The Art of Aesthetic Surgery Principles and Techniques Three Volume Set Second Edition

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Refinements in
Otoplasty Techniques

BRUCE S. BAUER, NETA ADLER
CHAPTER 52

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Part IX  Rejuvenation of the Cheeks, Chin, Lips, and Ears
D
espite recognized standards of idealized facial proportions and anthropomet-
ric measurements for each facial feature, the sought-after “look” of the mo-
ment tends to change, depending on which new fashion model or celebrity is hot, or
which individuals are currently revered in today’s media. Strangely, when wishing to
depict an oddball character, a less intelligent individual, or a “funny-looking kid,” the
media often portray individuals with large, prominent, or oddly shaped ears. Regard-
less of what we may later learn about these characters, we initially assign a level of
low intellect or immaturity to them. The fact remains that without calipers or other
instruments of measure, and without memorizing a set of standards, we visually rec-
ognize when facial features appear to be in balance, and few if any features elicit such
negative responses as ears that are prominent, overly large, or misshapen. Like it or
not, we tend to attribute these negative traits to these unfortunate individuals.
The literature in plastic surgery and otolaryngology abounds with approaches to
correct these deformities, many described as the “definitive procedure.” Yet the fail-
ure to properly analyze each deformity and modify the technique to fit the specific
features of each ear is likely to lead to an unfavorable outcome. Although the vast
majority of otoplasty patients are extremely pleased with the outcome of their sur-
geries, there are few patients more distraught than those whose previously atten-
tion-grabbing ears are now less prominent—but just as unsightly.
In this chapter we will outline the evolution of our current technique for correction
of the prominent ear. We will demonstrate how the technique has been modified to
make it flexible enough to correct a wide variety of deformities, from simple ear
prominence to an accompanying deformation of the helical rim, excessive promi-
nence of the lobule, and moderate degrees of constriction. To master the technique,
surgeons must understand how to properly balance and subtly position the varied
ear contours to obtain an outcome that “looks right” and that does not immediately
tell the observer that the ears have been operated on. Although the final ear position
and shape are critical, the exact measurements are not.
Indications and Contraindications
Many of the patients presenting for otoplasty are easy to spot in a crowded waiting
room, but not every person with large, prominent ears wants to change his or her
appearance, and many, even if teased in childhood, have become comfortable with
their appearance. That being said, experience has demonstrated that many of the
parents bringing their children in for correction of prominent ears are strongly mo-
tivated by the desire to spare their child the embarrassment and teasing that they
themselves endured. More than a few have subsequently elected to undergo oto-
plasty after their child has had surgery. In these cases the satisfaction rate and feel-
ings of relief are a constant feature of their recovery.

These issues come into play in deciding the appropriate timing for the surgery, and
whether the decision should be made based on the parents’ concerns or whether the
surgery should be postponed until the child expresses concern. Such a decision needs
to be made case by case, but by the time children approach 5 years of age, they may
well have been teased, even if the teasing has not started to affect the way they feel
about themselves. Once the discussion is initiated, the child will express willingness
to go through the surgery to avoid this teasing.
The growth patterns of the ear also factor into the timing of surgery. According to
Adamson et al, the external ear reaches 85% of its adult size by the time a child is
3 years of age. Growth continues until adulthood, but little change in width or dis-
tance from the scalp occurs after 10 years of age, and for all practical purposes the
normal ear is almost fully developed by 6 years of age. Farkas reported slightly dif-
ferent data, with the ear reaching 85% of full size by 8 years of age, 90% by 9 years,
and 95% by 14 years.
Although it is quite possible to correct a protruding ear before 5 years of age with
no effect on the growth of the ear, it has been our experience that children younger
than 5 years of age are rarely perceptive enough about their appearance, or com-
ments made about them, to feel that correction is urgent. Experience has demon-
strated that young children may have significant difficulty cooperating with postop-
erative routines, such as dressings and limitations on activity. The ear cartilage at
ages younger than 5 years may be softer and more pliable, and thus the risk is greater
that some degree of protrusion will recur. Taken together, with very rare exceptions,
age 5 is the low end of our patient spectrum.
More subtle cases of ear prominence, distortion of ear shape, or ear asymmetry may
not spark the desire for correction until a child is older, more concerned about over-
all appearance, or eager to adopt a different style and wear his or her hair back or cut
short. In each case, the ear or ears that may have been kept well hidden are now ex-
posed for all to see.
There are very few contraindications to otoplasty. In the pediatric population, surgery
is appropriate and extremely well tolerated if the child does not strongly resist the
idea of surgery. If a younger child begins to act out or becomes excessively worried
about going to the doctor for a preoperative discussion or going to the hospital, it
is best to delay the surgery until the child requests the procedure. Another contraindi-
cation is a history of chronic ear infection and ear drainage that has not been thor-
oughly investigated and corrected. It is not uncommon for children to have previ-
ously undergone myringotomy and placement of a pressure equalization tube. If
there is no active infection or significant drainage, otoplasty can be performed safely.
At the other end of the age spectrum, adults seeking changes in ear shape, size, or
prominence must, as with any aesthetic surgery candidates, be able to express their
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Chapter 52  Refinements in Otoplasty Techniques

reasons for seeking a change at this stage and demonstrate realistic expectations of
what the change will mean for them. Careful case selection is critical, and never more
important than when the deformity is a minimal or subtle one. Although beyond the
scope of this chapter, the same is especially true in patients who have previously un-
dergone one otoplasty and are dissatisfied with the outcome.
Pertinent Anatomy
Anatomy of Ear Prominence
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Part IX  Rejuvenation of the Cheeks, Chin, Lips, and Ears
Helical rim
Helix
Triangular fossa
Concha
Tragus
Antitragus
Lobule
Scapha
Antihelical fold
Antihelix
Helix
Concha
Although the majority of otoplasty techniques have historically concentrated on the
effaced antihelical fold as the main cause of ear prominence, failure to fully appre-
ciate all the elements distorting the ear position and shape is a recipe for an unfa-
vorable outcome. Experience has revealed that the vast majority of prominent ears
demonstrate some degree of conchal hypertrophy, and the concha may be the cor-
nerstone to the treatment of the prominent ear.
Causes of Ear Prominence
Correct analysis of each deformity is the most important step in otoplasty. Ear promi-
nence results from one or more of the following features: (1) effacement or a defi-
cient antihelical fold, (2) conchal hypertrophy or abnormalities in conchal shape,
(3) deformity of the underlying skeletal anatomy, and (4) macrotia, or generalized
overgrowth of the ear. The first two of these features are accentuated when seen in
combination with the decreased radius of curve of the helical rim in a constricted
ear. We will look at each of these elements separately.

