Reoperative Aesthetic & Reconstructive Plastic Surgery

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The oblique views re ect the different positions of the middle vault:the left side is
more concave than the right.When the nose is viewed from the left, the right lat-
eral wall comes into view. Since it is more prominent, the contour is more convex,
giving the appearance of a dorsal hump. On the right oblique view, the left middle
vault seems more concave and the contour appears straighter and more acceptable.
The basal view reveals a atness across the tip lobule.The angle of diversion is ap-
propriate but the length of the middle crura is short, producing a lobule that is dis-
proportionate to the size of the nostrils.
Surgical Plan
1. Single left intercartilaginous incision with dissection across the midline,
forming long rectangular pocket to root with minimal lateral dissection
2. Hemitrans xion incision with 2 mm reduction of caudal septum
3. Elliptical (1.3 by 0.5 cm) mucosal trim of posterior membranous septum
4. Reduction of bony arch at junction with frontal bone
5. Trimming of anterior septum at caudal half
6. Creation of spreader graft pockets
7. Septoplasty
8. Placement of spreader grafts
9. Reroo ng with bruised cartilage graft
10. Placement of tip graft consisting of multiple bruised septal cartilage grafts

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Bone is removed from bony arch at its root
Caudal half of anterior septum is trimmed
Specimen from septoplasty
Dorsal graft
Lateral wall graft

628
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Postoperatively a straight line extends from root to tip, with the tip being the high-
est projecting part. The nostril-lobular disproportion has been corrected by lobu-
lar augmentation.The tip has a softly rounded natural contour.

The nose now appears to occupy a more midline position. The spreader graft has
not only broadened the middle third of the nose but also secondarily opened the
internal valves. By clearing out the obstructing septal parts and removing the lat-
erally placed vomer and ethmoid, I was able to completely open the airways. The
lateral lines ow in symmetrical divergent lines from root to base. Even though the
nose is broader, it has a more natural look. The tip is well differentiated from the
dorsum and is an identi able unit.
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The larger spreader graft on the concave (left) side makes the nose appear to be lo-
cated more in the midline. The tip lobule is less at now that the interdomal area
has been lled with multiple tip grafts.

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The tip shows similar projection on both left and right oblique views. It has more
anterior projection and is distinct from the dorsal line. These views con rm the
symmetrical position of the lateral walls of the middle vault.The columella has an
improved relationship to the nostril rims.

Moderate Dorsal Loss (Sheen Case)
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This woman has an unattractive pro le with an out-of-balance nose. The root is
low, and a high supratip masks a relatively large base that is made visually more
prominent by virtue of the overreduced root.The columellar-labial angle and junc-
tion are good as is the relationship of the columella to the alar rims.
There continues to be disproportion: the root is wide, the middle third is narrow,
and the base is wide.There is telangiectasia over the middle and upper thirds of the
dorsum—the result of subdermal rather than subperiosteal elevation of tissues.

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The oblique views are different, with the left oblique view demonstrating a much
greater supratip deformity than the right view. The right oblique view shows a
near con uent contour, but the dorsum is much too low.
Having had two prior rhinoplasties, this woman continued to be dissatis ed with
nasal contour and function. She brought two photographs of models with high,
strong dorsal lines that she wanted to have replicated.To achieve her aesthetic goal,
I chose septal cartilage. However, when it was harvested, it was of poor quality and
contained too much bone. The cranium was selected as a secondary donor site to
provide the necessary graft material. The extra cartilage was then used as crushed
lateral wall grafts.This serendipitous use of lateral grafts has proved to be so success-
ful I now rarely place cranial bone grafts without some augmentation of the mid-
dle vault.
Surgical Plan
1. Single left intercartilaginous incision with skeletonization past the midline to
right side and then creation of rectangular pocket to root
2. Brisk rasping of bony arch with Foman rasp
3. Septoplasty
4. Harvesting of cranial bone
5. Dorsal augmentation using cranial bone
6. Placement of lateral wall grafts consisting of bruised septal cartilage
7. Placement of tip grafts consisting of multiple crushed cartilages

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Cranial bone harvesting
Bruised cartilage graft at root
Bruised lateral cartilage grafts
Total harvest from septoplasty yielded mostly
unusable bone and badly distorted cartilage

634
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Four years postoperatively, the left and right lateral views of this patient demonstrate
a close similarity in nasal contour. The dorsum is strong and straight, and the tip
projects above the dorsum.The result is a natural, nonsurgical appearance.

