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

ministered, the nasal vibrissae are clipped and the nares are swabbed with povidone-
iodine (Betadine) solution.
We mark a line for the anticipated incision (transcolumellar stairstep, if using an
open approach) and then inject approximately 10 ml of 1% lidocaine with 1:100,000
epinephrine into the intranasal mucosa, along the septum, and into the soft tissue
envelope. The inferior turbinates are injected if we anticipate performing an inferior
turbinoplasty.
1922
Part X  Rhinoplasty
Location and Volume Distribution of 1% Lidocaine
With 1:100,000 Epinephrine
Location
Amount (ml)
Vestibules/aperture
2
Dorsum
1
Lateral walls
2
Tip/columella
2
Distal septum
2
Inferior turbinates
1
TOTAL
10
After the local anesthetic is injected, the nasal mucosa is shrunk with cottonoid pled-
gets soaked in oxymetazoline. A drop of methylene blue is added to the oxymetazo-
line to differentiate this from the local anesthetic and prevent inadvertent injection.
We do not use 4% cocaine, because comparable hemostasis can be obtained using
lidocaine with oxymetazoline, avoiding the use of a controlled substance with po-
tential cardiac effects that may be seen with cocaine, although certainly both have
proved effective. A throat pack is placed in the oropharynx to prevent possible in-
gestion of blood during surgery, which could lead to postoperative nausea and vom-
iting. At this point the patient is prepared and draped for surgery.
Operative Technique
Incision: Endonasal Approach
When deciding on what incision to use in the endonasal approach, once again the
surgeon must employ accurate preoperative nasofacial analysis. Because the objec-
tive is to minimize incisions, any incision that can be used to access multiple areas
should be used so that separate incisions become unnecessary. For example, if an
alar contour graft will be needed as well as rasping of a dorsal hump, the access in-
cision can be made on the same side as the alar contour graft.

There are two basic techniques for access in endonasal rhinoplasty: nondelivery and
delivery. The nondelivery approach can use either a transcartilaginous (cartilage-
splitting) incision or a retrograde or eversion incision. The transcartilaginous inci-
sion is made several millimeters cephalad to the caudal margin of the lateral/middle
crura, thus preserving a rim strip to support the ala. Double hook retraction com-
bined with digital alar eversion provides the necessary exposure to facilitate this.
1923
Chapter 55  Primary Rhinoplasty
The vestibular skin is carefully dissected off the overlying cartilage to expose the car-
tilage for resection. In the retrograde approach, the vestibular incision is made at the
most cephalic margin of the lower lateral cartilage rather than through it. Again, a
double hook retractor and digital manipulation are used to facilitate exposure. The
theoretical advantage to this incision is that it maintains the caudal alar margins and
prevents potential scar contracture deformities in this area.
Cartilage-splitting
incision
Transfixion
incision

1924
Part X  Rhinoplasty
The delivery approach is used in cases in which moderate tip modifications are nec-
essary, especially if the angle of divergence (as a measure of tip bifidity) is large.
Again, using a double hook retractor in the ala and digital counterpressure to ex-
pose the cartilaginous margins, a No. 15 blade scalpel is used to create an intercar-
tilaginous incision starting laterally just above the cephalic margin of the lateral crus.
It is extended medially approximately 2 mm caudal and parallel to the limen vestibule.
An infracartilaginous incision is then created along the caudal margin of the lower
lateral cartilage (from lateral crus to medial crus), ending at the columellar-lobular
junction. Sharp scissors are then used to dissect the soft tissue off the cartilage just
above the perichondrium, including over the dorsal cartilaginous septum. The same
incision is made on the contralateral side, and the two incisions are connected in the
midline over the anterior septal angle, ending in a hemitransfixion incision. If nec-
essary, this may be extended to a full (complete) transfixion incision. The lower lat-
eral cartilage is then dissected free from the surrounding tissue and “delivered” out-
side the incision. If there is difficulty delivering the cartilages, the incisions may be
extended and the soft tissue undermined to a greater extent. Once the cartilages (and
domes) are delivered, modifications may be made.
Incision: Open Approach
In the open approach, we use a stairstep transcolumel-
lar incision across the narrowest portion of the columella
with a No. 15 blade scalpel. The stairstep is important,
because it helps to provide landmarks for accurate clo-
sure, prevents linear scar contracture, and camouflages
the scar.
Intercartilaginous
incision
Transfixion
incision
Marginal
incision
4
55-1 Open approach
to primary
rhinoplasty

Bilateral infracartilaginous extensions are then performed. These begin first from lat-
eral to medial along the caudal border of the lower lateral cartilage, then from me-
dial to lateral, from the level of the transcolumellar incision to the apex of the mid-
dle crus, where it joins the lateral incision. A double-pronged skin hook placed along
the alar rim is used to perform this maneuver. External digital pressure is used to
evert the ala and augment visualization of the lateral crus.
Important points during this step are as follows:
 Take your time—most mistakes are made trying to obtain exposure.
 Keep the incisions superficial to prevent unnecessary injury to the underlying
cartilages.
 Identify the caudal border of the lower lateral cartilage before cutting.
Skin Envelope Dissection
1925
Chapter 55  Primary Rhinoplasty
Dissection of the skin envelope should be done meticulously. As mentioned previ-
ously, it is important to perform the dissection in the supraperichondrial/submus-
culoaponeurotic plane, because this avoids injury to the arterial, venous, and lym-
phatic supply to the nose. There should be no residual soft tissue remaining on the
lower lateral cartilages if the dissection is performed properly. This dissection is then
continued in a superior direction, exposing the cartilaginous dorsum and ULCs. At
the level of the bony pyramid, the scissors are traded for a Joseph periosteal eleva-
tor, which continues the dissection in a subperiosteal plane to the radix. It is im-

1926
Part X  Rhinoplasty
portant to limit the extent of the subperiosteal dissection to just the area of the bony
dorsal hump that needs to be addressed; otherwise, all the periosteal attachments to
the nasal bones may be disrupted, leading to prolonged wound healing and poten-
tial nasal bone malposition, especially after osteotomy.
Key points are as follows:
 Take your time—it is easier to go slowly through the correct dissection than
to spend more time fixing mistakes from inadvertent mishaps resulting from
haste.
 Stay just above the perichondrium in the submusculoaponeurotic plane.
 Limit lateral subperiosteal dissection over the bony pyramid.
 Make certain the ULCs are not detached from the nasal bones by accidental
dissection under the nasal bones (rather than on top).
Nasal Dorsum
We prefer to perform component dorsal hump reduction of the osteocartilaginous
hump instead of composite reduction because component reduction offers incre-
mental control and greater precision. This process involves four basic steps, after the
skin envelope dissection just described:
 Separation of the ULCs from the septum
 Incremental reduction of the septum proper
 Incremental dorsal bony reduction (using a rasp)
 Three-point palpation test
Separation of the Upper Lateral Cartilages From the Septum
To minimize mucosal trauma that could result in internal nasal valve stenosis or
vestibular webbing, it is critical to create bilateral dorsal submucoperichondrial tun-
nels before embarking on reduction of the dorsal hump. This is done by elevating

