Reoperative Aesthetic & Reconstructive Plastic Surgery

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Spacers
The use of spacer inserts in the lower lid posterior lamella in patients undergoing
primary surgery has been described earlier in this chapter. The same procedure is
performed in a patient with secondary lower lid retraction for corrective surgery.
Spacer inserts in the lower lid (AlloDerm, ENDURAGen, ear cartilage, autoge-
nous dermis) lengthen the posterior lamella and elevate the lower lid margin up-
ward in patients with signi cant eye prominence (de ned as 19 mm or more as
measured by an exophthalmometer).
On the left, this patient is shown after lower lid blepharoplasty with extremely
prominent eyes and moderately severe lower lid retraction. She required transcuta-
neous placement of spacer material in the posterior lamella of the lower lid with
vertical recruitment of skin. Her postoperative result is on the right.
Even in patients with Standard eye prominence with significant middle lamella
scarring, spacers can help prevent postrepair contracture of scar tissue. On occa-
sion, in reconstructive patients who do not require skin recruitment, the spacer
may be placed internally without a transcutaneous approach.
Spacer
Capsulopalpebral
fascia
The position of the spacer material is shown af-
ter internal or transconjunctival placement in
the lower lid. Spacers are usually needed in pa-
tients with very prominent eyes or those who
have retraction from middle lamella scarring. In
the more severe cases, transcutaneous spacer
placement, in conjunction with orbicularis ele-
vation for skin recruitment, may be required.

AESTHETIC GOALS IN UPPER LID
BLEPHAROPLASTY
SPACING AND DEFINITION
Harmony of positioning with the upper lid and brow is of the utmost importance
in terms of patient satisfaction. It is important to produce the desired contours of
the eyelid crease, the position of the eyelid margin, and even brow spacing that is
desired by the patient. In practice, the desired result can be highly individualized,
and the same xed formula of spacing and positioning should not be arbitrarily
applied in all patients.This aspect of the proposed surgery should be discussed with
the patient in detail for surgical planning to determine patient preferences and to
avoid patient dissatisfaction when the result does not meet the patient’s aesthetic
goals.
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Reoperation and Avoidance and Treatment of Complications in Eyelid Surgery
After upper lid blepharoplasty with a very high upper lid crease and a very wide
“eye shadow space,” this woman was unhappy because her appearance was too dra-
matic a change from her previous appearance. Her previous eyelid spacing is seen
on the right, before the upper lid blepharoplasty.
Old pictures may be helpful in de ning goals and the amount of eye shadow space
the patient desires. Preoperative planning is even more important in Asian patients
who may vary in their desire for a “Westernized” look. It is important to recognize
the tendency for the upper crease to migrate upward in patients with prominent
eyes, and this should be pointed out to the patient.
POSITION OF THE UPPER LID MARGIN
It is important to make note of the relationship of the upper lid mar-
gin to the pupil of the eye.
How much “color” of the eye can be seen above the pupil? Compensatory brow
arching or severe dermatochalasis may mask preexisting ptosis.True upper lid pto-
sis should be pointed out and discussed before surgery.

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PREVENTION OF UPPER BLEPHAROPLASTY
COMPLICATIONS
An important functional goal in upper blepharoplasty is that surgery
should not compromise the strength and velocity of upper lid closure.
Among patients who have poor moisture or reduced ocular motility, any lagoph-
thalmos, however subtle, may cause distressing symptoms. Severe lagophthalmos in
any patient can cause damage or disability of the eye from corneal exposure.
DIFFERENCES BETWEEN THE NASAL AND
TEMPORAL UPPER LID
Lagophthalmos in the nasal half of the upper eyelid is more poorly
tolerated than lagophthalmos in the temporal half of the upper lid,
either with symptoms or corneal changes.
Cautious skin removal in the nasal half of the upper lid is advised. In some patients,
skin laxity and unwanted fullness in this area can be improved by brow elevation
and fat removal alone. Minimizing skin removal in the nasal half of the upper lid re-
duces the chance of symptomatic lagophthalmos.
Considerations in the nasal half and the temporal half of the upper lid are depicted
with regard to problems, pitfalls, and corrective procedures. Stiffness in the outer
half of the upper lid is much better tolerated by the eye, so more complete removal
of redundant skin may be carried out in this area. Lateral brow stability in uences
the amount of residual folding that may occur in the lateral upper lid postopera-
tively. To avoid annoying residual folds in this area and ensure a continuous space
with the pretarsal area, stabilizing the lateral brow, either with a temporal lift or an
internal browpexy, is recommended. It is our practice to include a transblepharo-
plasty internal browpexy with almost every upper lid blepharoplasty.
Minimal skin excision
(must use brow)
ß Avoid orbicularis excision
ß Maximal nasal fat removal
(no transitional fat)
Maximal skin excision
ß Sculpting of ROOF
ß Plication of lacrimal gland
ß Internal brow support
NASAL
TEMPORAL

DESIGN OF THE UPPER BLEPHAROPLASTY SKIN EXCISION
The amount of skin that is surgically removed in the upper lid is not as important
as the skin that remains in the lid.The general placement of skin markings for ex-
cision is depicted below.
579
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Reoperation and Avoidance and Treatment of Complications in Eyelid Surgery
This illustration demonstrates the recommended excision of skin and underlying
orbicularis and septum in the so-called open-sky approach to upper lid blepharo-
plasty.This approach emphasizes the principle that the most important considera-
tion in upper lid blepharoplasty is how much skin is left behind rather than how
much is excised.
One should minimize the excision of skin in the nasal half of the eyelid because, as
previously described, nasal lagophthalmos causes the most severe exposure. Exces-
sive laxity in this area can be addressed with cautious skin excision, but correction
of any brow laxity may reduce the amount of skin excision needed.The open-sky
technique, with removal of skin and the underlying orbicularis and septum, is safer
and provides the surgeon more options at the time of upper blepharoplasty. Debulk-
ing the subcutaneous tissue produces less skin tightness on closure, and the added
exposure provided allows access to the levator aponeurosis if ptosis surgery is
needed. One should avoid scarring in any orbicularis or septal layers that remain.
Postoperative upper lid lagophthalmos from middle lamella scarring is most dif -
cult to correct. The open-sky technique of upper blepharoplasty may require ex-
cision of the orbicularis and septum near the insertion of the levator aponeurosis,
which may in some cases, particularly those patients who are predisposed to ptosis,
weaken the levator aponeurotic insertion, and produce postoperative ptosis.
10 mm
6 mm
5 mm
15 mm
Junction
of thick and
thin skin

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R EOPERATIVE SURGERY OF THE HEAD AND NECK
THE APONEUROTIC SAFETY STITCH
When upper blepharoplasty is performed, even in patients in whom no ptosis is
present, plication of the upper pretarsal skin edge to the aponeurosis is a safeguard
against levator dehiscence and controls the position of the upper crease.This is eas-
ily performed with the open-sky technique.
This illustration demonstrates the “safety stitch” in conjunction with the open-sky
technique to ensure levator aponeurosis attachments and to control the position of
the upper lid crease.
Surgical images show placement of the safety stitch using 6-0 Vicryl. The stitch is
placed through the skin at the upper edge of the incision and then into the levator
aponeurosis.The suture is tightened but not enough to cause eyelid gapping.
Levator
aponeurosis
Pretarsal skin

BROW TREATMENT
For significant eyebrow laxity, we recommend a formal brow procedure, endo-
scopic forehead lift, or temporal lift for stabilization of the eyebrow/eyelash dis-
tance. In milder cases the problem can be addressed in the lateral upper eyelid with
transblepharoplasty internal browpexy. Fixation of the subbrow fat pad (retroor-
bicularis fat) to the deep temporal fascia with permanent sutures can reduce or
eliminate brow sagging and avoid residual lateral folding in many patients.
581
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Reoperation and Avoidance and Treatment of Complications in Eyelid Surgery
The steps in the internal browpexy are illustrated.The image on the left shows the
area to be undermined in the preperiosteal plane, and the image on the right shows
the exposure of the deep temporal fascia.
The image on the left shows the xing suture being placed in the deep temporal
fascia.The image on the right shows insertion of the suture in the retroorbicularis
oculi fat at the level of the inferior edge of the brow. The vector of pull is usually
in an upward/outward direction.

582
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
This patient is seen after upper lid blepharoplasty with internal browpexy. On the
left, the temporal half of the upper lid and tail of the brow are shown preoperatively.
The desired postoperative result is shown on the right.This includes rm support
of the tail of the brow, an upper lid crease, and an eye shadow space that extends
past the canthal angle without residual skin folds.
PREVENTION OF PTOSIS
CORRECTION OF COEXISTENT PTOSIS
In a patient requesting upper lid blepharoplasty, the usual cause of ptosis is a dehis-
cence of the levator aponeurosis. Aponeurotic repair can easily be performed
through the upper lid blepharoplasty incision if surgical exposure is adequate.The
open-sky approach to upper lid blepharoplasty provides adequate exposure of the
levator muscle and aponeurosis, facilitating repair in these patients.
THE MECHANISM AND CAUSE OF LEVATOR DEHISCENCE
Levator aponeurotic attachments to the upper lid travel to the anterior surface of
the tarsal plate and to eyelid skin in the crease area.With levator dehiscence, because
of thinning and disinsertion, the aponeurotic portion of the levator pulls away from
its tarsal attachments and with its retraction, the upper lid becomes ptotic.

