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

2022
Part X  Rhinoplasty
Kridel RW, Konior RJ, Shumrick KA, et al. Advances in nasal tip surgery. The lateral crural
steal. Arch Otolaryngol Head Neck Surg 115:1206-1212, 1989.
Kridel RW, Scott BA, Foda HM. The tongue-in-groove technique in septorhinoplasty. A 10-
year experience. Arch Facial Plast Surg 1:246-256, 1999.
Peer LA. The neglected septal cartilage graft (with experimental observations on the growth
of human cartilage grafts). Arch Otolaryngol 42:384-396, 1945.
Sheen JH. Rhinoplasty: personal evolution and milestones. Plast Reconstr Surg 105:1820-
1852, 2000.
Tardy ME. Rhinoplasty: The Art and the Science. Philadelphia: WB Saunders, 1996.
Toriumi DM. New concepts in nasal tip contouring. Arch Facial Plast Surg 8:156-185, 2006.

Secondary Rhinoplasty

GILBERT C. AIACH, OLIVIER F. GERBAULT,
MARTIN H. KELLY
CHAPTER 57

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Part X  Rhinoplasty
I
n primary rhinoplasty, the surgeon is faced with numerous anatomic variations
of the underlying skeleton as well as variable qualities of the soft tissue cover and
the dynamics of the nose. Even if the surgeon manages to exert a positive influence
over healing, complete control over the healing process after rhinoplasty is not pos-
sible and may alter the outcome after months and even years. Thus it is not surpris-
ing to observe defects of varying severity that have resulted from overresection or
overcorrection that require a secondary procedure.
Defects observed after primary rhinoplasty are caused principally by these factors:
 Errors in judgment: The rhinoplasty may have been technically well done, yet
the nose is unbalanced, not fitting with the other components of the face or
with the individual’s overall appearance.
 Technical mistakes: These vary in extent and can lead to distortion of the
anatomy, asymmetry of the osteocartilaginous skeleton, and scarring soft tis-
sue. This makes the dissection planes difficult to differentiate and affects the
aesthetics and function of the nose.
 Unpredicted poor results: In some cases, the planned correction is successfully
executed, the surgeon is satisfied with the immediate result, and no apparent
technical error occurred, yet the outcome is still suboptimal.
Secondary problems can be classified as minor or major defects.
MINOR DEFECTS
Minor defects occur frequently, in 5% to 20% of cases, as as-
sessed by the surgeon. These defects are often accepted by patients who are satisfied
with their overall improvement. Some patients with unreasonable expectations may
exaggerate minor defects, asymmetries, and prominences. These patients may com-
plain of palpable imperfections. A frequent example is a small deviation of the dor-
sum or a minute asymmetry of the nostrils that is seldom noted before the opera-
tion but is immediately reported by the patient postoperatively. Slight asymmetry of
the nasal tip that can be caused by retraction of soft tissue cover may follow the
healing process.
MAJOR DEFECTS
Over the past two decades, surgeons have become more conser-
vative in their technical approach to rhinoplasty. Better teaching through videos, live
surgery, rhinoplasty courses, numerous books, and the use of the open approach
have decreased the severity of postrhinoplasty problems. Nevertheless, major defects
still occur. These defects may result from excessive and asymmetrical resections or
from a failure to understand the importance of the soft tissue environment, the dy-
namics of the nose, and, of crucial importance, the quality of support of the tip, alae,
and middle vault, which have often been damaged.

Most often, major secondary defects are observed in noses that look unnatural and
were operated on because of certain frequently encountered features. For example,
as seen in this patient, the nasofrontal angle was underresected and the dorsum
overreduced, leading to a shortened nose with a round, underprojected tip. In addi-
tion, the airway was compromised and internal and external valve function was al-
tered. These defects were corrected through secondary rhinoplasty.
Anatomic and Technical Challenges Posed
by Reoperative Surgery
Difficulties encountered during secondary rhinoplasty depend on the degree of nasal
shortening, the extent and location of the bony and cartilaginous resections, the con-
dition of the remaining cartilages, the medial crural support, and the suppleness and
thickness of the skin cover.
Soft tissues can be scarred and adherent to the osteocartilaginous skeleton as a re-
sult of aggressive surgery on the muscular and subcutaneous layers or aggressive de-
fatting. The cutaneous layers may be adherent to the mucosal lining when cartilagi-
nous resections have been excessive. A lack of suppleness of the nostrils increases
the difficulty of the exposure.
In patients with thick skin, certain defects can be masked by the thickness of the
cover that cannot be thinned out. The most that one can expect in such instances is
only moderate improvement, justifying preoperative preparation of the skin by a der-
matologist. Limited dissection and placement of the dorsal and tip grafts are recom-
mended to augment rather than reduce the nose. Dead space should also be eliminated.
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Chapter 57  Secondary Rhinoplasty

The thin skin on the nasal tip and lateral aspect of the radix, where soft tissues be-
come thinner toward the eyelid, is unforgiving. Thus the difficulties vary from case
to case, and problems can exist at the level of the covering tissues, mucosa, and os-
teocartilaginous skeleton during the reconstruction.
The Reoperative Rhinoplasty Patient
The psychological profile of a patient undergoing multiple rhinoplasty operations
is a key issue. Whereas primary rhinoplasty patients have not been sensitized by a
disappointing result, secondary rhinoplasty patients are well aware of the risks of
surgery and will frequently ask only for an improvement. As they recall the pitfalls
of the first procedure, some may simply request restoration of their original form
and function.
One must be careful when a patient’s expectations are very high but the defect is sig-
nificant and the outcome unpredictable. In major defects with excessive scarring,
minor surgery is recommended, with placement of a dorsal onlay and alar graft us-
ing an endonasal approach with limited dissection.
Despite significant improvement from the primary rhinoplasty, some patients may
still present with minor defects; they express confidence in their first surgeon but re-
quest further revision. The surgeon must be wary of unhappy patients who com-
plain of very minor defects and expect perfection, or those who present with more sig-
nificant defects and make disparaging statements regarding their previous surgeon.
Sometimes such patients have consulted many experts, and their expectations may be
too high.
Preoperative Assessment
Examination
It is important to take a detailed history and closely examine photographs and re-
ports or worksheets of previous surgeries.
Worksheets accurately detailing the position, amount of resection, and grafts (see
p. 2027) are very useful. This combination of information helps the surgeon to ap-
praise the original deformities and understand how they were treated, whether the
septum or other sites were harvested, and if any complications occurred. Examina-
tion of the nose should be conducted in the same manner as in a primary case. The
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2027
Chapter 57  Secondary Rhinoplasty
Number: _________ Last Name: ______________________ First Name: _________________ Anesthesia: Dr. ___________________
Date: _______________________ Hospital: ____________________________________ Assistant: ___________________________
=======================================================================================================
Specifics:
Primary rhinoplasty
Deviation
Racial
Secondary rhinoplasty
Touch-up
Other
Skin:
Ultra thin
–
N
+
Very thick
Tip Projection:
–
–
–
N
+
+
+
Cartilage (recoil):
–
–
–
N
+
+
+
Surgical Approach:
Intercartilaginous
Intracartilaginous
Marginal
RETHI
Other
Transfixing
Hemitransfixing
Partial
Lateral crus (left) = ______ mm
Domes:
Resection
Incisions
Sutures
Shortening: Upper lateral cartilage
Septum
Nasal spine
Mucosa
EXTRAMUCOSAL DISSECTION
Septum: Resection
Incisions
Reinsertion
Dorsum: Osteotome
Rasp
Grafts:
Cartilage:
Septum
Ear
Bone
Other
• Radix
• Dorsum
• Spreader graft Lateral grafts
• Nasal Tip
• Columella Alae
• Premaxilla
Osteotomes:
• Medial:
Endo N
Percutaneous
• Lateral:
Endo N
Percutaneous
Low-to-low
Low-to-high
• Bony wedges
Alae = ______ mm
Packing:
Gauze
Hemostatic ointment
Tubes
Plate
Commentary and Criticism:
Graft
Graft
Graft
6
2

