short nose.
I
Septal
extension graft
Posterior caudal septum resection
Lower dorsal
septum resection
Tip graft
J
Tip graft
Fig. 19.15, cont’d
515
Common secondary problems
Continued
K
Tip graft
L
Transdomal suture
Posterior caudal septum resection
Tip graft
M
N
(M,N) Pre- and postoperative side views.
Fig. 19.15, cont’d
516
SECTION I
CHAPTER 19 • Secondary rhinoplasty
O
P
Fig. 19.15, cont’d (O,P) Pre- and postoperative front views.
and is sutured in place. Septal cartilage is ideal as it is thin
and will not produce unnecessary thickening. The patient in
Fig. 19.15 is a good example of a secondary short nose problem.
She had a silicone implant at the first surgery and still had a
severely short nose. At surgery, the implant was removed. A
rib graft was required to make a dorsal graft, a columellar
strut, and septal extension graft. Ear cartilage was used for
the tip graft.
Broad nasal base
Some secondary noses still have a broad nasal base, despite
having received prior alar base or sill excision. In some cases,
further nasal base (ala or sill) excision may help. But in most
cases, further skin removal will either make the nostrils
stenotic or the ala so small that they appear unnatural. One
solution is to perform an alar base release and secure the alae
medially with an interalar suture,45 a procedure developed
by many surgeons over the years.46 This procedure is particu-
larly useful in those patients who have a vertically oriented
alar axis (parenthesis alae, Fig. 19.16). Further narrowing at
the alae alone has the potential in those patients to make the
alae assume a bowling pin appearance. By mobilizing the
entire ala (including the cephalic aspect), that problem can
be minimized. Before executing the procedure, one should
perform the pinch test. The examiner should bring the
alae together with two fingers to see if the nasolabial angle
becomes more obtuse than desired (see Fig. 19.16). If so, a
limit should be placed on how much alar release is performed,
or one should plan to resect some of the anterior septal spine
region to prevent an abnormally obtuse nasolabial angle
postoperatively.
Through a buccal sulcus incision, a Joseph periosteal eleva-
tor is used to free the soft tissue off the maxilla (see Fig. 19.16).
The surgeon is also releasing the recently described pyriform
ligament47 by sweeping the instrument along the horizontal
pyriform rim. If necessary, the release can extend into the floor
of the nasal vault. A 2-0 nylon interalar suture is then passed
from the dermis of one ala to that of the other. Alternatively,
two smaller sutures can be used. Care must be taken to avoid
placing the large suture knots too close to the skin surface.
The patient in Fig. 19.17 had a prior nasal base excision but
not enough improvement. Further excision would have only
distorted her alae and possibly nostrils. Alar release was
performed to get further improvement.
Nasal dorsum irregularities
One of the most common problems requiring secondary or
revision rhinoplasty is dorsal irregularities (Fig. 19.18
).
Often this is because of a failure to accurately sculpt the
dorsum. The dorsum may not have been rasped properly, or
small particles of cartilage may have been left behind inad-
vertently. Often it is due to cartilage graft warping, which is
not uncommon when ear cartilage grafts are used. Despite
what appears to be a very smooth graft at the primary surgery,
the graft may shift and form small excrescences that are either
visible or palpable in the upper dorsum where the skin is very
thin. It is for this reason that fascia and diced cartilage in fascia
grafts are used today more than ever before as a means of
treating dorsal deficiency in primary rhinoplasty. The treat-
ment of choice for small irregularities is a simple rasping of
the dorsum. This, however, can cause a slight dorsal deficiency
and the surgeon should be prepared to put in a soft-tissue
filler such as fascia or even a dermafat graft. A small dermafat
graft can often be harvested from behind the ear by
de-epithelializing that area first and removing a segment that
is often 3 × 1 cm in size. It is mostly fat, of course, but will
make a satisfactory padding of the dorsum when minimal
augmentation is needed.
Fig. 19.18 appears online only.
Airway problems (septoplasty)
The fundamentals of septoplasty are discussed elsewhere
in another chapter. An important caveat to be mentioned,
516.e1
Postoperative care
Fig. 19.18 (A,B) The patient exhibited
dorsal deficiency, treated with ear cartilage
augmentation. Late postoperatively, one can
see dorsal irregularities on the profile view
– a not uncommon problem when using ear
cartilage for dorsal augmentation.
A
B
517
Common secondary problems
D
E
Ai
Aii
Aiii
B
C
Fig. 19.16 (A) The nose has an alar axis. When it points straight down and the two axes are parallel, the patient is said to have parentheses alae. It is a potential problem,
in that if an alar base excision is performed, the axes may turn inward giving the patient a bowling pin deformity as seen on the far right. (B,C) The pinch test is done to be
sure that bringing the alar together does not cause an abnormal nasolabial angle when an alar release and interalar suture procedure is performed. (D) An incision is made
at the junction of ala and nostril sill. An elevator is used to release the ala from the maxilla and pyriform groove. (E). A large intra-alar, 2-0 nylon suture is used to bring the
alae together now that the alae have been released from the maxilla.
518
SECTION I
CHAPTER 19 • Secondary rhinoplasty
A
B
C
D
Fig. 19.17 (A,B) Pre- and postoperative
frontal views of a patient who received alar
base excision and thinning of the alar wall
but incomplete correction of the broad
nasal base. (C,D) Pre- and postoperative
basal views of a patient who received alar
base excision and thinning of the alar wall
but incomplete correction of the broad
nasal base.
however, is that in a secondary case, the lining of the septum
is often frail and difficult to elevate from the cartilage. Per-
forations are easy to acquire unless one is extra careful. For
this reason, the open approach is imperative when doing
septal work on secondary cases. The anterior septal angle
is a structure that can be seen and palpated even in the
most difficult secondary cases. From there, elevation of the
mucoperichondrium can be done under direct vision. Sharp
dissection is often necessary. A suction elevator that is fairly
sharp is indispensible. This is the type of surgical dissection
that will tax the surgeon more than any other because there is
an ever-present risk of septal perforation. Small perforations
should be repaired immediately with plain catgut as one
proceeds to expose the septal cartilage.
519
Postoperative care
E
F
G
H
(E,F) Pre- and
postoperative frontal view of the same
patient who received further reduction of
nasal base width, using the alar release
method including interalar sutures.
(G,H) Pre- and postoperative basal view of
the same patient who received further
reduction of nasal base width, using the
alar release method including interalar
sutures.
Fig.19.17, cont’d
Postoperative care
Early bad result
Results48–51 are never perfect, but the patient’s nose should
have a very satisfactory appearance in the early postop-
erative period. On occasion, the nose may appear unusually
unaesthetic the day after surgery or several days later when
the splint is removed (Fig. 19.19
). These occurrences can
be divided into two broad categories: The first type can be
viewed as an “expected”, or planned, unaesthetic appearance
of the nose that will resolve over the postoperative period.
The most common problem in the “expected” category is
that the nose has an extremely obtuse nasolabial angle in
anticipation of expected postoperative tip drop and settling.
520
SECTION I
CHAPTER 19 • Secondary rhinoplasty
The more common use of columellar struts in both primary
and secondary rhinoplasties has minimized the amount of
tip drop seen postoperatively, allowing for a more exact
setting of the tip height intraoperatively, ultimately allowing
this problem to occur less frequently than in the past. The
second category of early bad results is almost always from an
underlying structural error of some sort. Hoping for a resolu-
tion and waiting several months to a year in anticipation of
eventual correction can be a poor option. The patient will not
be happy to wait that long with a gross deformity. The patient
is very likely to become hostile during that watch-and-wait
period. Giving the patient false hope that the problem will
correct itself will not help either.