A symmetrical appearance is seen on both oblique views. The edge of the bone
graft is visible but not distracting. The tip is softly contoured, and the lobule is
slightly enlarged.
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The nasal contour is con uent and has symmetrical lines extending from the supe-
rior orbital rims and diverging to a well-de ned, symmetrical tip.The telangiecta-
sia is less obvious. A good relationship between the columella and alar rims has
been achieved.When I rst began using cranial bone grafts, a common and unwel-
come late problem in some of my patients was a visible graft over the middle vault.
The incidence of this deformity was virtually eliminated when I started using lat-
eral wall grafts.
Traumatic Nasal Deformity (Sheen Case)
This patient had undergone three previous nasal surgeries to correct a nasal defect
that resulted from trauma. She had suffered an extensive midface LeFort III fracture,
enucleation of the left eye, and blindness in the right eye. She needed an almost rec-
tangular augmentation, that is, as much height at the root as at the caudal end. A
suitable graft would be either a pyramidal piece of ninth rib or a rolled piece of ear
cartilage.
The traumatized tissues are of poor quality. Scars, dermal thinning, and telangiec-
tasia warn of problems following wide dissection. The patient is not a candidate
for an open technique. Furthermore, it is doubtful that a transcolumellar incision
would provide improved access and it would de nitely be more traumatic.The al-
ready compromised tissues would be placed in greater jeopardy.

There is a marked de cit over the dorsum with a low middle third. It is obvious
that a relatively large dorsal graft is needed.The root is at and high, and the tip is
rounded and without de nition.There is striking evidence of tissue compromise.
There is a disharmony and imbalance of the relationship of the root to the base.The
right lateral wall is concave, whereas the left is slightly convex, giving the nose a
twisted appearance. The base is asymmetrical, and the columella is low relative to
the alar rims.The right nostril is considerably higher than the left.
Surgical Plan
1. Removal of ellipse from caudal membranous septum
2. Left intracartilaginous incision that stops short of midline
3. Wide dissection over dorsum to right side and then creation of rectangu-
lar pocket to root
4. Rasping of bony dorsum—especially bony arch at root
5. Single, short intercartilaginous incision on right side with dissection to
right nasal bone
6. Septoplasty
7. Harvest of one concha
8. Preparation of dorsal graft from ear cartilage
9. Placement of dorsal graft
10. Augmentation of right lateral wall at nasal bone—soft tissue reduction over
right upper cartilaginous vault
11. Augmentation of left lateral wall from nasal bone to left middle vault
12. Placement of tip grafts
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Lateral wall cartilage graft on right side
Primary tip graft
Lateral wall grafts with placement of ethmoid medial to cartilage
Dorsal graft of rolled ear cartilage lled with scraps of cartilage and bone
Total septoplasty harvest

The nasofrontal notch was moved cephalad from about the midpupillary line to the
superior palpebral crease, which has given the nose added length visually.The result
is shown 3 years postoperatively.The nose is in a more youthful and feminine po-
sition, with the base rotated more cephalad.The columellar-labial junction has been
attened by an excessive resection of membranous septum. The tip has a much
more aesthetic contour, and the well-de ned tip is in line with the new dorsum.
639
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The lateral walls are now more symmetrical and have considerably more width
than preoperatively.To make the nose more symmetrical, the trade-off was that the
additional width was necessary.The nostrils are in a much improved position rela-
tive to the columella and are more symmetrical.
VAULT DEFORMITIES
Narrowing or collapse of the lateral walls subsequent to narrowing of the bony
vault or excessive resection of the dorsal roof is a problem frequently encountered
in secondary rhinoplasty patients.63 A visible deformity between the upper and
lower vaults is produced, manifesting itself as an inverted V. Furthermore, nasal valve
function is compromised because the size of the airway is decreased as the internal
nasal valve is compressed.72,73