Antihelical Fold
Effacement or deficiency of the antihelical fold ranks foremost in most discussions
of the prominent ear. This deformity presents as a spectrum from a totally indistin-
guishable antihelix, with a confluent concavity from antihelix to scapha and the he -
li cal rim projected outward and forward, to loss of definition of only the superior
antihelix with prominence of the upper pole of the ear.
Conchal Size and Shape
Although less attention has been given to the importance of the concha in overall
shape and projection of the ear, it makes sense in considering the three-tiered con-
figuration of the auricular cartilage framework that because the more delicate anti-
helix and helical complex are mounted on the sturdier concha, changes in conchal
size and shape will profoundly influence the overlying tiers. In our experience, it is
rare to see ear prominence that does not have some conchal element.
There appear to be three ways in which the concha affects the prominence of the
ear: (1) overall enlargement of the concha, which projects the ear away from the
mastoid surface, (2) an extension of the helical crus across the concha, which cre-
ates a firm “cartilage bar” that pushes the ear outward, and (3) the effect of the an-
gulation of the cartilage at the junction between the cavum concha and the sweep
of cartilage up to the antitragal prominence, which affects the position and promi-
nence of the lobule and lower third of the ear. The first of these is well recognized.
Little attention has been drawn to the second, but once seen, it is easy to understand.
The third element, once recognized, leads to an understanding of the approach to
the isolated lower pole and lobule prominence.
Conchal shape, although not the only cause of prominence of the lobule, appears to
play a key role. As the cartilage angle between the concha cavum and antitragus be-
comes more acute (that is, as the antitragus tips closer toward the concha), this sup-
porting structure projects the lower third of the ear and lobule outward. We think
that this feature has a greater influence on lobule position than the commonly de-
scribed helical tail does.
Anatomy of the Underlying Skeleton
Little attention has been drawn to the affect of the underlying skeleton on ear promi-
nence, but it should be recognized and taken into account in planning correction of
a prominent ear. The external ear is mounted on the bony base of the underlying
temporal bone. Anomalies in skeletal shape and skeletal asymmetries can affect one
or both ears. Perhaps the most recognizable example of this relationship is the change
in ear position and projection associated with positional, nonsynostotic plagio-
cephaly. With the parallelogram deformation of the cranial vault, the ear on the side
of occipital plagiocephaly is projected forward and is often more prominent. In more
subtle cases of this deformity, the ear prominence may become more evident when
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Chapter 52  Refinements in Otoplasty Techniques

the individual is older, with ears that are asymmetrically positioned, and residual oc-
cipital flattening and mild facial asymmetry may not be readily apparent on first
view. This effect of head shape on ear position is clear when viewing illustrations of
Ely’s description of his otoplasty technique in 1881.
A less subtle example of the influence of the skeleton on ear position is the effect of
deficient temporal bone and medial positioning of the temporomandibular joint in
hemifacial microsomia. In more severely affected patients without microtia, the nor-
mal ear may seem to be “sheered off the head,” with the upper half of the ear pro-
jecting outward and the lower half canted medially toward the hypoplastic face. An
additional example with some similarities is the small group of patients whose gen-
eral craniofacial shape includes a relatively broad head, with a narrow face and
mandible. Seen from the frontal view, there is a triangular configuration to the head
and face. This slope from head to face may project the upper ear outward, creating
ear prominence, but showing otherwise normal and proportional ear features.
Macrotia
There are wide variations in ear size and a broad spectrum of “normal,” but some
patients have overall enlargement of the ear, out of proportion to the other facial
features. This may occur as a result of congenital overgrowth in isolation, or in com-
bination with hemihypertrophy of the face. It may also occur as a result of a disease
process, such as neurofibromatosis, or a vascular anomaly. The ear, while enlarged,
may be normal in shape, or show elements of the above-mentioned features. Each
of these anomalies is relatively rare. Less rare, and not true macrotia, is an isolated
congenital enlargement of the lobule, with the lower third of the ear projecting out-
ward from the face.
Preoperative Assessment
In the majority of cases, if the patient is a child at an appropriate age to undergo a
procedure, the preoperative assessment is completed with the initial evaluation and
one subsequent preoperative visit (usually within the week before surgery). For chil-
dren too young for surgery, or not presently concerned with the deformity, a return
visit is planned for the appropriate age. For an adult patient, particularly one re-
questing a secondary procedure, the surgeon may elect to meet an additional time
to ensure that the patient’s expectations are appropriate and can be fulfilled. All pa-
tients require routine history-taking and a physical examination (plus a laboratory
workup in adults) to be completed by the primary physician. Photographs are taken
preoperatively and reviewed to ensure that all appropriate views are documented.
The specifics of the deformity are discussed with the patient or family, taking care
to point out any asymmetries that may exist between the two ears. The surgical pro-
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Part IX  Rejuvenation of the Cheeks, Chin, Lips, and Ears

cedure is discussed in detail, including a review of the options for anesthesia (a gen-
eral anesthetic is used in the majority of pediatric cases; possibly a local anesthetic
with or without sedation in minor cases or in adults), discussion of incisions, dress-
ings, and postoperative care. Such risks as infection, chondritis, and hematoma are
discussed, as well as their implications and treatment. The surgeon also discusses the
fact that there may be minor asymmetry or a partial recurrence in younger patients
that can be corrected through a minor revisional procedure with a local anesthetic
when the child is ready and comfortable with this.
In most cases, and particularly in children, it is helpful to review photographs of a se-
ries of otoplasty cases illustrating a variety of prominent ear deformities. With some of
the more atypical deformities of the helical rim or with a constricted ear, this will help
to clarify the potential limitations of the surgery while still demonstrating its benefits.
Preoperative Planning
Proper assessment of the patient’s deformity is the key element of preoperative plan-
ning. Our current approach to correction of the prominent ear evolved from the
Stark-Saunders technique, which combined posterior thinning (dermabrasion) of the
proposed antihelical fold and suture fixation; our technique emphasizes chondrocu-
taneous conchal resection as the cornerstone of correction of the prominent ear, com-
bined with posterior suture shaping and fixation of the antihelical fold. Our current
approach totally avoids any thinning or potential irregularities in the antihelix seen
with many of the cartilage-scoring techniques, while still minimizing the risk of re-
currence that may be seen with suture techniques alone. The integrity of the antihe-
lical cartilage is maintained because the perichondrium overlying both surfaces of
the antihelix is left undisturbed, yet the cartilage spring is diminished as a result of
the “break” at the conchal level.
This evolution in our approach followed assessment of our own postoperative re-
sults as well as critical evaluation of a reasonably large series of patients seeking re-
vision otoplasty. In the latter group, most demonstrated an overaccentuation of the
antihelical fold and failure to recognize conchal hypertrophy as the underlying cause
of the initial ear prominence. Addressing conchal hypertrophy in these patients, alone
or in conjunction with ancillary techniques, has produced consistent and repro-
ducible outcomes that are satisfactory to both the patient and surgeon.
The goals of otoplasty should be to (1) correct the protrusion, (2) correct the promi-
nently visible helix and antihelix while leaving a visible helical rim (3) create a smooth
antihelical fold, (4) avoid disturbance of the postauricular sulcus, and (5) avoid a “plas-
tered down”or “pinned back” look. To achieve these goals, each deformity must be crit-
ically evaluated and the technique modified to correct subtle differences in the two sides.
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Chapter 52  Refinements in Otoplasty Techniques