soft tissues should be inspected and palpated to evaluate their condition and the
presence of scarring in all areas.
Examination should proceed from the radix to the tip, assessing the position and
projection of the radix, projection of the dorsum, and, by very meticulous inspec-
tion and palpation, any minor asymmetry of the bony and middle vault. The tip,
alae, and middle vault supports are evaluated, as are alar configuration and symme-
try, the alar-columellar relationship, and the nasolabial angle.
Endonasal examination may reveal septal deformities, external and/or internal valve
collapse, perforations, and synechia. To determine whether the septum has been har-
vested, the surgeon can gently palpate the septum on one side with a smooth-tipped
instrument while observing the other side with the aid of a headlight. If the septum
has been harvested, a softness in the harvested area will be evident on the other side.
Consent
Obtaining informed consent from patients for revision or secondary rhinoplasty fo-
cuses more on gaining their trust than on securing their signature on an exhaustive
list of potential complications. The simple statement, “There are no guarantees,”
succinctly summarizes the requisite degree of understanding. A minimum of two
consultations is necessary, in which the same message is communicated after a thor-
ough explanation of the potential pitfalls of further surgery. The goal of the consent
process is to allow patients to understand that they have an active, participatory role
in what is essentially a journey back from a less than ideal result toward an aesthetic
and functioning nose. The patient and the surgeon should make the journey as a
team, and any problems encountered along the way are best dealt with as a team.
Some problems can be anticipated, such as prolonged edema; some are unfortunate
and unforeseen, such as infection or bleeding. Finally, a potentially hostile outcome
between an unhappy patient and a defensive surgeon is more likely to be avoided
by a close, caring relationship than by the patient’s being presented with an overly
long and impenetrable consent form.
Secondary rhinoplasty is more demanding from the surgeon’s perspective, and the
requisite few millimeters of form are more difficult to obtain in any direction. It is
tempting for a confident nasal surgeon to condemn previous interventions as clumsy,
decry the previous surgeon as inept, and promise great improvements. Such an ap-
proach, however, is ill advised. During consultation before the procedure, it better
serves the surgeon’s goals to underplay the chances of a wonderful result. This will
imbue the patient with a sense of wonderment if things go well—and lead at worst
to resigned acceptance if they do not.
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Chapter 57  Secondary Rhinoplasty
Preoperative Planning
Timing of Reoperative Surgery
Many early problems such as slight asymmetry, tip bulbousness, and lack of defini-
tion may resolve in the months following surgery. During this healing period, the
patient needs good support from the surgeon. It is usual to perform a revision after
1 year, but a very early surgery may occasionally be performed during the first week
if a severe defect can be quickly corrected. Examples include the removal of a dis-
placed graft or correction of an overshortened nose by reduction of the caudal sep-
tum and nasal spine.
A minor defect such as a visible dorsal prominence can be rasped or shaved after a
few months with the patient under local anesthesia with the use of a short intranasal
incision and narrow instruments. Correction of secondary nasal tip deformities and
thick or scarred soft tissues should be performed at least 1 year after the primary
procedure.
Surgical Technique
The surgical approach depends on the surgeon’s preferences. No single approach or
technique is the sole correct one for performing primary or secondary rhinoplasty; it
depends on the indications. The technique selected will also depend on the difficul-
ties encountered, including unforeseen ones.
Intranasal Approach
An intranasal approach can be performed for minor defects, such as a dorsal promi-
nence or tiny depression, nostrils of normal size and suppleness, and defects limited
to the dorsum without significant asymmetry. A single pocket can be developed with
accuracy through an intercartilaginous incision and a graft, bony or cartilaginous,
can be inserted.
A transcartilaginous or intercartilaginous incision can provide adequate exposure
for the desired corrections, particularly when the nasal tip is symmetrical and does
not constitute a major problem. However, the surgeon should not hesitate to shift
to the open approach if any difficulty is encountered or if the exposure does not per-
mit adequate correction.

External Approach
We use the external approach in more than 90% of our secondary procedures. With
the transcolumellar external approach, a better anatomic assessment can be made
of the deformities and supportive structures. It provides easy access to the septum
and usually makes harvesting septal cartilage possible, even when septal surgery has
previously been performed.
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Part X  Rhinoplasty
The external approach also facilitates corrections that can be achieved by judicious
resections, suture techniques, and reconstruction of the cartilaginous framework and
support with accurately fixated grafts.
INCISIONS
A transverse columellar incision is placed at the narrowest part of the
columella; the incision can be placed at the level of the base of the columella in the
labiocolumellar crease when the columella is short with narrow columellar foot-
plates. The extent of soft tissue elevation should be carried out according to soft tis-
sue conditions. The dissection should be less extensive in overly thick skin and in
patients with scarred, rigid soft tissues.
A transcolumellar incision is usually indicated for difficult cases in which the patient
has small nostrils, a skin cover lacking suppleness, and major defects of the nasal tip.
In multioperated patients or those who have undergone several transcolumellar-
approach procedures (this is becoming more frequent), dissection of overly scarred
nasal tip and columellar soft tissues is still very difficult. Doing so may worsen the
scarring when there is thin, adherent soft tissue cover. An endonasal approach or a
midsagittal columellar incision may be the last resort, which allows limited maneu-
vers but permits adequate and accurate placement of grafts.
The midline columellar approach has been used for decades, most often for correc-
tion of secondary cleft lip noses and multioperated noses. However, secondary cleft
lip noses can often be considered as secondary multioperated noses with nasal tip
deformities and significant scarring. The incision is usually placed in the midline of
the infratip segment; its length is usually 4 to 6 mm, depending on the deformities.
It can be extended anteriorly if the surgeon plans to work on the nasal tip, or poste-
riorly to introduce a large graft.