Fig. 19.19 appears online only.
The treatment of problems in this category involves return-
ing to the operating room and correcting the problem before
the tissues heal (Fig. 19.20
). Early return should be done
only if it is obvious that there is an easily correctable and
significant anatomic error (e.g., an obviously displaced graft).
It is easier to tell the patient that an immediate adjustment is
necessary than to see the patient repeatedly and deal with the
frustration of an obviously poor result. For us, re-exploration
as late as 12 days after surgery has been successful at making
a surgical adjustment of this type. There is no significant
increase in edema or induration by so doing.
Fig. 19.20 appears online only.
Tape
Taping the nose has become an integral part of postoperative
rhinoplasty in recent years. At the time the splint is removed
(usually 6 days postoperatively) the patient receives flesh-
colored tape to the nose (one across the infratip lobule from
cheek to cheek, and two across the dorsum just cephalic to the
supratip; Fig. 19.21
). The patient is instructed to remove the
tape 4 days later to control the edema now that the splint has
been removed. However, the main reason for the tape is to
bridge the psychological gap as the patient adjusts their body
image to the new nose. The patient actually looks better with
the tape. The tape, in fact, masks some of the nasal edema. Our
study in the past52 indicated that patients show an immediate
positive response to their result as soon as tape is applied.
Without a smooth transition over several days, the patient
is at risk of what has been described as “post-rhinoplasty
dissatisfaction syndrome”. A patient may “imprint” (loosely
speaking) the traumatized nose in the brain and not be able to
envision their nose as physically improved, even as the nose
actually improves in appearance with time. It is hypothesized
that the brain encodes the emotional memory of the nose in
the amygdala. If a drug such as propranolol (a beta blocker) is
given at the time of splint removal, the patient’s negative
emotional memory of the traumatized nose is likely to be
removed.53 However, none of that may be necessary and has
not been necessary in our experience since tape has been used
to bridge a time interval of several days as the patients adapts
psychologically to the new physical change.
Fig. 19.21 appears online only.
There is another aspect of taping that has been extraordi-
narily helpful in the later postoperative stages. Patients are
seen at about 4–6 weeks postoperatively. If, for some reason,
there is more edema (especially in the tip) or if the patient feels
anxious about the result, elastic tape (Blenderm, 3M Inc., St.
Paul, MN) is applied in the same manner that the flesh-colored
tape was described. The elasticity of the tape literally reduces
edema and improves nasal appearance (Fig. 19.22
). It is
applied by the patient every night (that they are not going out
or entertaining) from dinner to bedtime. Wearing it overnight
is optional. Four hours a day is enormously beneficial to
speeding the healing process in primary or secondary rhino-
plasty. In the event there is some crookedness of the tip, elastic
tape can be used to straighten the nose if worn in the same
manner. The principal of controlling nose shape by elastic tape
is borrowed from orthodontics. For that reason, it has been
referred to as “orthorhinotics”.
Fig. 19.22 appears online only.
An extension of this concept is to control nostril shape
postoperatively when necessary. Patients may complain of
asymmetry, or the nostril on one side may literally contract to
a small degree resulting in a size asymmetry. The best solution
we have found for that is the use of a particular nasal cone
(Clear Max-Air Nose Cone, Sanostec Corp., Beverly Farms,
MA; Fig. 19.23
). Generally, one size fits all, it is inexpensive,
and it is comfortable for the patient. It is also worn from
dinner to bedtime. Just as in the case of elastic tape, getting
the patient involved with their own treatment is so much
more effective than asking the patient to simply be patient and
having to wait until 10–12 months postoperatively when a
minor revision can be performed.
Fig. 19.23 appears online only.
Fillers
Some patients experience problems early after their surgery
due either to absorption of autogenous material placed in the
nose or a failure to fully correct the deformity. These patients
may have small depressions. Rather than waiting until the
8- to 12-month period has passed, when they will receive
permanent filler, e.g., dermis or fascia or crushed cartilage
grafts, it is often useful to give the patient temporary filler
such as a collagen or hyaluronic acid product. This will relieve
the patient’s anxiety during the healing phase and “buy time”
until a more permanent solution can be provided.
Corticosteroids
Secondary patients, in particular, have swelling. Triamcino-
lone54 is a useful means of reducing that edema and induration
and helps to get the patient through that difficult period when
the nose (particularly the tip) can be alarmingly large. Starting
at 4–6 weeks postoperatively, the patient is seen for the pos-
sible use of triamcinolone. An initial low dose is used (1 mg).
Great care must be taken not to inject it intradermally (as
would be evidenced by a wheal) in order to avoid dermal
atrophy. This injection technique is repeated every 3 weeks,
as many as six times if necessary. Since the elastic tape has
been used, however, the need for corticosteroid injections has
fallen precipitously.
Complications and untoward results
Columellar scar
Fortunately, columellar scars (Fig. 19.24
) are seldom a
problem requiring secondary correction. However, there will
520.e1
Postoperative care
Fig. 19.19 An unhappy patient is first noticed when the splint is removed and the
patient stares in the mirror. If the patient says nothing as they look at their new
nose, it is an ominous sign. The patient may be reluctant to criticize their surgeon
and yet is unwilling to give a compliment.
Fig. 19.20 (A,B) This patient was seen 1 week after surgery and noted to have a
severely obtuse nasolabial angle. Because this problem was not likely to abate, it
was advised that she return to surgery and have it adjusted before the tissues had a
chance to heal.
A
B
521
Complications and untoward results
be occasions when surgical correction will be necessary. The
problem is often a thickening of the soft tissue (due to scar
deposition) just anterior to the actual scar. The design of the
scar is seldom the cause of the problem, however. Another
problem is a notching along one side of the columella due,
usually, to inadequate apposition of tissues at the time of the
original closure. Rather than excising the entire scar, it is
usually best to deal with the specific problem as if there were
no columellar scar. For example, in the case of notching, it is
best to simply excise the bulge along the side of the columella
as if it were a small growth. In the case of a bulging fibrotic
columellar flap, it is often best to leave the scar as it is (assum-
ing it is flat) and simply open the side of the columella and
debulk the soft tissue.
Fig. 19.24 appears online only.
In certain situations where it may be favorable to avoid the
original columellar scar, Rohrich et al.55 showed no untoward
result, tissue loss, or increase in complications with the use of
a new columellar scar as opposed to using the original scar in
secondary rhinoplasty.
Post-rhinoplasty fibrotic syndrome
Occasionally, we will see a patient for a secondary rhinoplasty
who requires either an open or closed approach and has a
satisfactory intraoperative course in terms of being able to
achieve a nicely sculptured framework. However, for one
reason or another, the patient goes on to have increased
edema, fibrous induration, and ultimately a thickened nose
that is wider, thicker, and worse than the original preop-
erative condition. The patient in Fig. 19.25
is such a case.
She had multiple prior surgeries resulting in a short nose
with nostril show. A secondary rhinoplasty was performed,
including a septal extension graft, tip graft, and rim graft.
Despite early improvement, the patient went on to have a
wider nose than before. The increased width of the nose,
which was the most distressing to the patient, was undoubt-
edly due to fibrous deposition. This problem is best dealt
with avoiding or minimizing surgery. If surgery has to be
done because the deformity is very obvious, it is best to
use a minimalist approach. In particular, it is wise to avoid
undermining, which tends to lead to edema and subsequent
fibrosis.