Whereas emphasis had previously been placed on the importance of correcting the an-
tihelical effacement, this approach emphasizes the concha’s role in the prominent
ear. This results in a treatment plan that readily achieves each of the above goals
while guaranteeing that a sharp, irregular antihelix and pinned-back look will be
avoided. The technique is also readily modified to suit the correction needs of a whole
host of unusual or atypical deformities.
With the exception of the rare cases in which there is no visible conchal component
to the deformity, the procedure begins with an anterior conchal incision, and exci-
sion of a crescent of cartilage with a smaller skin component. For a lesser degree of
cartilage resection, no skin may be excised. Although minor degrees of conchal promi-
nence can be handled by creation of a new antihelical fold or by setback with con-
chal mastoid suture, most patients with conchal hypertrophy require cartilage exci-
sion. The choice of an anterior or a posterior approach to cartilage excision is one
of personal preference. In our opinion there is considerably more control with the
anterior approach, and in cases with wider resection of 1 cm or more, the extra skin
left from the use of a posterior approach may not shrink down enough. The fold
created in the conchal floor can be much more noticeable than a finer anterior con-
chal scar that is rarely visible by 1 year after otoplasty.
After repair of the concha, the surgeon turns attention to the postauricular surface,
where skin excision and exposure of the posterior perichondrium over the scapha, he -
li cal sulcus, and helical tail are followed by suture placement. Sutures are tied to cor-
rect the prominence, and closure of the inferior incision sets the shape and correc-
tion of the lobule. Next the surgeon performs adjunctive procedures, such as
correction of helical rim deformities, excessive prominence of the antitragus, and
additional reduction of lobule size. Corrections of adhesion or defects of the helical
rim may make use of the resected conchal cartilage as a graft.
Operative Technique
Although we will make every effort in this section to describe the nuances of each
step, the indications and benefits of each maneuver will become readily evident as
one gains more experience with the procedure and better appreciates the flexibility
inherent in this approach. With rare exceptions, which will be noted, the techniques
used are similar for children and adults.
General anesthesia is induced with a reverse airway endotracheal tube, or intra-
venous sedation is used. The face and both ears are sterilized with a green soap so-
lution and draped with a standard head drape. Stray hairs are secured with Tego-
derm or another clear sterile drape. A solution of 0.5% lidocaine with 1:200,000
epinephrine is infiltrated into the anterior and posterior surfaces of both ears. Bilat-
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Part IX  Rejuvenation of the Cheeks, Chin, Lips, and Ears
3
52-1 Otoplasty

eral great auricular nerve blocks with 0.25% bupivacaine are also injected for post-
operative analgesia. A broad-spectrum antibiotic is given intravenously after place-
ment of the IV line.
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Chapter 52  Refinements in Otoplasty Techniques
This incision is deeper in the concha than the incision described by Elliott. Placing
the incision too high in the concha will decrease control of the antihelical fold, al-
lowing the cut edge adjacent to the antihelix to spring forward when the antihelix
is shaped. The incision is carried through both the anterior skin and conchal cartilage,
stopping shy of the posterior conchal skin.
Sharp dissection in the loose areolar plane behind the concha (not in the subperichon-
drial plane) frees soft tissue and skin from the posterior surface of the conchal bowl.
A gentle setback of the antihelix with finger pressure will accurately estimate the de-
gree of conchal hypertrophy and the amount of cartilage and skin resection needed
to create an aesthetically pleasing position for the ear.
The procedure typically begins on the
more prominent side and starts with the
incision on the anterior surface of the con-
cha. The incision is placed at the junction
of the posterior conchal wall and “floor”
of the concha. It begins in the cymba con-
cha and continues along the cavum con-
cha to a point below the antitragus, but
not as far as the external auditory meatus.

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Part IX  Rejuvenation of the Cheeks, Chin, Lips, and Ears
Usually a crescent-shaped chondrocutaneous segment is excised. To ensure a tension-
free closure, more cartilage is typically resected than skin, particularly along the in-
ferior concha deep to the antitragus (where excessive resection would tend to pull the
antitragus upward and increase prominence of the lower pole of the ear and lobe).
The edges of the conchal cartilage are then approximated with three or four inter-
rupted 5-0 clear nylon sutures. How the most inferior suture is placed, at the junc-
tion of cavum concha and antitragus, will adjust the angle between these landmarks
and strongly influence the cartilage support to the lobule. A slight overlapping of
cartilage (antitragal segment over conchal segment) will tip the lobule posteriorly.
Once the cartilage is repaired, the anterior skin is closed with a combination of 5-0
chromic gut, with horizontal mattress sutures, followed by a running 6-0 mild (fast-
absorbing) chromic gut. With these maneuvers completed, the helical rim and ear
may at first seem more prominent, but gentle pressure applied to the antihelix will
demonstrate a relaxing of the tension needed to bend the antihelix back to its de-
sired correction.

Correction of the effaced antihelix and prominence of the lobule first begins with a
retroauricular “squid”-shaped skin excision down to the perichondrium. This squid-
shaped excision (which, in essence, is the typical dumbbell-shaped ellipse with the
inferior end widened to a diamond shape) is designed to allow access to the posterior
surface of the scapha and helical sulcus for suture placement and to assist in correc-
tion of the lower pole prominence. The diamond-shaped inferior extension of the
“squid” is positioned with its maximal width at the point of maximal lobule promi-
nence. When designing the squid-shaped excision, failure to taper the skin excision
in its midportion may result in a postoperative “telephone-ear” deformity in which
the upper ear and lobule protrude, resulting in an ear shaped somewhat like the hand-
set of a telephone. Exposure of the posterior surface of the conchal bowl and scapha
is achieved without dissection of any perichondrium off the cartilage. Preserving the
perichondrium is essential to lessen the possibility of subsequent sutures pulling
through the cartilage. As the dissection proceeds to expose the posterior surface of
the cartilage, care is taken to identify and free the helical tail. The latter is seen as a
duplication of cartilage extending inferiorly from the middle to the lower third of the
helical rim. This dissection must not free the cartilage of the tail from the skin over-
lying its anterior surface, because this would diminish the effectiveness of correcting
the prominence of the lobule. The final dissection proceeds onto the mastoid surface,
freeing the soft tissues sufficiently to ensure that later sutures can be securely placed
into the mastoid fascia. Bipolar cautery is used throughout to ensure hemostasis.
Before placing sutures that will further correct the ear prominence, the surgeon
gently puts pressure on the helical rim and antihelix to again demonstrate that the
spring (resistance of the cartilage to further shaping of the antihelix) is significantly
decreased, and now the reshaping can be accomplished without any sharpening of
the antihelix. Surgeons must recognize this key point of this otoplasty technique, be-
cause even a limited amount of conchal resection will still result in this lessened
spring and increased ease of shaping the antihelix. With the current exposure of the
posterior surface of the concha, if additional sutures are needed to complete an ac-
curate closure of the conchal defect, they can be placed now before the key poste-
rior shaping sutures are done.
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Chapter 52  Refinements in Otoplasty Techniques
A
B
C
A