A tip graft is inserted through a short sagittal midcolumellar incision. Dissection can
usually be performed easily and quickly. Because of the shortness of this incisional
approach, maneuvers must be very carefully executed with narrow instruments and
attention to the integrity of the skin edges. Narrow scissors, an elevator, and a Beaver
blade protected with a strip can be used to dissect heavily scarred soft tissues when
there is no more dissection plane.
Local anesthesia of the lobule alone frequently suffices and is less distressing than
vestibular or total nasal infiltration. The postoperative course is reduced in time and
magnitude. Such advantages allow the surgeon to minimize the significance of mi-
nor touchups (particularly our own retouches) in terms of duration and ease and
represent less pain and lower hospital costs for the patient.
Dissection can be performed over and between the domes and extended laterally to
the alae and upward to the dorsum. If the incision is extended posteriorly to the
labiocolumellar junction, it may provide access to the membranous septum and
straightforward placement of graft within the membranous septum and columella
for correction of a retracted columella. A columellar strut can easily be placed through
this approach, and tip projection can be augmented with a graft slightly longer than
the pocket. The tip lobule can be grafted with a single or multilayered graft. For in-
fratip and infracolumellar grafts, the skin should be conservatively dissected later-
ally to avoid tension and the risk of disruption or necrosis.
The best indications for this approach are heavily scarred or thick soft tissue cover
with narrow nostrils that do not permit an endonasal approach, or in cases in which
a transcolumellar approach is not desirable because of the presence of overscarring
of the endonasal lining. Precise undermining can be performed to place a dorsal and
tip graft, producing less postoperative edema.
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Chapter 57  Secondary Rhinoplasty

The limitation of this approach is the short incision length, which does not allow
the same degree of exposure and precise cartilage manipulations that more exten-
sive dissection techniques permit.
Secondary Problems
Moderate and Minor Defects
Minor defects most often involve a cartilaginous or bony projection problem, a slight
asymmetry or deviation, or a minor depression. Such defects may appear after sev-
eral months, when the edema has completely resolved. Correction is usually simple
and rapid and in most instances can be carried out with the patient under local anes-
thesia. A bony or septal prominence can be trimmed or rasped using a narrow 3 or
4 mm rasp, which, after an endonasal puncture incision, permits direct access to the
prominence without preliminary undermining. A bony projection can be easily rasped,
as can a slight excess of the rigid dorsal border of the septum.
The danger in correcting these tiny defects lies in making the problem worse. Rasp-
ing a graft that has been bruised in the previous surgery or rasping a thin bone graft
placed under thin skin may displace fragments of the graft and create more pro-
nounced defects.
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Part X  Rhinoplasty
In this patient, a radix defect is evident on the lateral aspect, where the soft tissue
thickness decreases. This slight dorsal prominence is shaved using a narrow rasp.

A small depression can be corrected by filling the area with crushed cartilage graft,
preferably harvested from the septum. The crushed cartilage can be introduced af-
ter minimal tunneling. Diced cartilage is the preferred method when large defects
must be corrected. Moreover, this allows a long-lasting correction.
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Chapter 57  Secondary Rhinoplasty
Very finely diced cartilage can also be injected with a 1 cc Luer-Lok syringe and a 16-
or 17-gauge injection cannula (the type used for fat grafting). Any kind of cartilage
can be used, but the most practical procedure is to anesthetize the area with a local
anesthetic, harvest concha, dice it, and reinject it through a small stab incision.
Small defects can also easily be corrected with fillers. The most frequently used fillers
for this purpose are hyaluronic acid gels and Radiesse, which consists of calcium hy-
droxylapatite microspheres suspended in a sodium carboxymethylcellulose gel.
Hyaluronic acid is used preferentially in thin skin locations where a deep injection
cannot be performed, such as the columella, and the tip in thin-skinned patients.
Radiesse may be used in the radix, dorsum, supratip, and premaxilla. Early inflam-
matory reactions, foreign body granulomas, and allergic reactions are very rare with
these fillers. Hyaluronic acid lasts 8 to 12 months; Radiesse lasts 2 to 3 years. It must
be injected deep, on the top of the bone or cartilage. Caution is necessary when cor-
recting an inverted-V deformity: the filler must not be injected close to the mucosa to
avoid infection and decrease the risk of granuloma formation.

Discrete deviations are difficult to correct; they are often caused by a residual car-
tilaginous deviation or asymmetrical resections. It is often easier, and preferable, to
correct them by limited procedures rather than carry out wide undermining and os-
teotomies, because there is a risk of incomplete correction and other sequelae. Plac-
ing camouflage grafts on the side opposite the deviation is sometimes a simpler and
more effective solution.
Radix Defects
The position of the radix is crucial to a harmonious result. Radix projection and po-
sition influence the nasal length and nasofacial angle. The ideal radix position is be-
tween the supratarsal fold and the eyelashes and can vary from 10 to 12 mm (when
overresection or overgrafting is being corrected).
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Part X  Rhinoplasty
Projection of the radix is 4 to 6 mm deep to the glabella (as noted by Guyuron) and
10 to 11 mm from the corneal plane (documented by Byrd). Projection of the radix
can make a nose look longer, particularly if there is no clear delineation between the
nose and the forehead, as with a Greek nose.
High Radix: Underresection
A high radix is frequently observed after a rhinoplasty. It is caused by underresec-
tion of the bony radix, which is difficult to correct because of the dense bony radix
and the thick muscular layer (the procerus muscle).
4-6 mm

Reduction of the radix is not an easy task. Bony radix reduction can be prepared by
using a 2 or 3 mm osteotome introduced percutaneously to create a trench above
the area to be resected. This facilitates resection with a beveled, well-sharpened os-
teotome; the surface of the bevel is angled to allow the osteotome to be directed at
a better angle.
Adequate deepening of the radix is essential when a dorsal graft extends to the radix.
Before a cartilage graft is placed, deepening should be limited to 1 mm. When using
a bone graft, the surgeon needs to maintain sufficient thickness of the cephalic end
of the graft to prevent a bony fracture. On the other end, the radix should be well
prepared for a bony union and sufficiently deepened to prevent a shallow radix.
Resection of the procerus allows moderate (1 to 2 mm) deepening of the radix. The
muscle is resected with scissors or a rasp. A vasoconstrictor-impregnated gauze pad
is then placed in the radix area to decrease bleeding. This approach should be avoided
in thin-skinned patients.
Excessive Bony Resection
Overresection of a dorsal hump resulting from use of an osteotome with the wrong
orientation may create a high middorsal notch with a high radix or dorsal saddling,
including the nasion area, which has been overresected, causing the glabella and
nasal base to appear more prominent.
It is important before any radix reduction to palpate and pinch the soft tissue of the
radix to assess thickness (average 7.5 mm) and laxity. Despite overreduction of the
bony radix, an excess of soft tissue of the radix may be present, creating fullness and
a wider appearance of the intercanthal distance. This is a result of poor soft tissue
response after bony reduction.
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Chapter 57  Secondary Rhinoplasty

