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

Janeke JB, Wright WK. Studies on the support of the nasal tip. Arch Otolaryngol 93:458-
464, 1971.
This is one of the first articles to delineate the support structure of the nose. They de-
fine four areas of support: the intercartilaginous ligament, the sesamoid complex, the
ligamentous sling between the lower lateral cartilages, and the attachment of the me-
dial crura to the caudal septum.
Rohrich RJ, Gunter JP, Friedman RM. Nasal tip blood supply: an anatomic study validating
the safety of the transcolumellar incision in rhinoplasty. Plast Reconstr Surg 95:795-799,
1995.
The nasal tip blood supply was studied through anatomic dissections and microan-
giography in 31 fresh cadaver specimens. Transcolumellar (external rhinoplasty) inci-
sions were performed in 11 of these cadavers before dye injection. A consistent crossover
flow (100%) was seen from the lateral nasal artery arcades to the distal aspect of the
transected columellar branches. We conclude that nasal tip blood supply is derived pri-
marily from the lateral nasal arteries, with a variable contribution from the columellar
arteries. Collateral flow to the nasal tip may be provided by branches of the ophthalmic
artery. The external rhinoplasty transcolumellar incision does not compromise nasal tip
blood supply unless extensive tip defatting or extended alar base resections (above the
alar groove) are performed.
Sheen JM. Achieving more nasal tip projection by use of a small autogenous vomer or septal
cartilage grafts. A preliminary report. Plast Reconstr Surg 56:35-40, 1975.
Sheen’s classic article describes the relationship of the nasal tip to the dorsum, empha-
sizing the supratip break and tip projection. He introduces the use of small pieces of au-
togenous cartilage and vomer and the shaping required to re-create the proper dorsum-
tip relationship, a clinical application of Peer’s early work on the transplantation of
autologous tissues.
Suggested Readings
Beekhuis GJ. Nasal septoplasty. Otolaryngol Clin North Am 6:693-710, 1973.
Bernstein L. A basic technique for surgery of the nasal lobule. Otolaryngol Clin North Am
8:599-613, 1975.
Dingman RO, Natvig P. The infracartilaginous incision for rhinoplasty. Plast Reconstr Surg
69:134-135, 1982.
Ford CN, Battaglia DG, Gentry LR. Preservation of periosteal attachment in lateral osteotomy.
Ann Plast Surg 13:107-111, 1984.
Gunter JP, Rohrich RJ. Management of the deviated nose. The importance of the septal re-
construction. Clin Plast Surg 15:43-55, 1988.
Hewell TS, Tardy ME. Nasal tip refinement. Facial Plast Surg 1:87-124, 1984.
Hilger JA. The internal lateral osteotomy in rhinoplasty. Arch Otolaryngol 88:211-212, 1968.
McCollough EG, Mangat D. Systematic approach to correction of nasal tip in rhinoplasty.
Arch Otolaryngol 107:12-16, 1981.
1872
Part X  Rhinoplasty

Millard DR. Alar margin sculpturing. Plast Reconstr Surg 40:337-342, 1983.
Peck GC. The onlay graft for nasal tip projection. Plast Reconstr Surg 71:27-39, 1983.
Pollock RA, Rohrich RJ. Inferior turbinate surgery: an adjunct to the successful treatment
of nasal obstruction in 408 patients. Plast Reconstr Surg 74:227-236, 1984.
Rohrich RJ, Huynh B, Muzaffar AR, et al. Importance of the depressor septi nasi muscle in
rhinoplasty: anatomic study and clinical application. Plast Reconstr Surg 105:376-383,
2000.
Sheen JH. Spreader graft: a method of reconstructing the roof of the middle nasal vault fol-
lowing rhinoplasty. Plast Reconstr Surg 73:230-239, 1984.
Sheen JH, Sheen AP. Aesthetic Rhinoplasty, 2nd ed. St Louis: Quality Medical Publishing,
1998.
Tardy ME, Denney JC. Micro-osteotomies in rhinoplasty. Facial Plast Surg 1:137-145, 1984.
1873
Chapter 53  Applied Anatomy of the Nose

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R
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Clinical Decision-Making
in Rhinoplasty

JEFFREY E. JANIS, JAMIL AHMAD, ROD J. ROHRICH
CHAPTER 54

Evaluation
When initially evaluating a potential patient for rhinoplasty, we resist the tempta-
tion to immediately launch into a comprehensive facial analysis, and instead con-
centrate on evaluating the patient’s desires and expectations. Proper patient selection
is vital to a successful outcome. Some patients will be dissatisfied with their postop-
erative result regardless of how well surgery has been executed. This emotional dis-
satisfaction supersedes technical failure as the most common cause of poorly per-
ceived results in our practice. (See Chapter 55 for additional discussion.)
To preoperatively identify potential problem patients, we ask patients to first elucidate
what issues they have. We encourage them to be as specific as possible, listing their
concerns in order of importance, and to do so in their own words. A handheld mir-
ror is useful in aiding them to pinpoint their areas of concern. The patient’s desires
are then documented verbatim in the chart. Frequently the patient will state his or
her desires in general terms: “I just want a better nose. What would you do?” This
has been a red flag in our practice, because it usually is a reflection of general dis-
satisfaction, poorly thought-out desires, or a poor self-image. We politely redirect
these patients in an attempt to ascertain what specifically bothers them about their
nose.
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Part X  Rhinoplasty
The surgeon should be wary of patients who express a disproportionate concern
about a minimal deformity. Regardless of the degree of deformity, however, if the
skill and expertise required to correct the deformity lie outside the surgeon’s techni-
cal ability, the patient should be referred to another surgeon who possesses the ap-
propriate knowledge and skill.

Other red flags in rhinoplasty include patients who desire a result that cannot be
predictably or reliably delivered or is outside the realm of the “aesthetic norm,” those
who appear to be angry or litigious as a result of a previous rhinoplasty, or where a
connection is not made between the surgeon and patient. This last criterion is ad-
mittedly vague, but we place a tremendous amount of stock in the development of
an interpersonal relationship with our patients, and if that relationship cannot be
forged, for whatever reason, then we decline to perform the operation. In other words:
Do not operate on a patient you don’t like.
Nasal History
A full and complete nasal history should be obtained, including any history of
trauma, previous nasal/septal/sinus surgeries, allergies and/or sinus problems, to-
bacco use, and illicit drug use. A list of current medications should also be obtained
(both nasal and nonnasal medications). Nonsteroidal antiinflammatory drugs
(NSAIDs), certain herbal supplements, and fish oil may increase bleeding complica-
tions after surgery and should be discontinued at least 7 to 10 days before a rhino-
plasty procedure.
Anatomic Features
Proper nasofacial analysis is paramount to a successful result. This not only includes
the nose proper, but also the nose within the context of the face, especially the lip-
chin complex. Each individual’s nose is different; therefore each operative plan should
be individualized. The development of the operative plan depends on native nasal
anatomy and morphology, its relative relationship to the rest of the face, and the pa-
tient’s goals and desires. Computer imaging is routinely used to help demonstrate
the potential outcome as well as to identify preoperative asymmetries for the patient.
However, it should be made clear to the patient that computer imaging does not
guarantee a specific result.
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Chapter 54  Clinical Decision-Making in Rhinoplasty
Nasal Analysis for Rhinoplasty
 Assess the level of patient concern versus the deformity.
 Identify potential problem patients.
 Assess the patient’s skin type, skin thickness, and skin texture.
 Analyze the relationship of the nose to the face based on anteroposterior, lateral, and
basal views.
 Perform an intranasal examination to assess functional aspects of the nose.