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Part IX  Rejuvenation of the Cheeks, Chin, Lips, and Ears
Keith needle
Two or three 4-0 clear nylon sutures are placed from the scaphal cartilage and helical
sulcus cartilage to the mastoid fascia to correct prominence of the upper and middle
third of the ear. The third superiormost suture may be placed from the region of the
triangular fossa to the temporal fascia. The proper placement of these permanent su-
tures is confirmed by applying pressure to the desired points on the anterior surface
of the ear with a straight Keith needle, then passing the point of the needle through
the selected spot so it can be visualized on the posterior surface of the cartilage.
The nylon suture is then placed at each specific point without the need of tattooing
the cartilage. As the suture is placed, the Keith needle is withdrawn. The sutures are
then passed through mastoid or temporal fascia.
Once all sutures are placed, beginning with the scaphal suture, they are tied to the
proper tension to create a smooth antihelical fold. Before cutting each suture, the sur-
geon uses a forceps to grasp the knot and slide it down against the mastoid surface
to minimize any risk of later extrusion of sutures. As these sutures are tied, care should
be taken to observe the relationship of the reshaped antihelix and the helical rim to
ensure that the helical rim remains visible from the frontal view. A triangular
fossa–to–temporal fascia suture is required only if there is a need to pull the helical
root closer to the head. This is best determined by looking at the superior helical rim
from the anterior view to see if there is a gentle slope downward from the apex of
the helical rim toward the helical crus. If the rim bulges forward after the superior
suture has been placed from scapha to mastoid, then this additional suture is required.
In adult patients, in whom there may be less flexibility in the cartilage of the anti-
helix, one or two additional sutures may be required to shape and round the anti-
helix. These sutures are placed from scapha to the cut edge of the concha, deep to
the inferior crus, and from the helical sulcus to the cut edge of the concha at right
angles to the antihelix. These sutures are placed before the ones described above to

“preshape” the antihelix before further correction of the prominence. This maneu-
ver is in lieu of other otoabrasion techniques that, even if done carefully, may still
result in irregularities on the anterior surface of the antihelix.
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Chapter 52  Refinements in Otoplasty Techniques
Once the upper and midauricular prominence is corrected the lobule position is ad-
dressed with closure of the posterior squid-shaped defect using 5-0 chromic gut.
With the diamond-shaped inferior portion of the squid designed as described pre-
viously, the appropriate contour, shape, and projection of the lobule are produced
by varying the initial suture position, with A (the point of the diamond at the point
of maximal lobule prominence) sutured to either A, B, or C (most frequently A to A
rather than A to B). Once this initial suture is placed, the closure is completed with
a running 5-0 chromic suture. Correction of the more prominent side first allows a
symmetrical setback by providing a guide for placement of the sutures that will de-
fine the antihelix and lobule prominence.
The most common adjunctive procedures include reduction of prominence of the
antitragus and correction of irregularities in the helical rim in the area of Darwin’s
tubercle. Each of these procedures is accomplished through a small incision paral-
lel to the border of the prominence (within the concha for the antitragus, lateral to
A
B
C
A
A
B
C
A
A
B
C
A
B
A

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Part IX  Rejuvenation of the Cheeks, Chin, Lips, and Ears
the helical rim for helical rim adjustment), followed by direct exposure and resec-
tion of the excess cartilage. Closure is done with an interrupted and running 6-0
mild chromic suture. (Additional procedures to treat major deformities of the heli-
cal rim, or reduction of excessively large lobule, are reviewed later, with specific ex-
amples.) Small degrees of lobule enlargement can be addressed with a small wedge
resection within the lobule, whereas larger resections are best placed at the lobule-
midthird (helix-antihelix) junction, where the splice can be stair-stepped at the splice
point. These procedures are the exception, not the rule.
Macrotia
Cases of true macrotia require reduction of the overall ear size in addition to cor-
rection of ear prominence. In general, reducing the vertical height of the ear is most
easily accomplished with an excision at the junction of the middle and lower thirds
of the ear in conjunction with helical rim advancement using a posteriorly based
chondrocutaneous flap. The excess skin and cartilage are excised from the scaphal
region, the rim is advanced along, and additional skin and cartilage are excised just
inferior to the helical tail. This approach affords an excellent view for either further
development of the helical fold or additional conchal reduction.
Dressings and Postoperative Care
The ears are dressed with bacitracin ointment, Xeroform gauze, and fluff dressings
secured with a stretch net head wrap. The dressing is left undisturbed for 6 or 7 days
postoperatively and then removed. Broad-spectrum antibiotic coverage is continued
for 4 or 5 days postoperatively. After the dressing is removed, the patient wears a

stretch terry sport headband for an additional 2 weeks, at night only. Physical ac-
tivity must be minimized for 3 weeks after surgery. After the dressing is removed,
the patient’s hair should be washed daily with mild shampoo and the ears cleansed
gently. This is continued until the sutures have dissolved. Patients are typically reeval-
uated at 6 and 12 months postoperatively.
Outcomes
Despite the preponderance of techniques describing accentuation of the antihelical
fold as the key component of correction of the prominent ear, our experience has
led to the conclusion that the prominent ear has many and varied etiologic factors,
but the common denominator is hypertrophy of the concha. The degree of conchal
hypertrophy does not need to be great to have a positive impact when employing
chondrocutaneous resection as the cornerstone of the otoplasty technique. Recog-
nizing this fact is imperative, but at present it is underappreciated. Even with lim-
ited resection and resuturing of the cut concha, the antihelix yields to the posterior
placement of sutures with a soft, smooth, rounded shape, unmarred by any sharp
irregular surfaces. Despite concerns expressed by some authors, and criticism of the
anterior approach to the concha as a potential source of a keloid scar, we have not
seen unsightly scarring in any of these cases, nor in a much larger series of conchal
donor sites for composite grafts used for ear reconstruction. This approach can read-
ily be adapted to the treatment of less common deformities and can be applied to
correction of deformities seen in group I and II constriction (where the deformity is
bilateral and significant increase in ear height is not required).
Although a small number of patients will have minor asymmetries in the upper pole
correction or in lobule shape or prominence, the adjunctive procedures mentioned
earlier are now applied more routinely at the initial procedure to avoid these issues.
To date, all revisional procedures, even in younger children, have been done in a sin-
gle procedure with local anesthetic in the office setting.
Results
The versatility of this approach is illustrated in the following patient examples, rang-
ing from typical ear prominence to varied deformities of the helical rim and moder-
ate constriction of the ear.
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Chapter 52  Refinements in Otoplasty Techniques