the mucoperichondrium of the dorsal septum from caudal to cephalad with a Cottle
elevator until the nasal bones are reached. The transverse processes of the ULCs are
then sharply separated from the septum using a No. 15 blade scalpel without dam-
aging the mucosa. If necessary, spreader grafts or dorsal grafts can then be placed in
this enclosed space, separated from the nasal cavity (later in the case).
Incremental Component Cartilaginous Dorsal Septal Reduction
At this point, the cartilaginous dorsal septum is separated into three components:
the septum centrally and the transverse portions of the ULC laterally. The cartilagi-
nous septum is addressed by serially shaving down the dorsal hump deformity with
a sharp scalpel under direct vision. This maneuver is done carefully, avoiding damage
to the adjacent ULCs. If the septum and ULCs were taken down en bloc, not in com-
ponent fashion, the patient will end up with a rounded dorsum. Furthermore, if the
ULCs were resected to a greater extent relative to the septum, an inverted-V defor-
mity will result. Although reduction of the ULCs is not routinely performed, it may
be necessary in certain circumstances. If so, it must be done after the septal carti-
laginous hump and bony dorsal hump are addressed. Again, overresection of the
ULCs must be avoided to prevent internal nasal valve collapse and long-term dorsal
irregularity. Maintaining the transverse portions of the ULC also preserves the dor-
sal aesthetic lines.
Component Bony Dorsum Reduction
1927
Chapter 55  Primary Rhinoplasty
The method of reducing the bony dorsum depends on the amount of deformity that
requires resection. Large humps (generally greater than 5 mm) are reduced either by
a power burr with a dorsal skin protector or a guarded 8 mm osteotome. For humps
smaller than 5 mm, a sharp rasp is used (we prefer a down-biting diamond rasp).
When rasping, it is important to maintain a slightly oblique bias to minimize po-
tential mechanical avulsion of the ULCs from the nasal bones. The rasping is done
in a controlled, methodical fashion, proceeding along the left and right dorsal aes-
thetic lines, and then centrally. The nondominant thumb and index finger are used
simultaneously for maximum control.

Three-Point Dorsal Palpation Test
1928
Part X  Rhinoplasty
The three-point dorsal palpation test is performed repeatedly throughout the com-
ponent dorsal hump reduction process, after redraping the skin envelope. This test
is performed with a saline-moistened dominant index fingertip, which is used to gen-
tly palpate the left and right dorsal aesthetic lines, as well as centrally, to detect any
dorsal irregularities or contour depressions.
Septal Reconstruction/Cartilage Graft Harvest
If the septum is deformed, or if cartilage is needed for graft construction, the sep-
tum is harvested. The septum is ideal for cartilage graft harvest in rhinoplasty be-
cause of its close proximity to the operating field and its minimal donor site mor-
bidity. In the endonasal approach, a Killian or hemitransfixion incision is generally
used because a full transfixion incision can lead to decreased tip projection, espe-
cially if dissected down over the anterior nasal spine.
In the open approach, the cartilage harvest is begun by separating the middle crura,
incising the interdomal suspensory ligament, and exposing the anterior septal angle.
A No. 15 blade scalpel is used to incise the septal perichondrium, exposing the dis-
tinct bluish-gray underlying cartilage (1). A Cottle elevator is used to create a sub-
mucoperichondrial plane posteriorly to the perpendicular plate of the ethmoid (2)
down to the nasal floor (3) and across the face of the septum (4).

If the dissection is difficult at first, it may be because the improper plane has been
accessed, and a deeper plane should be sought. The dissection should be more diffi-
cult at the junction of the cartilaginous and bony septum, and therefore one should
proceed with caution in this area because perforation of the overlying mucoperi-
chondrium is more likely. It may be advantageous to dissect two separate tunnels,
one subperichondrial and one subperiosteal, and then divide the junction sharply to
help avoid potential perforation in this area. The same dissection is then performed
on the contralateral side. After this is complete, a Vienna speculum is used to directly
visualize both sides of the septum to identify underlying deformity and to help achieve
exposure for the septal harvest.
1929
Chapter 55  Primary Rhinoplasty
Classification of the Deviated Nose
 Type I: Caudal septal deviation
a. Straight septal tilt
b. Concave deformity (C-shaped)
c. S-shaped deformity
 Type II: Concave dorsal deformity
a. C-shaped dorsal deformity
b. Reverse C-shaped dorsal deformity
 Type III: Concave/convex dorsal deformity (S-shaped)
When harvesting septal cartilage, it is necessary to
preserve an L-strut with 10 mm of dorsal septum
and 10 mm of caudal septum retained to support
the lower nasal vault. After the cartilage is resected,
it is preserved in saline solution. Any residual devi-
ations in the ethmoid or vomer are rongeured or re-
sected, and any mucosal perforations are repaired.
Correction of the Deviated Nose
Septal deviation, described previously in this chapter, can manifest as external devi-
ation of the nose. We classify the deviated nose into three basic types: caudal septal
deviations, concave dorsal deformities, and concave/convex dorsal deformities.

1930
Part X  Rhinoplasty
Correction of the deviated nose is based on the following principles:
1. The open approach to expose all deviated structures
2. Release of all mucoperichondrial attachments to the septum, especially the
deviated part
3. Straightening of the entire septum while maintaining a 10 mm caudal and
dorsal L-strut
4. Restoration of long-term support with buttressing caudal septal batten or dor-
sal spreader grafts
5. Outfracture or submucous resection of hypertrophied anteroinferior turbi -
nates, if necessary, for correction of the deviated septum
6. Precisely planned and executed external percutaneous osteotomies
Inferior Turbinoplasty
In patients with symptomatic nasal airway obstruction caused by inferior turbinate
hypertrophy that is refractory to medical management, an inferior turbinoplasty is
performed. This can be done by turbinate outfracture, submucous morselization of
the turbinate bone, or submucous resection of the anterior one third to one half of the
inferior turbinate. The submucous resection is done by developing medial muco -
periosteal flaps, exposing the conchal bone using a Cottle elevator, and sharply re-
secting the proper amount. The flaps are replaced after this resection without the
need for suture repair. It is important to note that the extent of the conchal bone re-
section is limited to the anterior portion. This is done mainly to avoid complications
of bleeding if the posterior portion is resected.
Resected lateral
mucosa and
lamina propria

Cephalic Trim
1931
Chapter 55  Primary Rhinoplasty
In cases in which the tip is boxy or bulbous and requires
better refinement and definition, when the tip-defining
points need medialization, or when rotation of the tip is
desired, a cephalic trim is performed. This is done by us-
ing a caliper to measure along the caudal margin of the
lower lateral cartilage to preserve a 6 mm rim strip. After
this is demarcated, the cephalic portion of the middle and
lateral crura is resected. The cartilage is preserved for pos-
sible use later in the case.
Lower Lateral Crural Turnover Flap
A lower lateral crural turnover flap is another useful technique to address parado-
mal fullness while providing additional support to the lower lateral cartilages. It is
beneficial for deformities, weakness, and collapse of the lower lateral crura and can
also be used to improve lower lateral crural strength during tip reshaping. However,
there must be sufficient lower lateral crura to leave a 6 mm rim strip. It can be used
in combination with other external valve and alar arch supporting techniques.
Thin line score
Scored
and
folded
cartilage
Full-thickness cut
A horizontal line that bisects the cephalic aspect of the lower lateral crus from the
6 mm rim strip is marked with methylene blue. The cephalic aspect is dissected from
the underlying vestibular skin inferiorly to this horizontal line and then the line is
scored with a No. 15 blade and 2 mm full-thickness cuts at the medial and lateral
ends of the horizontal line are performed. The flap is turned over and its caudal edge
is secured with multiple horizontal mattress sutures.