1878
Part X  Rhinoplasty
The type, thickness, and texture of the patient’s skin are assessed first. Thicker skin
tends to camouflage changes to the underlying osteocartilaginous framework and
thus may necessitate more aggressive manipulation of the underlying framework to
produce an appreciable change. Conversely, thinner skin tends to reveal even minor
changes to the underlying framework. We have found thinner-skinned patients more
challenging in general than thicker-skinned patients, because there is less room for
error. Patients with thicker, more sebaceous skin tend to have more postoperative
edema, especially in the tip or lobule area. This assessment of native skin quality will
factor into the development of the operative plan and the power of the techniques
selected to achieve the desired result (such as the use of grafts versus tip suturing
alone).
Next, a meticulous systematic analysis of the nose and face is performed. Initially
we evaluate potential anomalies of the underlying facial skeleton, including the max-
illomandibular relationship. The face is divided into thirds using horizontal lines ad-
jacent to the hairline, brow (at the level of the supraorbital notch), nasal base, and
menton. The upper third is the least important, because it is the most variable. The
lower third of the face is then subdivided into thirds by visualizing a horizontal line
between the oral commissures (stomion). The upper third of this subdivision lies be-
tween the nasal base and the oral commissures, and the lower two thirds between
the commissures (stomion) and the menton. If disproportions exist, the patient may
have underlying craniofacial anomalies (such as vertical maxillary excess) that may
need to be addressed.
1/3
1/3
1/3
1/3
2/3
1/3
1/3
1/3
2/3
1/3

The nasal length (radix-to-tip distance, or RT) should be equivalent to the stomion-
to-menton distance (SM), as described by Byrd and Hobar.
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Chapter 54  Clinical Decision-Making in Rhinoplasty
A natural horizontal facial plane is determined by drawing a line perpendicular to
a plumb line superimposed over the head in repose and the eyes in straightforward
gaze. This will be used as a future reference for further analysis.
The lip-chin relationship is assessed by dropping a vertical line from a point one half
the ideal nasal length tangential to the vermilion of the upper lip. The lower lip should
lie no more than 2 mm behind this line. The ideal chin position varies with sex, with
the chin lying slightly posterior to the lower lip in women, but equal to the lower lip
in men. If there is a discrepancy in these relationships, orthodontics, orthognathic
surgery, or a chin implant may be necessary to improve facial harmony.
Natural horizontal
facial plane
Natural horizontal
facial plane
R
T
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A
R
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Nasal Deviation
1880
Part X  Rhinoplasty
Nasal deviation is then assessed by drawing a line from the midglabellar area to the
menton, bisecting the nasal ridge, upper lip, and Cupid’s bow. In patients with nor-
mal occlusion, this line will also pass between the central incisors. Any deviation of
the nose from this line typically indicates an underlying septal deviation that will
need to be addressed during surgery to correct the deformity.
Dorsum
The nasal dorsum is then assessed on anteroposterior or frontal photographs of the
patient. The curvilinear dorsal aesthetic lines are traced from where they originate
at the supraorbital ridges to the tip-defining points, slightly diverging from each other
along the dorsum during their course. Ideally, the width of the dorsal aesthetic lines
should match the width of either the tip-defining points or the interphiltral distance.
These lines may be ideal, narrow, wide, asymmetrical, or ill defined.

Bony Base
1881
Chapter 54  Clinical Decision-Making in Rhinoplasty
The width of the bony base relative to the alar base is then assessed. The bony base
width should be 80% of the normal alar base width, and a normal alar base width
is equal to the intercanthal distance, or the width of the palpebral fissure. If the bony
base is greater than 80% of the alar base width (assuming the alar base width is nor-
mal), it is likely that osteotomies will be required to narrow the bony base. Because
men tend to have a wider bony base than women, it is important not to make the
dorsum overly narrow in men, because this could feminize the nose.
Alar Base
The alar base itself is analyzed as well as the alar
rim morphology. If the alar base width is greater
than the intercanthal distance, it must be determined
whether this is the result of a narrow intercanthal
distance, a true increased interalar width, or alar
flaring. If the intercanthal distance is smaller than
one eye width, it is better to maintain a slightly
wider alar base. If there is true increased interalar
width, a nostril sill resection may be indicated. If
the increase in width is secondary to alar flaring
(more than 2 to 3 mm outside the alar base), an alar
base resection should be considered. The alar rims
should also be assessed for symmetry and should
flare slightly outward in the inferolateral direction.

1882
Part X  Rhinoplasty
While the frontal view is still being addressed, the tip is assessed to determine the
supratip break, the tip-defining points, and the columellar-lobular angle. These points
serve as landmarks to draw two equilateral triangles with their bases opposed. If
these triangles are asymmetrical, the underlying reason should be investigated, and
the patient will likely require tip modification.
Alae
The final assessment on frontal view is of the outline of the alar rims and the col-
umella, which should resemble a seagull in gentle flight, with the columella lying just
inferior to the alar rims. If the curve is too steep, the patient likely has an increased
infratip lobular height that will need correction. On the other hand, if the curve is flat-
tened, it is likely the patient has decreased columellar show, which may require col-
umellar augmentation or alar rim modification. Facets of the soft tissue triangles should
be noted, because these may require alar contour grafts to prevent alar notching.

Basal View
1883
Chapter 54  Clinical Decision-Making in Rhinoplasty
1/3
2/3
ANTEROPOSTERIOR/FRONTAL ASSESSMENT OF THE NOSE AND FACE
ASSESS AP/
FRONTAL VIEW,
DIVIDING FACE
INTO THIRDS
Nasal deviation
Disproportion
within lower
third of face
Underlying craniofacial
anomalies may exist that
need addressing
Assess dorsal
aesthetic lines
Assess alar base,
compared with inter-
canthal distance
Tip-defining points
and supratip break
Alar rim outline
and columella
Septal surgery needed
with multiple options
available to straighten
Compare dorsum width to tip, interphiltral distance,
or alar base. If dorsum width is more than 80% of alar
base, or wider than tip, or wider than philtrum . . .
Consider infracture
nasal osteotomy
If alar base is wider, then
decrease width of nasal sill
Improve with tip suturing or
tip grafting as needed
Depending on relationships,
columella and/or rim may
need modification
The basal view of the nose is addressed next, with the outline of the nasal base de-
scribing an equilateral triangle with a lobule-to-nostril ratio of 1:2. The nostril itself
should have a teardrop-like geometry, with the long axis from the base to the apex
oriented in a slight medial direction.

1884
Part X  Rhinoplasty
Lateral View
The lateral view is analyzed, beginning with the position and depth of the nasal root
at the radix. The nasofrontal angle connects the brow and dorsum through a soft
concave curve. The apex of this angle should lie between the upper lid eyelashes and
the supratarsal fold, with the eyes in a natural horizontal gaze. Although this angle can
vary from 128 to 140 degrees, it is ideally 134 degrees in women and 130 degrees in
men. Other important reference measurements from this view include the nasion–
medial canthal distance, which should be approximately 15 mm, and the nasion–
corneal plane distance, which is approximately 11 mm.
While still concentrating on the lateral view, the surgeon must remember that the
perceived nasal length and tip projection can be altered by the position of the na-
sofrontal angle. For instance, if the nasofrontal angle is positioned more anteriorly
and superiorly than normal, the nose will appear elongated, the nasofacial angle will
be decreased, and the tip projection will appear diminished (yellow line). On the
other hand, if the nasofrontal angle is positioned too posteriorly and/or inferiorly,
the nose will appear shorter, and the tip more projecting (red line). Ideally, the na-
sofacial angle (as defined by the junction of the nasal dorsum with the vertical fa-
cial plane) should measure 32 to 37 degrees.

Tip Projection
1885
Chapter 54  Clinical Decision-Making in Rhinoplasty
The examiner addresses tip projection next, while looking at the lateral view. Al-
though several methods have been described to assess this, we prefer the following
two ways. In a patient with normal upper lip projection, we begin by drawing a line
from the alar-cheek junction to the tip of the nose. The tip projection is considered
normal if 50% to 60% of the tip lies anterior to a vertical line adjacent to the most
projecting part of the upper lip. The tip is considered to be overprojecting if more
than 60% of the tip lies anterior to this reference line and may therefore require de-
projection. Conversely, if less than 50% of the tip lies anterior to the line, the pro-
jection may need to be augmented (in any number of ways).
The second method we use to help assess tip projection is to compare it with the alar
base width (they should be equal) (left), and compare the ratio of nasal length (radix-
to-tip, RT) to the tip projection (alar base-to-tip). In the latter, the ideal tip projec-
tion is 0.67  RT (right).
A
B
A  50%-60%
of AB
A
B
A  B
1.0
0.67