This 14-year-old girl’s ear prominence resulted from a mild degree of underdevel-
opment of the antihelical fold, with conchal hypertrophy playing a greater role in
the prominence, particularly on the more prominent left side. She is seen 9 months
postoperatively. The smooth contour of the antihelix is apparent in the lateral views.
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Part IX  Rejuvenation of the Cheeks, Chin, Lips, and Ears

The antihelical folds were barely visible in this 13-year-old with prominent ears, and
there was significant conchal hypertrophy. The superior antihelical fold was barely
developed, and the prominence was greater on the left side. The postoperative re-
sults at 1 year after correction demonstrate excellent symmetry, clearly visible heli-
cal rims on frontal and posterior views, and smooth antihelical folds on the lateral
view.
1839
Chapter 52  Refinements in Otoplasty Techniques

This 37-year-old woman had relatively symmetrical bilateral ear prominence, with
a mild degree of conchal hypertrophy, a relatively well-developed lower segment of
the antihelical fold, and primarily upper pole prominence. In the preoperative views,
an additional deformity of the helical rim can be seen on the right side in the region
of Darwin’s tubercle. Our surgical approach was similar to the technique described
1840
Part IX  Rejuvenation of the Cheeks, Chin, Lips, and Ears

earlier, with a small conchal reduction followed by posterior placement of sutures
to correct the upper pole deformity. The helical rim deformity was approached
through an incision paralleling the helical rim, and the cartilage of the rim was ex-
posed. The cartilage was found to be relatively normal, with the deformity prima-
rily resulting from an excess of skin and subcutaneous fat in the region. The latter
was resected, correcting the deformity. The patient is shown 13 months postopera-
tively. The subtle degree of conchal reduction allowed correction of prominence with-
out sharpening the lower and middle region of the antihelix. The superior antiheli-
cal fold is better defined, and the helical rim deformity is corrected.
1841
Chapter 52  Refinements in Otoplasty Techniques
This 6-year-old boy with “skip hemihypertrophy” had enlargement of the structures
on the left side of his face and right side of his trunk and extremities. Although both
ears were prominent, as seen on frontal and posterior views, the left concha was
larger, the antihelical fold less defined, and the overall ear size was larger. Cor-
rection of the prominence involved bilateral conchal reduction combined with re-
duction of the size of the left ear. This was accomplished with additional resection
of a segment of the scapha through an incision parallel to and within the helical

curve, which released the helical rim to allow advancement and resplicing at the
junction with the lobule.
The 1-year postoperative frontal and posterior views show excellent symmetry, nat-
ural shape and visibility of the helical rim, and an undisturbed postauricular sulcus.
1842
Part IX  Rejuvenation of the Cheeks, Chin, Lips, and Ears
Closeup lateral views show good symmetry in shape; scars from the ear reduction
are well hidden beneath the helical rim and within the helical sulcus. Careful inspec-
tion shows the small scar at the splice point of the midhelical rim and lobule.
This young boy’s prominent ears resulted from the combined effects of conchal en-
largement and deformity of the scapha and helical rim on the right side. The defor-
mity of the right ear differed from the typical constriction in that the antihelical fold
was well formed, but the midscapha was sharply folded on itself and the helical rim
was tipped forward, with a lack of support to the upper pole of the ear and a de-
gree of lidding as well.

Lateral views demonstrate the difference in the support to the upper pole of the ear
and the slight counterclockwise rotation of the right ear in comparison to the left ear.
1843
Chapter 52  Refinements in Otoplasty Techniques
The concha was reduced initially, as describe previously, and the incision was closed.
This first intraoperative view shows the acute fold in the scapha as well as the lid-
ding of the helical rim. The helical rim incision followed the line of the future helical
rim, exposing the distorted cartilage.

While the cartilage of the upper pole of the ear was skeletonized, dissecting both
posterior and anterior to the helical rim, all adhesions were released. In this case,
the cartilage was split through the acute fold, releasing the entire upper pole carti-
lage to be reshaped and advanced into a natural position by overlapping the carti-
lage medial to the fold and realigning the helical rim.
1844
Part IX  Rejuvenation of the Cheeks, Chin, Lips, and Ears
After suture fixation, the newly shaped upper pole of the ear was well supported with
intercartilaginous sutures, and sutures were placed from scapha to mastoid. The skin
was redraped and the slight excess of skin along the helical rim resected. Through-
and-through sutures reattached the skin envelope securely to the reshaped cartilage.

The prominence of the left ear was addressed as described, concentrating on the con-
chal hypertrophy. Although the results at 3 months postoperatively demonstrate a
small size discrepancy between the two ears, the natural shape, and symmetrical pro-
jection mask this difference.
1845
Chapter 52  Refinements in Otoplasty Techniques
Closeup lateral views demonstrate the smooth, natural configuration of the antihe-
lix and the well-hidden scars.

1846
Part IX  Rejuvenation of the Cheeks, Chin, Lips, and Ears
This patient illustrates the application of this technique to a moderate constriction.
The combined effects of lidding, constriction of the helical rim, and vertical short-
ness of the ear are evident in group 2B constriction. Although this group of constricted
ears characteristically demonstrates shortages in both skin and cartilage, the pres-
ence of a bilateral deformity allows correction without concern for the fact that the
restructured ear may be relatively small, because the two ears will still match in size.
The approach used in this patient was as described on pp. 1842 through 1845, with
initial conchal resection, followed by correction of prominence through the poste-
rior suture placement, then final reshaping of the upper helical rim by a direct ante-
rior approach to the helical lid and constricted rim. Because some additional suture
placement from scapha to mastoid may be required in this reshaping of the upper
pole, the final posterior closure is delayed until the former area is fully corrected.
The patient is shown 3 years postoperatively with a symmetrical increase in the size
of her ears and a pleasing correction of the distorted cartilage shape. The final re-
sults of the combined otoplasty procedure illustrate her excellent outcome.