This illustration demonstrates the normal levator on the left with its aponeurotic at-
tachments to the anterior surface of the tarsal plate and to the eyelid skin to form
the upper lid crease. With dehiscence of the levator aponeurosis, as seen on the
right, the aponeurotic attachments dehisce allowing the lid to relax downward caus-
ing ptosis combined with upward pulling of the skin attachments; this produces a
visibly high upper lid crease (unless there is severe dermatochalasis).
583
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Reoperation and Avoidance and Treatment of Complications in Eyelid Surgery
Levator muscle
Tarsus
Müller’s muscle

Residual
attachment
to skin
Dehisced levator
Normal levator
Persistent aponeurotic attachments to the upper eyelid skin may cause a character-
istically high upper lid crease, depending on the fullness of the upper lid. In suscep-
tible individuals, surgical trauma or the postoperative edema of surgery may cause
levator dehiscence resulting in postoperative ptosis, as seen in this patient.

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R EOPERATIVE SURGERY OF THE HEAD AND NECK
CORRECTION OF PTOSIS
Ptosis repair can be performed in patients with preexisting ptosis while they are un-
dergoing upper blepharoplasty, or it can be performed to correct ptosis that has
occurred as a complication. The technique for ptosis repair in these patients is
anatomic reattachment of the levator aponeurosis. A single suture is used for the at-
tachment of the tarsal plate to the musculoaponeurotic junction of the levator.
Other anatomic changes that commonly occur with age must be taken into ac-
count for proper contouring of the lid. With the use of the single-suture repair
(double-armed 6-0 silk), suture placement must be in a vertical line with the mid-
pupil near the superior edge of the tarsal plate.
The normal levator attachments and landmarks are illustrated. In most adults, be-
cause of dehiscence of nasal attachments of the lid, there is a lateral shift of the
tarsal plate.To produce the desired contour in the upper lid, the required placement
of the single lifting suture used in acquired ptosis (placed in the tarsus near the su-
perior edge of the tarsal plate) must be in line with the pupil.
Levator muscle
Normal
Levator
aponeurosis
Dehisced
Suture placement
Normal

Lateral tarsal shift
Tarsus

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Chapter 20
Reoperation and Avoidance and Treatment of Complications in Eyelid Surgery
Placement of the lifting suture in the musculoaponeurotic junction of the levator
muscle is illustrated. After suture placement in the tarsal plate, the suture arms are
brought under the levator aponeurosis; the edge of the dehisced aponeurosis has
been dissected free of Müller’s muscle, and the suture is placed through the levator
at the musculoaponeurotic junction.
In cases of bilateral ptosis, the anatomic placement of sutures should be symmetri-
cal. Placement of the suture for ptosis at the junction of the muscular portion of the
levator and its aponeurosis is illustrated.
Musculoaponeurotic
junction
Suture alignment with the apex of the upper tarsal curve is not appropriate be-
cause in patients of this age there is a lateral shift of the tarsus.

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PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
This patient (left) had bilateral levator dehiscence.The same patient (right) is seen af-
ter blepharoplasty and bilateral aponeurotic repair with the technique described. No
secondary surgery for symmetry was necessary in this patient.
After suture placement and temporary tightening, adjustments should be made to
ensure symmetry (in cases in which the ptosis is bilateral).This can be done under
general anesthesia without patient cooperation. After the suture has been tight-
ened, the intraoperative gapping of the lid ssure that occurs should be even be-
tween the lids. An additional test—the “springback test”—is needed to help achieve
symmetry.When one of the upper lids is pulled closed and quickly released, the ve-
locity of upward spring should be the same in each eye. If these adjustments are ob-
served, in most cases there will be postoperative symmetry in the ptosis correction.
Cases of unilateral ptosis may require postoperative adjustments.
COMPLICATIONS IN THE UPPER LID
AND TREATMENT OF POSTOPERATIVE
LAGOPHTHALMOS
Poor upper lid closure after blepharoplasty can be attributed to these causes:
Surgically induced upper lid stiffness
Patients without stiffness, because of loss of lateral canthal anchoring
Poor closure mechanics
Intrinsic upper lid stiffness can result from excessive skin removal causing skin
shortage or from internal scarring.

The three possible areas of restriction are graphically depicted; these may cause
lagophthalmos in the upper lid after surgery. In the gure on the left, poor closure
resulting from a shortage of skin is represented, which, if it is not overcome by rm
canthal reanchoring, will require skin replacement. In addition to a skin shortage,
patients may have scarring of the middle lamella with adhesions of the orbicularis
and septum to the superior orbital rim, as seen in the middle gure. These adhe-
sions must be separated to restore closure of the upper lid. The most severe situa-
tion occurs when the levator is bound to structures at the superior orbital rim, as
seen in the image on the far right. The levator adhesions can be released, but it is
common to produce ptosis postoperatively in these patients.
Corneal symptoms are more severe with lagophthalmos occurring in the nasal half
of the upper lid than in the lateral half, as mentioned earlier.The lateral half of the
eye seems to be more forgiving of lagophthalmos because of lateral brow laxity.
Scarring in the internal structures of the upper lid, orbital septum, and fat pads
(middle lamella scarring) produces lagophthalmos, which is more dif cult to cor-
rect. Care should be taken to avoid scarring of the middle lamella by inappropriate
cautery, particularly if the tissue is to be left behind in the upper lid. The orbicu-
laris and orbital septum are best treated with excision using the open-sky tech-
nique as described earlier; however, one may leave varying amounts of orbicularis
to avoid excessive crease formation, if indicated.
APPROACH TO THE TREATMENT OF UPPER LID
LAGOPHTHALMOS
Surgical intervention in the upper lid directly to correct lagophthalmos after ble-
pharoplasty can be problematic, because it usually requires skin grafts and can be
upsetting to the patient who is undergoing a cosmetic procedure. Direct surgical in-
tervention is restricted to those patients who have vision-threatening problems and
587
Chapter 20
Reoperation and Avoidance and Treatment of Complications in Eyelid Surgery
Middle
lamella
scarring
Levator
adhesions
Skin
shortage

588
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
in whom all else has failed. In patients with poor eyelid closure after blepharoplasty,
every attempt should be made to relieve the problem by rst attempting corrective
surgery in the lower lid. It is important to ensure that rm canthal anchoring is
present, because de ciencies in that area can signi cantly contribute to poor eye-
lid closure mechanics. When faced with definite upper lid tethering from skin
shortage or internal scarring, repositioning the lid upward by the methods de-
scribed in the previous section can help reduce the exposure by narrowing the eye-
lid separation. This approach often precludes the need for direct surgery on the
upper lids. Improvement in the eyelid closure mechanics, preferably by drill-hole
xation as described earlier, can overcome some of the resistance of a stiff upper lid
and produce an improvement in upper lid closure.This is particularly true if the ob-
served lagophthalmos is accompanied by the sh-mouthing effect, a sure sign of in-
adequate canthal attachment.
This patient is shown after blepharoplasty with a reasonably normal eye ssure ap-
pearance but poor eyelid closure because of weakened canthal anchoring. On the
right, the same patient is shown immediately after rm reanchoring of the lateral
canthus with improved eyelid closure.The double drill-hole technique is indicated
in these patients if the eye is prominent.

This patient shows adequate restoration of eyelid closure with lower lid reposition-
ing and canthal anchoring even in the face of signi cant upper lid stiffness. She
presented with retraction of the lower lid and lagophthalmos of the upper lids af-
ter blepharoplasty and laser resurfacing. Poor closure in the upper lids was the re-
sult of skin shortage as well as canthal dehiscence resulting in poor eyelid closure
mechanics. After bilateral canthal anchoring with the use of drill-hole xation of
the canthal tendons, her situation is much improved. Lower lid repositioning was
also performed with recruitment of skin, with orbicularis vertical reanchoring and
spacer implants of autogenous dermis. No skin grafts were placed in the upper lid.
Restoration of closure of the upper lid was accomplished by rm reanchoring of
the lateral canthus and repositioning of the lower lid only.The upper lid stiffness re-
sulting from the presence of a skin shortage was overcome by strengthening the
eyelid closure mechanics by means of the canthal reanchoring.
Only after restoring lower lid position and improving closure mechanics should
one resort to direct surgery to the upper lid. However, some patients because of the
severity of upper lid stiffness from a skin shortage or internal scarring, even though
improved from the approaches described earlier, will not have return of adequate
closure and will have continuing problems with corneal exposure. In these patients,
skin grafts to the upper lid are needed.
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This illustration depicts the proper placement of a full-thickness skin graft in the
upper lid for correction of lagophthalmos resulting from skin shortage. In most
cases the skin can be released with an incision just above the lashes, allowing the
skin edge to retract upward to the crease area.The graft can then be placed in the
space between the lashes and the crease so as to maintain a Standard eye shadow
space and crease position in these patients.