After the tip projection is assessed, the dorsum is analyzed. The aesthetic nasal dor-
sum should lie approximately 2 mm behind and parallel to a line from the radix to
the tip-defining points in women, but in men it should be slightly higher to avoid
feminizing the nose.
The degree of supratip break is appraised when the nasal tip projection and dorsum
are evaluated. A slight supratip break is preferred in women but not in men. This
gives the nose more definition and distinguishes the dorsum from the tip.
1886
Part X  Rhinoplasty
The nasolabial angle is used to determine the degree of tip rotation. This angle is ob-
tained by measuring the angle between a line coursing through the most anterior
and posterior edges of the nostril and a plumb line dropped perpendicular to the
natural horizontal facial plane. This angle should be 95 to 100 degrees in women
and 90 to 95 degrees in men.
Natural horizontal
facial plane
95°-100°

The nasolabial angle should not be confused with
the columellar-labial angle, which is formed at
the junction of the columella with the upper
lip/infratip lobule. Increased fullness in this area
is usually caused by a prominent caudal septum
and gives the illusion of increased rotation, even
though the nasolabial angle is normal. This an-
gle is normally 30 to 45 degrees.
1887
Chapter 54  Clinical Decision-Making in Rhinoplasty
LATERAL ASSESSMENT OF THE NOSE
ASSESS
LATERAL
VIEW
Assess nose length
Assess lip-chin
relationship
If discrepant, employ orthodontics, orthognathics,
chin implant, or genioplasty as needed
Assess tip projection
based on relationship
with line from alar-
cheek junction to
nasal tip
Assess nasal dorsum
with line from radix to tip
Assess tip rotation based
on nasolabial angle
Assess alar-columellar
relationship
If too long, shorten via tip setback or caudal trim
of septum, or use a septal extension graft
if too short
May also assess
tip projection by
comparing it to
alar base width
or nasal length
Reduce or augment
dorsum as needed
Modify tip-to-lip
relationship
accordingly
Classify abnormality
and treat accordingly
If too short, lengthen via tip advancement/rotation,
septal spreader graft, or dorsal graft
If 60% of tip is
anterior to reference
line, decrease tip
projection
If 50% of tip is
above reference line,
increase tip projection
Tip setback, resect
base of lower laterals
or base of medial crura
Use tip sutures, tip
advancement, tip graft,
columellar strut
Include supratip
break in this analysis
Remember sex and age
differences and consider
quality of upper lip
30°-45°

The alar-columellar relationship is then assessed (lateral and frontal views). A line is
drawn through the long axis of the nostril, and a perpendicular line is drawn from
the alar rim to the columellar rim that bisects this axis. The distance from the alar
rim (point A) to the long-axis line (point B) should equal the distance between the
long-axis line and the columellar rim (point C) if the alar-columellar relationship
(ACR) is normal (AB  BC  2 mm).
If these measurements are not normal, the deformity can be categorized into six
classes. Classes I to III describe increased columellar show, whereas classes IV to VI
demonstrate decreased columellar show. These may be treated differently, depend-
ing on the class of deformity.
1888
Part X  Rhinoplasty
Normal ACR

The above proportions generally apply to white women. Generally, the male face
tends to have a squarer, less rounded appearance, with stronger, more pronounced
features. The key differences in men are as follows:
 The male dorsum tends to be straighter and wider, with decreased concavity
at the superciliary ridges.
 The male nasal dorsal profile should hug a line drawn from the radix to the
tip-defining points instead of falling 2 mm behind and parallel to this line, as
seen in women.
 There should be no supratip break.
 The tip rotation in men is slightly less than in women (90 to 95 degrees ver-
sus 95 to 100 degrees in women), inasmuch as men have less nostril show as a
result of a longer nasal dorsum.
 Men have a stronger chin, abutting the plumb line drawn tangential to the up-
per lip (versus 2 to 3 mm posterior to this line in women).
 In general, men have a broader, more bulbous nasal tip.
 Male skin is usually thicker, masking the amount of change that can be seen.
1889
Chapter 54  Clinical Decision-Making in Rhinoplasty
Hanging columella
Type I
A
B
C
Retracted ala
Type II
A
B
C
Combination of I and II
Type III
A
B
C
Hanging ala
Type IV
A
B
C
Combination of IV and V
Type VI
A
B
C
Retracted columella
Type V
A
B
C

1890
Part X  Rhinoplasty
NOTE: These proportions are general guidelines and will vary within sex and race.
They are only meant to be used as a systematic method of analysis of general pro-
portions and relationships. The plan for each nose should be individualized to the
patient’s facial structure and tempered by the patient’s desire to create nasofacial
harmony and balance.
The final but equally important part of the preoperative analysis of a rhinoplasty
patient is the intranasal examination. This is performed with a nasal speculum, head-
light, and vasoconstriction. Intranasal examination should focus on evaluation of
the external nasal valve, internal nasal valve, the septum, inferior turbinates, and
should rule out the presence of polyps or masses.
The external nasal valve is evaluated for collapse, and a Cottle test is performed to
assess the function of the internal nasal valve. The septum should be evaluated for
septal deviation or perforation. According to Guyuron, there are six classifications
of septal deviation, with septal tilt being the most common.
If inferior turbinate hypertrophy is identified, the underlying cause should be inves-
tigated. Inferior turbinate enlargement can be congenital or acquired. If acquired, it
is most commonly secondary to septal deviation but may also be the result of auto-
nomic, environmental, medical, or anatomic factors. A complete workup, especially
a detailed history, is required. The presence of polyps or masses may require further
evaluation.
Medical
Inflammatory
Hyperthyroidism
Pregnancy
Rhinitis medica-
mentosus
Environmental
Allergic rhinitis
Dust
Tobacco
Autonomic
Vasomotor rhinitis
Sexual stimulation
Emotions
Anatomic
Associated with
deviated nasal
septum*
Congenital
*Deviation of nasal septum may also be congenital.
Acquired
CAUSES OF INFERIOR TURBINATE HYPERTROPHY

Surgical Approach
There are two basic incisional approaches to rhinoplasty: the open technique and
the closed, or endonasal, technique. Each has its staunch proponents, and each has
been used successfully in the practice of rhinoplasty.
1891
Chapter 54  Clinical Decision-Making in Rhinoplasty
Systematic Approach to Rhinoplasty Planning*
 A thorough history should be taken, with emphasis on past facial or nasal surgery,
facial/nasal trauma, nasal function, and ease of breathing.
 The patient’s desired nasal shape and aesthetic outcome are systematically delineated.
 An intranasal examination is done with a headlight and speculum.
 Imaging is performed: anteroposterior, lateral, and basal views.
 The images are reviewed with the patient, emphasizing what is and is not surgically
possible.
 A systematic, surgeon-directed review of imaging forms the basis of a line-by-line surgi-
cal plan.
 The surgical plan is reviewed with the patient before surgery.
 The surgical plan is carried out.
*All secondary and posttraumatic rhinoplasties are performed using an open approach; a closed approach is consid-
ered for isolated dorsal deformities or minor tip modifications.
Open
Endonasal
Approach
Approach
Binocular visualization


Evaluation of complete deformity without distortion


Precise diagnosis and correction of deformities


Direct control of bleeding


Nasal incision


Operative time


Prolonged nasal tip edema


Choosing the Best Option
Degree of effectiveness indicated by the number of pluses.
The open approach involves a transcolumellar incision, which can assume varying
geometries, depending on the surgeon’s preference. We prefer a stairstep configura-
tion, because it lends itself well to realignment and facilitates reapproximation while

breaking up the scar (preventing contracture deformities and camouflaging the re-
sult). The open approach also involves skeletonizing the underlying osteocartilagi-
nous framework, which gains enormous exposure for its manipulation and correction
of deformities.
The closed, or endonasal, approach can be performed using a cartilage delivery ap-
proach or a nondelivery approach. The delivery approach involves an intercartilagi-
nous incision, a marginal incision, and either a transfixion or hemitransfixion inci-
sion with subsequent transposition of the lower lateral cartilages to a location outside
of the skin envelope. A nondelivery approach uses either a transcartilaginous inci-
sion or an eversion (retrograde) incision, with the lower lateral cartilages remaining
in their native positions. Manipulation and modification of the osteocartilaginous
framework are then carried out, although the skin envelope is not reflected, as in the
open approach.
We perform the vast majority of our operations using the open approach, because
it affords excellent exposure and control, grants the ability to manipulate the osteo-
cartilaginous framework under direct visualization, and has minimal negative con-
sequences, other than an external scar and occasional prolonged tip edema, which
resolves in virtually all of our patients. We are able to obtain predictable and repro-
ducible results using this type of approach. Furthermore, we think the tradeoff of in-
creased accuracy and versatility using the open approach is worth the tradeoff of an
external scar that typically heals very well. We rarely have a patient who objects to the
transcolumellar scar, since it usually is invisible at conversation distances.
We reserve a closed approach for isolated deformities of the dorsum or when minor
tip modifications are necessary. However, all secondary rhinoplasties and posttrau-
matic rhinoplasties are performed exclusively with the use of the open approach in
our hands.
1892
Part X  Rhinoplasty
Minor tip modifications
Isolated deformity of
the dorsum
*Open approach affords excellent exposure of all major components of the nose.
CHOOSING THE BEST APPROACH: OPEN VERSUS CLOSED
Any secondary procedure
Posttraumatic rhinoplasty
Any primary rhinoplasty
requiring more than one
maneuver
Difficult tip
Closed approach
Open approach*