The middle vault is composed of two triangular cartilages that attach to the lateral
edges of the septal T. The contour of the middle vault is con uent with the bony
arch and joins with the cephalic edges of the lower lateral cartilages to form the
movable side of the triangular internal valve.The remaining walls of this triangle—
that is, the septum and the oor of the nose—are rigid.The shorter the nasal bone,
the more dependent the lateral walls are on the width of the middle vault roof (the
septal T) for support.The function of the internal valve also depends on the char-
acter and substance of the soft tissues and cartilage that make up the walls of the
middle vault.73
When a dorsal hump is removed, the top of the septal T is resected, causing the lat-
eral walls to fall medially against the septum. This is an expected consequence of
hump removal and especially occurs in primary rhinoplasty patients with short
nasal bones. If the nasal bones are long enough to adequately support a short mid-
dle vault, the visible or functional defect is minimal. However, patients with short
nasal bones who have soft middle vault tissues have a high incidence of airway dys-
function as a result of the collapse of the internal valve on inspiration. Character-
istically these patients complain of airway obstruction. Often in this situation the
surgeon places a speculum in the nostril and widely de ects the internal valve but
nds no evidence of a mechanical obstruction. Once the speculum is removed, the
walls fall medially and the increase in negative pressure with inspiration causes in-
ternal valve collapse once more.73
The treatment of both acquired and congenital internal valve collapse is the place-
ment of spreader grafts to distract the walls of the middle vault laterally.49,74 A small
strip of cartilage is placed submucosally at the anterior border of the septum,
thereby creating the same laterally distracting effect as that of the septal T. Place-
ment of spreader grafts improves con uence of the lateral wall with the bony arch.
The physical relationship of the moveable leaf of the internal valve (lateral wall)
against the immovable septal partition is also improved.
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PATIENT EXAMPLES
Inverted V Deformity (Sheen Case)
After a conservative rhinoplasty procedure this patient was pleased with the general
contour of the nose but was unable to breathe comfortably. She also said the nose
had the appearance of being “in two pieces” when viewed directly.
A deep inverted V deformity that separates the middle vault from the caudal edge
of the bony arch is evident.The nasal bones are short, exaggerating the inverted V
deformity and coincidentally causing greater internal valve dysfunction. The tip
cartilages are visible as unnatural projections.The right nostril arches slightly higher
than the left.The columella is low relative to the alar rims.The dorsal height is ex-
cellent, but the tip projects abruptly above the dorsal line. The nasolabial angle of
just over 90 degrees is normal.

The symmetrical oblique views show nice projection of the tip above the dorsal
line, but the sharp cut off at the cephalic edge gives a surgical look.The patient be-
lieved the tip looked unnatural but could not say why. She asked for a softer, less
well-de ned tip.
Surgical Plan
1. Intercartilaginous incision on left side only
2. Limited dissection to root
3. Incision carried around angle of septum on one side only
4. Pockets developed for spreader grafts
5. Septoplasty
6. Placement of spreader grafts
7. Placement of crushed cartilage dorsal onlay graft
8. Small tip lobule augmentation using crushed cartilage
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644
PART III
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Postoperatively there has been very little change in the contour of the nose on the
lateral view. Most notably, the dorsal line has been raised slightly to eliminate the
slight retroussé appearance she objected to. I believed a dorsal graft was important
to completely eliminate the inverted V deformity. Had she wanted to preserve the
retroussé, I would have extended the tip slightly by using a tip graft. On the frontal
view there is a dramatic change in the “two-piece” preoperative nose. Spreader
grafts alone might have been suf cient to eliminate this look, but a strip of bruised
cartilage is the best and most certain way of ensuring a nonsurgical-appearing
frontal view.