This patient is seen after blepharoplasty (left) with extreme upper and lower lid re-
traction, poor eyelid closure, and corneal damage from exposure.The skin shortage
in the upper eyelids was profound. The position of the lower lids was improved,
with drill-hole canthal anchoring, but exposure problems were not totally elimi-
nated. Upper lid skin grafting is needed.When skin grafts are indicated, they should
be positioned so as not to alter the crease formation of the upper lid or disturb the
aesthetic contours of the upper lid. Graft placement should not span the crease
area, and grafts are best placed between the lashes and the crease or above the crease
if a second graft is needed. After the placement of upper lid skin grafts (right), this
patient was able to achieve more normal eyelid closure. Middle lamella scarring
was also encountered in this patient, and lysis of adhesions from the lid to the su-
perior orbital rim was required.
In some patients, even after the release of the skin between the lashes and the crease,
the upper lid may still show resistance to closure. This is a sign of internal, middle
lamella, or septal scarring, which requires release before the graft is placed.The pa-
tient pictured above is now seen after drill-hole canthal anchoring, a reconstructive
cheek lift with autogenous spacers, and full-thickness skin grafts to the pretarsal
area of her upper lids. In this patient there were also internal scar tissue adhesions
in the middle lamella that required release.
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UPPER LID CREASE: SULCUS ABNORMALITIES
The most common sulcus abnormality that causes distress to the patient is an ex-
cessively high upper lid crease or a hollowed-out appearance in the upper lid.
Overzealous removal of fat from the upper lid in patients who are not used to a
deep crease or do not want a high crease is a common cause of this problem and
can produce an unwanted deep-set look. Even a conservative amount of fat re-
moval, if the eye is very prominent, can produce an unwanted high crease. Exces-
sive removal of fat in the nasal third of the upper lid may produce a peaking of the
crease in that area producing an “A-frame” deformity. Another uncommon but
de nitely occurring complication of aggressive fat removal in this area is injury to
the superior oblique tendon, either by direct trauma or cauterization of bleeding in
that area.
Restoration of fullness in these areas is dif cult. The most fortuitous situation is
when there is still available preaponeurotic fat present in the upper lid that can be
brought out and sutured forward to the crease area in the upper lid. An open inci-
sion through the orbital septum is necessary.This approach may not be available in
many patients.
Attachment of dermis fat strips to the arcus marginalis for augmentation in this
area has been helpful in some patients, but the possibility of tethering upper lid
movement always exists if secondary brosis occurs and affects the levator muscle.
Direct grafts that may adhere to the levator are ill advised.
An undesirable high upper lid crease can be seen in some patients with early dehis-
cence of the levator aponeurosis in which retraction of the aponeurotic skin crease
attachments precedes the actual ptosis (see p. 583). In these patients, conservative re-
pair of the levator aponeurosis may restore upper lid crease position and ward off
an incipient true ptosis.
References—With Annotated Key References
1. McCord CD, Shore J, Coles W, et al. Treatment of essential blepharospasm. I. Comparison of
facial neurectomy vs muscle stripping. Arch Ophthalmol 120:250-268, 1984.
2. McCord CD, Boswell CB, Hester TR. Lateral canthal anchoring. Plast Reconstr Surg 112:222-
237, 2003.
Any surgeon performing cosmetic or reconstructive surgery procedures on the lower lid or midface
through the lower lid should be comfortable with canthal anchoring procedures.This article discusses
the principles involved in canthal support for patients undergoing cosmetic and reconstructive surgery,
variations in surgical techniques required to perform canthal anchoring in a variety of patients, the sig-
ni cance and techniques of canthal anchoring (canthoplasty and canthopexy) as they relate to cosmetic
and reconstructive lower lid surgery, and the effect of canthal anchoring on the function of the upper
and lower lids and eyelid ssure shape.
3. Shore JW. Changes in lower eyelid resting position, movement, and tone with age. Am J Oph-
thalmol 99:415-423, 1985.

4. Hester TR, Codner MA, McCord CD. The “centrofacial” approach for correction of facial
aging using the transblepharoplasty subperiosteal cheeklift. Aesthetic Surg Q 16:51, 1996.
5. Hester TR , Codner MA, McCord CD, et al. Evolution of technique of the direct trans-
blepharoplasty approach for the correction of lower lid and midfacial aging:Maximizing results
and minimizing complications in a 5-year experience. Plast Reconstr Surg 105:393-406, 2000.
6. Malbouisson JM, Baccega A, Cruz AA.The geometrical basis of eyelid contour. Ophthal Plast
Reconstr Surg 16:427-431, 2000.
The authors described a two-dimensional, frontal-view model of eyelid contour. After performing an
observational study of palpebral ssure images from 110 normal subjects, they concluded that the
parabolic shape of the upper ciliated contour seen in two-dimensional images can be justi ed geomet-
rically in a simple way, allowing a precise quanti cation of its shape.The same was not true for the
lower eyelid.The parabolic shape of the upper eyelid can be demonstrated, using the Taylor series, to
be a close approximation of the arc of a circle.
7. Hirmand H, Codner MA, McCord CD, et al. Prominent eye:Operative in lower lid and mid-
face rejuvenation and the morphologic classi cation system. Plast Reconstr Surg 110:620-628,
2002.
8. McCord CD. The correction of lower lid malposition following lower blepharoplasty. Plast
Reconstr Surg 103:1036-1039, 1999.
Lower eyelid malposition is the most common complication after lower eyelid blepharoplasty.When this
problem occurs, it is imperative to correct the malposition by the most ef cient method.The author pres-
ents methods for correcting minor as well as severe cases.
9. McCord CD. Lower lid reconstruction. In McCord CD, ed. Eyelid Surgery. Philadelphia:Lip-
pincott-Raven, 1995, p 274.
10. McCord CD, Ellis DS.The correction of lower lid malposition following blepharoplasty. Plast
Reconstr Surg 92:1068-1072, 1993.
11. McCord CD, Codner MA, Hester TR. Redraping the inferior orbicularis arc. Plast Reconstr
Surg 102:2471-2479, 1998.
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1. A 40-year-old woman seeking blepharoplasty has recently undergone vision
correction procedure (Lasik). At least how long should she wait before under-
going the blepharoplasty?
a. 1 month
b. 6 months
c. 18 months
d. 3 months
2. The inner canthal orbicularis is innervated by which branch of the facial nerve?
a. Temporal
b. Zygomatic
c. Buccal
d. Marginal mandibular
3. Factors leading to lid malposition, retraction, and frank ectropion include:
a. Overzealous skin resection
b. Failure to anchor the lateral canthus
c. Preexisting lid laxity
d. Variation in eye prominence
e. All of the above
4. To avoid lagophthalmos in the upper eyelid, skin resection should be cautious
and conservative in which segment of the upper eyelid.
a. Temporal
b. Central
c. Nasal
d. All of the above
5. Following upper lid blepharoplasty poor closure mechanisms may result from:
a. Scarring
b. Loss of lateral canthal anchoring
c. Excessive skin excision
d. All of the above
R EVIEW QUESTIONS

595
Secondary Rhinoplasty
Rod J. Rohrich, Jack H. Sheen, and Sumeet S.Teotia
C ha pter 2 1
Reoperative Problems
Dorsal deformities
Supratip deformities
Short nasal length
Vault deformities
Nasal tip deformities
You may have to ght a battle more than once to win it.
Margaret Thatcher
Unlike primary rhinoplasty, in which the surgeon can usually trust that normal
anatomy and tissue will be present, secondary rhinoplasty affords no such zone of
comfort. Distorted, de cient anatomy, scarred tissues, and diminished vascularity
characterize the secondary nasal deformity.1,2 Surface contours may mask structural
deformities, and tissue behavior may defy expectations. Each successive surgical in-
tervention offers diminishing returns.Thus secondary rhinoplasty presents a unique
challenge, testing the rhinoplasty surgeon’s artistry, judgment, and ingenuity.There
is scant margin for error. The goal is clear-cut: to restore nasal function and form
to near normal without further compromise.
This chapter focuses on the major problems faced in secondary rhinoplasty and of-
fers guidelines for diagnosis and treatment.3-13 It is written as a collaborative effort
that combines our experience in treating nasal deformities and recommends guid-
ing principles and surgical approaches that we have found helpful. In some cases
certain approaches to treatment may vary, depending on the speci c preference of
the surgeon. For instance, Sheen advocates an endonasal approach for secondary

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rhinoplasty,14,15 whereas Rohrich often prefers the external approach.16 With this in
mind, both approaches are described, with the appropriate indications and limita-
tions outlined. Recommendations speci c to each surgeon are noted when appro-
priate as well as their individual case.
TOPOGRAPHIC ANATOMIC EXAMINATION
Key to the treatment of the secondary rhinoplasty patient is a careful anatomic ex-
amination to identify the problems involved. Most secondary deformities are attrib-
utable to structural de ciencies and displaced anatomy, which often have resulted
from overresection or underresection.17-19 A systematic anatomic and aesthetic
analysis of the nose is essential to thoroughly assess the extent of these nasal defor-
mities and to determine the problems that need to be addressed.20,21
Superiorly, the nasofrontal angle and radix depth are noted.The bony pyramid, up-
per lateral cartilages, and supratip area are assessed based on height, width, and sym-
metry on frontal and lateral views.
Radix
TOPOGRAPHY
Dorsum
Tip
Columella
Dorsum
Tip
Supratip
ANATOMY
Nasal bones
Upper lateral
cartilages
Lower lateral
cartilages
Nasal bone
Upper lateral
cartilage
Lower lateral
cartilage

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The projection, rotation, symmetry, and de ning points of the nasal tip are also
evaluated. Often the radix is low from overresection of the skeletal parts.Therefore
one must use palpation to help assess the deformity—for example, whether the
supratip deformity is caused by overresection of upper skeletal parts (the most com-
mon case) or by prominence of the septum.
Suspensory
ligament
Fibrous
connections
Piriform abutment
Elastic fibers
Low radix
One must remember that the length and strength of the lower lateral cartilages are
the most important contributions to tip projection. Other factors include the -
brous connections between the lower lateral cartilages and upper lateral cartilages,
suspensory ligament, piriform abutment, and elastic bers between the feet of me-
dial crura and caudal septum.The septum itself also is a signi cant but not primary
contributor to tip projection.