1847
Chapter 52  Refinements in Otoplasty Techniques

This 101⁄2-year-old girl is shown preoperatively in a candid frontal view and lateral
views and at 1 year after otoplasty. The preoperative frontal view shows marked bi-
lateral prominence caused by bilateral conchal hypertrophy and an effaced antiheli-
cal fold on the right. The overall ear size bordered on macrotia. There was a promi-
nent Darwin’s tubercle on the left, which was excised through a small rim incision
following correction of the prominence, as described earlier. Although her ears were
asymmetrical and had different underlying cartilage anatomy, the postoperative
frontal view shows excellent final symmetry.
1848
Part IX  Rejuvenation of the Cheeks, Chin, Lips, and Ears

1849
Chapter 52  Refinements in Otoplasty Techniques

This 23-year-old woman presented with concerns related specifically to the promi-
nence and abnormal folding of her upper ear. The preoperative views show atypical
lidding and crimping of the helical rim. The mid and lower ears were symmetrical.
During correction of an upper pole deformity it is important to avoid changing the
shape of the helical rim in the middle third of the ear and secondarily leaving a hid-
den helix. Using an approach similar to that shown on pp. 1842 through 1845, the
upper pole of the ear was approached directly with release of adhesions, reshaping
of the helical rim, and support of the new shape with a conchal cartilage graft. Seen
1 year after surgery, the ear has a natural, unoperated appearance with excellent
symmetry, correction of the upper pole prominence, and no evidence of overcorrec-
tion of the midhelical rim. Lateral views in particular show how the correction of
the upper pole deformity not only rounded the curve of the superior helical rim, but
also increased the vertical height of the ear.
1850
Part IX  Rejuvenation of the Cheeks, Chin, Lips, and Ears

1851
Chapter 52  Refinements in Otoplasty Techniques

This 13-year-old girl was frequently teased about her prominent ears and tried to
keep her ears as well hidden as possible with her hair. Six weeks after otoplasty, it
is apparent how the combined otoplasty approach adapts to treatment of the var-
ied causes of prominence on the two sides.
1852
Part IX  Rejuvenation of the Cheeks, Chin, Lips, and Ears

1853
Chapter 52  Refinements in Otoplasty Techniques
The closeup views show slight differences in the position of the conchal incision and
how the procedure has resulted in a smooth, near-identical antihelical fold on both the
side on which it was already formed (left) and the side on which it was absent (right).

Concluding Thoughts
Ear deformities, even those of a minor degree, can have profound effects on an in-
dividual. These effects may persist years after teasing by classmates ceases. Unless
all aspects of the deformity are addressed in a systematic manner, correction can result
in secondary deformities that are even more disturbing. This chapter presents an
in-depth look at how the conchal shape represents the cornerstone of prominent ear
deformities and how, coupled with other modifications of the helical rim, conchal
release and resection allows correction of the antihelical effacement in a manner that
avoids the secondary distortions that trades one deformity for another. Following
the approach illustrated in this chapter, one will find the procedures not only more
reproducible than others currently in vogue, but also readily applicable to virtually
all other nonmicrotia ear deformities.
Clinical Caveats
 Correct analysis of each ear deformity is the most important step in otoplasty.
 Failure to fully appreciate all elements distorting the ear position and shape (par-
ticularly the role of conchal hypertrophy) is likely to result in an unfavorable out-
come.
 Otoplasty techniques that involve scoring or abrasion of the cartilage all run the
potential risk of producing visible cartilage irregularities and a sharp antihelical
fold.
 Placing the incision for conchal resection too high in the concha will decrease con-
trol of the antihelical fold, allowing the cut edge adjacent to the antihelix to spring
forward when the antihelix is shaped.
 To ensure a tension-free closure of the concha, more cartilage is typically resected
than skin, particularly along the inferior concha deep to the antitragus.
 Excessive resection of skin or cartilage will pull the antitragus upward and in-
crease prominence of the lower pole of the ear and lobe.
 When designing the “squid”-shaped excision, failure to taper the skin excision in
its midportion may result in a postoperative telephone-ear deformity.
 Preserving the perichondrium on both surfaces of the cartilage will lessen the pos-
sibility of subsequent sutures pulling through the cartilage with resultant partial
recurrence of the deformity.
1854
Part IX  Rejuvenation of the Cheeks, Chin, Lips, and Ears

Annotated Bibliography
Bauer BS. Congenital and acquired deformities of the ear. In Bentz ML, Bauer BS, Zuker
RM, eds. Principles and Practice of Pediatric Plastic Surgery, vol 2, St Louis: Quality
Medical Publishing, 2008.
This chapter discusses the full spectrum of both congenital and acquired ear deformi-
ties, demonstrating otoplasty techniques for treating the range of abnormalities from
more commonly recognized nonmicrotia ear problems (constricted ear, cryptotia, and
Stahl’s ear) to rare and unnamed deformities that plastic surgeons may encounter. It also
demonstrates how these techniques can be applied to the reconstruction of acquired ear
deformities with similar cartilage and skin deficiencies.
Elliott RA. Otoplasty: a combined approach. Clin Plast Surg 17:373-381, 1990.
This paper describes the need to assess both conchal size and antihelical definition to
properly address the individual case. It did not describe the combination as a “standard”
approach to otoplasty. The conchal incision is also placed considerably higher on the
lateral conchal wall.
Erol OO. New modification in otoplasty: anterior approach. Plast Reconstr Surg 107:193-
202; discussion 203-205, 2001.
This paper describes a combined approach to otoplasty with both conchal resection and
reshaping of the antihelix, but does the latter by undermining over the antihelix, scor-
ing of the cartilage, then suture fixation. The scoring is seen to result in irregularities of
the antihelix.
Mustarde JC. The correction of prominent ears using simple mattress sutures. Br J Plast Surg
16:170-178, 1963.
This classic paper describes suture fixation techniques for correction of ear prominence.
The relatively high recurrence rate with this procedure alone underscores the added ben-
efit of the initial conchal resection described in this chapter.
Stark RB, Saunders DE. Natural appearance restored to the unduly prominent ear. Br J Plast
Surg 15:385-397, 1962.
This article was a predecessor of the authors’ technique that described a combination
of otoabrasion of the posterior surface of the antihelix to soften the folding with poste-
rior suture fixation. As with other otoabrasion techniques, even with great care, irregu-
larities were still occasionally seen on the surface of the antihelix. There was also a higher
recurrence rate than seen with the current technique described in this chapter. Experi-
ence with this technique did demonstrate the accessibility of the posterior approach to
allow fine tuning of correction through varied suture placement.
Stenstrom SJ. A “natural” technique for correction of congenitally prominent ears. Plast Re-
constr Surg 32:509, 1963.
This is the classic paper on otoplasty describing anterior scoring of the antihelix to stim-
ulate the folding and shaping of the cartilage. It typifies the type of procedure that can
risk irregularities on the surface of the antihelix.
1855
Chapter 52  Refinements in Otoplasty Techniques