Concluding Thoughts
The evolution of rhinoplasty has been long; advances in analysis and techniques have
led to the ability to produce a predictable result, yet rhinoplasty remains one of the
most challenging procedures in all of plastic surgery. Just as there is a fine line (per-
haps only 1 or 2 mm) between an excellent result and a good one, the line is just as
fine between an acceptable and an unacceptable result. The surgeon must become
familiar with nasal anatomy and the limitations of techniques used to manipulate
that anatomy. Complications may result (either from iatrogenic injury or from ad-
verse cicatricial formation) that will require secondary revision. The surgeon should
be able to address these complications as well, or at least know his or her own lim-
itations and refer the patient to someone who can rectify the problem.
Much has been made about the incisional approach throughout this evolution. At
one point, most rhinoplasties were performed using the closed approach. The pen-
dulum swung to favor the open approach and now has settled somewhere in be-
tween, as is the case with most concepts in plastic surgery. In the end, the surgeon
should choose the approach that he or she is most comfortable with. Furthermore, it
cannot be overemphasized that the proportions and relative relationships introduced
in this chapter must be individualized to every patient. There is no cookie-cutter or
cookbook approach to rhinoplasty. The ultimate successful result will be determined
by proper patient selection, the ability to accurately diagnose the deformity and gen-
erate an operative plan, and the capacity to execute that plan in a predictable, reli-
able, and reproducible fashion based on the principles described here.
Annotated Bibliography
Byrd HS, Hobar PC. Rhinoplasty: A practical guide for surgical planning. Plast Reconstr
Surg 91:642-654; discussion 655-656, 1993.
An excellent article that describes nasofacial analysis using objective reference points.
Gorney M, Martello J. Patient selection criteria. Clin Plast Surg 26:37-40, 1999.
A useful review of patient selection criteria and the features characteristic of poor can-
didates that should be avoided.
Gunter JP, Rohrich RJ, Adams WP Jr, eds. Dallas Rhinoplasty: Nasal Surgery by the Mas-
ters, 2nd ed, vols I and II. St Louis: Quality Medical Publishing, 2007.
A comprehensive text on all aspects of rhinoplasty. Renowned contributors make this
an essential reference for rhinoplasty surgeons of all experience levels.
Rohrich RJ, Janis JE, Kenkel JM. Male rhinoplasty. Plast Reconstr Surg 112:1071-1085; dis-
cussion 1086, 2003.
A comprehensive discussion of proper evaluation of the male rhinoplasty patient, sur-
gical planning, intraoperative techniques, and postoperative treatment.
1893
Chapter 54  Clinical Decision-Making in Rhinoplasty

Suggested Readings
Byrd HS, Hobar PC. Rhinoplasty: a practical guide for surgical planning. Plast Reconstr Surg
91:642-654; discussion 655-656, 1993.
Daniel RK. Rhinoplasty and the male patient. Clin Plast Surg 18:751-761, 1991.
Daniel RK, Lessard ML. Rhinoplasty: a graded aesthetic-anatomical approach. Ann Plast
Surg 13:436-451, 1984.
Farkas LG, Kolar JC, Munro IR. Geography of the nose: a morphometric study. Aesthetic
Plast Surg 10:191-223, 1986.
Farkas LG, Kolar JC, Munro IR. Inclinations of the facial profile: art versus reality. Plast Re-
constr Surg 75:509-519, 1985.
González-Ulloa M, Castillo A, Stevens E, et al. Preliminary study of the total restoration of
the facial skin. Plast Reconstr Surg 13:151-161, 1954.
Gorney M. Patient selection in rhinoplasty. In Daniel RK, ed. Aesthetic Plastic Surgery: Rhino-
plasty. Boston: Little Brown, 1993.
Gorney M, Martello J. Patient selection criteria. Clin Plast Surg 26:37-40, 1999.
Gunter JP. Rhinoplasty. In Courtiss EH, ed. Male Aesthetic Surgery, 2nd ed. St Louis: Mosby,
1990.
Gunter JP, Hackney FL. Clinical assessment and facial analysis. In Gunter JP, Rohrich RJ,
Adams WP Jr. Dallas Rhinoplasty: Nasal Surgery by the Masters, 2nd ed. St Louis: Qual-
ity Medical Publishing, 2007.
Guyuron B, Uzzo CD, Scull H. A practical classification of septonasal deviation and an ef-
fective guide to septal surgery. Plast Reconstr Surg 104:2202-2209; discussion 2210-
2212, 1999.
Howard BK, Rohrich RJ. Understanding the nasal airway: principles and practice. Plast Re-
constr Surg 109:1128-1146, 2002.
Kasperbauer JL, Kern EB. Nasal valve physiology. Implications in nasal surgery. Otolaryn-
gol Clin North Am 20:699-719, 1987.
Loomis A. Drawing the Head and Hands. New York: Viking Press, 1956.
Rohrich RJ, Adams WP Jr, Gunter JP. Advanced rhinoplasty anatomy. In Gunter JP, Rohrich
RJ, Adams WP Jr. Dallas Rhinoplasty: Nasal Surgery by the Masters, 2nd ed. St Louis:
Quality Medical Publishing, 2007.
Rohrich RJ, Gunter JP, Deuber MA, Adams WP Jr. The deviated nose: optimizing results us-
ing a simplified classification and algorithmic approach. Plast Reconstr Surg 110:1509-
1523, 2002.
Rohrich RJ, Gunter JP, Shemshadi H. Facial analysis for the rhinoplasty patient. Dallas Rhino-
plasty Symp 13:67, 1996.
Rohrich RJ, Janis JE, Kenkel JM. Male rhinoplasty. Plast Reconstr Surg 112:1071-1085; dis-
cussion 1086, 2003.
Wright MR. The male aesthetic patient. Arch Otolaryngol Head Neck Surg 113:724-727,
1987.
1894
Part X  Rhinoplasty

Cartilage-splitting
incision
Transfixion
incision
CHAPTER 55
Primary Rhinoplasty

JEFFREY E. JANIS, JAMIL AHMAD, ROD J. ROHRICH

R
hinoplasty is one of the most complex and challenging operations in plastic
surgery. The rhinoplasty surgeon must have a thorough understanding of the
three-dimensional anatomy of the nasal region, a proficiency in nasal and facial analy-
sis, and a firm grasp of the core concepts in manipulating nasal soft tissues, carti-
lage, and bone. The surgeon must also be able to visualize the dynamic interplay be-
tween these structures and have an aesthetic eye to craft a result that will produce a
balanced, harmonious nose in relationship to the rest of the face. The initial opera-
tion is critical to the long-term result, because the tissues are virginal and undistorted
by prior operative procedures.
Evolution of Technique
Aesthetic rhinoplasty has its roots in nasal reconstruction. The first recorded treat-
ment of nasal injuries dates back to approximately 3000 BC, as recorded on the
Egyptian Edwin Smith surgical papyrus. Reconstructive surgery for nasal deformi-
ties is described as early as 600 BC by Sushruta. After a long period of quiescence
during the Dark Ages, descriptions of nasal reconstruction again appeared as the
Renaissance brought forth advances in science and medicine. The Indian methods
for nasal reconstruction with forehead and cheek skin were practiced and modified
by Italian surgeons into the Italian method, using arm skin to reconstruct the nose.
In the early nineteenth century, German surgeons including Carl von Graefe and Jo-
hann Friedrich Dieffenbach continued to develop methods for nasal reconstruction;
Dieffenbach was one of the first to describe nasal surgery for aesthetic improvement
of the nose.
John Orlando Roe, an American otolaryngologist, is credited with describing the
first aesthetic rhinoplasty and introducing the endonasal approach. In 1887, Roe pub-
lished “The Deformity Termed ‘Pug Nose’ and Its Correction, by a Simple Opera-
tion” and in 1891, “The Correction of Angular Deformities of the Nose by a Sub-
cutaneous Operation.” Roe’s descriptions preceded those of Jacques Joseph, a
German orthopedic surgeon often regarded as the father of modern rhinoplasty,
given his contribution to the analysis, classification, and repair of various nasal de-
formities, outlined in his two-volume textbook on plastic surgery of the nose.
In the first half of the twentieth century, the emergence of plastic surgery as a spe-
cialty was spurred forward by experience gained reconstructing devastating war in-
juries. The second half of the twentieth century saw significant contributions to the
rhinoplasty literature, with gains in preoperative assessment and diagnosis, man-
agement of the nasal airway, cartilage-grafting techniques, and popularization of the
open approach to rhinoplasty. The open approach was first described by Aurel Réthi
1896
Part X  Rhinoplasty