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Next the alae are inspected to detect increased or decreased width, collapse, or re-
traction.This problem is usually caused by overresection of lower lateral cartilages
or rim strip interruption. The columella is examined for increased or decreased
show.22 The columellar-lobular and the columellar-labial angles are observed to
evaluate the degree of angulation.
Internal nasal examination con rms the functional deformity.The nasal mucosa is
first constricted using aerosolized 4% cocaine or oxymetazoline hydrochloride
(Afrin) spray.The internal valves are assessed by tilting the patient’s head back and
observing whether the valves narrow or collapse on inspiration. The condition of
the turbinates and the structure and amount of septum available are documented.23
Because the septum is the primary source of autogenous material, it is crucial to as-
certain whether the quantity and quality of the septum are suf cient for its use in
reconstruction.
Finally, the soft tissue envelope is inspected to evaluate its overall condition. The
surgeon should assess the thickness of the nasal tip skin and determine whether its
vascularity has been compromised. In secondary nasal deformities the nasal skin is
often tethered, thin, and adherent to the lower lateral cartilages. Decreased vascu-
larity and scarring are typical problems in secondary rhinoplasty. As a result, routine
rhinoplastic techniques may further compromise the remaining circulation and
cause tissue loss in patients who have undergone several procedures.Therefore the
placement of incisions and the extent of dissection must be limited. Defatting to
reestablish tip projection or de nition should never be attempted, because this ma-
neuver will further compromise nasal tip vascularity.The condition of the soft tis-
sue will in uence the incision approach and have a major effect on the overall aes-
thetic result.
AESTHETIC ANALYSIS
Once the surgeon has completed the anatomic examination, the nose is evaluated
according to basic aesthetic concepts. Facial proportions must always be consid-
ered, since the nose constitutes a central subunit in overall facial aesthetics.18,24,25
Aesthetic nasofacial analysis in the rhinoplasty patient essentially involves propor-
tions. For the purpose of this chapter, the typical proportions of a Caucasian woman
are used since she is the patient who most commonly seeks rhinoplasty.Variations
for the male patient are noted when appropriate.
Alar pinching

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The face is divided into thirds by transverse lines at the level of the menton, sub-
nasale, brows (at the level of the suborbital notch), and hairline. Obviously, the up-
permost line varies with choice of hairstyle and changes secondary to the aging
process. The upper third of the face merits the least consideration for purposes of
nasofacial diagnosis.
The lower face is divided into an upper third and lower two thirds by a transverse
line at the level of the oral commissures. A transverse line through the labiomental
groove divides the distance from the stomion to the menton in a 1:2 ratio.
Byrd further re ned this facial analysis.20,21 He relates facial proportions to nasal
length and calculates nasal length (RT) as equal to the distance from the stomion
to the menton (SM). Ideal nasal tip projection (AT) is equal to 0.67 times the ideal
nasal length (RT): AT
0.67
RT.
1 3
1 3
1 3
1 3
1 3
1 3
1 3
2 3
1 3
2 3
R
R
T
T
S
A
M

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A natural horizontal facial plane is determined by drawing a line perpendicular to
a plumb line superimposed over the head with the eyes in straightforward gaze.
This plane may or may not correspond to Frankfort’s line. All photographs should
be taken and analyzed on the natural horizontal facial plane.
Attention is then focused on nasal aesthetics. Any sign of nasal deviation is identi-
ed.26 A line is drawn from the midglabellar area to the midmenton. It should bi-
sect the nasal bridge, upper lip, and Cupid’s bow. In patients with a normal occlu-
sion this midline is a vertical line that falls between the two central incisors.
The nasal dorsum is outlined by two slightly curved divergent lines extending from
the medial supraciliary ridges to the tip-de ning points.
Natural horizontal
facial plane

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The width of the bony base is measured. In the normal nose, this dimension should
be 75% to 80% of the width of the alar base. In many patients seeking secondary
rhinoplasty, the nasal base width is within normal range and does not need to be al-
tered. However, if the bony base is wide, mobilization of the bones may be required
to narrow the dorsum.
The width of the alar base should be approximately the same as the intercanthal dis-
tance or the width of one eye. If the interalar distance is wider than the intercan-
thal width, one must determine if this discrepancy is caused by increased interalar
width or alar aring.
Normal
interalar width
Increased
interalar width
The normal degree of alar aring in a Caucasian woman is 2 mm beyond the alar
base. If alar aring is greater than 2 mm, then alar base resection should be consid-
ered. Alar aring should be distinguished from increased interalar width. If interalar
width is excessive, then nostril sill resection may be indicated.
A B
A
B
A 0.75 B
A
B
A B
A
B

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The alar rims are assessed for symmetry.27 They should have a slight outward are
in an inferolateral direction.The normal nose has four tip-de ning points, but in a
secondary rhinoplasty patient these points may be ill de ned, missing, or displaced.
Next the outline of the alar rims and the columella is assessed.28 This outline should
resemble a seagull in gentle ight. The columella lies just inferior to the alar rims
on the frontal view, giving the outline of the rims and the lowest portion of the col-
umella a gentle, gull-wing appearance.Too much curvature to this line indicates a
hanging columella, whereas a straight line indicates a retracted columella.

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From basal view the outline of the nasal base should form an equilateral triangle.
The length of the lobular portion of the nose should have a 1:2 ratio with the
height of the columella. The nostrils should have a teardrop shape, with the long
axis from the base to the apex extending in a slightly medial direction.
On lateral view one should note the position and depth of the nasofrontal angle.
The angle should begin at the infrabrow area and form a gentle, concave curve
that connects the brow to the dorsum.With the eyes in natural horizontal gaze, the
deepest portion of the nasofrontal angle should lie between the upper eyelash line
and supratarsal fold. In many secondary rhinoplasty patients this nasofrontal angle
has been overreduced and must be corrected. Unfortunately, an adequate guideline
for accurately assessing the depth of the nasofrontal angle has not been de ned, al-
though the distance from the cornea to the nasofacial angle has been suggested.
The aesthetic nasal dorsum in women lies approximately 2 mm behind and paral-
lel to a line that extends from the nasofrontal angle to the tip-de ning points. In
men the dorsum is slightly higher.
1 3
2 3

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Tip projection is assessed next. A line is drawn from the alar-cheek junction to the
tip of the nose. If normal upper lip projection is present and 50% to 60% of the tip
lies anterior to a vertical line that is adjacent to the most projecting part of the up-
per lip, tip projection is normal. If more than 60% of the tip extends beyond this
point, the tip may be overprojecting and require reduction. As mentioned earlier,
according to Byrd’s analysis,20,21 ideal nasal length is assessed as a ratio of nasal length
to tip projection:AT
0.67
RT.When nasal tip projection and the dorsum are
evaluated, one should assess the degree of supratip break. A slight supratip break is
preferred in women, but not in men. This feature gives the nose more de nition
and distinguishes the dorsum from the tip.
The degree of tip rotation is determined by extending a straight line through the
most anterior and posterior edges of the nostril; where this line transects a plumb
line the so-called nasolabial angle is created. In women this angle is 95 to 100 de-
grees;in men it is 90 to 95 degrees. In contrast, the columellar-labial angle is formed
at the junction of the columella with the upper lip. Increased fullness in this area is
usually caused by a prominent caudal septum and can give the illusion of increased
rotation even though the nasolabial angle is within normal limits.
A
AT 50%-60% of (A B)
B
A
T
AT 0.67 RT
R
95°-100°

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Next the columellar-lobular angle is assessed;a 45-degree angle is considered to be
normal.
Finally the aesthetic relationship of the lip and chin is assessed.29 The upper lip pro-
jects approximately 2 mm above the lower lip. In women the chin is slightly pos-
terior to the lower lip, approximately 2 to 3 mm. In men this distance may be
slightly less.
DOCUMENTATION
Standardized color photographs or slides of patients should include frontal, right
and left lateral, right and left oblique, and basal views. Measurements and aesthetic
proportions are checked against these photographs and are recorded.These photo-
graphs are used during the nal preoperative patient consultation to assess whether
realistic improvements can be achieved surgically.
PATIENT CONSULTATION
SURGICAL HISTORY
A detailed surgical history of prior operations and current functional problems (for
example, nasal obstruction, discharge, crusting) is invaluable. If available, preopera-
tive and/or sequential postoperative photographs should be reviewed;these photo-
graphs graphically document the progression of the nasal deformity. Operative
records are not always useful. Details concerning the etiologic factors of the second-
ary nasal deformity are often missing. Nevertheless, these records should be re-
viewed preoperatively.
45°
Natural horizontal
facial plane
2-3 mm
2 mm