Fig. 19.25 appears online only.
Bonus content for this chapter can be found online at
Anesthesia
Grafts – general principles
The difficult patient
Fig. 19.2 (A) This autoclavable model of the prototype ideal framework for
the nose makes it easy for the surgeon to perform their biological sculpting.
Copying from a model is much easier than memorizing the angles and
relationships between various parts of the tip complex. (B) The deformed
nasal tip should ideally look something like the prototype model.
(C,D) Appearance after suture techniques, excisional techniques, and grafts
are complete.
Fig. 19.5 A single universal horizontal mattress suture can increase the strength
of cartilage by 35%. Scoring the cartilage to achieve the same degree of
straightness can reduce the cartilage strength by 50%.
Fig. 19.6 (A–E) The ear is a great source of donor cartilage. This concha
cavum/cymba graft is applied to a silicone block where it will be divided into
two units: cymba and cavum. As individual units, they are easily straightened
with horizontal mattress sutures and made into usable units of cartilage to
reconstruct various parts of the secondary nose.
Fig. 19.7 (A) Rib is relatively easily obtained by making an inframammary
incision and exposing the nearest available cartilaginous rib (usually the fifth
rib). (B,C) Often, only the anterior surface of the rib need be removed with the
aid of a slightly curved osteotome or septal knife. (D) The rib is sliced into
pieces 1 mm thick and 3-4 cm long for surface graft reconstruction. When a
structural L-strut unit is needed, thicker segments are carved to make it. The
structural support remains deep to the surface grafts.
Fig. 19.9 (A,B) The suture algorithm for secondary rhinoplasty is identical to
that for primary rhinoplasty. It begins with a hemi-transdomal suture (a variant of
the transdomal suture). It is a single suture that narrows the cephalic side of the
dome and everts the rim of the lateral crus to minimize rim deformities. (C) A
lateral crural mattress suture reduces convexity of the lateral crus and thereby
removes unwanted bulbosity or increased width of the tip. Often two to three
such sutures are needed to do the job. (D) Intraoperative view of a lateral crural
mattress suture. Note how it converts a convex lateral crus to a straight one and
gives it additional strength. Two or three such sutures are often necessary.
Typically 5-0 Vicryl is a good suture for this purpose. This next patient exhibited
a broad tip, supratip deformity, and radix deficiency. Because of the very thick
skin, it was decided to use a closed approach. The tip cartilages were delivered.
The patient received cephalic trim of the lateral crus along with interdomal and
lateral crus sutures (5-0 PDS). A radix graft from the septum was used, and the
caudal septum was shortened. A lateral osteotomy was also performed. At 14
months postoperatively, considerable improvement was obtained as seen on
front view (E,F), side view (G,H), and basal views (I,J).
Fig. 19.10 (A,B) This schematic illustration demonstrates the shape of an
“anatomic tip graft”, which simulates the surface of the middle crurae and
domes. Usually, a support graft (appearing as a block of cartilage) is placed
deep to the tip graft in order to enhance the effect of tip augmentation.
Sometimes bruised grafts are placed adjacent to the tip graft to soft the facet
region. (C) Tip graft sizers are made of silicone. They come in three sizes.
(D,E) Note that the sizer covers the middle crus and domes of the anatomic
model. (F) The sizer is held in place to the existing tip complex with a needle.
When the appropriate size is chosen, it is placed on the donor cartilage and
used as a cookie cutter-like device to carve a tip graft. (G) The cartilaginous tip
graft itself is pinned to the existing tip complex to see what the best location for
it is. (H) After securing the posterior end of the tip graft to the existing tip
complex, a support graft (in this case only a one-layer graft) is applied to the
deep side of the tip graft. So doing helps secure the tip graft at the proper angle
and fill the dead space.
Fig. 19.12 (A,B) Suspension sutures reinforce the internal valve when spreader
grafts cannot do it. This is particularly true when the walls of the upper lateral
cartilages (ULC) are flaccid. The suspension suture is basically a large mattress
suture from the most flaccid part of the lateral wall to the dorsal septum region
where there is some rigidity.
Fig. 19.18 (A,B) The patient exhibited dorsal deficiency, treated with ear
cartilage augmentation. Late postoperatively, one can see dorsal irregularities on
the profile view – a not uncommon problem when using ear cartilage for dorsal
augmentation.
Fig. 19.19 An unhappy patient is first noticed when the splint is removed and
the patient stares in the mirror. If the patient says nothing as they look at their
new nose, it is an ominous sign. The patient may be reluctant to criticize their
surgeon and yet is unwilling to give a compliment.
Fig. 19.20 (A,B) This patient was seen 1 week after surgery and noted to have
a severely obtuse nasolabial angle. Because this problem was not likely to
521.e1
Complications and untoward results
Fig. 19.21 (A) One 12 -inch flesh colored tape is frequently applied to the nasal tip shortly after the splint
is removed on day 6. The tape helps reduce the edema but, more importantly, gives the patient more time to
adapt to the new nose as the swelling recedes. (B) The patient’s unhappy face is more often than not
improved visibly after the tape (C) is applied.
A
B
C
521.e2
SECTION I
CHAPTER 19 • Secondary rhinoplasty
Fig. 19.22 (A) Elastic tape (Blenderm, 3M
Inc., St. Paul, MN) is extraordinarily helpful
to reduce edema in the first several months
post-rhinoplasty when edema is frequently a
problem causing such problems as an
enlarged tip. (B) It is applied to the infratip
lobule and across the dorsum cephalic to the
supratip region. The patient applies it from
dinner to bedtime each night for 6 weeks to
see a significant difference. (C,D) The frontal
view of this patient shows a significant
difference in tip size reduction when this is
done.
A
“Blenderm”
B
C
D
One Month Later
521.e3
Complications and untoward results
Fig. 19.23 (A) Early nostril stenosis or asymmetry can be dramtically improved with (B) a nasal cone if (C) it is applied during the evenings for many weeks.
A
B
C
A
Fig. 19.24 Nothing of a columellar scar is
best treated by direct vertical excision of
the bulge. (A) Columellar scars, if not
retracted, occasionally appear as
irregularities along the side of the
columella.(B)Rather than excising the
whole scar and starting afresh, it is often
best to simply excise the bulge along the
side of the columella as if it were a small
growth.
B
522
SECTION I
CHAPTER 19 • Secondary rhinoplasty
34. 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 Reconst Surg.
2005;116:268–281. Constantian makes the point that an extraordinary
number of nasal cases have an inherent malposition of the nasal tip
cartilages, particularly the lateral crus. It is this malorientation, in his
opinion, that is responsible for both esthetic and functional (external
valve) airway problems. Noticing this malrotation ahead of time and
planning for its correction at surgery, in his view, reduces the number of
postoperative problems related to external valve airway obstruction and
residual aesthetic deformities of the nasal tip.
35. Daniel RK. Discussion of: The essential elements for planning tip
surgery in primary and secondary rhinoplasty: observations based
on review of 100 consecutive patients. Plast Reconstr Surg.
2004;114:1582–1585. The anatomy of the lateral crus is carefully
delineated by Daniel. It is important to note where the normal lateral crus
rests in relation to the nostril skin border. So doing indicates where an
incision may be placed within the nostril such that when the reconstructed
lateral crus is formed, its caudal edge can rest against the opening
incision. Thus, one only needs to apply cartilage to the caudal aspect of
the existing lateral crus and not have to make a tunnel for it, as is
commonly done.