The postoperative oblique views are symmetrical, and there is no discontinuity as
a consequence of graft placement.This view is a critical test of proper graft size and
placement. A spreader graft that is too large or too anterior will be visible as a
hump on the side where it is placed.
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646
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Inverted V Deformity (Rohrich Case)
This 55-year-old woman had undergone two previous septal rhinoplasties. She pre-
sented with nasal airway obstruction, inverted V deformity, middle vault collapse,
and irregularities of the nasal dorsum. She complained of nasal airway obstruction,
nasal dorsal irregularities, and asymmetrical nasal tip.
On examination of the frontal view the patient has thin nasal skin with good facial
proportions.The dorsal nasal lines are interrupted at the middle vault, which reveals
an indentation with an inverted V deformity compatible with middle vault col-
lapse (left side greater than right). Nasal tip–de ning points are asymmetrical, and
the alae are retracted (right greater than left), which is compatible with a pinched
nasal tip.
On lateral view the radix is in good position. She has some dorsal irregularities in
the area of the cartilaginous dorsum with slight overresection.

The oblique views con rm alar retraction on the right and dorsal irregularities.
The nasolabial angle is 95 degrees; tip projection is normal.
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The basal view con rms the asymmetry of the nasal tip, with disruption of the alar-
columellar relationship and a retracted right ala.
Intranasal examination revealed normal mucosa with no evidence of septal perfo-
ration. Probing with a cotton applicator uncovered a reasonable amount of septal
cartilage but a narrowed internal nasal vault. Inferior turbinate hypertrophy was
greater on the right than the left.The posterior septum was deviated.

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Operative Goals
1. Correct dorsal cartilaginous irregularities
2. Correct inverted V deformity and internal nasal valve collapse
3. Correct right alar retraction
Surgical Plan
1. External approach with stairstep transcolumellar incision with infracartilagi-
nous extensions to expose nasal framework
2. Left hemitransfixion incision to expose and harvest septal cartilage grafts
with preservation of 1.5 cm L strut of septum
3. Separation of scarred upper lateral cartilages from the upper lateral cartilages
via superior submucosal tunnels and suture fixation of bilateral internal
spreader grafts
4. Partial anterior/inferior turbinate resection (right greater than left)
5. Reestablishment of angle of divergence and tip dome symmetry using me-
dial crural interdomal (5-0 PDS) sutures
6. Incremental dorsal rasping
7. Placement of nonanatomic septal cartilage graft in right alar rim to correct
alar notching (graft is placed within the vestibular lining below infracartilagi-
nous incision)
Bilateral internal spreader grafts
Turbinate resection

Intraoperative Findings
1. Dorsal cartilaginous irregularities
2. Scarred middle vault
3. Remnant (3 mm) of right lower lateral cartilages (lateral crura) with rim
strip disruption
4. Adequate septal cartilage with no septal perforation
649
Chapter 21
Secondary Rhinoplasty
Dorsal
reduction
(1 mm)
Remnant
(5 mm) of
lower lateral
cartilage
Remnant
(3 mm) of
lower lateral
cartilage
Alar rim cartilage graft
Alar rim
cartilage
graft
Dorsum
reduced
1 mm
Dorsum
reduced
1 mm
Previously
resected
septum

650
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
At 2 years postoperatively the frontal view reveals improved nasodorsal lines, with
correction of the patient’s inverted V deformity and improvement of the right alar-
columellar relationship.
Comparison of preoperative and postoperative lateral views con rms an improved
pro le without irregularities and with correction of the right alar notching.