The average soft tissue response (contraction and redraping) in the radix area is
25%, resulting from two factors: (1) the thickness and laxity of the covering soft tis-
sues, and (2) the limitation of redraping laterally by the fixed inner canthal points.
Correction of a radix defect can be performed with cartilaginous grafts, deep tem-
poral fascia, fillers, or diced cartilage. The cartilaginous graft is the benchmark pro-
cedure for correcting an overresected radix. The best adapted grafts are septal or
lower lateral crural grafts. They are very effective, but their main drawbacks are edge
visibility and displacement. To avoid those problems, undermining over the radix
area must be limited on the lateral aspects. The sides of the grafts are beveled, the
grafts are weakened (with incisions or slight crushing), and two percutaneous
through-stitches are performed. Grafts can be superimposed if the radix needs more
than 2 or 3 mm of augmentation.
Deep temporal fascia is very easy to harvest, and the resulting 3 cm scar in the tem-
poral scalp is inconspicuous. This fascia can be folded on itself for more projection.
Two percutaneous through-stitches are also used. Edge visibility is never an issue
with the use of this fascia, but swelling is more prolonged than with a cartilaginous
graft.
Acellular dermal matrix products such as AlloDerm can be used in place of deep
temporal fascia, but partial resorption may sometimes occur for such allogenic ma-
terials.
Fillers are very practical for correcting radix defects. Radiesse may be more appro-
priate than hyaluronic acid, because it lasts longer. If hyaluronic acid is selected, a
highly reticulated form is used (Juvéderm Ultra 4, Perlane). The injection can be per-
formed in the office, and the resultant correction is immediate.
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Part X  Rhinoplasty

Diced cartilage is very useful in this location and produces a long-lasting result. This
procedure can be performed with the use of a local anesthetic in the office.
Saddle Nose Deformities and Flat Nose
Saddle Nose
Saddle nose deformity can involve the entire dorsum from the root to the supratip
region or only the lower dorsum, causing a “hatchet stroke” deformity with a more
or less noticeable hump above it. Overresection of the dorsum with an osteotome,
including nasal bone, upper lateral cartilage, and the dorsal edge of the septum,
causes saddle nose, with middle vault collapse. However, saddling may also result
from an underlying septal cartilage fracture or weakness, from collapse of the dor-
sal edge of the septum after a submucosal resection of the septum, or from harvest-
ing too close to the dorsal edge of the septum.
Saddle nose deformity is commonly considered to affect the nasal width, length, and
nasal valves. Posttraumatic effects may include broadened nasal width, with a flat
appearance of the nasal vault and a more pronounced nasal base. Tip and columel-
lar support may have been damaged by overresection of the nasal spine and septal
caudal border, causing a retracted columella; these supports can be assessed by press-
ing backward on the nasal tip. Supratip saddling may also occur after overresection
of the lower dorsum or a large septal perforation.
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Chapter 57  Secondary Rhinoplasty
Saddle nose deformity from the radix to the supratip area after aggressive dorsal re-
section of the hump is illustrated on the left. Deformity of the lower dorsum caus-
ing a hatchet-stroke deformity with a more or less noticeable hump above it (true
or false hump, respectively) is shown on the right.

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Part X  Rhinoplasty
Surgical correction of a saddle deformity consists of restoring the damaged supports
and filling the defects by various means:
 Repositioning of asymmetrical and displaced structures with restoration of
the original septal height.
 Reconstruction of the dorsum with single or multilayered cartilage, with diced
cartilage wrapped in fascia, or, rarely, with bone grafts, depending on the mag-
nitude of the deformity, the availability of cartilage, the quality of the recipient
beveled graft, and the skin. Septal cartilage is best for augmenting the dorsum.
Conchal cartilage will not provide a sufficiently long fragment, and its curva-
ture is less suitable for the dorsum. The external portion of the concha may
provide a long (3 cm) graft that can be flattened by a superficial partial-depth
incisions followed by light bruising.
A longer graft can be obtained by overlapping two grafts as tandem grafts. But if
support grafts must be used and if the septum is not of good quality (for instance,
because it has been fractured, bent, or partially harvested previously), costal carti-
lage is the best option. Rib grafts allow the use of long, straight, solid pieces of car-
tilage for support and provide a sufficient quantity of cartilage to be diced and
wrapped in the deep temporal fascia for dorsal augmentation. The diced cartilage
and fascia (DCF) technique avoids the use of a monobloc cartilage trimmed from
the costal cartilage, with its own risk of bending, and obviates the need for a K-wire
to stabilize the graft to decrease the risk of bending.
After an extramucosal dissection, the upper lateral cartilages are separated from the
anterior septal border. An anterior septal deviation can then be corrected by carti-
laginous incisions or cartilaginous struts to reinforce the septal buttress and to cam-
ouflage a deviation. The nasofrontal angle should be slightly deepened when the dor-
sal graft extends toward the radix. Medial and lateral osteotomies allow correction
of an asymmetrical, flat, wide nose, but the surgeon must keep in mind that saddling
creates the illusion of flatness and, after dorsal augmentation, the nose may appear
less broad. Secondary osteotomies to correct a broad or asymmetrical bony vault
are best achieved by external percutaneous osteotomies. Two-millimeter perfora-
tions allow the surgeon to trace a pattern along the desired osteotomy line, followed
by gentle pressure only when all bony struts have been securely broken. This method
also allows asymmetrical osteotomies to be safely performed to correct nasal bones
that were malpositioned at the primary surgery.

The endonasal approach is sufficient if the dorsal deformity is isolated. When other
defects are present, notably at the level of the nasal tip, a transcolumellar approach
is used, particularly for a difficult nasal tip reconstruction.
ASYMMETRICAL RECIPIENT GRAFT BED
An asymmetrical recipient graft bed is
quite common in saddle nose deformity because of previously undetected and un-
treated asymmetry, asymmetrical cartilaginous hump resection, uneven osteotomies,
or multifragmented bone during hump resection.
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Chapter 57  Secondary Rhinoplasty
An asymmetrical graft can sometimes be used to correct an asymmetrical recipient
graft bed, as in this patient, who complained of a dorsal depression with asymme-
try and impaired breathing. She desired a longer nose with a straight dorsum. On
frontal view, on the right side, one can see collapse of the lateral bony and middle
vault, which produced the optical illusion of a deviation. The defect was more dis-
cernible on the bone (with a vertical depression) than on the middle vault. The lat-
eral view shows a slightly retroussé nose and an open nasolabial angle greater than
110 degrees. The basal view shows that the left dome was higher than the right and
that there was a slight deviation on the left. The oblique view shows saddling of the
upper dorsum. On forced inspiration, there was a discernible collapse at the poste-
rior junction of the lateral crura and upper lateral cartilages.