36. Gruber RP, Fox P, Peled A, et al. Grafting the alar rim: application
as anatomical graft. Plast Reconstr Surg. 2014;134:880e–887e.
52. Belek KA, Gruber RP. The beneficial effects of postrhinoplasty
taping: fact or fiction? Aesthet Surg J. 2014;34:56–60. The authors
borrowed an idea from Daniel that the rim graft can be applied in a very
different way, one that avoids the difficulties some note with the tunnel
method. It also allows the surgeon to create exactly the right size rim
graft. By making an incision where the caudal border of the lateral crus
should be, the surgeon fills in the gap between the existing lateral crus
and where it is supposed to be under direct vision. Taping of the nasal tip
immediately upon splint removal is vitally important, as the authors note,
because the patient does not get an anxiety reaction, which occurs
commonly when viewing the nose for the first time postoperatively. Taping
smoothes the psychological transition so that the patient adapts better to
the new body image.
53. Gruber RP, Roberts C, Schooler W, et al. Preventing postsurgical
dissatisfaction syndrome after rhinoplasty with propranolol: a pilot
study. Plast Reconstr Surg. 2009;123:1072–1078. Approximately 1 in
100 patients were found to exhibit a syndrome of postoperative
dissatisfaction with their nasal result such that even when the nasal result
did improve over time (e.g., due to edema reduction) the patient still
acquired a body image that they were deformed. The use of a beta blocker
was found to ameliorate this problem and allow the patient to adjust to
their new body image. The drug is identical to the one used in the
treatment of post-traumatic stress disorder.
55. Unger JG, Roostaeian J, Cheng DH, et al. The open approach in
secondary rhinoplasty: choosing an incision regardless of prior
placement. Plast Reconstr Surg. 2013;132:780–786. It is the opinion of
these authors from their study that the incision to open a nose that has
previously undergone an open approach can be placed anywhere.
Apparently, there is no compromise to the circulation of the new
columellar flap. Previously, incisions have been placed at exactly the
location of the previous columellar scar so as to avoid flap necrosis.
Access the complete reference list online at
abate, it was advised that she return to surgery and have it adjusted before the
tissues had a chance to heal.
Fig. 19.21 (A) One 12-inch flesh colored tape is frequently applied to the nasal
tip shortly after the splint is removed on day 6. The tape helps reduce the
edema but, more importantly, gives the patient more time to adapt to the new
nose as the swelling recedes. (B) The patient’s unhappy face is more often than
not improved visibly after the tape (C) is applied.
Fig. 19.22 (A) Elastic tape (Blenderm, 3M Inc., St. Paul, MN) is extraordinarily
helpful to reduce edema in the first several months post-rhinoplasty when
edema is frequently a problem causing such problems as an enlarged tip. (B) It
is applied to the infratip lobule and across the dorsum cephalic to the supratip
region. The patient applies it from dinner to bedtime each night for 6 weeks to
see a significant difference. (C,D) The frontal view of this patient shows a
significant difference in tip size reduction when this is done.
Fig. 19.23 (A) Columellar scars, if not retracted, occasionally appear as
irregularities along the side of the columella. (B) Rather than excising the whole
scar and starting afresh, it is often best to simply excise the bulge along the
side of the columella as if it were a small growth.
Fig. 19.24 (A,B) This patient started out with a relatively thin but crooked nose.
Several rhinoplasties were performed in an attempt to improve the crookedness.
However, with each surgery there was scar deposition that gave the patient a
wider nasal tip than before – a condition referred to as the post-rhinoplasty
fibrotic syndrome. Ideally, revisionary nasal surgeries should be smaller in
magnitude, and less invasive to avoid this type of problem.
Fig. 19.25 (A,B) Patient example of post-rhinoplasty fibrotic syndrome.
522.e1
Complications and untoward results
Fig. 19.25 (A,B) This patient started out with a
relatively thin but crooked nose. Several rhinoplasties
were performed in an attempt to improve the
crookedness. However, with each surgery there was
scar deposition that gave the patient a wider nasal tip
than before – a condition referred to as the post-
rhinoplasty fibrotic syndrome. Ideally, revisionary nasal
surgeries should be smaller in magnitude, and less
invasive to avoid this type of problem.
A
B
The difficult patient
As is the case for all types of aesthetic surgery, there is a group
of patients that are difficult to please. Postoperative manage-
ment requires patience and tolerance. The patient’s concerns
should be acknowledged and not ignored. The patient should
be reassured that everything will be done that can be done to
give the best result possible. As soon as it is obvious that the
patient’s condition is not going to improve and that a revision
is likely in the future, it should be discussed with the patient.
The patient will fare better if they know that they can look
forward to an improved result. Getting a second opinion for
these patients can also be very helpful. A second opinion from
a colleague assures the patient that everything possible is
being done and often provides the surgeon with some alterna-
tive ideas that they had not considered. Waiting for the patient
to get their own second opinion is problematic because that
surgeon may not be familiar with you or your work and may
be unnecessarily critical.
522.e2
SECTION I
CHAPTER 19 • Secondary rhinoplasty
References
1. Byrd HS, Constantian MB, Guyuron B, et al. Revision rhinoplasty.
Aesthet Surg J. 2007;27:175–187.
2. Gruber RP. Use of the internet by patients. How it affects your
practice and what to do about it. In: Korman J, ed. The business of
plastic surgery: navigating a successful career. World Scientific, New
York, NY, 2012.
3. Gunter JP, Rohrich RJ, Adams WP. Dallas Rhinoplasty: Nasal Surgery
by the Masters. St. Louis, MO: Quality Medical Publishing; 2008.
4. Kim DW, Toriumi DM. Nasal analysis for secondary rhinoplasty.
Facial Plast Surg Clin North Am. 2003;11:399–419.
5. Oneal RM, Bell RJ Jr, Schlesinger J. Surgical anatomy of the nose.
Clin Plast Surg. 1996;23:195–222.
6. Daniel RK. Secondary rhinoplasty following open rhinoplasty.
Plast Reconstr Surg. 1995;96:1539–1546.
7. Marcus JR, Tyron JW, Few JW, et al. Optimization of conscious
sedation in plastic surgery. Plast Reconstr Surg. 1999;104:1338–1345.
8. Gruber RP, Nahai F, Bogdan MA, et al. Changing the convexity
and concavity of nasal cartilages and cartilage grafts with
horizontal mattress sutures: part I. Experimental results. Plast
Reconstr Surg. 2005;115:589–594.
9. Gruber RP, Nahai F, Bogdan MA, et al. Changing the convexity
and concavity of nasal cartilages and cartilage grafts with
horizontal mattress sutures: part II. Clinical results. Plast Reconstr
Surg. 2005;115:595–606.
10. Cochran CS, Gunter JP. Secondary rhinoplasty and the use of
autogenous rib cartilage grafts. Clin Plast Surg. 2010;37:371–382.
11. Marin VP, Landecker A, Günter JP. Harvesting rib cartilage grafts
for secondary rhinoplasty. Plast Reconstr Surg. 2008;121:1442–1448.
12. Daniel RK. Diced cartilage grafts in rhinoplasty surgery: current
techniques and applications. Plast Reconstr Surg. 2008;122:
1883–1891.
13. Erol OO. The Turkish delight: a pliable graft for rhinoplasty. Plast
Reconstr Surg. 2000;105:2229–2241.
14. Strauch B, Wallach SG. Reconstruction with irradiated homograft
costal cartilage. Plast Reconstr Surg. 2003;111:2405–2411.