of Budapest in 1921 but did not gain popularity. In the 1960s his approach was re-
discovered by Ante Sercer of Zagreb and introduced to North America by his asso-
ciate, Ivo Padovan, in 1970. William Goodman of Toronto was the first North Amer-
ican to adopt the open approach, and this technique has gained in popularity since
the 1980s.
Indications and Contraindications
Rhinoplasty can be performed for many indications, which fall along a spectrum
from purely functional to purely aesthetic. However, each individual’s nasal anatomy
must be taken into account when deciding whether the patient is a good surgical
candidate, and what approach should be used to address the problem. No single ap-
proach is appropriate for all situations.
Obviously, there can be great advantages for the patient when rhinoplasty is prop-
erly performed. Patients who suffer from nasal airway obstruction can achieve sig-
nificant amelioration, if not total eradication, of their symptoms. Frequently these
patients have had difficulty breathing for several years. Whether the deformity is con-
genital or traumatic, patient satisfaction is extremely high after corrective surgery is
performed.
Similarly, a patient who undergoes rhinoplasty for purely aesthetic reasons stands
to benefit significantly with respect to self-image and self-esteem after a successful
rhinoplasty. One must be wary, however, of patients who perceive a significant de-
formity in themselves when the deformity appears minor to the surgeon. Such pa-
tients may never be satisfied with the outcome, no matter how well the rhinoplasty
is executed (see Chapter 1). Multiple preoperative visits are necessary to completely
understand not only what the patient desires, but also to confirm whether the pa-
tient’s expectations are realistic.
The Open Versus the Endonasal Approach
In modern rhinoplasty, both the open and the endonasal (closed) approach have
their staunch proponents. The open approach continues to gain in popularity over
the endonasal approach for both primary and secondary rhinoplasty. There are ad-
vantages and disadvantages to both techniques, with the correct approach deter-
mined by the patient’s anatomic deformity and the surgeon’s experience. Clearly,
what is performed to alter the underlying anatomy is far more important than the
type of incision used.
1897
Chapter 55  Primary Rhinoplasty

1898
Part X  Rhinoplasty
Despite the disadvantages to the open approach, in our experience we have not had
patient dissatisfaction related to these specific factors, other than prolonged nasal
tip edema. As long as the expectation level is set preoperatively, this has not proved
to be a problem.
Those who favor the endonasal approach to rhinoplasty submit that the advantages
offered by the open approach are outweighed by its disadvantages.
We prefer the open approach, in general, because it provides full visualization of the
nasal framework to more accurately diagnose the cause of the nasal airway ob-
struction or the aesthetic deformity. Manipulation of the various structures, from
the dorsum to the septum to the tip, can be done with precision and can yield re-
producible results. We strongly recommend the open approach when addressing a
posttraumatic deformity or in secondary/revisional surgery, as well as when com-
plex tip modifications are necessary.
Open Rhinoplasty Approach Rationale
Distinct Advantages
Potential Disadvantages
Binocular visualization
External nasal incision (transcolu-
Evaluation of complete deformity without distortion
mellar scar)
Precise diagnosis and correction of deformities
Prolonged operative time
Allows use of both hands
Protracted nasal tip edema
More options with original tissues and cartilage grafts
Columellar incision separation
Direct control of bleeding with electrocautery
Delayed wound healing
Suture stabilization of grafts (invisible and visible)
Endonasal Approach
Advantages
Disadvantages
Leaves no external scar
Requires experience and great reliance
Limits dissection to areas needing modification
on accurate preoperative diagnosis
Permits creation of precise pocket so graft material
Prohibits simultaneous visualization of
fits exactly without need for fixation
the surgical field by a teaching surgeon
Allows percutaneous fixation when large pockets
and students
are made
Does not allow direct visualization of
Promotes healing by maintaining vascular bridge
nasal anatomy
Encourages accurate preoperative diagnosis and
Makes dissection of alar cartilages diffi-
planning
cult, particularly in cases of malposition
Produces minimal postsurgical edema
Reduces operating time
Results in fast patient recovery
Creates intact tip graft pocket

We find the endonasal approach to be advantageous in patients with an isolated dor-
sal hump deformity or when minimal modification of the tip is required. In these
instances, we prefer access through a marginal incision (approximately 1 mm cepha-
lad to the caudal margin of the lateral crus). We combine this with an intercarti-
laginous incision in cases of minor tip refinement to allow adequate cartilage deliv-
ery and exposure. If the caudal septum needs to be corrected as well, we perform a
concomitant hemitransfixion or transfixion incision.
Pertinent Anatomy
As in every other area in plastic surgery, thorough knowledge of anatomy is para-
mount to obtaining a superior result. The nose is divided into external skin and soft
tissue, the underlying osteocartilaginous framework, and ligamentous support. Rhino-
plasty surgeons must be familiar with each structure’s native morphology and its
variants and must have an appreciation for the dynamic interplay between the com-
ponents.
Skin
1899
Chapter 55  Primary Rhinoplasty
The thickness, mobility, and sebaceous character of the nasal skin vary along its
length, with the upper two thirds being thinner, more mobile, and less sebaceous
than the inferior third. The nasal dorsum thickness averages approximately 1300 mi-
crons, whereas the lobule skin thickness averages 2400 microns. A straight dorsum ac-
tually has a slight underlying convexity of its osteocartilaginous framework in the
cephalic area; therefore a straight dorsal profile is actually produced by the combi-
nation of this convexity in the osteocartilaginous framework with the variation in
dorsal skin thickness.
Thinner skin
Thicker skin

1900
Part X  Rhinoplasty
Some ethnic subgroups, such as those of African descent, Hispanics, and those of
Mediterranean descent, can have thicker, more sebaceous skin. These differences are
important, because the skin over the underlying nasal framework can either reveal
or mask changes depending on its characteristics. For instance, it is advisable to err
on the conservative side when operating on a white woman with thin skin compared
with a man of African descent with thick, sebaceous skin. More dramatic manipu-
lation to the underlying nasal framework will be necessary in the patient with thick
skin to obtain an appreciable change in the external appearance.
Muscle
Levator labii
alaeque nasi
Depressor
septi nasi
Two muscles, in particular, are important in rhinoplasty—the levator labii alaeque
nasi and the depressor septi nasi. The levator labii alaeque nasi helps to maintain the
patency of the external nasal valve, whereas the depressor septi nasi, if overactive, can
shorten the upper lip, cause a transverse upper lip crease, and alter tip projection.
Evaluation of the depressor septi nasi is routine in our preoperative assessment. Its
effect on depressing the nasal tip and shortening the upper lip can be appreciated in
some patients on animation (especially when smiling). In the subgroup of patients
in whom this muscle significantly alters the nasal appearance, we dissect and trans-
pose the muscle. By doing so, several goals are achieved:
1. Enhancement of the tip-lip relationship
2. Relative upper lip lengthening
3. Relative fullness to the upper lip
4. Maintenance of tip rotation/projection on animation