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INTERVIEW
The initial interview is the time to establish a line of communication between the
patient and physician and to determine whether the patient is a candidate for a
secondary rhinoplasty procedure. During a carefully directed interview the patient
can voice expectations and the surgeon can assess the realistic possibilities for cor-
rection in light of the patient’s needs.30
The patient’s attitude and motivation for surgery warrant close attention.The sur-
geon who undertakes secondary rhinoplasty is often faced with a patient who is
dissatis ed, unhappy, and possibly angry. This patient has been disappointed and
may be reluctant to trust yet another surgeon. However, disillusionment often co-
exists with hope for improvement. Paradoxically, as the severity of the problem be-
comes more pronounced, the level of hope seems to increase.The consulting rhino-
plasty surgeon walks a ne line between reassuring the patient on one hand and
presenting an honest and realistic picture on the other.The truth is not simple, and
an emotionally involved patient may not be receptive to the message the surgeon
presents.
It is essential to have the patient list speci c complaints about nasal appearance and
function and rank them in order of importance.
It is helpful to ask the patient, “If you had only one problem that
could be corrected, what would it be?” This “one thing” that would
make the surgery worthwhile is then written verbatim in the patient’s
notes. Before agreeing to operate, the surgeon must be sure that he or
she can improve at least this one problem.
A patient focused on a minor or an uncorrectable problem is likely to be disap-
pointed regardless of any postoperative aesthetic and/or functional improvement
achieved.The wise course may be not to operate on such a patient.
Problems such as stenosis of the vestibule, supratip deformity, irregularities of the
dorsum, and septal perforations must be accurately detailed and visually demon-
strated to the patient.31 The cause of these problems and previous surgical experi-
ences are of secondary importance. Emphasis is placed on conveying the complex-
ity inherent in any rhinoplasty operation. It is helpful to explain that various
surgeons use different approaches and techniques with good results;even an excel-
lent surgeon’s best efforts may produce unpredictable rhinoplasty results.
It is important to stress that anatomic limitations make secondary
rhinoplasty complex, and thus possible reoperations must be judged in
light of the present condition of the nose, not according to its appear-
ance before primary rhinoplasty.

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Patients must understand the proposed surgical plan so that they can grasp the logic
of the surgical solution. Potential sequelae and complications must be fully out-
lined and understood. Photographs are used to demonstrate problems that will per-
sist postoperatively or that are inevitable consequences of reconstruction such as
notches, grooves, surface irregularities caused by dorsal grafts, or an unnaturally
sharp tip resulting from a tip graft. As speci c details of the photographs are re-
viewed, it is important to point out to the patient that each surgical step involves a
trade-off. It is essential to stress those features that will not be improved and to
have patients clearly acknowledge that they understand what improvements can be
expected. Facial disproportions also should be pointed out, with an explanation
that these asymmetries will not be corrected by nasal surgery; in some cases or-
thognathic or craniofacial procedures may be necessary.18,24,29 These preoperative
discussions are then fully documented in the patient’s le to avoid future problems
and to clarify possible misconceptions.
Because a secondary rhinoplasty patient’s overriding concern about the nasal defor-
mity may interfere with his or her ability to retain information provided in the
initial consultation, we recommend a second consultation to clarify and reinforce
key points, review the patient’s photographs, describe the speci c nasal deformities,
and reiterate which problems can and cannot be improved. Rhinoplasty is both an
art and a science, but it is not magic. It is crucial for the surgeon to clearly and
honestly explain to the patient what can be delivered surgically. Realistic patient ex-
pectations are key to accepting a patient for surgery.
GOALS
Restoration of nasal function and form to near-normal condition is the goal of sec-
ondary rhinoplasty. Correction of functional problems is paramount. Septal recon-
struction, partial anterior/inferior turbinectomies, and internal nasal valve recon-
struction may be necessary to treat internal nasal obstructions or stenosis.32
Aesthetic goals may include straightening and/or augmenting the nasal dorsum,
augmenting the nasofrontal angle, lowering and/or correcting the supratip area, cor-
recting nasal tip asymmetry and alar collapse, and normalizing the alar-columellar
relationship. If the nasal structures are displaced, they are repositioned, augmented,
or replaced. If the tissues are overresected or underresected, the area to be altered
and the amount of augmentation or resection are determined. In an area of over-
resection the framework is rebuilt with autogenous cartilage.
DONOR MATERIALS
We recommend the use of only autogenous tissue in secondary rhino-
plasty. The use of alloplastic material is fraught with problems. The
risk of rejection, infection, or late extrusion is too high in this situation
to recommend its use. Donor areas readily provide excellent autoge-
nous material for a safe and permanent reconstruction.

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The choice of donor material varies with the location of the defect.33 Sheen sug-
gests the donor materials shown in the box below, which are listed in order of pref-
erence.
Dorsum
Septal cartilage
Ear cartilage
Rib bone or cartilage
Cranial bone
Dermis
Super cial temporal fascia
Donor Material Sources
Nasal Tip
Septal cartilage
Ear cartilage
Rib cartilage
Ethmoid or vomer
cartilage
Nasal Wall
Ethmoid or vomer
cartilage
Septal cartilage
Ear cartilage
Alar Rim
Ethmoid or vomer
cartilage
Composite ear grafts
Septal cartilage
Full-thickness alar
lobule graft
Vestibule
Composite ear grafts
Full-thickness alar
lobule graft
TIMING
Complete wound maturation after rhinoplasty usually takes 1 year. Minor revisions
requiring minimal dissection may be performed 6 months postoperatively, but as a
rule secondary rhinoplasty should not be undertaken for at least 1 year following
the previous procedure. In the case of the tertiary rhinoplasty patient with exces-
sive scarring, soft tissue changes, and/or persistent edema, induration, and dimin-
ished vascularity nal wound maturation may take up to 2 years and reoperative
procedures should not be performed until wound maturation has occurred.
OPERATIVE APPROACH:
ENDONASAL VERSUS EXTERNAL
We are all aware of the potential consequences of primary rhinoplasty that resur-
face in the secondary rhinoplasty patient. A magnitude of problems can occur. Dor-
sal support may be lost, nasal bones can be broken and moved medially following
bony arch removal, septal support may be compromised following septoplasty, soft
tissues may not drape aesthetically over the new skeleton, airways can be compro-
mised subsequent to mucosal trim or collapsed alar walls, and relationships of
anatomic structures may be abnormal. The choice as to whether to proceed en-
donasally or through a transcolumellar incision depends on the surgeon’s skill and
experience with each technique and the complexity and seriousness of the sec-

ondary deformity.34-43 Rohrich is an enthusiastic advocate of the external ap-
proach16; Sheen is equally committed to the endonasal approach.14,15
However, both agree that in a severely scarred, tethered nose with di-
minished vascularity, the endonasal approach is always indicated.
In the following pages, Rohrich and Sheen describe the potential advantages and
disadvantages of these two approaches.
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Chapter 21
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Advantages
Leaves no external scar
Limits dissection to areas needing modi cation
Permits creation of precise pocket so graft material ts exactly without need for xation
Allows percutaneous xation when large pockets are made
Promotes healing by maintaining vascular bridges
Disadvantages
Requires experience and great reliance on accurate preoperative diagnosis
Prohibits simultaneous visualization of surgical eld by teaching surgeon and students
Does not allow direct visualization of nasal anatomy
Makes dissection of alar cartilages dif cult, particularly in cases of malposition
Endonasal Approach
Advantages
Provides binocular visualization
Permits complete evaluation of deformities without distortion
Allows precise diagnosis and correction of deformities
Allows bimanual use of hands
Provides a wide range of reconstructive options with original tissues and cartilage grafts
Allows direct control of bleeding with electrocautery
Permits suture stabilization of grafts
Allows optimal control in repositioning/suturing lower lateral cartilages and grafts
Disadvantages
Leaves transcolumellar scar
Prolongs operative time
May result in slightly protracted nasal tip edema
May cause columellar incision separation and delayed wound healing (rare)
External Approach

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External Approach
Rod J. Rohrich
The 6 mm transcolumellar scar, which is minimal in most instances, is well worth
the increased visualization the open approach affords. The access provided by this
approach permits direct visualization of the deformity without distortion and allows
correction of the deformity by suture repositioning as opposed to graft stabilization.
With the external approach it is possible to execute techniques that in many cases
are less accurate with the endonasal approach.
My review of more than 800 cases in which an external approach via a stairstep
transcolumellar incision was performed revealed only one instance in which an in-
cision required revision because of a step-off that had resulted from a technical er-
ror during the initial closure at the lateral columellar rim. Furthermore, my expe-
rience with the external approach indicates that this technique does not prolong
operative time and does not increase tip edema any more than some endonasal car-
tilage delivery techniques. Delayed healing and wound separation have not been
problems in my experience with the external approach. However, it must be em-
phasized that the open approach is not merely an approach to explore and expose
the nose; rather it is another technique in our armamentarium through which the
operative principles of rhinoplasty are applied.
If one violates the principles of rhinoplasty by failure to follow proper techniques,
signi cant scarring, asymmetry, and even loss of nasal skin can result. The key to
performing proper meticulous surgical technique is a knowledge of nasal anatomy
and vasculature. Speci cally, when one transects the columellar arterial branches to
the nasal tip, the blood is now supplied from the lateral nasal vessels, which arise
2 mm above the alar groove and off the angular vessels bilaterally.44,45 One must
stay close to the perichondrium of the lower lateral cartilages as one proceeds me-
dial to lateral with both endonasal and external approaches to maintain the in-
tegrity of these vessels. If one is aggressive in undermining, dissects on the wrong
plane, and transects these vessels concomitant with alar base resection and tension
on closure of the nasal tip, disastrous consequences will result. These problems are
related to improper technique and inadequate knowledge of nasal anatomy and
can occur with both the external and endonasal approaches.
Furthermore, the improper placement of the incision either at the base or near the
tip will guarantee a poor result. I must stress that an accurate preoperative anatomic
diagnosis in the clinical aesthetic nasal analysis must be made before proceeding
with the approach described.