A transcolumellar approach was used to correct the problem. After skeletonization,
the radix was moderately freshened with an osteotome to obtain a radix recipient
graft as flat as possible. The septum was approached dorsally, and major harvesting
of cartilage and thin bone (vomer and perpendicular plate) was performed.
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Part X  Rhinoplasty
Reconstruction was achieved by placing grafts in different areas of the nose. Because
the upper dorsum was quite asymmetrical, an asymmetrical dorsal graft was pre-
pared. The main graft was bruised and two narrow grafts were placed at the under-
surface of the right edge of the main graft to fill in the lateral depression. A small
bony graft was placed laterally on the right side of the bony vault. The caudal end of
the graft was fixed to the dorsum. Two flat, thin, bony fragments from the septum
were positioned in the weak area at the upper and lower lateral cartilage junction.

A columellar strut and an onlay graft were placed to strengthen the columella and
improve the tip definition and contour. No osteotomy was performed. The patient
is shown 13 months postoperatively.
2041
Chapter 57  Secondary Rhinoplasty

DICED CARTILAGE
Diced cartilage rolled up in fascia (DCF) is the most appropri-
ate technique for correction of saddle nose deformity. It consists of tailoring a com-
posite graft of pieces of diced cartilage and wrapped in a layer of deep temporal
aponeurosis. This initially malleable graft allows an effective dorsum augmentation
(1 to 10 mm), which is adjustable until the end of the operation and even postoper-
atively. It can easily be introduced through a closed or open approach.
This graft is applicable to all primary and secondary augmentation rhinoplasties.
However, the elective indications are for secondary augmentation rhinoplasties with
cartilaginous donor site depletion or when cartilaginous grafts are of poor quality
(because they are of insufficient length or are multifragmented), or when the recip-
ient bed is uneven or asymmetrical. In this last situation, the DCF is prefabricated
on the back table to fit the defect. After positioning the DCF on the dorsum, it is
precisely and delicately molded onto the defect to fit the uneven recipient site. In all
cases, the DCF is positioned at the end of the operation, after all the septal work has
been done and all support grafts have been sutured.
2042
Part X  Rhinoplasty
This patient had undergone three previous rhinoplasties through an endonasal ap-
proach to correct a wide, overprojected nose with a hump and wide nasal tip. Car-
tilage from one ear was harvested on the first revision surgery, and from the other
ear for the second revision. The patient had not been able to breathe well since her
first surgery. The frontal preoperative view shows an inverted-V deformity with a
left nasal bone that was too lateral. The tip was too wide, bifid, and asymmetrical,
and the nostrils were too visible because of alar retraction. On basal view the upper
lateral cartilages were collapsed into the nostrils because the previous hump removal
was performed without reconstruction of the internal valve.

2043
Chapter 57  Secondary Rhinoplasty
The lateral and oblique views show an obvious lack of tip projection, tip bifidity,
and alar retraction. A ninth costal cartilage was harvested; then a 4 by 4 cm deep
temporal aponeurosis was harvested for the DCF.
A transcolumellar approach was planned. The intraoperative view on p. 2044 shows
a complete transfixion of both lateral crura. The lower lateral cartilage had been
overresected, and there was marked flaring of the middle crura. The central carti-
lage was to be used for the two spreader grafts, the columellar strut, and the tip graft.
Slightly naturally bent slices of outer rib cartilage were used as alar batten grafts,
extending caudally to lower the alar rims.

The remaining cartilage was diced to be used as a DCF. The diced cartilage was in-
troduced in a 1 cc tuberculin syringe and compacted. The deep temporal aponeuro-
sis was sutured around the syringe, and the hub of the syringe was cut. The distal
part of the DCF was closed and the diced cartilage was injected in the aponeurosis
tube. The DCF was then carefully molded on the back table.
2044
Part X  Rhinoplasty
After approximating the domes with an interdomal suture, a columellar strut and
shield graft was placed, and alar batten grafts were sutured to the vestibular skin
and the cut end of the lateral crura. The aponeurosis tube was inserted on the dor-
sum at the end of the operation, after the supporting grafts were sutured; it was su-
tured to the remaining upper lateral cartilage, and its cephalic part was stabilized
with two percutaneous stitches.
Operative view after opening
Tip graft and alar rim grafts
Before closure

The patient is seen at 1 year postoperatively. The aesthetic dorsal lines are restored,
the tip is smooth, and the alar notching is corrected.
Flat Nose
A flat nose often results from trauma or a previous surgery in which the caudal sep-
tum and the lower lateral cartilages have been damaged or overresected, with sig-
nificant loss of the tip supports. On examination, the interalar base distance appears
wide in respect to the length of the columella. The nasal tip is easily depressed, with
poor columellar and septal support, and on palpation alar cartilages appear weak
and soft. A dorsal depression and retracted columella are caused by overresection
of the dorsal septum or by a large septal perforation extending anteriorly.
2045
Chapter 57  Secondary Rhinoplasty

2046
Part X  Rhinoplasty
Correction of flat noses involves strengthening the anterior and caudal buttress and
the tip and columellar supports and restoration of the septal deformity. In a moder-
ately flat dorsum and nasal tip, extended spreader grafts are sutured to a wide col-
umellar strut to provide a solid L-shaped strut. Then the medial and middle crura
are sutured caudally to the columellar strut. It is sometimes necessary to conceal
dorsal irregularities with deep temporal fascia or crushed cartilage. In a markedly
flat dorsum and nasal tip, a dorsal graft and a long bony or costal cartilaginous L-
shaped strut may be placed. This type of reconstruction is rigid and often does not
look natural. Its aesthetic appearance can be improved by the use of a DCF on the
dorsal part and by a columellar strut with the medial and middle crura sutured to
it on the caudal part. If a costal or bone graft is used in the columella, it can be fixed
to the nasal spine. The medial crura are then advanced on the strut and transfixion
sutures are placed through previously made perforations on the strut.
This patient had undergone two previous rhinoplasties and septoplasty. She pre-
sented with a flat nasal base, short columella, and severe loss of nasal tip supports.
On frontal view, there was a wide dorsum and a large interalar base distance with
a flat nasal tip. On basal view, the scar of a previous transcolumellar incision was
obvious; the columella was very short, with pseudoalar flaring caused by the severe
loss of tip supports. Endonasal examination showed a large anterior septal perfora-
tion, precluding any septal harvesting.