Autospreader Flaps
Reduction of the nasal dorsum may compromise the internal nasal valves. Even a
slight decrease in the angle between the upper lateral cartilage and the septum can
lead to a significant increase in nasal airway resistance. Patients who have a high,
narrow dorsum, a weak middle vault, short nasal bones, or a positive Cottle test pre-
operatively are at risk for developing postoperative internal nasal valve dysfunction
and consequently, nasal airway obstruction.
1932
Part X  Rhinoplasty
In these cases, the use of autospreader flaps fashioned from the dorsal aspects of the
upper lateral cartilages can maintain patency of the internal nasal valves while pre-
serving the dorsal aesthetic lines. After component dorsal hump reduction has been
performed, the overprojecting dorsal aspect of the upper lateral cartilages is incised,
leaving the underlying mucoperichondrium intact. This dorsal portion of the upper
lateral cartilage is then rotated internally approximately 90 degrees to lie between
the septum and the medial edge of the upper lateral cartilages supported as a flap
by its attachment to the mucoperichondrium. The new dorsal edges of the upper lat-
eral cartilages are then sutured with 5-0 PDS at the midline to the rotated au-
tospreader flaps and secured along the septum.
Limitations using this technique include patients with a deviated dorsal septum or
asymmetrical dorsal aesthetic lines, a weak bony vault or lower lateral cartilages, a
deviated nasal tip, or lack of tip support. Spreader grafts are indicated in these cases.

Spreader Grafts
1933
Chapter 55  Primary Rhinoplasty
Spreader grafts can be used to help stent open the internal valve, stabilize the sep-
tum, and preserve the dorsal aesthetic lines. These grafts usually are obtained from
septal cartilage and are designed to measure approximately 25 to 30 mm by 3 mm.
Their cephalic ends can be trimmed obliquely to fit snugly underneath the bony dor-
sum and their caudal ends can be placed either at the septal angle (if lengthening of
the nose is not desired) or extending past it (if lengthening is desired). Furthermore,
the grafts can be placed in a visible position (secured in a higher position along the
septum) or in an invisible position (positioned lower). We secure the grafts with 5-0
PDS in horizontal mattress fashion.
Spreader grafts

Tip Modification
Altering Tip Projection
It is important to recognize the factors that contribute to tip projection in situ be-
fore embarking on a discussion on how to precisely alter tip projection. There are
six key anatomic elements to tip projection:
1. The supporting ligament between the anterior septal angle and the overlying
dermis
2. The length and strength of the lower lateral cartilages
3. The suspensory ligament bridging the anterior septal angle
4. The fibrous connections between the upper and lower lateral cartilages (and
septum)
5. The abutment of the cartilages with the piriform aperture
6. The anterior septal angle
Alteration of any of these anatomic structures can result in incremental changes in
tip projection.
A graduated approach to tip projection is predicated on precise, incremental, non-
destructive changes made to the tip complex, beginning with placement of a col-
umellar strut graft, proceeding with suture modification, and finishing with the use
of tip grafts.
The algorithm begins with placement of a columellar strut graft. This strut is usu-
ally fashioned from septal cartilage, and measures approximately 25 by 4 mm. It can
be placed in a “fixed” (secured to the anterior maxilla) or a “floating” (not secured
to the maxilla) fashion. This strut not only controls the columellar profile, but also
bolsters tip projection and unifies the tip complex. The strut is placed by dissecting
a pocket between the medial crura. A double-pronged hook is then used to gently
retract the middle crura anteriorly to set the desired projection and symmetry. The
strut is positioned in the pocket, and a 25-gauge needle is used to stabilize this con-
figuration. Most are left floating on a soft tissue pad between the base of the pocket
and the nasal spine. Medial crural sutures (described previously) are placed in hor-
izontal mattress fashion to secure the complex. Further medial crural sutures can be
placed more caudally on the medial crura to control flaring, if necessary.
The next step in altering tip projection involves suture techniques, which can increase
tip projection by 1 to 2 mm. Suture techniques are ideal for controlling cartilage in a
precise, nondestructive fashion. Although the choice of a particular suture material is
surgeon dependent, the underlying premise is to choose a material that one can easily
work with that will hold the cartilage in its altered position long enough to allow the
natural fibrotic reaction to solidify the result. Although many suture techniques can
be performed in both open and closed rhinoplasty (with cartilage delivery), we find
1934
Part X  Rhinoplasty

1935
Chapter 55  Primary Rhinoplasty
them easier to place using the open method, because it affords greater visualization
and ease of placement. We commonly use four suture techniques to alter projection
and shape the nasal tip:
1. Medial crural
2. Medial crural septal
3. Interdomal
4. Transdomal
Medial crural sutures serve to unify the medial crura of the lower lateral cartilages
and are frequently used in conjunction with a columellar strut (to help stabilize the
strut). They can also be used to straighten out flaring of the medial/middle crura (ei-
ther on the caudalmost aspect or near the domal area), thereby effecting an increase
in projection, albeit to a limited degree. We generally use 5-0 PDS suture in hori-
zontal mattress fashion for this technique; however, the suture choice can vary by in-
dividual preference.
Medial crural septal sutures anchor the medial crura to the caudal septum, and can
alter projection as well as rotation. They are often used in conjunction with col-
umellar struts. We frequently use 5-0 clear nylon suture in spanning fashion for this
technique.

1936
Part X  Rhinoplasty
Interdomal sutures are placed through the medial walls of the domes in mattress
fashion and are tied to narrow the interdomal distance. This results in both an in-
crease in tip refinement and an increase in projection.
Transdomal sutures are placed across the dome of the middle crura in mattress fash-
ion so that the vestibular skin is not perforated. Local anesthetic can be used to hy-
drodissect a plane between the cartilaginous dome and the adherent underlying mu-
coperichondrium to help prevent inadvertent incorporation into the suture bite. We
generally use 5-0 PDS in horizontal mattress fashion and leave the knots on the me-
dial aspect of the dome. These sutures can be made asymmetrical to correct anatomic
asymmetries, if necessary. They can be fashioned with one end left long on each side,
and then subsequently tied together in a spanning configuration (resembling an inter -
domal suture) to narrow the tip-defining points. It is important, however, to prevent
overtightening of this suture, which can result in an unnaturally sharp tip-defining
point.
If more tip projection or definition is desired after the preceding maneuvers, tip grafts
may be used. We find it easier to place these grafts using the open approach, because
it allows excellent visualization, precise placement, and facilitates subsequent ma-
nipulation, if necessary. It should be noted that grafts, in general, have a tendency to
be visible, so their use is reserved only for the patient in whom the prior, more pre-
dictable methods do not result in satisfactory tip projection. There are three general
types of tip grafts:
1. Onlay tip grafts
2. Infratip lobular graft
3. Anatomic tip graft