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OVERVIEW OF OPERATIVE TECHNIQUE
A logical, carefully executed surgical plan is essential for performing external rhino-
plasty.
Surgical Plan
1. Anesthesia
2. Incisions
3. Skin elevation (dissection of tip cartilages and dorsum)
4. Intraoperative diagnosis
5. Initial tip projection assessment/correction
6. Septal and/or turbinate surgery and septal graft harvest (if indicated)
7. Dorsal reduction/augmentation and lateral wall support (if indicated)
8. Final tip projection/re nement/positioning
9. External percutaneous osteotomies (if needed)
10. Final inspection
11. Wound closure
12. Alar base/nasal site correction with composite grafts (if indicated)
13. Splints and dressing
With the patient under general anesthesia, the external nose and septum are in-
jected with 8 ml of 1% lidocaine (Xylocaine) with 1:200,000 epinephrine, and the
nose is packed internally with 1⁄4-inch cotton pledgets soaked with oxymetazoline
hydrochloride (three pledgets per side).
Bilateral infracartilaginous incisions are made along the caudal edges of the lower
lateral cartilages. Medially the incision ends at the narrowest part of the columella
and is connected with a stairstep transcolumellar incision. The stairstep incision is
made in the midportion of the columella and allows for precise wound closure.
Transcolumellar
incision
Infracartilaginous
incision
Transcolumellar
incision
Infracartilaginous
incision

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Skin elevation is begun by dissecting the columellar skin off the caudal edges of the
medial crura superiorly to the middle crura. The dissection continues lateral to
medial along an intracartilaginous incision, hugging the lower lateral cartilages and
then exposing the domes at the nasal tip area.The dissection is continued along the
upper lateral cartilages and onto the bony dorsum up to the radix. Retraction of the
undermined area exposes the entire nasal framework. If tip projection must be al-
tered, the new tip con guration will determine the height at which the nal dor-
sal pro le line is set. Any changes in the dorsum must be performed in concert
with the nal tip projection.
If septal cartilage grafts are required or if the septum needs correction for obstruc-
tion, the septum is approached from the septal angle or through a separate trans x-
ion incision. The mucoperichondrial hemi aps are elevated, and the appropriate
septal modi cation and/or septal cartilage harvest is performed. One must leave at
least an 8 mm dorsal and caudal L strut.
L strut
Transfixion
approach
Anterior septal
(open) approach

If the caudal septum is deviated, the medial crura are separated to gain better ex-
posure and to correct the caudal septal deviation.46,47 The medial crural support is
reestablished once the medial crura are sutured back together after the septal cor-
rection is completed. If it is indicated, partial resection of hypertrophied anterior-
inferior turbinates is performed at this time.23 If donor material is needed (rib or
ear), these grafts are harvested after the nasal framework has been exposed and the
deformities and de ciencies have been con rmed.48
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Chapter 21
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Next the cartilaginous-bony dorsum is evaluated, and any needed dorsal reduc-
tion/augmentation is performed. The bony dorsum is usually reduced obliquely
with a sharp, down-biting rasp, and the height of the cartilaginous dorsum is low-
ered incrementally with a No. 15 Bard-Parker blade.The mucosa at the junction of
the septum and the lateral cartilages is freed from the cartilages to form submucosal
tunnels bilaterally so that the septum can be separated from the upper lateral carti-
lages without transecting the mucosa.
Window removed
to show dissection

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Maintaining the integrity of the mucosa helps to stabilize the septum. The intact
mucosa also forms a trough so that spreader grafts can be placed to move the up-
per lateral cartilages laterally in the event of the collapse of the upper lateral carti-
lages and/or the pinching of the internal nasal valves.49 The goal is to preserve or re-
constitute the internal nasal valves at an angle of 10 to 15 degrees.
Attention is then directed to nal tip cartilage modi cations.50,51 If increased tip
projection and/or re nement is desired, it is usually initiated with the placement of
an autogenous cartilage strut in a pocket extending from between the feet of the
medial crura, which uni es the lower lateral cartilages.The strut is placed and me-
dial crura are advanced on the strut until the desired tip projection is achieved.The
medial crura are secured to the strut with 5-0 PDS sutures.
Further increase in tip projection and refinement is obtained with interdomal
and/or transdomal sutures.These maneuvers will increase tip projection 2 to 3 mm.
If more tip projection is needed, the uni ed tip complex can be hinged off the an-
terior septal angle.
Submucosal tunnels

Spreader grafts
Nasal valve
Inferior
turbinate
Undermined
areas
10°-15°
valve angle
Interdomal sutures
Transdomal sutures

Columellar
strut
Once satisfactory tip projection has been attained, any needed dorsal augmentation
is performed.52 Our graft preference is septum, if available. In most instances dor-
sal onlay grafts are stabilized with 5-0 PDS sutures at the osteocartilaginous junc-
tion and near the anterior septal angle. Final positioning of the tip cartilages is ac-
complished with suture stabilization. If indicated, onlay tip grafts are placed and
secured.53 A Peck graft placed on the domal area increases tip projection, whereas
an infratip lobular graft described by Sheen is more versatile by increasing de ni-
tion and projection and giving the illusion of increased nasal length.53-55
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Chapter 21
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A combination tip/infratip graft provides further versatility by increasing tip pro-
jection, de nition, and re nement.55,56 If further dorsal augmentation is indicated,
a dorsal onlay graft is contoured and secured in place.52,57
The skin is redraped after nal inspection of the nasal framework. The infracarti-
laginous incisions are closed with interrupted 5-0 chromic catgut sutures, and the
transcolumellar incision is meticulously closed with interrupted 6-0 nylon sutures.
If septal surgery has been performed, bilateral septal splints are placed and sutured
in place with through-and-through 3-0 nylon sutures. Alar base or nostril site cor-
rection and/or composite graft placement are performed next. Nasal packing is
avoided if hemostasis is adequate. An external dressing of 1⁄2-inch Steri-Strips from
the radix to supratip area and a metal splint (Denver) to mold the lateral walls are
applied on the nose and worn for 1 week.
Onlay tip graft
Infratip lobular graft

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Endonasal Approach
Jack H. Sheen
Any surgical approach is technique dependent. With regard to secondary rhino-
plasty it is my belief that in comparison to the external approach, the endonasal ap-
proach, in general, is more forgiving, less traumatic, and less time consuming and
produces a better result because the dissection is limited to the area of correction.
The endonasal approach has served me well during my 40-year fascination with
secondary rhinoplasty. I have never believed that the exposure provided by the ex-
ternal approach was of suf cient bene t to offset its disadvantages. I simply do not
agree with the advocates of the open approach who argue that only a few excep-
tional surgeons can truly master the endonasal approach. With some effort and
practice, most plastic surgeons can become pro cient using the closed technique
with obvious bene t to the patient. The trend today is toward limiting incisions;
minimally invasive surgery has revolutionized the practice of general surgery and is
beginning to have a similar impact on aesthetic and reconstructive surgery. It makes
little sense to embrace a surgical approach that creates an external incision in an aes-
thetic procedure when it is possible to perform the same operation successfully
with no visible scars. Proponents of the open approach maintain that an invisible
scar that crosses the columella is the only residual effect. However, I have witnessed
complications far more serious—everything from severely notched columellar scars
to sloughs of the base of the nose.The novice is well advised to take heed of these
complications.
Other attributes of the external approach have been highly overrated, and the mer-
its of the endonasal approach have been too often overlooked.The endonasal tech-
nique offers limited dissection and preservation of vascularity, whereas all too often
the sequela of the open technique is decreased vascularity subsequent to wide skele-
tonization.The endonasal approach eliminates the need for graft xation by creat-
ing a pocket just large enough to accept the graft. If the pocket is oversized, a trans-
cutaneous suture is a simple remedy. In addition, a closed pocket supports tip grafts.
Stabilization can be achieved as simply endonasally as with the open technique be-
cause graft stabilization is more dependent on bed preparation than on suture x-
ation. Diagnosis of a problem does not depend on surgical exposure. Contour is an
external manifestation of the underlying skeleton. If alar cartilages are de cient,
the notch or collapse is visible externally. The same is true of the middle vault
where the position, size, and condition of the upper lateral cartilages and their re-
lationship to the caudal bony arch are visible through the skin as is the dorsal edge
of the septum.With very short nasal bones an inverted V is prominent;the position
of the fractured bony arch and the relationship of the two sides to each other are
readily assessed on frontal view of the nose. The condition and presence of septal
cartilage, need for turbinate reduction, and presence of internasal synechiae or
stenosis can be determined with a good headlight, speculum, and cotton swab.The