Blood Supply
1901
Chapter 55  Primary Rhinoplasty
The blood supply to the nose is derived both from branches of the ophthalmic ar-
tery and branches of the facial artery. It is important to note the vascularity to the
nasal tip because an open rhinoplasty approach using a transcolumellar incision will
transect the columellar vessels (when present), leaving the lateral nasal and dorsal
nasal arteries as the remaining blood supply. In our 1995 study, we found the lateral
nasal arteries to be present (either singularly or bilaterally) in 100% of cases, with
the columellar branches present 68.2% of the time. Since the lateral nasal vessels are
found approximately 2 to 3 mm above the alar groove, extended alar resections to
this level are prohibited, because injury to these vessels after the transcolumellar ap-
proach would severely compromise blood flow to the nasal tip. Furthermore, one
must be extremely cautious when debulking the nasal tip after an open approach,
because the subdermal vascular plexus connecting the dorsal nasal and lateral nasal
blood supplies may be damaged, leading to a similarly disastrous result, with necro-
sis of the nasal tip skin.
Tardy and Toriumi studied the vascular and lymphatic anatomy of the nose and de-
termined that the transcolumellar incision itself did not compromise major venous
or lymphatic outflow. Furthermore, they recommend dissection just above the peri-
chondrium in the deep areolar plane, leaving the musculoaponeurotic layer intact,
which preserves the major arterial vascular supply and avoids damage to the venous
and lymphatic vasculature that lies in a more superficial (subcutaneous) plane. In
this way, bleeding and postoperative edema are minimized.
Angular artery
Lateral nasal artery
Arcades
Columellar branches
Superior labial artery
Facial artery

1902
Part X  Rhinoplasty
Nasal Vaults
The osteocartilaginous nasal framework can be subdivided into three separate vaults:
bony, upper cartilaginous, and lower cartilaginous. The bony vault constitutes the
upper third to half of the nose and is made up of the paired nasal bones and the as-
cending frontal process of the maxilla. It is important to note that the nasal bones
are narrowest and thickest above the level of the medial canthi. As a result, os-
teotomies are rarely indicated above this level.
The upper cartilaginous framework begins where the nasal bones overlap the upper
lateral cartilages (ULCs) and septum for 4 to 6 mm, creating what is known as the
keystone area. This area should be the widest part of the dorsum, and resembles a
T shape in cross-section. The remainder of this vault is composed of the paired ULCs
and dorsal cartilaginous septum. Overresection during dorsal hump reduction in this
area can lead to deformities such as the inverted-V deformity and/or disruption of
the dorsal aesthetic lines. A component dorsal hump reduction is advised to avoid
these complications.

The lower cartilaginous framework begins where the ULCs interdigitate with the
lower lateral cartilages (LLCs) in what is called the scroll area. The lower lateral car-
tilages comprise the medial, middle, and lateral crura. These cartilages are connected
to each other, the ULCs, and the septum by fibrous tissue and ligaments. Disruption
of these ligaments can result in diminished tip projection during rhinoplasty. Thus
if these structures are violated, maneuvers that increase tip support (for example,
columellar struts, extended spreader grafts, batten grafts, suture techniques) may be
necessary.
Nasal Function
1903
Chapter 55  Primary Rhinoplasty
The septum, turbinates, and internal and external nasal valves serve as the anatomic
functional foundation for the nose, contributing to respiration, filtration, humidifi-
cation, temperature regulation, and protection. The septum is made up of the septal
cartilage, the perpendicular plate of the ethmoid, the nasal crest of the maxilla, and
the vomer.
Piriform
abutment
Elastic fibers
Fibrous
connections
Suspensory
ligament
Septal cartilage
Perpendicular plate
Nasal crest
of maxilla
Vomer

1904
Part X  Rhinoplasty
Deformities in the septum can lead to significantly impaired airflow through the nose,
as well as compensatory turbinate pathology. When addressing septal deformities,
it is important to assess all septal components. When performing a septal resection,
it is important to remember that the perpendicular plate of the ethmoid is contigu-
ous with the cribriform plate posterosuperiorly. Therefore, a sidewise fracture of the
perpendicular plate should be performed with care to prevent iatrogenic fracture of
the cribriform plate and its untoward consequences (for example, cerebrospinal fluid
rhinor rhea, potential ascending infection/meningitis). Restoration of a normal straight
septum will help reestablish laminar airflow.
The turbinates help to guide the transport of air during respiration and condi-
tion/humidify inspired and expired air. These structures are mucosa-lined extensions
of the lateral nasal cavity, and undergo a normal autonomically mediated cycle of ex-
pansion and contraction. Of all the turbinates, however, it is the inferior turbinate that
has the greatest impact on airway resistance, providing up to two thirds of the total
airway resistance from its most anterior aspect. However, overresection of the ante-
rior inferior turbinate can have a deleterious effect on its regulatory and physiologic
functions, and can lead to crust formation, bleeding, and nasal cilia dysfunction.
Middle turbinate
Parasagittal view of lateral nasal wall
Superior
turbinate
Inferior
turbinate

The internal nasal valve can contribute up to 50% of the total airway resistance, and
is the narrowest segment of the nasal airway. It is composed of the angle formed by
the intersection of the nasal septum and the caudal margin of the upper lateral car-
tilage, and is usually 10 to 15 degrees. In some cases, the anterior portion of the in-
ferior turbinate may be a significant contributor to the decrease in the cross-sectional
area of this region. Patients with short nasal bones and long, poorly supported ULCs
have a propensity to have collapse at this area. Traditionally, lateral traction on the
cheek (positive Cottle’s sign) diagnoses collapse of the internal nasal valve and sig-
nals the need for spreader grafts to increase the valve angle and stent the airway open.
The external nasal valve is the cartilaginous vestibule bounded by nares and lateral
alar sidewalls. It is caudal to the internal valve. Obstruction at this area may be caused
by foreign bodies, weak or collapsed lower lateral cartilages, loss of vestibular skin,
or scar tissue. Several options are available to reestablish proper airflow through this
area, including alar contour grafts, lateral crural strut grafts, lateral crural cephalic
turnover flaps, lysis of adhesions, scar revision, mucosal grafts, skin grafts, or com-
posite grafts.
Preoperative Assessment
Initial Consultation
Before proceeding with a rhinoplasty, it is important to completely evaluate the pa-
tient’s motivations and expectations for surgery to determine whether the patient is
a suitable surgical candidate. Gunter and Gorney have both commented on “danger
signs” that may be exhibited by certain patients. Patients that meet these criteria
should be approached with caution because surgical intervention may not be in the
1905
Chapter 55  Primary Rhinoplasty
Nasal valve
Valve angle
Head inferior
turbinate
10°-15°
Internal
valve
External
valve

1906
Part X  Rhinoplasty
best interests of either the patient or the surgeon. Gunter identified the following 13
danger signs that may signify underlying psychological issues:
1. Minimal disfigurement
2. Delusional distortion of body image
3. Identity problem or sexual ambivalence
4. Confused or vague motives for wanting surgery
5. Unrealistic expectations of change in life situation as a result of surgery
6. History of poorly established social and emotional relationships
7. Unresolved grief or currently in a crisis situation
8. Present misfortunes blamed on physical appearance
9. Older neurotic man who is overly concerned about aging
10. Sudden dislike for one’s anatomy, especially in an older man
11. A hostile, blaming attitude toward authority figures
12. History of consulting physicians and being dissatisfied with them
13. Indication of paranoid thoughts
Similarly, Gorney uses two systems to identify potential problem patients. The first
uses the acronym SIMON (single immature males, overly expectant, narcissistic) to
describe certain traits to be wary of. The second method Gorney uses plots the pa-
tient’s concern on one axis and the degree of deformity on the other. Patients with
an appropriate amount of concern relative to their degree of deformity are excellent
candidates for treatment. However, those with minimal deformity but dispropor-
tionate concern should be avoided, because frequently their expectations exceed the
amount of aesthetic improvement that is possible. Furthermore, regardless of the de-
gree of deformity, if the level of skill and expertise required to perform the rhino-
plasty exceeds the surgeon’s ability, the patient should be referred to a more profi-
cient surgeon.