15. Guyuron B, Behmand RA. Nasal tip sutures part II: the interplays.
Plast Reconstr Surg. 2003;112:1130–1145.
16. Behmand RA, Ghavami A, Guyuron B. Nasal tip sutures part I: the
evolution. Plast Reconstr Surg. 2003;112:1125–1129.
17. Daniel RK. Rhinoplasty: a simplified, three-stitch, open tip suture
technique. Part II: secondary rhinoplasty. Plast Reconstr Surg.
1999;103:1503–1512.
18. Gruber RP, Weintraub J, Pomerantz J. Suture techniques for the
nasal tip. Aesthet Surg J. 2008;28:92–100.
19. Gruber RP, Friedman GD. Suture algorithm for the broad or
bulbous nasal tip. Plast Reconstr Surg. 2002;110:1752–1764.
20. Tebbetts JB. Shaping and position the nasal tip without structural
disruption: a new systematic approach. Plast Reconstr Surg.
1994;94:61–77.
21. Dosanjh AS, Hsu C, Gruber RP. The hemi-transdomal suture for
narrowing the nasal tip. Ann Plast Surg. 2010;64:708–712.
22. Toriumi DM. New concepts in nasal tip contouring. Arch Facial
Plast Surg. 2006;8:156–185.
23. Gruber RP, Grover S. The anatomic tip graft for nasal
augmentation. Plast Reconstr Surg. 1999;103:1744–1753.
24. Constantian MB. Elaboration of an alternative, segmental,
cartilage-sparing tip graft technique: experience in 405 cases. Plast
Reconstr Surg. 1999;103:237–253.
25. Daniel RK. Tip refinement grafts: the designer tip. Aesthet Surg J.
2009;29:528–537.
26. Gruber RP, Park E, Newman J, et al. The spreader flap in primary
rhinoplasty. Plast Reconstr Surg. 2007;119:1903–1910.
27. Byrd HS, Meade RA, Gonyon DL Jr. Using the autospreader
flap in primary rhinoplasty. Plast Reconstr Surg.
2007;119:1897–1902.
28. Constantian MB. The incompetent external nasal valve;
pathophysiology and treatment in primary land secondary
rhinoplasty. Plast Reconstr Surg. 1994;93:919–931.
29. Davidson TM, Murakami WT. Tip suspension suture for
superior tip rotation in rhinoplasty. Laryngoscope.
1983;93:1076–1080.
30. Lieberman DM, Most SP. Lateral nasal wall suspension using
a bone-anchored suture technique. Arch Facial Plast Surg.
2010;12:113.
31. Troell RJ, Powell NB, Riley RW, et al. Evaluation of a new
procedure for nasal alar rim and valve collapse: nasal alar rim
reconstruction. Otolaryngol Head Neck Surg. 2000;122:204–211.
32. Rohrich RJ, Raniere J Jr, Ha RY. The alar contour graft: correction
and prevention of alar rim deformities in rhinoplasty. Plast
Reconstr Surg. 2002;109:2495–2505.
33. Guyuron B. Alar rim deformities. Plast Reconstr Surg. 2001;107:
856–863.
34. 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 Reconst Surg.
2005;116:268–281. Constantian makes the point that an extraordinary
number of nasal cases have an inherent malposition of the nasal tip
cartilages, particularly the lateral crus. It is this malorientation, in his
opinion, that is responsible for both esthetic and functional (external
valve) airway problems. Noticing this malrotation ahead of time and
planning for its correction at surgery, in his view, reduces the number of
postoperative problems related to external valve airway obstruction and
residual aesthetic deformities of the nasal tip.
35. Daniel RK. Discussion of: The essential elements for planning tip
surgery in primary and secondary rhinoplasty: observations based
on review of 100 consecutive patients. Plast Reconstr Surg.
2004;114:1582–1585. The anatomy of the lateral crus is carefully
delineated by Daniel. It is important to note where the normal lateral
crus rests in relation to the nostril skin border. So doing indicates where
an incision may be placed within the nostril such that when the
reconstructed lateral crus is formed, its caudal edge can rest against the
opening incision. Thus, one only needs to apply cartilage to the caudal
aspect of the existing lateral crus and not have to make a tunnel for it, as
is commonly done.
36. Gruber RP, Fox P, Peled A, et al. Grafting the alar rim: application
as anatomical graft. Plast Reconstr Surg. 2014;134:880e–887e.
37. Hobar PC, Adams WP, Mitchell CA. Lengthening the short nose.
Clin Plast Surg. 2010;37:327–333.
38. Gruber RP. The short nose. Clin Plast Surg. 1996;23:297–313.
39. Naficy S, Baker SR. Lengthening the short nose. Arch Otolaryngol
Head Neck Surg. 1998;124:809–813.
40. Toriumi DM, Patel AB, DeRosa J. correcting the short nose in
revision rhinoplasty. Facial Plast Surg Clin of North Am.
2006;14:343–355.
41. Guyuron B, Varghai A. Lengthening the short nose with a
tongue-and-groove technique. Plast Reconstr Surg. 2003;111:
1533–1539.
42. Gunter JP, Rohrich RJ. Lengthening the aesthetically short nose.
Plast Reconstr Surg. 1989;83:793–800.
43. Aiach G, Monaghan P. Treatment of over-reduction of the nose
and subsequent deformities. Br J Oral Maxillofac Surg.
1995;33:250–261.
44. Gruber RP, Kryger G, Chang D. The intercartilaginous graft for
actual and potential alar retraction. Plast Reconstr Surg. 2008;
288e–296e.
45. Gruber RP, Freeman MB, Hsu C, et al. Nasal base reduction: a
treatment algorithm including alar release with medialization.
Plast Reconstr Surg. 2009;123:716–725.
46. Erol O. Alar base release for broad nasal bases. Presented at the
International Society of Aesthetic Plastic Surgery, New York, 2001.
47. Rohrich RJ, Hoxworth RE, Thornton JF, et al. The pyriform
ligament. Plast Reconstr Surg. 2008;121:277–281.
48. Rohrich RJ, Ahmad J. A practical approach to rhinoploasty. Plast
Reconstr Surg. 2016;137:725e–746e.
522.e3
References
49. Gryskiewicz JM, Hatef DA, Bullocks JM, et al. Problems in
rhinoplasty. Clin Plast Surg. 2010;37:389–399.
50. Gruber RP. Early surgical intervention after rhinoplasty. Aesthet
Surg J. 2001;2:549–558.
51. Teichgraeber JF, Riley WB, Parks DH. Nasal surgery complications.
Plast Reconstr Surg. 1990;85:527–531.
52. Belek KA, Gruber RP. The beneficial effects of postrhinoplasty
taping: fact or fiction? Aesthet Surg J. 2014;34:56–60. The authors
borrowed an idea from Daniel that the rim graft can be applied in a very
different way, one that avoids the difficulties some note with the tunnel
method. It also allows the surgeon to create exactly the right size rim
graft. By making an incision where the caudal border of the lateral crus
should be, the surgeon fills in the gap between the existing lateral crus
and where it is supposed to be under direct vision. Taping of the nasal tip
immediately upon splint removal is vitally important, as the authors
note, because the patient does not get an anxiety reaction, which occurs
commonly when viewing the nose for the first time postoperatively.
Taping smoothes the psychological transition so that the patient adapts
better to the new body image.