idea that anatomy is somehow distorted using the endonasal technique is also in-
accurate.The middle vault, bony arch, and root can be effectively visualized through
a single intracartilaginous incision using an Aufricht retractor and a headlight.
I nd it puzzling that proponents of the external approach cite the use of two hands
as a bene t of the open technique. It is hard to imagine operating open or closed
without the use of two hands. The nondominant hand, speci cally the index and
middle ngers, is essential for determining the position and depth of the dissecting
instrument.
The value of the open technique as a teaching tool is questionable. The anatomy
laboratory is a more appropriate setting for learning anatomy and technique than
the operating room.
OVERVIEW OF OPERATIVE TECHNIQUE
Careful planning is key to secondary rhinoplasty using the endonasal approach.
Surgical Plan
1. Anesthesia
2. Incisions
3. Pocket dissection and bed preparation (dorsal alignment)
4. Intranasal surgery (functional correction if necessary including treatment of
turbinate and bony problems)
5. Dorsal augmentation
6. Lateral wall support/augmentation or reduction
7. Tip exposure and preliminary positioning
8. Alar wedges, composite grafts, etc. with complete closure of all wounds
9. Final tip graft placement and closure
10. Packs, splints, and dressing
My anesthesiologist uses propofol (Diprivan) to induce general anesthesia and
maintains the level of anesthesia with de urane (Suprane). Neither a narcotic nor
an amnestic is used preoperatively. For local anesthesia I have found that 0.75%
bupivacaine hydrochloride (Marcaine) with 1:100,000 epinephrine produces a
longer lasting effect than lidocaine, decreasing the need for pain medication in the
immediate postoperative period. Although some believe there is little difference, I
believe the high concentration of epinephrine has a superior hemostatic effect. In
my experience the low concentration is associated with more intraoperative bleed-
ing. In my rst 15 years of practice, I used only local anesthetics because the effect
of early anesthetics (before the introduction of en urane) was an increase in oper-
ative bleeding. During that time I used lidocaine with 1:50,000 epinephrine and
the eld was de nitely less bloody than it is today using 1:100,000 epinephrine.
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The exact areas to be augmented or reduced are marked before the tissues are in-
jected.These marks are excellent guides when the pocket is being formed.
Accurate anatomic diagnosis is essential, since separate incisions must be made for
each deformity. For instance, if the dorsum is de cient and there is a collapsed ala
on the left side as well, the opening incision will begin at the left nostril rim, pen-
etrate the lateral wall to the dorsum, and then extend to the root.This one incision
not only elevates a good pocket for augmenting the de cient dorsum but also al-
lows for the placement of a support graft along the rim.
The guiding principle is to limit the dissection.
Incisions and dissections are customized. If alar wedges are planned, the dorsal in-
cision is made approximately 1.5 cm cephalad to the rim. An alar rim pocket is
then formed through the opened alar lobule. A narrow pocket can be fashioned to
support a collapsed ala or a broad pocket may be created to elevate a deepened alar
groove.The pocket thus can be designed to precisely t the deformity.The support
graft may be inserted through the open alar incision with confidence since the
pocket is closed. If lateral wall augmentation on the opposite side is needed, a very
short (1 to 1.5 cm) incision on the opposite side at the intercartilaginous area is
made, and dissection is limited to the area to be augmented.This allows for precise
placement of a suitable graft.
The graft material—whether septal cartilage and bone, ear cartilage, cranial bone,
or rib—is usually harvested after the initial incisions and dissections have been
made. A separate setup is used for each donor site, and instruments and gloves are
changed after the material has been obtained.The choice of graft material is made
before surgery. Occasionally the harvest of poor-quality material from a primary site
will force the use of a secondary donor area.
I perform tip graft placement last because the tip is the nasal structure that is the
most sensitive to manipulation, and by establishing the dorsal height rst, I can de-
termine tip position and contour in relation to the new position of the dorsum.54,55
Although I may prepare the tip graft pocket before complete closure of all the
wounds, the tip graft is placed last to avoid graft displacement.The one exception
to this rule is alar wedges. Nostril size and shape are dependent on the anterior
position of the tip lobule, and so a preliminary tip graft is placed to better judge the
size and placement of the alar resection.
To prepare for a tip graft, the tip lobule is approached through an incision along the
border of the middle crus beginning at the columellar-lobular junction and ex-
tending approximately 1 cm anteriorly. It is here the closed pocket can be most
useful in obtaining anterior projection.With a closed pocket the graft is xed at the
posterior limit of the pocket and the tissue of the tip has to be forced anteriorly. Af-
ter dissection of the tip graft pocket is completed, tip grafts are inserted, extending

the tip lobule into its anterior position.The quality, size, and character of the graft
material determines the contour and position of the tip lobule.The alar wedges are
completed, and then the de nitive tip grafts are placed. Surface de nition is ob-
tained as the grafts are inserted.The grafts are placed only after all of the incisions
have been closed and no further manipulation is anticipated. Tip grafts must al-
ways be rinsed in saline solution before dipping into an antibiotic solution (lin-
comycin hydrochloride [Lincocin]), and they must not be touched with the gloved
hand before insertion.The most common problem after tip grafting is infection, a
complication that is completely related to technique and is thus preventable.
After all of the incisions have been closed, intranasal packs are placed over a No. 14
catheter if septal surgery has been performed.The use of splints sutured across the
septal partition is appealing and feasible if the dissection is limited and the mu-
coperichondrial flaps are intact on both sides. The nostrils limit the size of the
splints. In my experience most septoplasties involve some bony resection and ex-
tend quite far posteriorly, which precludes the usual intranasal splint. For that rea-
son I believe that total packing will guard against postoperative bleeding. I leave the
packing in place for 1 week.
The rst strip of 1⁄2-inch paper tape is placed on the nose with a notch that ts over
the lobule and onto the lateral nasal walls to support the lobule. The second strip
is taped just cephalad to the tip and perpendicular to the rst piece to secure the
grafts. Subsequent strips of tape extend to the root. Final adjustments are made
during taping to ensure proper position of the dorsal graft. Fast-setting plaster (two
layers) is placed over the dorsum, folding the distal edge over 4 to 8 mm to make
the distal part more substantial.This plaster is molded into the tape for good xa-
tion, and two more strips of tape x its position and complete the dressing. A small
2
2-inch gauze pad is then placed under the nose and held in position with a
strip of 1⁄2-inch paper tape (mustache dressing).
Special Considerations
THE COCAINE NOSE
Cocaine abuse by snorting the drug into the nostril causes intranasal septal necro-
sis with de ciency in nasal lining in the presence of an intact external cover. The
gradual destruction of the nasal lining with subsequent exposure of nasal septum
and bones causes chondritis and eventually osteomyelitis.58 The end result is nasal
collapse caused by severe loss of cartilage and retraction. Both lining and support are
compromised, and restoration usually entails more than local nasal aps.The nd-
ings on physical examination are visible perforation of various sizes, in ammation,
evidence of granuloma, and necrosis. Depending on the size of defect, symptoms
include epistaxis, obstruction, discharge, crusting, dryness, pain, and whistling.
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Traditionally, for smaller defects (less than 1 cm) of the nasal lining with no frame-
work collapse, local aps are generally successful and include mucosal aps from ad-
joining nasal vestibule or even nasal septum such as septal mucoperichondrial ap.
For intermediate defects of 1 to 2 cm, advanced local aps may be necessary and in-
clude septal door ap, bipedicled mucosal advancement ap, buccal mucosal ap,
nasolabial ap, and turnover nasal or cheek skin aps.59 Skin grafts and buccal mu-
cosal aps are often inadequate since they leave the nose dry and crusted, decreas-
ing the chance for optimal healing.
When local aps have failed or signi cant lining destruction has led to necrosis, in-
fection and tissue contraction from inadequate blood supply, staged reconstruction
offers the greatest bene t in reconstruction. For large septal defects with collapse of
nasal framework, the staged reconstruction improves the chances of healing and
provides the most effective treatment in the cocaine nose. Usually in the rst stage,
the nasal lining and airway reconstruction is provided by vascularized aps such as
transferring bilateral tunneled nasolabial ap. Once the new lining has healed and
softened, dorsal onlay support is provided by costal cartilage grafting in the second
stage.The multistage process maintains and improves structural integrity of the re-
construction.
Occasionally, recurrent cocaine abuse leads to massive destruction of nasal frame-
work, loss of a large amount of nasal lining, and a signi cant infection resistant to
healing. Such defects require careful and adequate surgical debridement, infection
control, and multistage reconstruction. Pedicled median forehead island ap can
restore a large amount of nasal lining by turning over and tunneling subcutaneously
to the nasal vestibule, after which nasal framework can be reconstructed with car-
tilage or bone grafts with coverage from alternate skin aps.60
For precise and de nite control of complete lining reconstruction, prelaminated
free aps such as radial forearm fascial ap and microsurgical reconstruction offers
a three-dimensional integration of the lining components with intrinsic skeletal
support. The prelaminated free aps reconstruct the complex three-dimensional
elements of the vestibule, oor, and columella by joining a variety of combinations
of bone, cartilage, skin, and mucosa at a remote site away from the severely injured
cocaine nose. The goal of this complex and sophisticated multistaged reconstruc-
tion is to minimize local surgical injury and re ne the reconstruction suited for
the patient. Such staged reconstruction permits the use of combination aps that
may include free and pedicled aps. Rarely, large centrofacial defects are best recon-
structed using a carefully thought out multistage process involving prefabrication at
distal sites, vascularized free and/or pedicled aps for lining or coverage, use of costal
cartilage or bone grafts for framework, and further surgical modi cation/debulking
to achieve an aesthetic result. The patient must be properly selected, cooperative,
and emotionally prepared before engaging in a multistage reconstruction requiring
various aps.