Suggested Readings
Adamson JE, Horton CE, Crawford HH. The growth pattern of the external ear. Plast Recon-
str Surg 36:466-470, 1965.
Bauer BS, Song DH, Aitken ME. Combined otoplasty technique: chondrocutaneous conchal
resection as the cornerstone to correction of the prominent ear. Plast Reconstr Surg
110:1033-1040, 2002.
Calder JC, Naasan A. Morbidity of otoplasty: a review of 562 consecutive cases. Br J Plast
Surg 47:170-174, 1994.
Elliott RA. Complications in the treatment of prominent ears. Clin Plast Surg 5:479-490,
1978.
Ely ET. An operation for prominence of the auricles. Arch Otolaryngol 10:97, 1881.
Farkas LG. Anthropometry of normal and anomalous ears. Clin Plast Surg 5:401-412, 1978.
Lavy J, Stearns M. Otoplasty: techniques, results, and complications—a review. Clin Oto-
laryngol 22:390-393, 1997.
Luckett WH. A new operation for prominent ears based on the anatomy of the deformity.
Surg Gynecol Obstet 10:635, 1910.
McDowell AJ. Goals in otoplasty for protruding ears. Plast Reconstr Surg 41:17-27, 1968.
Spira M, Stal S. The conchal flap: an adjunct in otoplasty. Ann Plast Surg 11:291-298, 1983.
Stal S, Klebuc M, Spira M. An algorithm for otoplasty. Oper Tech Plast Surg 4:88-103, 1997.
Weerda H. Surgery of the Auricle: Tumors, Trauma, Defects, Abnormalitites. New York:
Thieme, 2007.
1856
Part IX  Rejuvenation of the Cheeks, Chin, Lips, and Ears

RHINOPLASTY
PART X

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Applied Anatomy of the Nose

ROD J. ROHRICH, WILLIAM P. ADAMS, JR.,
JOEL E. PESSA, JACK P. GUNTER
CHAPTER 53

1860
Part X  Rhinoplasty
T
he nose consists of three elements: framework, support, and external cover. The
nasal framework consists of the skeletal components of cartilage and bone. Sup-
port is provided by connective tissue and ligaments that hold the framework together.
The skin and soft tissue provide the external covering of the nose. These components
are intricately related and must be anatomically visualized in every step of the rhino-
plasty sequence. In this chapter we will review the clinically relevant anatomy en-
countered in rhinoplasty.
Principles that must be adhered to in the anatomic sequence of a rhinoplasty include
the following:
1. Precise definition of anatomic goals preoperatively
2. Adequate anatomic exposure of the nasal deformity
3. Preservation/restoration of the normal anatomy
4. Correction of the specific deformity using incremental control
5. Maintenance/restoration of the nasal airway
The skin is thinner and more mobile in the upper two thirds of the nose and thicker
and more adherent in the distal third in the nasal lobule.
Vessels and nerves pass within the subcutaneous tissue above the muscle. It is im-
portant to note the type, texture, and sebaceous content of the skin, because these
will affect the final result. Overzealous alteration of the underlying framework in a
thin-skinned tip may have a long-term adverse outcome. In contrast, in a patient
with thick sebaceous skin, more aggressive alteration of the underlying framework
is possible, and necessary, to obtain significant tip definition.
Thinner skin
Thicker skin

Muscles
1861
Chapter 53  Applied Anatomy of the Nose
Although there are several nasal muscles, two are most clinically significant: the le-
vator alae and depressor septi muscles. The levator labii alaeque nasi assists in keep-
ing the external nasal valve open and can cause functional nasal obstruction with
facial paralysis if alar flaring is impaired. The depressor septi nasi, when clinically
significant, shortens the upper lip and can decrease tip projection on animation.
The nasal muscles interconnect so that animation of one affects the others. For ex-
ample, contraction of the lip elevators pulls the transverse nasalis. This has the effect
of opening the internal valve by distracting the upper lateral cartilages. Nasal air-
way patency is therefore also a function of dynamic muscle activity, in addition to
proper skeletal and cartilaginous support.
Levator labii
alaeque nasi
Depressor
septi nasi
Levator labii
alaeque nasi
Depressor
septi nasi
Levator alae
muscle
Depressor
septi muscles
Transverse
nasalis muscle
Levator labii
muscle
Alar piriform
muscle

In a cadaver study to define the anatomic variations of the depressor septi muscle,
we identified three types of depressor septi muscles. Type I depressor septi muscles
(62%) are visible and identifiable and can be traced to full interdigitation with the
orbicularis oris from their origin at the medial crural footplate.
Type II muscles (22%) are visible and identifiable, but unlike the first group, these
muscles insert into the periosteum and demonstrate little or no interdigitation with
the orbicularis oris. In type III muscles (16%), no muscle or only a rudimentary de-
pressor septi muscle is visible.
1862
Part X  Rhinoplasty
Type I
depressor
septi muscles
Alar piriform
muscle
TYPE II
Periosteum
22%
TYPE III
Diminutive
16%
TYPE I
Orbicularis oris
62%

Routine preoperative examination of rhinoplasty patients should easily identify those
who demonstrate a drooping nasal tip and shortened upper lip on animation, par-
ticularly when smiling. In such patients (types I and II) dissection and transposition
of the distal depressor septi muscles and suturing together of the cut ends reliably
and effectively correct this dynamic facial deformity. Dissection and transposition
rather than excision of tissue provide fullness to the central upper lip. Follow-up of
up to 2 years shows well-maintained aesthetic results without signs of relapse. Specifi-
cally, the technique achieves the following goals:
 Enhancement of the tip-lip relationship
 Relative upper lip lengthening
 Relative fullness to the upper lip
 Maintenance of tip rotation/projection on animation
Blood Supply
There has been concern, especially with the growing popularity of the external ap-
proach to rhinoplasty, that the transcolumellar incision may compromise the blood
supply to the nasal tip. However, one must take into account the considerable blood
supply to the nose, with contributions from both the internal and external carotid
arteries.
1863
Chapter 53  Applied Anatomy of the Nose
Angular artery
Lateral nasal artery
Arcades
Columellar branches
Superior labial artery
Facial artery
The ophthalmic artery and its branches, anterior ethmoids, dorsal nasal, and exter-
nal nasal arteries supply the proximal portion of the nose.