The main problem was the loss of columellar support, which had to be reconstructed
with a stiff columellar strut.
2047
Chapter 57  Secondary Rhinoplasty
The conchae were harvested using a retroauricular approach. A transcolumellar ap-
proach was performed, revealing the poor laxity of the alar cartilages.
A pocket was developed on the dorsum for placement of a dorsal graft. The col-
umella and nasal tip were reconstructed with a fleur-de-lis graft with the two lateral
edges of the conchae. Because the cartilage was very soft, a rigid 0.5 mm thick bat-
ten of polydioxanone (PDS) plate (15 by 5 mm) was placed between the two carti-
lages and sutured to them to provide sufficient stiffness to the grafts. The divergent
anterior extensions of the grafts were positioned on the top of the domes and su-
tured to the lateral crura. A single-layer graft was placed on the dorsum, and lateral
and medial osteotomies were performed.

The patient is shown 12 months postoperatively. The PDS plate has been resorbed
and replaced by connective tissue. The plate was used as a temporary scaffold to
provide a stiff columellar support during the early stages of healing.
2048
Part X  Rhinoplasty

Graft Defects
Problems include defects that occur after placement of grafts in the radix, dorsum,
or tip; in addition, secondary rhinoplasty in a graft-depleted patient presents a chal-
lenge. Grafting techniques are frequently used to augment, contour, balance, and re-
construct the skeletal structures that produce the nose’s function and aesthetics.
However, as in every technique, there are advantages and drawbacks, and various
defects or complications may be seen during and after grafting. Besides the difficul-
ties that follow graft placement, the surgeon may encounter the complications in-
herent in the harvesting process, such as these:
 Auricular deformity
 Retroauricular keloids
 Septal perforations
 Creation of a supratip hatchet defect after a loss of septal support
 Fracture of the perpendicular plate of the ethmoid after aggressive resection
with forced twisting motions that may cause cerebrospinal fluid leakage
 Pneumothorax after rib graft harvesting
The problems that occur most frequently after placement of grafts are seen when
using “visible graft” in the radix area, dorsum, and tip. They include undergrafting
or overgrafting, prominence with graft visibility, asymmetry, and irregularities caused
by warping of the graft; graft displacement; and a poorly prepared recipient bed.
2049
Chapter 57  Secondary Rhinoplasty
An asymmetrical recipient graft bed will automatically cause displacement and asym-
metry. Infection is rare, but it may occur with conchal cartilage and in severely scarred
or thick, soft tissues; resorption may be seen, mostly after bone grafting, and may
follow an infection. Skin discoloration and telangiectasis are more frequent after
several surgeries in a patient with thin or scarred soft tissues. The incidence of such
defects can be decreased by scrupulous attention to and management of the succes-
sive steps of grafting.

Radix Graft Defects
Radix defects may be observed after using grafts that have not been modeled by
bruising, that are too wide, and that have edges that have not been beveled and do
not feather with the adjacent areas. Visibility of a radix graft usually occurs later-
ally and caudally in areas where soft tissues are thin.
Soft tissue thickness varies over the bony skeleton; it is thinner over the rhinion (2
to 3 mm), where a step off may be observed when the graft ends at the level of the
rhinion. Soft tissue thickens (7 to 9 mm) as one approaches the midline of the na-
sion, but thickness progressively diminishes laterally toward the inner canthi. This
explains why defects of radix grafts are seldom observed on the midline and are
more frequent laterally and caudally.
Radix defects can be limited by careful preparation of the recipient graft bed with
moderate, symmetrical undermining at the level of the radix, followed by light rasp-
ing to remove the soft tissue remaining on the periosteum. Bruised narrow grafts
should be used, with particular attention to the preparation of the caudal end of the
graft, where a smooth continuity with the dorsum should be obtained.
When the radix and upper dorsum are to be grafted, it is sometimes better to use a
longer graft that extends from the radix to the supratip after slightly rasping the
dorsum. This provides more stability to the graft and decreases the risk of a defect in
the rhinion area.
Correction of radix defects is not easy and depends on the type and condition of the
graft. The graft can be bone or cartilage (septal, ear, costal). If a septal graft had been
placed, it can be rasped with a narrow rasp introduced intranasally. It is risky to
rasp an ear cartilage graft or a cartilage that has been bruised. The prominent de-
fect can be punctured percutaneously with a Keith needle if the defect is inconspic-
uous. In selected cases, a skin incision placed laterally provides a good approach and
an easy correction with a narrow rasp and a Beaver blade. The scar will be scarcely
visible. If the edge of the graft is visible and the defect is mild, injection of hyaluronic
acid around the graft’s edge can reduce its visibility.
2050
Part X  Rhinoplasty

Bruising should be gentle and incremental. The graft should be checked after each
stroke of the hammer to determine whether it has the requisite malleability to con-
form to the recipient graft bed, maintain its integrity, and not be visible at the skin sur-
face. The best materials to use for radix grafting are the resected cephalic portions
of a lateral crus or a bruised septal cartilage. A dorsal graft should be formed into
a tilelike shape by bruising or partial-depth incisions.
Dorsal Graft Defects
On the dorsum, besides overgrafting, undergrafting, and wrong positioning of the
graft, defects frequently encountered are graft visibility and asymmetry caused by
displacement of the graft. One can also observe a lateral depression along the lat-
eral edges of the graft, mostly in patients with thin skin, when the graft has not been
modeled by bruising or by longitudinal partial-depth incisions and when the dor-
sum is narrow.
Grafting the dorsum requires assessment of the shape and volume of the graft. This
can be done preoperatively by using modeling paste or perioperatively by using tem-
plates of different sizes and shapes. Preparation of the recipient graft bed should be
carefully checked by palpation with a wet finger on the skin surface and, if possible,
by direct visualization to trim any projection or irregularity that would create an in-
stability or displacement of the graft. If a bone graft is planned, one must flatten the
bony dorsum and deepen the radix.
Correction of defects of the dorsum can vary in difficulty. A slight septal cartilagi-
nous or bony prominence can be shaved. If asymmetry is severe, balanced resections
and additional grafts will be needed. When additional grafts are required on the dor-
sum, it is better to insert the new graft at the undersurface of the main graft when
the dorsal contour is correct. In some situations, it is better to remove the graft and
replace it after better preparing the recipient graft bed and suture fixation.
2051
Chapter 57  Secondary Rhinoplasty

This patient had undergone two previous rhinoplasties that resulted in an overre-
sected middle third of the dorsum and fullness of the radix and supratip. The in-
fratip lobule had an increased angle of rotation. The alae were retracted and a hang-
ing columella was evident. In addition to flatness of the middorsum (seen on the
frontal view), the nasal base had a wide interdomal distance. The domes were
markedly visible (more on the right side) in relation to a section of the lateral genu
of the domes.
2052
Part X  Rhinoplasty