It should also be noted that men in general tend to have a poorer understanding of
their deformity than women do. Furthermore, they tend to have a more difficult time
elucidating the changes they want. Thus, for this subgroup of patients, during the
initial consultation the physician must determine the patient’s goals and whether
they are realistic. A second follow-up consultation is recommended to reiterate the
patient’s desires, develop a realistic operative plan, and reaffirm the patient’s under-
standing of the anticipated procedure.
Although there are different methods for integrating the patient into the surgical
process, we find that computer imaging provides an excellent way for patients to
gain a realistic understanding of the anticipated outcome. Although the images are
not meant to guarantee surgical results, they do provide a visual level of under-
standing that may otherwise be lacking. These images, combined with standardized
anterior, lateral, oblique, and basal photographs, serve as an integral element of the
preoperative surgical plan.
Facial Analysis
Another critical element to proper preoperative surgical planning is critical facial
analysis. Each individual nose has different proportions, morphology, and relative
relationship with the surrounding face. To preserve nasofacial harmony, it is crucial
to perform a systematic and meticulous analysis of the nose and face to accurately
diagnose the deformity and then to determine the optimal surgical plan to correct
the problem. It is also important to point out natural facial asymmetries to the pa-
tient preoperatively so the patient gains a better understanding of what was actually
present before any operative intervention is performed.
We begin by evaluating the patient’s skin type, thickness, and texture. As previously
mentioned, this is important because thicker, more sebaceous skin tends to camou-
flage changes made to the underlying osteocartilaginous framework, whereas thinner
skin tends to show even minor changes.
We then proceed with the remainder of the facial analysis. There are some propor-
tions and relationships of facial structures that make up an “attractive” face. Al-
though more proportions have been described, the following are some of the fun-
damental relationships that we routinely use in our preoperative evaluation of the
rhinoplasty patient. We will describe these relationships briefly for white women and
point out when the proportions differ between men and women.
1907
Chapter 55  Primary Rhinoplasty

1908
Part X  Rhinoplasty
We start by evaluating for disproportions and anomalies of the underlying facial
skeleton, including the maxillomandibular relationship. To do this, we divide the
face into thirds using horizontal lines adjacent to the hairline, brow (at the level of
the supraorbital notch), nasal base, and menton. The upper third (between the hair-
line and the brow) is the least important as it is the most variable (depending on the
hairstyle). The lower third of the face is then subdivided into thirds by visualizing a
horizontal line between the oral commissures (stomion). The upper third of this sub-
division lies between the nasal base and the oral commissures, and the lower two
thirds between the commissures (stomion) and the menton. If there are significant
deviations from this, the patient may have underlying craniofacial disproportion (i.e.,
vertical maxillary excess) that may need to be addressed in addition to rhinoplasty.
The nasal length (radix to tip, or RT) is verified against the stomion-to-menton dis-
tance (SM), which should be equal, as was described by Byrd and Hobar.
1/3
1/3
1/3
1/3
2/3
1/3
1/3
1/3
2/3
1/3
R
T
S
M
A

For future reference, a natural horizontal facial plane is determined by drawing a
line perpendicular to a plumb line superimposed over the head in repose and the
eyes in straightforward gaze. As the external auditory canal position may differ be-
tween patients, this line may or may not correspond to Frankfort’s line.
The lip-chin relationship is assessed next. Byrd determines ideal chin projection by
dropping a vertical line from a point one half the ideal nasal length tangential to the
vermilion of the upper lip. The lower lip should be no more than 2 mm behind this
line. The ideal chin position varies with gender, with the chin lying slightly posterior
to the lower lip in women but equal to the lower lip in men. If there is a discrepancy
in these relationships, orthodontics, orthognathic surgery, or a chin implant may be
necessary to improve facial harmony.
1909
Chapter 55  Primary Rhinoplasty
Nasal deviation is noted by drawing a line from the
midglabellar area to the menton, bisecting the nasal
ridge, upper lip, and Cupid’s bow. This line will pass
between the central incisors in patients with nor-
mal occlusion. Any deviation of the nose from this
line will likely require septal surgery.
Natural horizontal
facial plane
Natural horizontal
facial plane

1910
Part X  Rhinoplasty
The nasal dorsum is then assessed on frontal (an-
teroposterior) view. The curvilinear dorsal aesthetic
lines are traced from where they originate at the
supraorbital ridges, and then follow along the cor-
rugators to converge at the medial canthal liga-
ments, from which they flare slightly at the keystone
area. From this point, they track to the tip-defining
points, slightly diverging from each other along the
dorsum during their course. Ideally, the width of the
dorsal aesthetic lines should match the width of ei-
ther the tip defining points or the interphiltral dis-
tance. These lines may be ideal, narrow, wide, asym-
metrical, or ill-defined.
The width of both the bony base and the alar base are then assessed. The width of
the bony base should be 80% of the normal alar base width (which typically is equal
to the intercanthal distance), or the width of the palpebral fissure. If the bony base
is greater than 80% of the alar base width (assuming the alar base width is normal),
it is likely that osteotomies will be required to narrow the bony vault. Although men
tend to have a wider bony base than women, it is important not to narrow the dor-
sum too much in males, since this could feminize the nose.

The alar base is analyzed, as is the geometry of the alar rims. If the alar base width
is greater than the intercanthal distance, it must be determined if this is the result of
a narrow intercanthal distance, a true increased interalar width, or alar flaring. If
the intercanthal distance is smaller than the width of the palpebral fissure, it is bet-
ter to maintain a slightly wider alar base. If there is true increased interalar width, a
nostril sill resection may be indicated. If the increase in width is secondary to alar
flaring (greater than 2 to 3 mm outside the alar base), an alar base resection should
be considered. Again, the alar rims should also be assessed for symmetry, and should
flare slightly outward in the inferolateral direction.
1911
Chapter 55  Primary Rhinoplasty
While still addressing the frontal view, the surgeon assesses the tip to determine the
supratip break, the tip-defining points, and the columellar-lobular angle. These points
serve as landmarks to draw two equilateral triangles with their bases opposed. If
these triangles are asymmetrical, the underlying reason should be investigated, and
the patient will likely require tip modification.

The final assessment on frontal view is of the outline of the alar rims and the col-
umella, which should resemble a seagull in gentle flight, with the columella lying just
inferior to the alar rims. If the curve is too drastic, the patient probably has an in-
creased infratip lobular height, which will need correction. If, on the other hand, the
curve is flattened, the patient probably has decreased columellar show, which may
require columellar augmentation or alar rim modification.
The basal view of the nose is addressed next, with the outline of the nasal base de-
scribing an equilateral triangle with a lobule-to-nostril ratio of 1:2. The nostril itself
should have a teardrop-like geometry, with the long axis from the base to the apex
oriented in a slight medial direction.
The lateral view is then analyzed, beginning with the position and depth of the nasal
root at the radix. The nasofrontal angle connects the brow and the dorsum through
a soft concave curve at the radix. The apex of this angle should lie between the up-
per lid eyelashes and the supratarsal fold, with the eyes in natural horizontal gaze.
Although this angle can vary from 128 to 140 degrees, it is ideally 134 degrees in
women and 130 degrees in men. Other important reference measurements from this
view include the nasion-medial canthal distance, which should be approximately
15 mm, and the nasion-corneal plane distance, which is approximately 11 mm.
1912
Part X  Rhinoplasty
1/3
2/3

While still concentrating on the lateral view, it is important to remember that the
perceived nasal length and tip projection can be altered by the position of the afore-
mentioned nasofrontal angle. For instance, if the nasofrontal angle is positioned more
anteriorly and superiorly than normal, the nose will appear elongated, the nasofa-
cial angle will be decreased, and the tip projection will appear diminished (yellow
line). Conversely, if the nasofrontal angle is too posteriorly and/or inferiorly posi-
tioned, the nose will appear shorter, and the tip more projecting (red line). Ideally,
the nasofacial angle (as defined by the junction of the nasal dorsum with the verti-
cal facial plane) should measure 32 to 37 degrees.
1913
Chapter 55  Primary Rhinoplasty
Tip projection is addressed next, still from the lateral view. Although several meth-
ods have been described to assess this, we prefer the following two ways. In a pa-
tient with normal upper lip projection, we begin by drawing a line from the alar-
cheek junction to the tip of the nose. The tip projection is considered normal if 50%
to 60% of the tip lies anterior to a vertical line adjacent to the most projecting part
of the upper lip. The tip is considered to be overprojected if greater than 60% of the
A
B
A  50%-60%
of AB