53. Gruber RP, Roberts C, Schooler W, et al. Preventing postsurgical
dissatisfaction syndrome after rhinoplasty with propranolol: a
pilot study. Plast Reconstr Surg. 2009;123:1072–1078. Approximately 1
in 100 patients were found to exhibit a syndrome of postoperative
dissatisfaction with their nasal result such that even when the nasal
result did improve over time (e.g., due to edema reduction) the patient
still acquired a body image that they were deformed. The use of a beta
blocker was found to ameliorate this problem and allow the patient to
adjust to their new body image. The drug is identical to the one used in
the treatment of post-traumatic stress disorder.
54. Guyuron B, DeLuca L, Lash R. Supratip deformity: a closer look.
Plast Reconstr Surg. 2000;105:1140–1151.
55. Unger JG, Roostaeian J, Cheng DH, et al. The open approach in
secondary rhinoplasty: choosing an incision regardless of prior
placement. Plast Reconstr Surg. 2013;132:780–786. It is the opinion of
these authors from their study that the incision to open a nose that has
previously undergone an open approach can be placed anywhere.
Apparently, there is no compromise to the circulation of the new
columellar flap. Previously, incisions have been placed at exactly the
location of the previous columellar scar so as to avoid flap necrosis.
SECTION I • Aesthetic Surgery of the Face
20
Otoplasty and ear reduction
Charles H. Thorne
SYNOPSIS
■ Analysis: Analyze the problem in thirds.
■ Endpoint: Know what normal looks like, so you know your surgical
endpoint.
■ Do not be destructive. Do not do anything to the ear that cannot be
reversed.
■ Skin is precious. Preserve skin in the sulcus, and do not rely on skin
tension to maintain ear position.
■ Lobule: Consider lobule setback in every case.
■ Asymmetry: In asymmetric cases, operate on both ears most of the
time.
■ Some ears need to be made smaller.
■ Facelifts are otoplasties: Do not deform the tragus, lobule or sulcus.
Access the Historical Perspective section online at
Introduction
The term “otoplasty” refers to surgical changes in the shape
or position of the ear. The most common indication is the
patient with prominent, but normally shaped, ears. In this
situation, otoplasty is an enormously rewarding procedure
for the surgeon and the patient/family, because good results
and satisfied patients can be expected in almost all cases. In
addition, the technical maneuvers required are among the
simplest in all of plastic surgery.
The complexity of the otoplasty procedure increases as
the deformity of the ear increases. If correction of prominent
ears is at one end of the otoplasty spectrum, then reconstruc-
tion of congenital microtia with rib cartilage grafts is at the
other. Surgical reshaping of the ears, or otoplasty, is best
conceptualized with the whole spectrum of ear deformi-
ties in mind; that way, the surgeon will avoid the pitfall of
learning a single recipe and attempting to apply it in every
situation.
The single most important exercise for the surgeon, before
performing any procedure in the otoplasty spectrum, is to
have the characteristics of a normal ear firmly in their mind’s
eye. With proper choice of technique, the surgeon can usually
avoid the uncorrectable problems of overcorrection and
unnatural contours.1
Basic science/disease process
The cause of ear deformities is not known. Some articles in
the literature suggest that ear deformities are the result of
absent or misplaced muscles around the ear. Some newborn
children have extremely soft, pliable ears. When these children
have prominent ears and they lie on their sides, the ears tend
to fold forward against the cheek, rather than back against
the head, tending to make them more prominent as the years
go on.
Diagnosis/patient presentation
Overall size and shape
The overall size and shape of the ear is evaluated to determine
if the ear is prominent with an otherwise normal size and
configuration, or if there are abnormalities in addition to the
prominence. Excessively large ears, Stahl’s ears, cryptotia,
underdeveloped shell-like helical rims, postoperative defor-
mities, cauliflower ears, elongated lobules, or earring-related
or facelift-related deformities are noted.
Upper third
The upper third of the ear is evaluated to determine if it is
prominent, if the antihelix/superior crus of the triangular
fossa is well formed, and if the helical rim is well defined.
Access video content for this chapter online at expertconsult.com
523.e1
Historical perspective
Historical perspective
The history of otoplasty techniques is instructive but mislead-
ing. Understandably, the original techniques focused on
changing the shape of the auricle, rather than on the nuances
of aesthetics, the stage we are at today. In the author’s opinion,
most classical otoplasty techniques, although essential in the
evolution of the craft, are unnecessarily destructive to the ear,
overly complicated in design, and excessively prone to over-
correction, complications, and unnatural appearance results.
Luckett2 recommended full-thickness incision through the
cartilage along the desired location of the antihelical fold.
Converse and others3 described the combination of full-
thickness incisions parallel to the desired antihelical fold, with
“tubing” sutures to create the fold. Various authors have
recommended weakening of the cartilage along the fold,
including Stenstrom,4 who described anterior cartilage scoring
in an effort to generate bending of the cartilage away from the
cartilage abrasion. Most of these techniques included, or
relied upon, skin excision in the retroauricular sulcus.
The current trend is toward less destructive methods of
auricular reshaping, preservation of the retroauricular skin,
and concentration on natural, non-surgical-appearing results.
The ultimate example of this phenomenon is neonatal, non-
surgical molding of the auricle, which can correct many of the
deformities for which an otoplasty might later be recom-
mended.5 Any surgical decision represents a trade-off and this
author’s approach is no exception. The approach described in
this chapter incorporates the bias that undercorrection, recur-
rence, and suture complications are preferable to overcorrec-
tion, unnatural contours, sharp edges, and unrepairable
deformities.
524
SECTION I
CHAPTER 20 • Otoplasty and ear reduction
whose parents desire early correction, otoplasty is recom-
mended as early as age 4 years. While there may be situations
when earlier intervention is warranted, it is reasonable to
view the age of 4 years as a minimum for most otoplasty
procedures and its variations. In situations where the entire
ears require reconstruction, as in microtia, this author prefers
to follow the recommendations of Firmin6 and wait until
approximately the age of 10 years.
In other cases, the parents may want the child to participate
in the decision process and that will necessitate later interven-
tion. General anesthesia or deep sedation by an anesthesiolo-
gist is usually required up until the early teenage years,
especially in boys. Occasionally, there are girls who are mature
enough to request and tolerate the procedure under local
anesthesia without an anesthesiologist, but this is rare. It is
also common to have patients present at approximately 18
years of age, when they are legally independent, or later when
they have earned the money for the procedure. Finally, it is
not unusual for adults at almost any age to request correction,
either because they have wanted it all their lives or because
their desire to have a facelift, for example, has led to the
realization that their ears are also prominent.
Families frequently ask about the effect of early surgical
treatment on growth of the ears. For whatever reason, this has
never been an issue in this author’s experience. For one thing,
there is a large variation in acceptable ear size. It has also
never been shown that an otoplasty retards auricular growth.
Finally, many prominent ears are on the large side, and some
growth retardation would be welcomed by the patient and/
or the family (Fig. 20.2).
Treatment/surgical technique
While the delicate, complex contours of the ear may be
difficult to create de novo (i.e., microtia), anatomic consider-
ations are minimal in standard otoplasty. There is abundant
blood supply, making almost any combination of incisions
Middle third
The middle third of the ear is evaluated to determine if the
concha is overly deep or protruding. In addition, the relation-
ship between the antihelix and the helix is examined to
determine if, for example, the underdevelopment of the
antihelix/superior crus in the upper third extends into the
middle third or if it is confined to the upper third.
Lower third
The lobule is evaluated to determine if it is prominent. It is
important to note that even if the lobule is not particularly
prominent on initial examination, it may be excessively
prominent once the upper two-thirds of the ear have been
corrected.