The oblique views con rm the improvements noted on the frontal and lateral nasal
views.
651
Chapter 21
Secondary Rhinoplasty
The basal view reveals an improved alar-columellar balance with tip re nement
and correction of the right alar notching.

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SUPRATIP DEFORMITIES
The terms supratip deformity, ram’s head deformity, parrot’s beak, and polly beak deformity
are used synonymously to describe a postsurgical fullness that occurs just above the
tip following rhinoplasty.75 This fullness is not a transient postsurgical edema but a
persistent, unattractive fullness just cephalad to the tip that distorts the dorsal line
and obscures tip delicacy. Frequently the patient cannot breathe adequately through
the nose and cannot comfortably wear eyeglasses as they tend to slip off the nasal
bridge.This problem is the most commonly seen deformity after classic reduction
rhinoplasty and is primarily caused by overresection of skeletal structures, tissue
thinning, and to a lesser extent underresection of the distal septum and upper lat-
eral cartilages. Identifying the cause is critical to the management of this defor-
mity. In treating supratip deformity, the surgeon must correctly identify the cause
of the problem. Occasionally a de cient or poorly projecting tip can be the cause.
Occasionally diagnosis is made by palpation. If the tissues are easily compressed to
the dorsal edge of the septum, structural de ciency is evident. Obviously, further re-
duction of the skeleton and/or scar is contraindicated. If the supratip area cannot be
fully depressed, it does not necessarily mean that it is supported by a cartilaginous
dorsum;scar tissue may have lled in this void. Subdermal dissection with resection
of the supratip scars should not be performed, especially after multiple surgeries.
This approach can cause irregular thinning, adhesions, telangiectasia, vertical
grooves, furrows, and possible skin loss. In a small percentage of patients, removal of
the redundant anterior septum is straightforward. However, further resection of the
anterior septum in patients with a low middle vault may aggravate the deformity.
The best approach therefore is to reduce the area that is excessive and augment
where de cient. Following a classic reduction rhinoplasty the nasal framework may
be overreduced with a low dorsum, blunt tip lobule, and excessively wide nasolabial
angle.76 In most of these cases correction of the tissue de ciency is accomplished by
the placement of dorsal grafts and tip grafts to re ne and enhance the tip.53,56 No
tissue is resected.
PATIENT EXAMPLES
Excessive Skin and Overreduced Skeletal Framework (Sheen Case)
When I rst saw this young woman of Middle Eastern origin in consultation, my
reaction was that the degree of soft tissue injury and size of the base would even-
tually mandate excision of soft tissue. However, she refused to accept any external
scars because of her career as a cabaret singer.

A disproportional relationship of root to base was evident; the cephalic half of the
nose was inappropriately low for the large, projecting base and supratip.The lateral
views alone indicate the diagnosis of excessive skeletal reduction. It was unlikely
that this supratip deformity would shrink enough to drape aesthetically over the
present dorsal line. If this patient were certain about having the nose made smaller
and would accept a midline scar, this con guration would be suitable for a direct
midline excision.
653
Chapter 21
Secondary Rhinoplasty
On frontal view the lack of suf cient dorsal height produced a midface atness
that is characteristic of Asians but inappropriate for this patient. The alar grooves
and middle vault were collapsed medially. Airway problems consequent to collapsed
internal valves are a common associated problem.The alar grooves crossed through
the alar rims, giving the tip a pinched look.The nostrils were asymmetrical. Mid-
line ink was drawn on the patient to show her the possible length and position of
a midline scar if tissue were to be removed.

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Nostril-lobular disproportion with prominent nostrils is obvious on basal view.The
nostrils were asymmetrical, with obvious loss of support to the left alar rim.
The excess skin is obvious.The two oblique views are symmetrical.The nostrils and
alar lobules were excessive, but the patient declined reduction of the alar base be-
cause she did not want external scars.