The onlay tip graft can be fashioned from any type of cartilage, although we find
that the cartilage obtained from the cephalic trim harvest works exceptionally well.
This graft is placed in a position overlying the dome of the middle/lateral crura and
fixed in place using the techniques just described. We generally use 5-0 PDS suture
for this, with the knots hidden underneath the dome.
The infratip lobular graft is positioned with its superior margin overlying the dome and
tip-defining points and extending inferiorly a variable distance, usually 10 to 12 mm.
It is usually shield-shaped, and has rounded graft edges to avoid a visible and pal-
pable step-off. This graft increases infratip lobular definition and projection, and is
secured in the same fashion as described previously.
1937
Chapter 55  Primary Rhinoplasty
The anatomic tip graft is a more aggressive type of graft that we generally use in dif-
ficult primary rhinoplasties, thick-skinned patients, and secondary rhinoplasties with
inadequate tip projection. Its superiormost aspect is anchored to the ULCs and its
inferiormost aspect secured to the caudal margin of the medial crura. It is essentially
a combination graft and can be visible, so it must be placed carefully.

When trying to decrease nasal tip projection, once again it is important to realize
the anatomic factors that contribute to tip projection in the first place. If the support
derived from the fibroelastic and ligamentous attachments is disrupted, tip projec-
tion becomes primarily dependent on the length and strength of the lower lateral
cartilages. Therefore, in the open approach, if the skin envelope has been undermined
and these fibroelastic tissues have been severed, the primary means of decreasing tip
projection lies in altering these lower lateral cartilages. This may include techniques
such as transection, setback, and resuturing of the medial or lateral crura. It is im-
portant to recognize that if the tip projection is decreased significantly, alar flaring
or columellar bowing may result, which would necessitate concomitant correction.
Altering Tip Rotation
Using the nasofacial analysis techniques described, rotation is evaluated generally by
the nasolabial angle. This angle, found by measuring the angle between a line cours-
ing through the most anterior and posterior edges of the nostril and a plumb line
dropped perpendicular to the natural horizontal facial plane, should be between 95
and 100 degrees in women and between 90 and 95 degrees in men.
1938
Part X  Rhinoplasty
When changing tip rotation, the extrinsic forces holding the tip at its current angle
must be released. This is generally done by severing the connection between the lower
and upper lateral cartilages. This frequently takes the form of a cephalic trim, as de-
scribed previously. Furthermore, the fibrous attachments of the medial crura and the
caudal septum can be transected to release tension on the nasal tip and allow for
more cephalad rotation. This is generally achieved by resecting a variable amount of
the caudal septum. This maneuver can also affect tip projection.

Depending on the amount of tip rotation, it may be necessary to perform a limited
resection of the nasal mucosa and membranous septum to maintain proper nasal
balance and harmony. After the tip is rotated, its position is maintained with suture
techniques (medial crural septal sutures) and/or a columellar strut or septal exten-
sion graft.
Alar Rims
Alar Contour Grafts
1939
Chapter 55  Primary Rhinoplasty
Alar contour grafts are used as a simple and effective method to correct and prevent
alar notching or retraction, and facets of the soft tissue triangles. A subcutaneous
pocket below the infracartilaginous incision and parallel to the alar rim is created
with dissection scissors. The pocket should span the length of the deformity and ex-
tend 3 mm to each side of it. An alar contour graft is typically 4 by 10 mm, but it
may be need to be larger, depending on the size of the deformity.
Lateral Crural Strut Grafts
Lateral crural strut grafts are used to support weak lateral crura, prevent collapse of
the external nasal valve, address malposition of the lateral crura, or increase tip pro-
jection. The vestibular skin is dissected from the deep surface of the posterior two
thirds of the lateral crus. The lateral crus is separated from the accessory cartilages.

1940
Part X  Rhinoplasty
A subcutaneous pocket below and adjacent to the accessory cartilages is dissected
posteriorly to the piriform aperture. To correct malposition of the lateral crura, the
pocket is dissected below the infracartilaginous incision and parallel to the alar rim.
A 4 by 25 mm lateral crural strut graft is placed in the pocket and rests on the piri-
form aperture posteriorly. The anterior aspect of the graft is placed deep to the lateral
crus and secured with two or three 5-0 PDS simple interrupted sutures.
Correcting the Alar-Columellar Relationship
Class I Deformity
When the patient has a class I deformity, or when the long axis–columellar rim dis-
tance (BC) is greater than 2 mm and the alar rim–long axis distance (AB) is normal,
this is an example of a true hanging columella. Correcting this involves resecting either
the caudal septum, the caudal portion of the medial crus, the caudal portion of the
middle crus, or a combination of these, whichever is responsible for the deformity.
Hanging columella

Class II Deformity
1941
Chapter 55  Primary Rhinoplasty
A class II deformity, or a retracted ala (AB greater than 2 mm, BC less than 2 mm),
is treated in several ways. One method is to insert an elliptically shaped composite
graft from an access incision made in the vestibular skin. The graft is made slightly
larger than is needed to compensate for secondary contraction. If the retraction is
mild and there is no tissue deficiency present, an alternative technique can be used
where the lateral crura are detached from the accessory chain and repositioned in-
feriorly. A final method is to place an alar contour graft (nonanatomic position) in
a pocket created along the vestibular rim to displace the ala inferiorly.
Retracted ala
Incision in
vestibular skin
Composite
graft

Class III Deformity
1942
Part X  Rhinoplasty
A class III deformity is a combination of a class I and class II deformity and is there-
fore corrected with a combination of the two procedures.
Class IV Deformity
A class IV deformity is a hanging ala (AB less than 1 mm, BC less than 2 mm). This
is usually treated with an elliptical excision of vestibular skin. Care is taken to avoid
overresection of skin in this maneuver, because an abnormal, rolled-in appearance
of the alar rim can result.
Hanging ala
Excision of
vestibular skin
Combination of I and II

Class V Deformity
1943
Chapter 55  Primary Rhinoplasty
A class V deformity is a retracted columella (AB less than 2 mm, BC less than 1 mm).
The treatment of choice for this deformity is placement of a columellar strut, which
is positioned more caudally to extend the caudal dimension of the columella.
Class VI Deformity
A class VI deformity is a combination of class IV and class V and is treated with a
combination of the techniques just described.
Combination of IV and V
Retracted columella
Cartilage graft