Asymmetry
Asymmetry is noted, mostly because patients and families
will always comment on it. In asymmetric cases, it is usually
preferable to operate on both ears rather than attempt to set
back only the prominent ear to match its less prominent
counterpart (Fig. 20.1).
Patient selection
Since otoplasty is perhaps the only cosmetic procedure that
can be performed in childhood, additional considerations
come into play. The fact that parents and grandparents may
be involved in surgical decision-making for a patient who
cannot yet express himself or herself alters the doctor–patient
relationship.
The degree of prominence/deformity and the age at pre-
sentation will determine when a surgical recommendation is
made. For young children with very prominent ears and
Fig. 20.1 Anatomical structures of the ear. The tubercle of the helix is synonymous
with Darwin’s tubercle. (Reprinted with permission from Janis JE, Rohrich RJ,
Gutowski KA. Otoplasty. Plast Reconstr Surg. 2005;115:60e–72e.)
Crura of
antihelix
Crus of helix
Tragus
External
auditory meatus
Intertragal
incisure
Lobe
Antitragus
Posterior
sulcus
Antihelix
Helix
Concha
Scapha
Tubercle
of helix
Triangular
fossa
Fig. 20.2 Main components of the prominent ear. (Reprinted with permission from
Janis JE, Rohrich RJ, Gutowski KA. Otoplasty. Plast Reconstr Surg. 2005;115:
60e–72e.)
Loss of antihelical fold
Conchoscaphal angle
greater than 90º
Conchal excess
525
Treatment/surgical technique
The earlobe is repositioned by closing the triangular defect
on the medial surface of the lobule created by the skin excision
(Fig. 20.5). The 5-0 PDS sutures do not just approximate the
skin; rather, they approximate the skin and take a bite of the
concha deep in the sulcus (similar to Gosain and Recinos8).
When these sutures (usually two) are tied, the earlobe posi-
tion will be corrected. Ideally, the endpoint of earlobe reposi-
tioning should be slight overcorrection because the skin will
stretch over time. The author has not had success when
repositioning of the helical tail is used as the sole method of
earlobe repositioning, as described by Webster.9
Mustarde concha–scapha and triangular fossa–scapha
sutures are placed using 4-0 clear nylon sutures on an FS-2
needle.10 The number of sutures depends on the how far into
the middle third of the ear the antihelical deficiency extends.
In some cases, the sutures will only be required in the upper
third of the ear. In other cases, they will extend through the
middle third as well. These sutures are placed in order to
create a soft curvature to the antihelix. The Mustarde sutures
are not parallel to each other but, instead, are arranged like
spokes on a wheel, all pointing toward the top of the tragus
(center of the wheel). Care is taken to create a superior crus
that curves anteriorly such that it terminates almost parallel
to the inferior curs. If the superior crus is created such that it
is a direct, cephalad extension of the antihelix (straight line),
the result will appear unnatural and amateurish.
Endpoint
Otoplasty surgery is all about the endpoint. How do you
know how tight to make the Mustarde sutures? That is, how
acceptable without the risk of necrosis. There are no motor
nerves in the neighborhood. The terminal branches of the
great auricular nerve will always be injured, but normal
sensory function returns.
The one anatomic structure that can be compromised in
otoplasty is the external auditory meatus (conchal setback
narrows the meatus). Otherwise, the anatomic considerations
of otoplasty are those of preservation: preservation of the
sulcus, preservation of the natural softness of the auricular
contours, and preservation of the normal landmarks such as
the posterior wall of the concha (that is, the middle third of
the antihelix).
Standard otoplasty for prominent
ears of normal size
Incision (Video 20.1 )
The incision is made in the retroauricular sulcus. In the upper
third of the ear, the incision can be extended up on to the back
of the ear to provide adequate exposure to place Mustarde
sutures between the triangular fossa and scapha. While an
incision placed higher, on the back of the ear, will make the
dissection easier, this author prefers the depth of the sulcus
where the ultimate scar will be better hidden.
Dissection
No skin is excised, except a small triangle from the medial
surface of the lobule (not the retrolobular skin), taking care to
preserve enough tissue for a normal earlobe and retrolobular
sulcus. This skin excision on the lobule is frequently necessary
for repositioning of the lobule at the end of the procedure. The
cartilage is exposed on the posterior (medial) surface of the
ear, and soft tissue is excised from deep to the concha. In
the region of the earlobe, deep dissection is performed under
the concha in preparation for lobule repositioning. Branches
of the great auricular nerve will be seen and divided.
Correction (Fig. 20.3)
A small crescent of cartilage (≤3 mm at its widest point) is
excised from the posterior wall of the concha, at its junction
with the conchal floor. The defect in the concha is closed
primarily using numerous 4-0 nylon sutures. It is important
that the conchal resection be placed precisely. If it is too large
or if it is too far up the posterior conchal wall, then it will
irrevocably deform the antihelix. If it is too far anterior, in the
floor of the concha, it will not decrease the height of the
posterior conchal wall and the closure may be visible. Lack of
attention to the placement of the conchal resection is a common
cause of complications. A conchal setback suture (Furnas
suture) is then placed between the reduced concha and the
mastoid fascia using a single 3-0 nylon or 3-0 polydioxanone
(PDS) suture.7 The author prefers not to tie this suture until
after lobule repositioning has been performed. This combina-
tion of a small conchal resection and a small conchal setback
avoids the distortion of a large conchal resection and the
unreliability of a large conchal setback. This author avoids
conchal setback alone in all but the mildest cases. The other
problem with reliance on a conchal setback (Furnas suture)
alone is that the external auditory meatus can be narrowed to
the point of significant stenosis (Fig. 20.4).
Fig. 20.3 Technique for the standard otoplasty. The combination of Mustarde
sutures, conchal resection/closure and conchal–mastoid sutures is shown.
(A) Suture placement. (B) Suture tightened and ties appropriately. (C) Position of
sutures as shown from the surgeon’s vantage point.
A
B
C
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CHAPTER 20 • Otoplasty and ear reduction
Fig. 20.5 Lobule repositioning. The technique for lobule repositioning is shown. A
triangle of skin is excised on the earlobe, never compromising the appearance of
the lobe or the ability for the patient to wear earrings. Sutures are placed close to
the skin defect while catching a bite of the concha deep in the closure.
A
B
Fig. 20.6 Otoplasty. The patient is shown before (A) and after (B) standard
otoplasty. The upper, middle, and lower thirds of the ear have been set back in a
harmonious fashion. The contours are soft and natural.
A
B
Fig. 20.4 Placement of
Furnas conchal–mastoid
sutures. Note that suture
placement too close to the
external auditory canal can
constrict the canal. (Reprinted
with permission from Janis JE,
Rohrich RJ, Gutowski KA.
Otoplasty. Plast Reconstr Surg.
2005;115:60e–72e.)
A
B
C
do you know how sharp to make the antihelix? How do you
know how tight to tie the Furnas conchal–mastoid suture? Or
the earlobe correction sutures? The answers to these questions
lie in the knowledge of a normal ear. If the surgeon remembers
the following regarding how the ear should look from various
vantage points, it will aid tremendously in the intraoperative
decision-making11:
1. From the front, the helical rim should be visible, poking
out from behind the antihelix.
2. From the side, the contours of the ear should be round
and soft, never sharp.