With a transfixing incision, the overexposed caudal septum (8 mm in height) was
resected. The quadrangular septum was approached through this incision and ma-
jor harvesting was performed, followed by placement of quilting sutures in the mu-
cosal flaps with 5-0 Vicryl Rapide.
The alar cartilages demonstrated the asymmetry resulting from previous resections.
The radix was deepened with a beveled osteotome. The dorsum was rasped slightly
to remove soft tissue, and the caudal borders of the medial crura were trimmed by
2 mm to improve the columellar-alar relationship.
Reconstruction was achieved with a fishtail dorsal graft. The caudal end of the graft
was notched to saddle the anterior septal border. The two parts of the tail were then
folded over the lateral aspect of the dorsal septal border and sutured to it. This su-
ture can include the anterior borders of the upper lateral cartilages. Such a graft may
provide both an aesthetic and functional effect by leveraging the skin cover. After
suturing, the dorsum was checked with a wet finger. Any excess can be shaved, or
the notch can be extended upward. A percutaneous suture was placed in the upper
portion of the graft, and the cut ends of the domes were approximated in the midline
with an interdomal suture.
2053
Chapter 57  Secondary Rhinoplasty
Alar grafts were prepared by splicing a thick septal fragment into two 0.5 mm thick
batten grafts. These grafts were sutured to the remaining lateral portion of the domes.
A bruised infratip shield graft was placed to improve the contour of the tip and in-
fratip. No osteotomies were performed.

The patient is shown 19 months postoperatively.
Tip Graft Defects
Numerous defects occur in the tip from overgrafting or undergrafting, malposition,
displacement, and graft visibility, which usually in thin-skinned patients.
Prevention
 The risks that these defects will occur are limited with an open approach.
 To correct a defect of the nasal tip, the surgeon should prepare the recipient site
accurately by equalizing the height of the domes and the caudal borders of the in-
termediate and medial crura before placing an onlay or infratip graft. Suture fix-
ation can prevent displacement.
 For very thin–skinned patients, cartilaginous sutures should always be considered
to treat the tip problems before using any visible graft. Capping the cartilage with
deep temporal aponeurosis or with perichondrium or periosteum decreases the
risk of early or late visibility.
2054
Part X  Rhinoplasty

Correction
Inconspicuous defects can be corrected with an infracartilaginous incision for shav-
ing a prominence of the graft or adding a thin graft to correct an asymmetry. A sagit-
tal midcolumellar incision can sometimes be used, especially when tip tissues are fi-
brous after several rhinoplasties. A transcolumellar approach constitutes the best
approach for correcting tip defects. Sometimes the whole graft must be removed and
discarded when it is not usable. Otherwise, the graft can be reshaped if it is large
and strong enough, or it can be covered with deep temporal fascia in thin skin.
Graft-Depleted Patients
Usually, part of the septum and at least one concha has already been harvested. It is
sometimes possible to harvest more septum if only a small piece has previously been
taken. Usually the remaining septal cartilage is behind and above the previous area
where the cartilage has been harvested. If both conchae have already been harvested
or if a small piece of cartilage is needed, ear cartilage can also be harvested on the
scapha or tragus.
Finally, costal cartilage is always usable, and the associated morbidity can be very
low with a good technique, but its harvesting is a little more lengthy and tedious.
Costal cartilage allows the use of long, straight pieces of cartilage, which is not usu-
ally possible using ear cartilage or parts of the septum. Those straight cartilages are
first used for the support grafts (spreader grafts, columellar struts, septal extension
grafts, alar grafts, or alar rim grafts). Smaller pieces are used for tip grafts, sidewalls
grafts, and radix grafts. If augmentation is needed, especially dorsum augmentation,
the remaining cartilage pieces are diced and used in the DCF technique.
2055
Chapter 57  Secondary Rhinoplasty
Harvesting septal material is sometimes possible by approaching the septum close
to it dorsal edge and dissecting above and behind the scarred area from a previous
septoplasty. The ear may provide adequate fragments from the scapha and tragus.

2056
Part X  Rhinoplasty
Prevention of Graft Displacement
After two previous rhinoplasties, this patient complained about several deformities
and impaired breathing. On lateral view, she had saddling of the upper dorsum and
radix highlighting the volume of tip and supratip. There was an obvious excess of
the dorsal septum in the supratip, and the tip was unpleasant with an increased an-
gle of rotation and a retracted ala, mostly on the left side.
Preventing or Minimizing Graft Displacement
The following measures are instrumental in preventing or minimizing graft displacement
and the effect on contour:
 Create an adequately sized graft pocket.
 Prepare a flat, symmetrical recipient graft bed and rasp the soft tissues over the skele-
ton. In the upper dorsum, prepare a solid, flat, bony foundation by rasping; however, it
is more difficult in the lower part of the dorsum, where the recipient site is composed
of the anterior border of the septum and upper lateral cartilages.
 Select a graft that extends down to the supratip to stabilize the upper and caudal por-
tions of the graft. A longer graft avoids a step-off, which can be observed in the transi-
tion zone (rhinion area) despite careful beveling of the lower end of the graft.
 Use endonasal and percutaneous suture fixation.
 Notch the two ends of the graft to create a fishtail shape for additional fixation. This
is useful in radix, shield, and dorsal grafts: notching provides more stability by inter-
position of soft tissues.

On frontal view, there was an inverted-V deformity with disruption of the dorsal
lines, and the tip was asymmetrical with a more prominent dome on the right side.
On basal view, collapse of the middle vault, asymmetry of the tip, and collapse of
the right ala were evident. The footplates of the medial crura were prominent. There
was an internal valve dysfunction on both sides and a septovomerine deviation.
The objectives of surgery were to balance this nose by augmenting the upper dor-
sum, refining the tip symmetry, and improving function and contour. After harvest-
ing the right concha, through a transcolumellar approach skeletonization was per-
formed, revealing the deformities and the weakness of the alar cartilages. The supratip
2057
Chapter 57  Secondary Rhinoplasty

excess was shaved by 2 mm and the radix freshened with a rasp. Major septal har-
vesting was carried out, and 2 to 3 mm of caudal septum was resected. Two spreader
grafts were placed and the tip was corrected; better symmetry was obtained by dome
resection, followed by suturing of the cut ends of the cartilages. The divergent foot-
plates of the medial crura were resected.
A septal columellar strut was positioned within the medial crura to provide better
tip support, and cartilage grafts were placed. A thin septal graft was placed on each
lateral crus. The configuration, projection, and definition of the tip were improved
with an infratip graft of ear cartilage; a buttress graft was positioned between the
domes and the cephalic aspect of the shield graft to decrease the angle of rotation.
A three-layered dorsal graft composed of vomer, ear cartilage, and septal cartilage
was sutured together, and the caudal end of the septal fragment was notched in a
fishtail shape with sutures of the two parts of the tail to the adjacent tissues to sta-
bilize the graft. Results are shown 2 years postoperatively.
2058
Part X  Rhinoplasty
Middle Vault and Alar Deformities
The role of the lateral cartilaginous wall (the upper lateral cartilage, lateral crus, and
soft tissue cover of the middle vault and alar wall) is often overlooked during routine
preoperative nasal examination and during surgery. Postoperative deformities of the
middle vault and alae are often caused by overresection and misidentification of un-
favorable anatomic variants of the cartilages. Other predisposing factors, such as
soft tissue cover and the anatomic configuration of nasal bones, may contribute as
well. The result may be a narrowing of the middle vault, with an inverted-V defor-
mity and collapse of the internal and external nasal valves.
Guidelines for the Use of Grafts in Secondary Rhinoplasty
 Preoperatively, assess the graft’s length, width, and thickness using photos and model-
ing paste.
 Never rush when choosing a design from harvested material. Carefully select the best
fragment for every area. Assess the priorities if many areas are to be grafted.
 Be very economical, because reconstruction often requires a large amount of graft.
 During the procedure, use a template or sizers to avoid damaging the graft by repeated
handling and insertions.