1944
Part X  Rhinoplasty
Osteotomies
Osteotomies are a powerful technique in rhinoplasty. The indications to perform os-
teotomies, regardless of technique, are as follows:
 To narrow the lateral walls of the nose
 To close an open-roof deformity (after dorsal hump reduction)
 To create symmetry by straightening the nasal bony framework
Contraindications to osteotomies can include patients with short nasal bones; eld-
erly patients with thin, fragile nasal bones; and patients with heavy eyeglasses. There
are several osteotomy techniques, including medial, lateral, transverse, or a combi-
nation of these. Furthermore, they can be performed through either an external or
internal approach.
A lateral osteotomy may be performed as low-to-high, low-to-low, or double-level.
They may be combined with medial, transverse, or greenstick fractures of the upper
bony segment, as well. No matter how the osteotomy is performed, however, it is
necessary to preserve Webster’s triangle, which is an area of the caudal aspect of the
maxillary frontal process that is near the anterior aspect of the inferior turbinate. By
preserving this area, patency of the internal valve is preserved during osteotomies,
and functional nasal airway obstruction from collapse is prevented. Furthermore,
regardless of the technique used in performing the lateral osteotomy, it is important
to maintain a smooth fracture line by staying low along the bony vault, thereby pre-
venting the potential for a step-off deformity. The cephalic margin of the osteotomy
should not be higher than the intercanthal line (the level of the medial canthi); the
thick nasal bones above this level increase the technical difficulty, and it is possible
to cause iatrogenic injury to the lacrimal system (with resultant epiphora).
A low-to-high osteotomy is generally used to correct a small open roof deformity or
to mobilize a medium-wide nasal base. It begins low at the piriform aperture and
ends high medially on the dorsum. The nasal bones are then “greensticked” to me-
dialize them, with predictable fracture patterns obtained based on nasal bone thick-
Low-to-high
Low-to-low
Double-level
Webster’s
triangle

ness. Occasionally, a separate superior oblique osteotomy is necessary to mobilize
thicker nasal bones enough to be greensticked. A low-to-low osteotomy is generally
a more powerful technique, in that it results in more medial movement of the nasal
bones, and therefore is classically used when there is a large open-roof deformity or
if a wide bony base requires correction. It starts low along the piriform aperture and
continues low along the base of the bony vault to end in a lateral position along the
dorsum near the intercanthal line. As there is more bone between the cephalic aspect
of this osteotomy and the midline, this type of osteotomy technique is frequently ac-
companied by a medial osteotomy to better mobilize the nasal bones to achieve the
desired result.
We have refined our preferred technique of external perforated lateral osteotomies,
which has proved to be well controlled, predictable, and reproducible. Furthermore,
there are certain unique advantages to this technique based on the preservation of
the periosteal attachments, namely:
 Decreased amount of dead space
 Reduced subluxation and subsequent airway compromise
 Greater overall stability after positioning
Our technique is as follows:
1. Inject both intranasally and along the lateral nasal sidewalls with 2 ml of 1%
lidocaine with 1:100,000 epinephrine, allowing 5 to 7 minutes for the he-
mostatic process to take effect.
2. Introduce a sharp 2 mm osteotome percutaneously on the midportion of the
bony nasal pyramid at the level of the inferior orbital rim and nasofacial junc-
tion. It must be held at a plane parallel to the surface of the maxilla.
3. To avoid injury to the angular artery, sweep the osteotome down the lateral
nasal sidewall in a subperiosteal plane.
1945
Chapter 55  Primary Rhinoplasty
Most efficient
cutting angle
Maximizing osteotome efficiency and precision
Nasal bone surface
4. Position the osteotome at an angle such that one edge is in contact with the
bone and strike with the mallet. The endpoints are a change in the feel and
sound at that location.

5. Extend the osteotomy in an inferior, superior, and superior-oblique manner
at the level of the piriform. Leave a 2 mm gap between each individual os-
teotomy.
6. Perform the same procedure on the contralateral nasal wall.
7. After the osteotomies are completed, use gentle pressure between the thumb
and forefinger to perform a greenstick fracture of the nasal bones to position
them in the desired location.
1946
Part X  Rhinoplasty
8. Cover with flesh-colored Steri-Strips and apply a dorsal compression splint
(Denver splint), which is kept in place for 7 days to minimize postoperative
edema.

Medial osteotomies are used to facilitate medial positioning of the nasal bones. They
are generally indicated in patients with thick nasal bones or a wide bony base to
achieve a more predictable result, because greenstick fractures in these subgroups
can sometimes be difficult and can lead to unpredictable fracture patterns. Medial
osteotomies can be used in conjunction with lateral osteotomies; however, it is not
necessary to use both types in all cases. When using both techniques, the medial os-
teotomy is usually performed first, because this makes it technically easier to per-
form subsequent lateral osteotomies. Although the cant of the medial osteotomy can
be varied (such as medial oblique, paramedian, or transverse), for the reasons just
stated, the cephalic margin should not cross the intercanthal line.
1947
Chapter 55  Primary Rhinoplasty
It is paramount to avoid placing the medial osteotomy too far centrally as it con-
nects with the lateral osteotomy because this can cause a rocker deformity in which
the upper portion of the fractured nasal bone “kicks out,” resulting in a widened
upper dorsum. This can be avoided by following an oblique angle. After the medial
and lateral osteotomies are created, the nasal bones are greensticked, as described
earlier, to the desired position.
Medial oblique
Paramedian
Superior oblique
osteotomy
Transverse fracture
Webster’s triangle
Preferred
superior
oblique
osteotomy
Rocker
deformity

Occasionally, a double-level lateral osteotomy is needed to
correct lateral wall convexities that are too great to be cor-
rected with a standard single-level lateral osteotomy, or
when significant lateral nasal wall asymmetries exist. This is
done by first making the upper (more medial) lateral os-
teotomy along the nasomaxillary suture line. The lower
(more lateral) of the two is then created in standard low-
to-low fashion.
1948
Part X  Rhinoplasty
Potential Complications of Lateral Nasal Osteotomies
Infections
Operative Trauma
Cosmetic Problems
Local
Hemorrhage (hematoma,
Excessive narrowing or convexity
Abscess
ecchymosis)
Insufficient mobilization of lateral bony walls
Cellulitis
Edema
Unstable bony pyramid
Granuloma
Nasal cyst formation
Rocker deformity
Systemic
Anosmia
Redundant soft tissue
Intracranial
Arteriovenous fistula
Stairstep deformity
Epiphora
Nasal bone asymmetry
Canalicular bleeding
Neuromuscular injury
Intracranial injury
Regardless of the operative technique, there are potential complications associated
with osteotomies.
Double osteotomy
Closure
After excellent hemostasis is achieved and the wound is irrigated to remove any ex-
cess debris, the skin envelope is redraped. If the patient has thick skin, and especially
if the patient is a woman, we may choose to place a single 5-0 Vicryl suture from
the dermis (underside of the skin envelope) to the underlying cartilaginous frame-
work in an attempt to recreate a supratip break.