1914
Part X  Rhinoplasty
tip lies anterior to this reference line and may therefore require deprojection. Con-
versely, if less than 50% of the tip lies anterior to the line, the projection may need to
be augmented (in any number of ways).
The second method we use to help assess tip projection is by comparing it to the
alar base width (they should be equal), and by comparing the ratio of nasal length
(RT) to the tip projection (alar base to tip). In the latter, the ideal tip projection is
0.67  RT.
After the tip projection is assessed, the dorsum is analyzed. The aesthetic nasal dor-
sum should lie approximately 2 mm behind and parallel to a line from the radix to
the tip-defining points in women, but in men it should approach this line to avoid
feminizing the nose.
A
B
A  B
1.0
0.67

The degree of supratip break is appraised when the nasal tip projection and dorsum
are evaluated. A slight supratip break is preferred in women, but not in men. This
gives the nose more definition and distinguishes the dorsum from the tip.
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Chapter 55  Primary Rhinoplasty
The nasolabial angle is used to determine the degree of tip rotation. This angle is ob-
tained by measuring the angle between a line coursing through the most anterior
and posterior edges of the nostril and a plumb line dropped perpendicular to the
natural horizontal facial plane. This angle should be between 95 and 100 degrees in
women and between 90 and 95 degrees in men.
The nasolabial angle should not be confused with the columellar-labial angle, which
is formed at the junction of the columella with the upper lip–infratip lobule. In-
creased fullness in this area is usually caused by a prominent caudal septum and gives
the illusion of increased rotation, even though the nasolabial angle is normal. This
angle is normally 30 to 45 degrees.
Natural horizontal
facial plane
95°-100°
30°-45°

The alar-columellar relationship is then assessed in the lateral and frontal views.
A line is drawn through the long axis of the nostril, and a perpendicular line is drawn
from alar rim to columellar rim that bisects this axis. The distance from the alar rim
(point A) to the long axis line (point B) should equal the distance between the long
axis line to the columellar rim (point C) if the alar-columellar relationship is normal
(AB  BC  2 mm). If these measurements are not normal, the deformity can be
categorized into six classes. Classes I to III describe increased columellar show, classes
IV to VI demonstrate decreased columellar show (described later in the section on
operative techniques). These may be treated differently depending on the class of
deformity.
Again, these proportions generally apply to white women. Generally, the male face
tends to have a squarer, less rounded appearance, with stronger, more pronounced
features. The key differences in men are as follows:
 The male dorsum tends to be straighter and wider, with decreased concavity
at the superciliary ridges.
 The male nasal dorsal profile should hug a line drawn from the radix to the
tip-defining points instead of falling 2 mm behind and parallel to this line, as
in women.
 There should be no supratip break.
 Tip rotation in men is slightly less than in women (90 to 95 degrees versus 95
to 100 degrees in women), because men have less nostril show as a result of a
longer nasal dorsum.
 Men have a stronger chin, abutting the plumb line drawn tangential to the up-
per lip; in women the chin is 2 to 3 mm posterior to this line.
 In general, men have a broader, more bulbous nasal tip.
 Male skin is usually thicker, masking the amount of perceivable change.
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Part X  Rhinoplasty
Normal ACR

It is important to remember that these proportions are general guidelines and can
vary tremendously between different individuals. In addition, it is important to con-
sider the patient’s ethnicity and culturally accepted aesthetic ideals as rhinoplasty is
becoming increasingly more popular amongst different ethnic groups.
Rhinoplasty in Patients of African Descent
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Chapter 55  Primary Rhinoplasty
Compared with the nasal ideals for whites, the noses of patients of African heritage
typically feature a wide, low nasal dorsum, decreased nasal length and tip projec-
tion, poor nasal tip definition, an acute columellar-labial angle, and alar flaring.
The goals of rhinoplasty in a patient of African descent include achieving a narrower,
straight dorsum, improved tip projection and definition, decreasing alar flaring and
alar base width. Improvement of the typically low nasal dorsum may require cartilage
grafting. Tip definition is improved by suture techniques and cartilage grafting, as
needed.
Wide dorsum
Ill-defined tip
Alar flaring
Diminished tip
definition
Low radix
Decreased
nasal length
Acute columellar-
labial angle
Narrower
dorsum
Tip refinement
Slight alar
flaring

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Part X  Rhinoplasty
Rhinoplasty in Patients of Middle Eastern Descent
The complex nasal morphology of the Middle Eastern nose warrants discussion: it
demonstrates a combination of features seen in individuals of African, Mediter-
ranean, and Hispanic origin. The Middle Eastern nose features thick, sebaceous skin
and is most prominent at the supratip. The radix may overproject, the bony and mid-
dle vaults tend to be wide, and a significant dorsal hump is common. The lower lat-
eral cartilages can feature malposition of the lateral crura and weak middle and me-
dial crura, resulting in various characteristic deformities of the tip, including poor
tip definition, underprojection of the tip, or a droopy tip with an acute columellar-
labial angle. The tip deformities may be exacerbated by hyperdynamic depressor septi
nasi muscles. Nasal deviation and nostril asymmetry are also common.
Achieving ethnic nasofacial harmony in a Middle Eastern patient includes moder-
ate dorsal hump reduction, narrowing of the wide nasal bones, debulking of soft tis-
sue, particularly at the supratip, modest correction of underrotation and underpro-
jection of the nasal tip, improvement of tip definition, repositioning of the alar bases,
and correction of nostril asymmetries.
Wide nasal bones
Ill-defined
bulbous tip
Bulky infratip
lobule
Slight alar
flaring
Overprojecting radix
High dorsum
Acute columellar-
labial angle
Elastic
fibers
Piriform
abutment
Suspensory
ligaments
Supratip
and lobular
fibrofatty
excess
Footplate/medial crural fatty tissue
Fibrofatty
connections

These guidelines are meant only as a systematic method of analysis with general pro-
portions and relationships. Each nose should be individualized to the patient’s facial
structure and tempered by the patient’s desires to create facial harmony and balance.
Intranasal Examination
The final part of the preoperative analysis of the rhinoplasty patient is the intranasal
examination. This is performed with a nasal speculum, headlight, and vasocon-
striction. The septum, turbinates, and external and internal nasal valves are evalu-
ated for obvious deformities or pathology. Septal perforation or deviation should be
identified. Septal deviation can involve deviation of the septal cartilage, perpendic -
ular plate of the ethmoid bone, or vomer and can cause obstruction of one or both
of the nasal airways, along with external deviation of the nose. Guyuron et al clas-
sified septal deviation as follows:
1. Septal tilt 40%
2. Anteroposterior C-shaped deviation 32%
3. Cephalocaudal C-shaped deviation 4%
4. Anteroposterior S-shaped deviation 9%
5. Cephalocaudal S-shaped deviation 1%
6. Localized deviation or septal spur 14%
Septal tilt is the most common type, where the quadrangular cartilage and perpen-
dicular plate of the ethmoid are straight but the quadrangular cartilage is tilted to
one side internally and to the opposite side externally. Hypertrophy of the inferior
turbinate contralateral to the side of internal deviation is usually present.
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Chapter 55  Primary Rhinoplasty

If inferior turbinate hypertrophy is identified, the underlying cause should be inves-
tigated. Turbinate enlargement can be congenital or acquired. If acquired, it may be
the result of autonomic, environmental, medical, or anatomic factors. A complete
workup, especially a detailed history, is essential. The external nasal valve should be
examined for patency on normal and forced inspiration. Collapse of the alar rim
from weakness of the lower lateral crus should be evaluated. A Cottle test should be
performed to assess the internal nasal valve. Septal deviation or midvault collapse
can contribute to airway obstruction in this area. Finally, nasal polyps or masses may
require further evaluation and treatment.
Preoperative Planning
After the initial history-taking and physical examination, the procedure is fully dis-
cussed with the patient. The risks and benefits of the procedure are detailed, and all
questions are answered. The patient is provided with a written, detailed estimate of
surgical charges with complete explanations by the practice’s billing staff. We ask the
patient to return for a second clinic visit to review the previous discussion and to as-
sess the patient’s psychological and emotional stability to ensure that he or she is a
good surgical candidate. We also reiterate the deformities we plan to correct and an-
swer any further questions. The consent form is reviewed again and signed. Our pa-
tients sign a form accepting financial responsibility. A preoperative instruction sheet
and a list of medications to be avoided are also provided.
1920
Part X  Rhinoplasty