Surgical Plan
1. Placement of maxillary implant
2. Single left intercartilaginous incision on left side
3. Limited skeletonization to root
4. Rasping of root and preparation of graft bed
5. Septoplasty
6. Harvest of ear cartilage
7. Placement of ear cartilage graft on dorsum
8. Placement of alar rim grafts
9. Placement of minimal crushed cartilage on tip
655
Chapter 21
Secondary Rhinoplasty
Material obtained with septoplasty
Anterior dorsal graft of folded conchal cartilage
(note insuf cient dorsal height with
septal cartilage graft in place)
Lateral wall graft of ethmoid
Preliminary cartilage graft

656
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Postoperatively on lateral view with the elevation of the dorsal line, the nose has an
improved balance. There is a very ne line between obtaining tip projection and
extending the tip lobule too far anteriorly, producing an ultraprojecting tip. I would
have liked to have made the tip more discrete from the slight fullness at the supratip,
but I did not want to extend the lobule further.The relationship of the alar rims to
the columella is good. The decision to augment the maxilla was made because of
the retrusive columellar-labial junction.

The midface atness was corrected by the dorsal augmentation.The eyes have sep-
aration once more, and the patient viewed herself as “being back to normal.” The
base of the nose appears narrower and in better balance with the broadened lateral
walls.The alar grooves are softened and do not extend through the alar rims.
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658
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R EOPERATIVE SURGERY OF THE HEAD AND NECK
Again on oblique view the tip is the most projecting part. The alar grooves have
been softened, and there is a con uence from root to tip.The raised dorsum has di-
minished the visual mass of the lower third of the nose.

Visible Dorsal Graft and Flat Nasofacial Angle (Sheen Case)
This Asian patient had undergone three previous rhinoplasties. Iliac bone had been
placed over the dorsum during the last procedure. The septal partition was accid
except for posterior bony obstruction.The patient requested a longer, more West-
ern-appearing nose.
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Chapter 21
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A supratip deformity, an irregular dorsal line, and a retrusive maxilla are evident.
The nasofacial angle was at.The tissues had been made less elastic by the previous
surgeries. On frontal view the midface demonstrated a atness characteristic of a
low dorsum.The nose appeared to comprise two halves, which were demarcated by
the cephalic edge of the supratip deformity.The tip had no de nition. Left of mid-
line the iliac bone graft can be seen.

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The oblique views of the nose are asymmetrical. On the left oblique view the
supratip deformity projects prominently secondary to the position of the bone graft
(left of midline).The appearance on right oblique view is in uenced by the promi-
nence created by the iliac bone graft (left of midline), which diminishes the supratip
deformity on that side.
Surgical Plan
1. Placement of maxillary implant
2. Intracartilaginous incision on left side
3. Limited dissection over dorsum to root
4. Removal of residual bone graft
5. Rasping of bony dorsum and preparation of graft bed
6. Septoplasty
7. Harvest of cranial bone
8. Harvest of ear cartilage
9. Placement of dorsal graft consisting of cranial bone
10. Placement of crushed ear cartilage grafts to lateral walls
11. Placement of bruised and crushed ear cartilage tip graft over buttress graft
of ethmoid or vomer

661
Chapter 21
Secondary Rhinoplasty
Ethmoid, vomer, and cranial bone
Immediate postoperative result
Cranial bone dorsal graft
Buttress graft of vomer

662
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
The result is shown 4 years postoperatively.The supratip was eliminated by dorsal
augmentation and tip graft placement.The patient’s nose appears longer because of
the well-de ned root and tip.The vertical position of the upper lip has been moved
anteriorly; with the more anterior position of the base, the nasofacial angle is im-
proved.The tip is well de ned and projects above the dorsal line, which is straight
to the root.

With the elimination of the supratip, a con uence from root to tip with symmet-
rical diverging lines continuous with the supraorbital ridge has been achieved.The
middorsal crease that had divided the nose into two parts has been eliminated by
the new dorsal graft.
663
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The left and right oblique views are similar and show good tip separation from the
dorsum. The down look caused by the relationship of the high supratip and the
poorly projecting tip has been made more feminine by the improved relationship
of the tip to the dorsum.