The transcolumellar incision is then closed using 6-0 nylon suture in simple inter-
rupted fashion, making sure the coaptation of the incision margins is precise. The
stairstepping of the original incision helps us close this accurately. The infracarti-
laginous incisions are reapproximated using 5-0 chromic suture in simple interrupted
fashion. We take special care to prevent overbiting with the suture, which can create
contour irregularities and notching, especially in the soft triangle area.
1949
Chapter 55  Primary Rhinoplasty
If septal work has been performed, we place intranasal Silastic splints coated with
antistaphylococcal antibiotic ointment. These are secured with a transseptal 3-0 ny-
lon suture. The nasal dorsum is then carefully taped, and a malleable metal splint is
applied over the dorsum. A drip pad is fashioned from a 2 by 2 gauze and secured
under the nose with 1⁄2-inch paper tape. The throat pack is removed, and the orophar-
ynx and stomach are carefully suctioned to help evacuate any blood that may result
in postoperative nausea and vomiting.
Alar Base Surgery
In cases in which alar base surgery is necessary, it is generally performed after clo-
sure of the transcolumellar and infracartilaginous incisions, but before intranasal
and external splints are placed.
Analysis of the alar base was discussed earlier in the chapter. Based on proper and
precise nasofacial analysis, alar base abnormalities may be diagnosed, which may

1950
Part X  Rhinoplasty
include wide or excessive nostril sills, a wide alar base, asymmetrical or malposi-
tioned alar bases, or any combination of these.
Wide nostril sills, or alar flaring, is a relatively common problem. It is corrected by
performing a small crescentic resection of the alar base, making sure to avoid ex-
tending the incision into the actual vestibule. The incision is placed approximately
1 to 2 mm above the true alar base to prevent alar notching. The soft tissue at the
base is mobilized with judicious use of electrocautery and then transposed medially
to the desired aesthetic endpoint, where it is sutured in place. We suture using the
“halving principle” in this region, because the interior incision is shorter than the
exterior incision.
A wide alar base is corrected in a similar fashion; however, the crescentic excision
assumes a more wedge-type geometry and may include a small portion of the nos-
tril sill. If a transcolumellar incision was used at the start, it is crucial that the alar
base excision stay within 3 mm of the lateral alar groove, because the blood supply
to the nasal tip can be jeopardized if the lateral nasal artery is inadvertently injured.
Although some have advocated suture techniques for narrowing the nasal base, we
generally perform this with excisional techniques, as just described.
Depressor Septi Translocation
In patients who have a tension tip on animation (foreshortened upper lip with de-
creased tip projection), translocation of the depressor septi muscles is indicated. This
is done in the following fashion.

An 8 to 10 mm transverse incision is made using electrocautery centered on the
frenulum.
1951
Chapter 55  Primary Rhinoplasty
The inferior attachments of the depressor septi muscles are identified and dissected
using electrocautery.
The depressor septi muscles are released from either the orbicularis or the perios-
teum (anatomy dependent).
The muscles are transposed and their ends sutured together using 4-0 chromic gut
suture. The transverse incision is closed vertically to lengthen the upper lip.

Postoperative Management
All preoperative and postoperative instructions are given to the patients in writing
before as well as on the day of surgery. Postoperatively, we routinely prescribe the
following:
 Medrol Dosepak for 7 days (to minimize postoperative edema)
 Hydrocodone/acetaminophen 5:500 for postoperative pain every 4 to 6 hours
as needed
 Normal nasal saline solution for postoperative nasal congestion
 Antibacterial ointment to incisions three times daily
The patient is instructed to keep the head of the bed elevated at an angle of 45 de-
grees beginning immediately after surgery to help minimize postoperative swelling.
Cool compresses (Swiss Therapy eye masks) are used periorbitally during the day for
the first 48 hours. Antibacterial ointment is applied three times daily to the incisions
after gentle cleaning with a half-strength hydrogen peroxide–saline solution. The pa-
tient is instructed to change the drip pad under the nose as necessary until the
drainage stops, at which time the pad and tape can be discontinued. Any manipula-
tion of the nose, including rubbing, blotting, or blowing, is discouraged for the first
3 weeks postoperatively. Sneezing should be done through the mouth during this
time. It is imperative to keep the nasal splint dry, and the patient’s hair should be
washed as in a beauty salon, with the patient leaning the head backward over the
sink.
We maintain our patients on a liquid diet on the day of surgery, which is subsequently
advanced the following day to a soft regular diet. Any foods that require excessive
lip movements, such as eating apples or corn on the cob, should be avoided for
2 weeks after surgery.
During the first 2 weeks, nasal congestion may be minimized by the use of normal
saline nasal spray and over-the-counter nasal decongestant sprays such as Afrin
(oxymetazoline). However, the use of Afrin should be limited, because cessation can
cause rebound nasal congestion. If patients have difficulty with the passage of air
through the intranasal splints, they are encouraged to breathe through the mouth.
If the patient is very congested, in-office suctioning may be warranted.
We ask the patient to return on postoperative day 5 to 7, at which time the sutures
and nasal splints are removed. The nose (especially the tip) may appear swollen and
turned up, and the tip may feel numb, but the patient is reassured that this is to be
expected and will resolve with time, with normal sensation returning within 3 to
6 months. The patient cannot let anything, including eyeglasses, rest on the nose for
1952
Part X  Rhinoplasty

1953
Chapter 55  Primary Rhinoplasty
at least 4 weeks. Glasses should be taped to the forehead. Contacts can be worn as
soon as the swelling has diminished enough to allow easy insertion (usually less than
5 to 7 days postoperatively). Patients are instructed to avoid direct sunlight and to wear
sunscreen of SPF 30 or higher to prevent possible hyperpigmentation of the scar.
We ask our patients to restrict strenuous activity that increases their heart rate (above
100 beats/min) or blood pressure for 3 weeks after surgery. After that, they can grad-
ually resume normal activity. Obviously, any contact sports or activities that may
cause direct trauma to the nose are prohibited for at least 4 weeks after surgery. Al-
though some patients’ noses look excellent within 6 to 8 weeks, some may remain
swollen for up to 1 year, but after 3 to 4 weeks such swelling will generally not be
obvious to anyone but the patient.
After the first postoperative visit (within the first week), we ask the patient to return
to the clinic at 3 and 8 weeks after the operation. We continue to follow the patient
3, 6, and 12 months after surgery, and then annually thereafter.
Outcomes
Although it is difficult to determine an exact revision rate following primary rhino-
plasty, a recent survey of plastic surgeons and otolaryngologists revealed that 58%
of those surveyed cited their revision rate less than 5%. This survey also revealed that
the open approach was preferred by 73% compared with 20% preferring the closed
approach for revision rhinoplasty.
In the senior author’s (R.J.R.) practice, approximately 1 in 25 primary rhinoplasty
patients requires revision. The most frequent reasons for reoperation include further
tip refinement or correction of tip asymmetries (lower third), parrot beak or pinched
supratip deformity (middle third), and excessive dorsal reduction or dorsal irregu-
larities (upper third).
Functionally, continued nasal airway obstruction after primary rhinoplasty has, in
our experience, usually been from excessive narrowing of the internal valve (with-
out placement of spreader grafts). We used to see this more frequently when we per-
formed more aggressive resection of the transverse processes of the ULCs. Once we
adopted the component dorsal hump reduction technique with preservation of the
ULCs, the incidence of internal valve obstruction decreased and the need for spreader
grafts greatly diminished.