1 cm
Local aps include:
Septal door ap, nasolabial
ap, bipedicled mucosal
advancement ap, buccal
mucosal ap
Prefabricated aps :
Radial forearm ap
RECURRENT SEPTAL PERFORATION
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When evaluating patients with recurrent septal perforations, a thorough history
and physical examination should be obtained and important factors that contribute
to perforations should be ruled out, such as evidence of malignant cancer, benign
tumor growth, illicit or recurrent use of over-the-counter drugs, recurrent trauma,
recalcitrant and untreated infection, and contributory systemic diseases. If infec-
tion is present, culture-directed treatment must be geared toward providing an op-
timal healing environment for future repairs. Suspicious mucosal lesions should be
sent for biopsy and pathologic analysis. Drugs contributing to perforation should be
stopped and the repair delayed for adequate healing.
For small, uncomplicated septal perforation, local mucoperichondrial or mucoperi-
osteal rotation aps with or without cartilage interposition grafts have a high rate
of success.61 Perforations generally considered small are less than 1 cm and require
good mucosal coverage with adequate blood supply. If a small perforation is asymp-
tomatic and there is a lack of bleeding and irritation, then the perforation should
be left alone. Location of perforation is also important and must be noted. The
more anterior a perforation, the more the patient is symptomatic, and more likely
the need for a surgical repair.The reason that primary local aps fail is inadequate
lining and cartilaginous support in an unsuitable environment for wound healing.
Alternative measurements are necessary for closure of nasal septal perforation from
previous failed repairs.
4 cm
or extremely large
perforation
Multistaged
reconstruction
Symptomatic/bleeding

50% of nasal septum
FAMM ap
(single stage)
No intervention
Asymptomatic
with no bleeding
Local septal aps
Free /pedicled aps :
Radial forearm ap,
medial forehead ap
Septal perforation
Mucoperichondrial
transposition aps
2 cm
1-2 cm
or recurrent
perforation
Two-s taged:
Tissue expansion,
bilateral tunneled
nasolabial ap
Interpos ition allograft:
AlloDerm or ENDURAGen

Local ap
Algorithm for the management of nasal septal perforation

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For smaller intermediate-size defects (1 to 2 cm) or symptomatic recurrent perfo-
rations, alternate local aps such as bilateral intranasal mucosal advancement aps or
“cross-stealing” turn-in aps taken from the opposite side of septum can be used.62,64,78
Other local aps are available, including the septal door ap, buccal mucosal ap,
and nasolabial flap. To increase successful healing, interposition of a connective
tissue graft helps to prevent further reperforation of the septal aps during healing.
Successes with connective tissue autografts have included temporalis fascia flap,
mastoid periosteum, and pericranial aps, all which serve as a template for mucosal
migration.These interpositional autografts can be placed even with compromise of
the overlying healing mucosal aps. Allografts such as acellular human cadaveric
grafts (AlloDerm; LifeCell Corp., Branchburg, NJ), porcine dermal collagen grafts
(ENDURAGen; Porex Surgical Corp., Newnan, GA), and porcine small intestine
submucosal interposition grafts have also shown success, and these materials avoid
the morbidity associated with harvesting autografts.65,66
Larger recurrent perforations (greater than 2 cm) are best repaired in a two-stage
process similar to the staged repair in a patient with a cocaine nose. Perforations
greater than 2 cm or more than 50% of the septum must have exposed cartilage
adequately debrided. Tissue expansion of the nasal oor is feasible in perforations
not caused by cocaine, an option available for a staged reconstruction. In this two-
stage procedure, a small soft tissue expander is inserted into a submucoperiosteal
pocket on the nasal oor to immediately advance posteriorly based expanded mu-
cosal aps. Single-stage reconstruction of large recurrent perforation can also be
successfully achieved using a facial artery musculomucosal (FAMM) ap and pro-
vides a well-vascularized graft.67 If perforations are even larger (greater than 4 cm)
with lack of support and nasal framework collapse, then free ap reconstruction in
a multistage procedure will provide the best chance for a controlled nal aesthetic
and functional result. Devastating large defects are approached through a multi-
stage process similar to defects caused by a cocaine nose, requiring careful plan-
ning, execution, and integration of individual components of nasal lining, support,
and coverage.68-70
NASAL SOFT TISSUE ENVELOPE
The thickness and texture of the nasal skin ap directly in uences the nal result
after a secondary rhinoplasty.Techniques of nasal framework reconstruction should
be modi ed to best predict the effect of skin on the skeletal support. A signi cant
adherent scarring of the nasal skin ap to the underlying cartilage structure is of-
ten encountered during an external approach.The dissection should always attempt
to preserve the perichondrium if feasible and not to thin the subcutaneous tissue
from the elevated nasal skin ap. Normally, nasal skin is thinner and more mobile
in the cephalic zone and thicker and glandular in the nasal tip zone. The skin is
thinnest over the osteocartilaginous junction and is thickest over the nasion and
supratip dorsum. These normal anatomic differences in skin thickness may be ab-
sent in a secondary rhinoplasty.

THE THICK-SKINNED NOSE
Thick nasal skin, especially in the tip region, is abundant with sebaceous glands, rel-
atively inelastic with increased subcutaneous fibrofatty tissue present above the
lower lateral cartilages, and contains “memory” of the soft-tissue envelope.The -
brofatty layer thickness can range from 2 to 4 mm in thickness. Persons of non-
Caucasian African descent typically have uniformly thick nasal skin.71 In a second-
ary rhinoplasty, often the entire nasal skin flap is scarred and changes to the
thickness pose a challenge in obtaining a uniform contour of the skin. A substan-
tial alteration to the skin thickness is difficult. It is essential to remember that
“descarring” is more important than “defatting” an already scarred nasal ap. Excis-
ing scar tissue must be judiciously performed and enough to obtain a difference
with adequate release.While removing a small amount of interdomal subcutaneous
fat can add to tip de nition, extensive defatting should be avoided to prevent vas-
cular compromise even to the thick nasal ap.
The maximum visual bene t in thick, sebaceous skin can be achieved by augmen-
tation of the structural support, which will automatically stretch the skin. In revi-
sion rhinoplasty, tip scarring and asymmetry or existing alar cartilage structure can
prohibit natural skin redraping. Augmenting the thick secondary nose requires a
greater dimensional power from cartilaginous support to counteract the thick and
scarred soft tissue envelope. Tip de nition and re nement requires a columellar
strut in addition to using medial crural, interdomal, and transdomal sutures. Larger
and thicker cartilage grafts from septum or rib are often needed for further infratip
lobular de nition.The grafts may need to be stacked for an appropriate soft tissue
response to the thick skin. A shield graft serves as a cornerstone in establishing -
nal tip de nition.
The thicker nasal skin also will not drape over the reconstructed osteocartilaginous
framework easily and will be edematous for a longer period of time. Patients must
be warned that protracted edema may last longer than 12 months. Methods in at-
tempting to reduce the prolonged edema include meticulous intraoperative hemo-
stasis and prolonged postoperative splinting as well as the use of perioperative
steroids. Prolonged postoperative use of silicone gel sheeting applied to the nose
further accelerates resolution of edema.
THE THIN-SKINNED NOSE
Thin nasal skin ap is common to secondary rhinoplasty because of the inherent
loss of subcutaneous tissue over a period of time. Unlike thick-skinned patients,
minuscule deformities are more likely to show when the thin skin redrapes over the
osteocartilaginous framework. The thin skin drapes almost too well and after the
edema subsides, shows even small deformities underneath the skin. Although most
sebaceous skin is thick, occasionally a patient will have sebaceous, oily skin that is
also thin. Hence thickness of the skin is more important than its sebaceous charac-
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ter in predicting the way it will drape. Caution must be exercised when degloving
the columellar skin flap, since a lack of fibrofatty layer in thin-skinned patients
makes the dissection dif cult because of adherence to the caudal edges of the me-
dial crura.Vascular compromise to the already thin and scarred columellar and tip
skin can result in skin necrosis and cartilage exposure. Defatting of the intervening
soft tissue in thin nasal skin ap should be avoided at all costs.
In contrast to grafting in a thick-skinned patient, augmentation of the dorsum or
nasal tip projection and cartilage re nement in a thin-skinned patient should take
into account that small framework changes will easily re ect through the draped
skin. Cartilage tip grafts must have sharp edges beveled or morselized to decrease
show. If draping causes skin blanching from skeletal framework as a result of tension,
then consider altering the framework and distribute the tension.Tip grafts should
only be used when absolutely necessary since they may become visible through
the thin nasal skin over the long term. Atrophy of the nasal tip skin also results over
the years and may require further tip modi cation at a later date. If osteotomies
are required, then they must be fashioned low-to-low to avoid palpability of any
step-offs. Contour deformities of the underlying nasal framework will also be vis-
ible through thin skin and should be covered by morselized cartilage, AlloDerm or
ENDURAgen, or temporalis fascia.71 Nasal splinting and taping should also be care-
fully performed to prevent additional pressure on the healing skin.
Speci c Problems
DORSAL DEFORMITIES
Most dorsal problems following rhinoplasty result from errors in judgment or tech-
nique. Overresection of the dorsum is the most common pitfall.When the straight
Joseph saw was commonly used for dorsal reduction, the incidence of overresection
was high.The quest for a safer, more controlled technique for reducing the dorsal
hump has led to use of the Foman rasp and direct scalpel reduction of the middle
vault. As more surgeons began using this combination, the incidence of the overre-
duction has dramatically decreased.
Despite this progress, overreduction of the dorsum continues to be a problem char-
acterizing secondary rhinoplasty patients. Most likely this lingering problem stems
from a failure to appreciate the importance of radix height during preoperative
planning. If a low radix is used as a point of reference in lowering the dorsal height,
the dorsum is frequently overreduced. A low root predisposes to an exaggerated na-
sofacial angle and a marked disproportion of root to base and is associated with a
high potential for supratip deformity. For these reasons augmentation/reduction
for a balanced nasal contour is essential in planning. Balance, tissue drape, skeletal
structure, and character of the skin are all important aspects of the preoperative
evaluation to provide good nasal balance and function.