3. From behind (and this is the most helpful to the surgeon
who is sitting behind the patient intraoperatively), the
contour of the helical rim should be a straight line, not a
“C”, a “hockey stick”, nor any other shape. If the helical
contour is a straight line, it almost ensures that a
harmonious correction will be achieved. Regardless if
the ultimate correction is slightly under- or slightly
overcorrected, a harmonious correction will read as
“normal” to the outside world, and almost all patients
will be happy. This is perhaps the single most important
lesson from this chapter.
A critical last judgment is how close to the head the ear should
be placed. The final position of the ear should be overcor-
rected minimally to allow for some relapse, but not enough
to create an unsatisfactory result if no relapse should occur.
Closure
The skin is approximated using 5-0 plain gut sutures without
excision skin (Figs. 20.6 & 20.7).12
Otoplasty for large ears or ears with
inadequate helical rim definition
Incision
An incision is made on the lateral (visible) surface of the
ear, just inside the helical rim (or where the helical rim would
be if it is underdeveloped).13 In addition, an incision in the
527
Treatment/surgical technique
determined precisely. The desired resection will leave the
helix the correct length for the new scapha and allow closure
without excess tension. However, in the case of ears with
inadequate formation of the helical rim, it is precisely the
slight tension on the helical closure that will cause the helical
rim to turnover and form a more natural contour. The helix is
reapproximated carefully using horizontal mattress sutures of
5-0 nylon sutures attempting to evert the skin edges to avoid
notching. The lateral incision is closed with a combination of
a few interrupted 5-0 plain sutures and a running 6-0 plain
suture. The author believes the running closure is desirable
because this skin edge is highly vascular and has a tendency
to ooze or even bleed actively when the adrenaline in the local
anesthesia solution wears off.
A frequent complaint of older patients, often at the time of
a facelift, is elongated earlobes. After using several different
techniques for lobule reduction, this author has concluded
that direct amputation with meticulous closure is the most
effective method.
Otoplasty for constricted ears
Constricted ears are tremendously variable, and no single
technique is applicable to all. Tanzer15 divided constricted ear
deformities into three types: type I – involving only the helix;
retroauricular sulcus may also be required depending on
what additional maneuvers are required.
Dissection
The lateral incision is extended through the cartilage. The
posterior surface of the cartilage is dissected, just as if a
standard posterior incision had been made.
Correction
In the case of excessively large ears, the scaphal cartilage (and
perhaps some scaphal skin) are trimmed to the desired size
and shape.14 Care is taken to excise more cartilage than skin.
At this point, the helical rim will be too long for the new
scapha and will require shortening at the end of the procedure.
Mustarde sutures are placed if necessary through this anterior
access. Conchal resection/setback and earlobe repositioning
are performed through a separate incision in the sulcus if
necessary (Figs. 20.8 & 20.9).
Closure
A wedge is then removed from the helical rim so that it
will fit the scapha, which is now of lesser circumference.
The amount of helix removed is important and should be
Fig. 20.7 Otoplasty. (A,B) Posterior view before and after otoplasty. The helical
rim contour is straight, and the scars are hidden within the sulcus. (C,D) Frontal
view of the same patient showing a harmonious correction and soft natural
contours.
A
B
C
D
Fig. 20.8 Ear reduction. The technique of ear reduction is shown. (Redrawn from
Argamaso RV. Ear reduction. Plast Reconstr Surg. 1990; 85:316–317.)
A
B
C
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CHAPTER 20 • Otoplasty and ear reduction
cartilage is normal in contour and only requires the soft-tissue
rearrangement described above for correction. In other cases,
the cartilage is misshapen, as in a lop ear, and requires
cartilage grafting to augment the deficient native cartilage
framework in addition to the soft-tissue considerations. The
deformity must be much more common in Asian patients
since almost all the publications on this deformity come from
Asian countries and the author of this chapter has seen very
few cases in a 20-year practice.16
Otoplasty for Stahl’s ears
The Stahl’s ear deformity consists of an abnormal crus extend-
ing superolaterally, as shown in Fig. 20.9. The deformity is
variable. In the mildest cases, the extra crus is barely notice-
able and can be ignored, and the otoplasty performed as if it
were a standard case of prominent ears. More severe deformi-
ties include excess scapha in the region of the abnormal crus
and termination of the abnormal crus in a point (“Mr Spock”
ears). In the most severe cases, there is also complete absence
of the normal superior crus.
Correction of the deformity mandates resection of the
abnormal crus.17 The author makes an incision inside the
helical rim as described above but not through the cartilage.
The skin is carefully dissected off the lateral surface of the
cartilage (Fig. 20.10). Note this is an entirely different plane
from that described for macrotia or underdeveloped helical
rims, and must be performed carefully, so as preserve the
viability of the skin. The lateral skin of the ear is more firmly
attached to the cartilage, and there is much less subcutaneous
tissue than on the back (medial surface) of the ear. The abnor-
mal crus is resected and placed as an onlay graft to reconstruct
the absent superior crus. The cartilaginous defect left by the
resected crus is closed primarily. The skin is then reapproxi-
mated. The Stahl’s ear deformity can be severe, and patients
are usually quite happy, even if the result falls short of com-
pletely normal.
Correction of aging, elongated earlobes
Earlobe reduction can be remarkably rejuvenative in a patient
with droopy, inelastic, elongated earlobes. The procedure is
also occasionally warranted in younger patients who have
congenitally enlarged earlobes. Earlobe reduction can be
type II – involving the helix and scapha; and type III – extreme
cupping of the ear. In the author’s opinion, they are also the
most difficult deformities to correct. The simplest-appearing
example of the constricted ear is the “lop ear”, in which the
upper pole of the ear is turned over. There is always deficiency
of tissue in this region. In other words, even if you could pick
up the lopped part of the ear it would still be slightly smaller
than the normal ear on the other side. In some cases, it is
adequate to excise directly the leading edge of the overhang-
ing skin and cartilage to create a less hooded appearance. In
more significant deformities (Tanzer type II), it is necessary to
expand the overhanging cartilage with radial cuts and rein-
force the area with a conchal graft.
Other constricted ears appear prominent, but unlike stan-
dard prominent ears, they are prominent because the helical
circumference is inadequate. It is as if the helix has been
tightened excessively like a drawstring, forcing the ear
forward. In other words, the ear cannot lie flat because the
excessively short helical rim draws the auricle into a cup. Any
attempt to set back a constricted ear must be accompanied by
elongation of the helix. The most common technique for
elongating the helix is by a variation of the incision described
above for large ears. The incision is made inside the helical
rim and extended anteriorly around the crus of the helix into
the preauricular region to the junction of the ear and the
temporal scalp. The crus of the helix is then mobilized, and
when standard otoplasty maneuvers are performed, the crus
of the helix is recruited into the helical rim. The donor site in
the concha is closed primarily as if the crus of the helix had
been taken for a composite graft to the nose. Any excess or
unusable crus of the helix is discarded.
In the case of more severely constricted ears (Tanzer type
III), it is preferable to discard the cartilage and construct a
framework as if the patient had classic microtia.
Otoplasty for cryptotia
The term “cryptotia” is used to describe the rare condition
where the upper portion of the ear is buried beneath the
temporal scalp. The ear can literally be pulled out of the scalp
to examine it. The correction is performed by pulling the ear
out of its bed in the scalp, incising around it in order to release
it fully, and resurfacing the defect behind the upper pole of
ear with a skin graft or a local flap. In some cases, the auricular
Fig. 20.9 (A,B) Oblique views before and after ear reduction and otoplasty. The scaphal reduction is apparent. (C,D) Close up oblique views showing the scar in the
helical rim where the wedge was removed.
A
B
C
D