Results
Patient Example 1
1954
Part X  Rhinoplasty
This healthy 24-year-old woman presented for cosmetic rhinoplasty without nasal
airway obstruction. She was unhappy with the appearance of her boxy tip and de-
sired correction. The frontal view demonstrates adequate dorsal aesthetic lines, but
asymmetrical fullness of her supratip. Her left lower lateral cartilage segment is more
obliquely rotated than the right lower lateral cartilage. She has excess lateral alar
convexity with preoperative alar notching.

Operative Goals
1. Drastically refine tip and narrow tip-defining points
2. Correct lateral alar convexity and alar notching
Surgical Plan
1955
Chapter 55  Primary Rhinoplasty
1. Open approach with transcolumellar stairstep incision connected to bilateral in-
fracartilaginous incisions
2. Cephalic trim of lateral and middle crura leaving a 6 mm rim strip
3. Medial crural, interdomal and transdomal suturing
4. Bilateral alar contour grafts to correct lateral alar convexity and prevent alar
notching
Medial
crural
Interdomal
Transdomal
Lateral and
middle crural
cephalic trim
Alar contour
graft
Medial
crural
Transdomal
Tip Sutures
• Medial crural
• Transdomal
• Interdomal
Lateral and
middle crural
cephalic trim
Alar contour
graft
Alar contour
graft
Lateral and middle
crural cephalic trim

Preoperative and 15-month postoperative views demonstrate improvement of dor-
sal aesthetic lines and correction of her boxy tip. She has dramatic tip refinement,
with reduction of supratip fullness and narrowed tip-defining points. Placement of alar
contour grafts has corrected the lateral alar convexity and prevented alar notching.
1956
Part X  Rhinoplasty

Patient Example 2
1957
Chapter 55  Primary Rhinoplasty
This healthy 24-year-old woman had aesthetic as well as functional concerns. Aes-
thetically, she did not like her dorsal nasal contour and boxy, asymmetrical nasal
tip. Functionally, she complained of left nasal airway obstruction. The lateral view
demonstrates a slight dorsal hump, supratip fullness, decreased tip projection, and a
columellar-labial angle of 100 degrees. Her basal view confirms an asymmetrical tip
with left-sided alar collapse. The left lower lateral cartilage is concave; the right is con-
vex. Her intranasal examination revealed left-sided deflection of the caudal septum.

Operative Goals
1. Remove small dorsal hump
2. Decrease tip rotation
3. Correct tip asymmetry
4. Refine the tip and reestablish tip-defining points
5. Correct left external nasal valve collapse and concave left lower lateral cartilage
6. Prevent postoperative alar retraction
Surgical Plan
1958
Part X  Rhinoplasty
1. Open approach with transcolumellar stairstep incision connected to bilateral in-
fracartilaginous incisions
2. Component reduction of dorsum (2 mm)
3. Caudal septal resection with medial crural set-back sutures to decrease tip rotation
4. Septal cartilage harvest leaving a 10 mm L-strut
5. Left lower lateral crural turnover flap to correct concave left lower lateral cartilage
6. Right cephalic trim leaving a 6 mm rim strip
7. Bilateral spreader grafts
8. Medial crural, interdomal, and transdomal suturing
9. Columellar strut
10. Lateral osteotomies (external perforated)
11. Bilateral alar contour grafts to prevent alar retraction
LLC turnover flap
Caudal septum
repositioning
Cephalic trim
Tip Sutures
• Medial crural
• Transdomal
• Interdomal
LLC turnover flap
Alar contour graft
Cephalic
trim
Columellar strut
Figure-
of-eight
suture
LLC turnover flap
3 mm dorsal reduction

Comparison of the patient’s preoperative and 12-month postoperative appearance
demonstrates a straight dorsum and a unified tip complex with correction of her tip
asymmetry. The lateral view confirms the straight dorsal profile with a supratip break,
normal tip projection, and a nasolabial angle of 95 degrees. There is an improved
alar-columellar relationship. The basal view confirms correction of her tip asymme-
try and shows restoration of the columellar-infratip lobular relationship. The left-
sided external valve collapse was corrected with the lower lateral crural turnover
flap while alar contour grafts were placed to prevent postoperative alar retraction.
1959
Chapter 55  Primary Rhinoplasty

1960
Part X  Rhinoplasty
Patient Example 3
This healthy 35-year-old man presented with a history of traumatic nasal airway ob-
struction, greater on the left than on the right. He was also concerned about a
pinched appearance to his nasal tip and deviation of his nose to the left. The frontal
view demonstrates obvious leftward septal deviation with deviated dorsal aesthetic
lines. He has a wide bony base, an asymmetrical tip with a concave, pinched ap-
pearance and narrowed tip-defining points. His lateral view demonstrates mild dor-
sal hump with a low radix but adequate tip projection. His basal view corroborates
the pinched tip deformity and a wide alar base. Intranasal examination revealed a
septal tilt, with left septal deviation.

Operative Goals
1. Correct nasal airway obstruction
2. Remove small dorsal hump
3. Remove/reposition septal deformity
4. Correct tip deformity (note thick skin)
5. Correct low radix
6. Narrow bony base
Surgical Plan
1961
Chapter 55  Primary Rhinoplasty
Low-to-low
osteotomy
3 mm morselized
cartilage graft
Turn down
cephalic
trim graft
Figure-of-eight
nasal spine suture
Swing
door
septal
flap
1. Open approach with transcolumellar stairstep incision connected to bilateral in-
fracartilaginous incisions
2. Component reduction of dorsum (2 mm) with concomitant radix augmentation
3. Septal cartilage harvest leaving a 10 mm L-strut
4. Correct intrinsic deformity of caudal L-strut with septal scoring, swinging door
septal flap and anchoring to anterior nasal spine
5. Lower lateral crural turnover flaps to correct pinched tip appearance
6. Medial crural and interdomal sutures
7. Submucous resection and outfracturing of inferior turbinates
8. Lateral osteotomies (external perforated)

Comparison views of the patient’s preoperative and 14-year postoperative appear-
ance demonstrates correction of the deviation with redefinition of symmetrical dor-
sal aesthetic lines, correction of the dorsal hump, narrowing of the bony base, and
refinement of the tip (without feminization). His subjective complaints of nasal air-
way obstruction resolved.
1962
Part X  Rhinoplasty

Patient Example 4
1963
Chapter 55  Primary Rhinoplasty
This healthy 41-year-old woman with Fitzpatrick type III thick nasal skin presented
for cosmetic rhinoplasty without nasal airway obstruction. She was unhappy with
the appearance of her dorsal hump and unrefined tip. This patient demonstrates the
classic Middle Eastern nasal morphology. The frontal view demonstrates nasal de-
viation and a plunging tip with infralobular deficiency. Her lateral view demonstrates
a large dorsal hump, a severely underprojected, underrotated, amorphous and plung-
ing tip, as well as absence of a supratip break. She has an alar-columellar discrep-
ancy with a retracted columella. Her basal view demonstrates nostril-tip imbalance
with “short nostrils.” Intranasal examination was normal. Her dynamic examina-
tion revealed a hyperdynamic tip. Following primary rhinoplasty, she requested a
more dramatic change in her tip, and this required a secondary soft tissue debulk-
ing operation.