The preoperative tip contour was somewhat obscured because the supratip was
more anterior. Postoperatively the supratip is not visible because of the improved
position and contour of the tip. Note the in uence of maxillary augmentation on
the position of the base.
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PART III
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Supratip Deformity, Shortened Nose, and Alar Pinching
(Rohrich Case)
This 30-year-old model had undergone three previous rhinoplasties that resulted in
a polly beak nasal tip deformity and a shortened nose. After the last rhinoplasty she
was left with an overresected nasal dorsum;in an attempt to remedy this defect she
underwent silicone injection to provide increased dorsal projection—obviously to
no avail. She presented with alar notching, shortened nose, and supratip deformity.
She complained of nasal airway obstruction, pinched nasal tip, shortened nose, and
liquid silicone in the nasal dorsum that caused skin dimpling in the supratip area.
On examination the patient’s skin was moderately thick. However, there was some
skin dimpling and irregularity of the supratip area as a result of the previous silicone
injections. She had a slightly long middle face. Excess infratip lobular projection
and a narrow middle vault are present.

On lateral view she had a low radix with supratip fullness as the result of the pre-
viously overresected nasal dorsum.The nasolabial angle was approximately 100 de-
grees, and the alae were severely retracted.
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Chapter 21
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These ndings are con rmed on oblique and basal views, which reveal alar aring,
alar notching, and excess infratip lobular projection.
Intranasal examination revealed normal pink mucosa with no evidence of septal
perforation. A surprising amount of normal septal cartilage was present.There was
synechial formation in the area of the internal nasal valves. Left inferior turbinate
hypertrophy was present.

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PART III
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Operative Goals
1. Removal of liquid silicone scar tissue in supratip area without compromis-
ing nasal skin blood supply
2. Dorsal augmentation
3. Increase tip projection/de nition
4. Correct alar notching
5. Correct nasal airway obstruction by internal nasal valve reconstruction
Surgical Plan
1. External approach with stairstep transcolumellar incision and infracartilagi-
nous extensions
2. Exposure of dorsal framework and separation of upper lateral cartilages from
septum via superior mucosal tunnels
3. Removal of remnants of injected silicone within scar tissue in supratip area
4. Harvest of 2 by 3 cm cartilage graft through left hemitrans xion incision to
preserve tip support
5. Partial resection of left anterior/inferior turbinate
6. Contouring of columellar strut and infratip lobular shield graft with suture
(5-0 PDS) xation
7. Placement of bilateral spreader grafts and anatomically contoured U-shaped
dorsal onlay grafts; they are secured in place at keystone area and anterior
septal angle with 4-0 PDS suture material
8. Placement of alar spreader graft to correct alar notching
9. Placement of alar spreader grafts bilaterally
Intraoperative Findings
1. Remnants of silicone in scar tissue of supratip area
2. Adequate nasal septum
3. Scarred internal nasal valves
4. Overresected nasal dorsum
5. Remnants (4 mm) of lower lateral cartilages (lateral crura)

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Chapter 21
Secondary Rhinoplasty
Dorsal
onlay graft
Interdomal
suture
Internal
spreader graft
Medial crural suture
Infratip lobular
shield graft
Dorsal
onlay graft
Infratip lobular
shield graft
Alar pinching
Alar spreader graft
U-shaped dorsal
onlay graft
Dorsal
onlay graft
Septal graft
harvested
Infratip lobular
shield graft
Interdomal suture
Alar
spreader
graft
Medial
crural suture

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PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
The results are shown 2 years postoperatively. On frontal view the nasal dorsum is
straight with improved dorsal lines.
On lateral view correction of alar-columellar discrepancy, increased nasal tip pro-
jection/de nition, correction of the low radix, and increased dorsal nasal length/
height can be seen.