The nasal tip area is supplied primarily by branches of the facial artery, including
the superior labial and angular vessels, with the lateral nasal branch coursing above
the alar groove, and the columellar branches, which are branches of the superior
labial vessels. In this dissection, one can see that even the infraorbital artery provides
collateral supply to the tip via the nasal arcades.
1864
Part X  Rhinoplasty
Angular artery
Supratrochlear
artery
Alar arcades
Infraorbital artery
Facial artery
This vasculature has been confirmed by an angiographic study in 22 fresh cadaver
heads injected with lead oxide dye. The lateral nasal vessels were consistently iden-
tified 2 to 3 mm above the alar groove in this study. The columellar and lateral nasal
arteries arise deep at the nasal base and end in the subdermal plexus at the nasal tip
area. The lateral nasal artery was consistently present either bilaterally or unilater-
ally (100%). The presence of the columellar branches was noted 68.2% of the time;
however, there was a predictable crossover arcade between the lateral nasal and col-
umellar branches in 10 specimens in which a transcolumellar incision was made be-
fore the dye was injected.
Nasal arcades
Lateral nasal
artery

The clinical relevance of this study is twofold. First, it is excessive defatting that jeop-
ardizes the nasal tip supply. In nasal tip procedures the surgeon should reconstruct
the underlying framework to redefine the tip rather than defatting the nasal tip, which
is anatomically dangerous. The other clinical point is that collateral blood supply
enters the nose via the alar arcades. Prior incisions in this region can jeopardize col-
lateral supply to the nasal tip in secondary procedures.
Nasal Vaults
1865
Chapter 53  Applied Anatomy of the Nose
There are three nasal vaults: the bony, upper cartilaginous,
and lower cartilaginous vaults.
The bony vault consists of paired nasal bones as well as
the ascending frontal process of the maxilla, which make
up the proximal third to half of the nose.
The bones are comparatively narrow and thick above the
canthal level. The clinical correlation is that osteotomies
are rarely indicated above the canthal level, because it is
quite narrow and the bone is thick.
Bony Vault

1866
Part X  Rhinoplasty
Upper Cartilaginous Vault
The upper lateral cartilages underlie the nasal bones for 6 to 8 mm as well as the lower
lateral cartilages in the scroll area between the upper and lower lateral cartilages.
The keystone area is defined by the junction of the upper lateral cartilages with the
nasal bones and the septum. It is important to stress the relationship of the upper
and lateral cartilages to the septum, especially at the keystone area, where the contour
is T-shaped.
Upper lateral
cartilage
Lower lateral
cartilage
Septal angle

Loss of these intricate relationships results in the loss of the dorsal aesthetic lines
and a potential inverted-V deformity, as seen on frontal view.
Lower Lateral Cartilaginous Vault
1867
Chapter 53  Applied Anatomy of the Nose
The lower cartilaginous vault comprises the medial, middle, and lateral crura of the
lower lateral cartilage.
The support factors for tip projection are:
 Length and strength of lower lateral cartilage and piriform abutment
 Domal suspensory or piriform ligament
 Fibrous connections between the upper lateral and lower lateral cartilage
 Medial crural ligaments
 Anterior septal angle
In a fresh-cadaver study, Adams et al reported the clinical significance of different
structures for nasal tip support using open versus closed rhinoplasty techniques.
Multiple nasal manipulations using fresh cadaver heads, including cephalic trim,
Upper lateral
cartilage
T configuration
of keystone region
Piriform
abutment
Elastic fibers
Fibrous
connections
Suspensory
ligament

1868
Part X  Rhinoplasty
cephalic trim and interruption of the lower lateral cartilages, dorsal hump resection
(1 to 4 mm), submucous resection of the septum, and complete septal removal, were
performed using both the open and closed rhinoplasty approaches. Changes in nasal
tip support were recorded.
Comparing similar procedures, the mean loss of tip projection for the open approach
was 3.43 mm versus 1.98 mm for the closed approach (p 0.001). There was a sig-
nificantly larger loss of tip projection for the open versus the closed procedure for
cephalic trim, cephalic trim plus interruption of the lower lateral cartilage, and
cephalic trim/interruption of the lower lateral cartilage/septum removal (all three
p 0.001). The differences between the open and closed approaches were attributed
to an increase in ligamentous disruption using the open approach. Manipulation of
the septum in general resulted in greater losses of tip support for both the open and
closed approach.
The combination of skin, ligaments, and cartilage ultimately provides tip support.
As progressively more of these structures are disrupted, greater loss of tip projection
occurs.
Sheen subdivided the lower lateral cartilage into the medial, middle, and lateral crura.
The angle of divergence is formed by the domal angulation of the middle crus.
Piriform
ligament
Upper lateral
cartilage
Nasal bone
Lower lateral
cartilage
Accessory
cartilages
60°
Middle crus
Medial crus
Lateral crus
Angle of divergence

This is an important factor in determining tip type, specifically whether there is a
bulbous versus a boxy tip. The tip-defining points are important: these consist of two
equilateral triangles from the supratip area to the apex of the domes to the columellar
lobule angle. The surgeon must use these reference points in assessing tip definition
and identifying tip asymmetries. Furthermore, a classification system based on the
angle of divergence of the middle crura and the width of the domes can aid in the
diagnosis and treatment of nasal tip deformities.
Nasal Function
The functional portion of a nose comprises three areas: the septum, nasal valve areas,
and turbinates. The septum includes three primary components: the quadrangular
cartilage, the perpendicular plate of the ethmoid, and the vomer.
1869
Chapter 53  Applied Anatomy of the Nose
Septal cartilage
Perpendicular plate
Nasal crest
of maxilla
Vomer
30°
30°
30°
4 mm
TYPE I ANATOMY
Divergence angle 30°
Domal width 4 mm
TYPE II ANATOMY
Divergence angle normal
Domal width 4 mm
4 mm
TYPE III ANATOMY
Divergence angle 30°
Domal width 4 mm
4 mm
The bony septum is made of the perpendicular plate of the ethmoid, which is in con-
tinuity with the cribriform plate. When performing a septal reconstruction and re-
moving posterior septal deviations, the surgeon must perform a sidewise frac-

1870
Part X  Rhinoplasty
ture/separation removal of the bony part of the perpendicular plate of the ethmoid
so as not to remove or dislodge the cribriform plate, which can cause cerebrospinal
fluid rhinorrhea. The most projecting part of the premaxilla is the nasal spine, and it
very infrequently needs to be removed or altered. In contrast, the caudal portion of
the septum is the most protruding part of the columella and may need to be altered
if there is an alar-columellar discrepancy.
The internal nasal valve is defined as the junction between the septum and the cau-
dal border of the upper lateral cartilage. This angle is usually 10 to 15 degrees. This
must be preserved or reconstructed with a spreader graft in a primary or secondary
rhinoplasty.
Of the three turbinates, the inferior turbinates are the most significant functional
component in nasal airway breathing, and this occurs in the lower third of the nasal
airway. Submucous resection of the turbinate is indicated for airway correction and
yields excellent functional results.
Concluding Thoughts
Nasal anatomy is well defined, and knowledge of this anatomy enables the surgeon
to analyze nasal form and shape precisely. Operative goals can be defined to restore
normal anatomic relationships, preserving function while improving nasal aesthetics.
Internal
nasal valve