Operative Goals
1. Remove large dorsal hump
2. Correct nasal deviation
3. Refine the tip and reestablish tip-defining points (note thick skin)
4. Drastically improve tip rotation and projection
Surgical Plan
1964
Part X  Rhinoplasty
1. Open approach with transcolumellar stairstep incision connected to bilateral in-
fracartilaginous incisions
2. Component reduction of dorsum (5 mm)
3. Anterior septal angle reduction
4. Septal harvest (for cartilage grafting purposes) with 10 mm L-strut
5. Bilateral spreader grafts
6. Cephalic trim leaving a 6 mm rim strip
7. Columellar strut graft with medial crural septal sutures
8. Medial crural, interdomal and transdomal suturing
9. Combined infralobular and onlay tip graft
10. Lateral osteotomies (external perforated)
Combined infralobular
and onlay tip graft
Anterior septal
angle reduction
Depressor septi release
Tip Sutures
• Medial crural
• Transdomal
• Interdomal
Spreader graft
Combined infralobular
and onlay tip graft
Cephalic trim
Columellar
strut
5 mm dorsal
reduction
Percutaneous osteotomies

Comparison views of preoperative and 2-year postoperative appearance demon-
strates a more balanced nose after reduction of the dorsum and refinement of the tip
including improving tip rotation, projection and definition. The drastic improvement
in overall nasal tip definition including enhancement of the supratip and infratip re-
quired a secondary operation with more soft-tissue debulking and visible onlay tip
graft replacement secondary to early graft resorption. The necessity for secondary
tip refinement or soft-tissue debulking is not uncommon in the Middle Eastern pop-
ulation and should be discussed during the initial informed consent.
1965
Chapter 55  Primary Rhinoplasty

1966
Part X  Rhinoplasty
Patient Example 5
This healthy 40-year-old African American woman with Fitzpatrick type VI thick
nasal skin presented for cosmetic rhinoplasty without nasal airway obstruction. Her
concerns were a wide and flat-appearing dorsum with a small dorsal hump defor-
mity; an ill-defined, flat but bulbous tip; and widened ala. She wanted a narrower,
more defined nose. The frontal view demonstrates a wide bony base, poorly defined
dorsal aesthetic lines, a prominent bulbous tip with bifidity, and a wide alar base.
Her lateral view demonstrates a small dorsal hump, decreased projection, and a class
IV hanging alar deformity. Her basal view corroborates the bulbous tip deformity
with bifidity and an increased alar base width. Intranasal examination was normal,
as was her dynamic examination.

Operative Goals
1. Dorsal augmentation and definition
2. Narrow middle vault
3. Drastically refine tip and narrow tip-defining points (note thick-skinned patient)
4. Increase projection
5. Decrease alar base width
Surgical Plan
1967
Chapter 55  Primary Rhinoplasty
1. Open approach with transcolumellar stairstep incision connected to bilateral in-
fracartilaginous incisions
2. Septal harvest (for cartilage-grafting purposes) with 10 mm L-strut
3. Cephalic trim leaving a 6 mm rim strip
4. Two-layer dorsal onlay graft (septal cartilage) for augmentation
5. Medial crural, interdomal and transdomal suturing
6. Columellar strut
7. Three-layer onlay tip graft (cephalic trim cartilage) for definition and projection
8. Medial osteotomies (internal)
9. Lateral osteotomies (external perforated)
10. Alar base resection
Two-layer onlay
septal graft
Lateral and medial
osteotomies
Three-
layer
tip graft
9 mm alar resection

Comparison views of preoperative and 24-month postoperative appearance demon-
strates nasal dorsum augmentation with concomitant narrowing of the middle vault
and redefinition of the dorsal aesthetic lines. She has dramatic tip refinement with
creation of well-defined tip-defining points, as well as an increase in projection. Her
alar-columellar deformity has been corrected, as has her widened alar base defor-
mity. She did not subjectively complain of nasal airway obstruction postoperatively.
1968
Part X  Rhinoplasty

1969
Chapter 55  Primary Rhinoplasty
Concluding Thoughts
Success in primary rhinoplasty is predicated on accurate preoperative analysis and
clinical diagnosis, identification of both the patient’s expectations and the surgeon’s
goals, and a thorough review of the plan of care and expected postoperative recov-
ery. Intraoperatively, adequate anatomic exposure of the nasal deformity, preserva-
tion and restoration of the normal anatomy, correction of the deformity using in-
cremental control, maintenance and restoration of the nasal airway, and recognition
of the dynamic interplay between the composite of maneuvers optimize outcomes
and lead to a successful experience for both patient and rhinoplasty surgeon.
Clinical Caveats
 The key to a successful outcome begins with proper patient selection.
 A thorough understanding of normal and abnormal nasal anatomy is paramount.
 Accurate, precise, and complete nasofacial analysis is mandatory to help plan the
operation.
 Full and complete disclosure of all risks and benefits, including financial respon-
sibilities, must be performed to both the surgeon’s and patient’s satisfaction. There
is no substitute for an informed patient.
 The surgeon should never enter the operating room without a well-thought-out
plan.
 The type of incision used is far less important than the correction of the underly-
ing problem. Choose appropriately according to the deformity and your own ex-
perience.
 If performing an open approach through a transcolumellar incision, one must
avoid excessively debulking the tip and avoid alar base incisions that are greater
than 3 mm outside the alar groove to preserve blood supply to the tip.
 The procedure should proceed in an organized, stepwise fashion from skin to skin,
without rushing. Iatrogenic injuries are difficult to correct.
 The dorsal reduction should always be performed before harvesting septal carti-
lage, so that the 10 mm L-strut is maintained.
Continued

1970
Part X  Rhinoplasty
Clinical Caveats—cont’d
 The dorsum must be reduced in component fashion to prevent an inverted-V de-
formity.
 The surgeon should attempt to preserve the transverse processes of the ULCs.
 Tip modifications should be performing using a graduated approach.
 Webster’s triangle should be preserved when osteotomies are performed.
 All incisions must be closed meticulously.
 The postoperative splints/tapes should be positioned carefully to prevent iatro-
genic deformity.
 The postoperative course should be reviewed with the patient and family before
and after the operation.
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.
Gunter JP, Rohrich RJ, Adams WP Jr. Dallas Rhinoplasty: Nasal Surgery by the Masters, 2nd
ed. St Louis: Quality Medical Publishing, 2007.
A comprehensive two-volume text on all aspects of rhinoplasty. Multiple renowned con-
tributors make this text an essential reference for the rhinoplasty surgeon, regardless of
experience level.
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 95:795-801,
1995.
An anatomic cadaver study evaluating the blood supply to the nasal tip via transcol-
umellar, lateral nasal, and dorsal nasal branches. The results validate the ability to use
the open approach (transcolumellar incision) and maintain blood supply to the nasal
tip. Suggestions are offered on how to avoid pitfalls that may result in embarrassment
of nasal tip blood supply.
Sheen JH, Sheen AP. Aesthetic Rhinoplasty, 2nd ed. St Louis: Quality Medical Publishing,
1998.
Another classic comprehensive text. Authored by Jack Sheen, one of the preeminent
master rhinoplasty surgeons.