Improved nasal balance and middle vault collapse correction are confirmed on
oblique view.
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Chapter 21
Secondary Rhinoplasty
Correction of the alar notching and restoration of symmetrical teardrop nostrils
can be veri ed on basal view.

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PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
NASAL TIP DEFORMITIES
Secondary nasal tip deformities are caused by distortion or displacement of the
lower lateral cartilages, scarring, or loss of support from overresected alar carti-
lages.51
Understanding the three-segment anatomy and position of the lateral crura en-
ables the surgeon to make an accurate preoperative assessment of postsurgical tip
problems. Malposition, wide angle of rotation, long middle crura, short middle
crura, and wide angle of diversion are responsible for a number of tip problems
that must be correctly diagnosed before a suitable correction can be planned.50
Tip deformities can be grouped as follows:
Excess alar cartilage
Ultraprojecting tip76
Insuf ciently reduced lateral crura
Overreduced lateral crura with long middle crura that produce knuckles
Insuf cient cartilage
Tip with inadequate projection (short middle crura)
Overresection of one or more parts of the alar cartilage complex
Disproportion of three segments in relation to each other and the angles they
form
Long middle crura
Wide angle of diversion (box tip)50
Narrow angle of diversion (ultraprojecting tip or overly narrow lobule)
Wide angle of rotation (square tip on lateral view)50
Flat angle of rotation (no columellar-lobular bend)
Short middle crura (tip with inadequate projection)
Contour abnormalities72
Convex lateral crura: Remaining caudal strip of convex lateral crura
maintains ball appearance at tip (the deformed cartilage must be re-
moved and either crushed and reinserted or replaced with septal car-
tilage)
Concave lateral crura: Residual concavity over the lateral wall persists
with cephalic trim (the concavity should be raised with onlay grafts)
Deformed lateral genu: Asymmetrical lateral genu or deformed middle
crura (complete resection and replacement with grafts is required)
Relation of lateral crura to alar rims22,28
Malposition:Varying degrees of cephalic rotation of the lateral crura away
from the alar rims predispose to a wide variety of secondary tip de-
formities (complete resection of all parts of the alar cartilage com-
plex and recontouring of the base using alar rim support and tip grafts
is recommended)

PATIENT EXAMPLES
Long Middle Crura and Wide Angle of Rotation (Sheen Case)
This patient had undergone three previous rhinoplasties, the most recent including
tip modi cation and dorsal grafting. She posed a special problem because of the
long middle crura with a wide angle of rotation.
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Chapter 21
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Her nose appeared shortened and blunted with a wide nasolabial angle and a col-
umella that was too low in relation to the high, arching right alar rim.The dorsum
was irregular.The tip is an excellent example of long middle aura with an angle or ro-
tation of close to 80 degrees, causing at, large alar lobules and a tip too cephalad.
The grossly deformed ear cartilage graft over the dorsum was obvious; it was
slightly off midline, giving the nose a twisted appearance.The right nostril arched
2 to 3 mm higher than the left. The alar-columellar relationship was poor as a re-
sult of the combination of a low columella and an arched (notched) right alar rim.

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PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
The oblique views reveal the fairly symmetrical position of the lateral walls of the
middle vault. The nose appears shortened. The nasolabial angle was exaggerated
by virtue of the long middle crura, which displaced the tip cephalad. The lobules
were inordinately large because of the length of the middle crura.
Surgical Plan
1. Limited skeletonization through left intracartilaginous incision to mid-line
2. Elliptical mucosal trim of posterior membranous septum (1.3 by 0.4 cm)
3. Dissection of ear cartilage graft and skeletonization to root
4. Rasping of bony dorsum and preparation of graft bed
5. Septoplasty
6. Placement of dorsal graft
7. Dissection and resection of alar cartilages lateral to medial genu
8. Harvest of composite ear graft and repair of donor site
9. Placement of composite graft to right alar rim
10. Support of left alar rim with cartilage graft
11. Placement of tip graft