Middle Vault Deformities
The middle vault is composed of the upper lateral cartilages, septum, and investing
soft tissues. Support of the upper lateral cartilage is provided cephalically by a tile-
like connection to the inner portion of the solid bony vault and medially by an
anatomic and histologic continuity with the widened dorsal edge of the septum. The
junction of the septum and the caudal margin of the upper lateral cartilage form the
internal valve angle, which is normally 10 to 15 degrees.
After resection of the wide T-shaped extension of the dorsal septum, the middle vault
narrows as a result of medial approximation of the free medial edges of the upper
lateral cartilages. The degree to which lateral movement occurs depends on the in-
trinsic stability of the upper lateral cartilage (its shape, elasticity, and size) and soft
tissue support, and on the pressure changes to which it is subjected during quiet and
forced inspiration. In the absence of a lateral osteotomy of a broad bony vault, there
is a high risk of middle vault collapse.
2059
Chapter 57  Secondary Rhinoplasty
After a lateral osteotomy with a high cephalic fracture, the bony cartilaginous wall
becomes mobile and can be moved toward the midline. However, when the nasal
bones are convex and the high cephalic fracture is incomplete or too high, the de-
gree of displacement of the bony portion is limited in respect to that of the flexible
upper lateral cartilage. When the nasal bone (upper lateral cartilage junction) has
been damaged, the upper lateral cartilages have a greater tendency to move inward.
It is important to evaluate the length of the nasal bones, because short nasal bones
provide less support to the upper lateral cartilages, as well as to assess the condition
of the skin and cartilages.

Evaluating Operative Causes of Middle Vault Collapse
2060
Part X  Rhinoplasty
Factors that contribute to the weakening of the upper lateral cartilage and increase
the potential deformation and collapse include the following:
 Avulsions or lacerations of the upper lateral cartilages as a result of aggres-
sive rasping or excessive resections of these cartilages, causing a depression of
the middle third of the nasal pyramid
 An osteotomy that is too high, with excessive resection of the tissue, especially
along a large nasal hump
 Preexisting extensive soft tissue undermining
 Neglecting to mobilize and suture the upper lateral cartilages back to the mid-
line after dorsal hump resection
Potential Problems
During preoperative examination, the surgeon observes the lateral walls for exter-
nal abnormalities. Middle vault collapse may occur when there is a narrow carti-
laginous vault, in contrast with a wide bony vault, or when the nasal bones are con-
vex, and a slight demarcation exists between the nasal bones and upper lateral
cartilages. Palpation may reveal a convexity at the lower border of the nasal bones
that can be followed downward to a noticeable narrowing of the cartilaginous vault.
Endonasal examination may detect an aspiration of the lateral walls of the nose,
with or without an alar collapse. The surgeon should look for mucosal scars in the
form of synechia or bands, and deviation of the anterior septal border.
A cotton-tipped applicator is used to gently spread the alae from the septum to ex-
amine the internal valve for suppleness, integrity, valve angle, and mobility of its lat-
eral border at rest and during forced inspiration.
The inner surface of a large resected hump should be examined to assess the width
of the septal T. After lateral osteotomy and medial displacement of the bony carti-

laginous flap, the surgeon can examine the oblique view from right and left and pass
a wet finger on the lateral aspect of the dorsum to detect any interruption of the con-
tinuity between the upper lateral cartilages or a step-off—the sign of a collapse or
weakening of the upper lateral cartilage.
Surgical Correction
Middle vault collapse can be difficult to correct through an endonasal approach,
and even more difficult when the nostrils are narrow. The external approach allows
good exposure and accurate correction. The normal anatomy of the cartilaginous
vault must be recreated; specifically, the septal T must be enlarged and a normal
valve angle created.
After an extramucosal dissection has been performed, the mucosal domes can be ap-
proximated toward the midline. Various types of grafts may also be used for correc-
tion. The role of grafts is not limited to morphologic aspects; they are also used to
prevent or correct functional problems. A cartilaginous dorsal graft placed over the
dorsum may provide a spreading effect of the upper lateral cartilages by leverage of
the soft tissue cover.
2061
Chapter 57  Secondary Rhinoplasty
A spreader graft, as described by Sheen, can be placed via an endonasal approach
in submucosal tunnels on either side of the anterior septal border but the open ap-
proach offers more accuracy in positioning and stabilizing the grafts. The spreader
grafts should extend from the junction of the nasal bones and upper lateral carti-
lages to the nasal valve area. Their ends and posterior border should be feathered.
Their thickness depends on the importance of the deformities. The caudal portion
of the septum usually provides a thick 2 to 3 mm fragment. The surgeon can use a
two-layered graft if there are thin fragments. When the septal mucosa has been widely
elevated, the spreader grafts must be stabilized with two sutures of 5-0 Vicryl
or PDS.

Septal cartilage is the best material for dorsal and spreader grafts. This cartilage can
also be bruised and positioned superficially to the upper lateral cartilage to fill in a
depression. In severe cases, with overresection of the upper lateral cartilages and
collapse, a splay graft (Guyuron) allows a pleasing reconstruction. The splay graft
saddles the middle vault with the two lateral portions of the graft being placed sub-
mucosally. Some patients complain of increased difficulty on quiet or forced inspi-
ration, often associated with excessive movement of the nasal ala toward the sep-
tum (collapse).
2062
Part X  Rhinoplasty
Parallel dorsal lines should be obtained after a rhinoplasty (left). On the secondary
rhinoplasty patient shown on the right, a disruption of these lines is caused by a mid-
dle vault collapse, highlighted by a broad bony vault with convexity more evident
on the left side.
This patient had several deformities of his nose and difficulties in breathing. On
frontal view, there was a broad bony vault. The middle vault was collapsed, with
disruption of the dorsal lines, and a deviation with a concavity on the right.

On the oblique and basal views, one could see a concavity of the alar walls that was
more significant on the right side, and a narrow tip lobule. Endonasal examination
showed a septal deviation and an internal valve dysfunction, both of which caused
the breathing impairment.
After harvesting the conchae through a retroauricular approach, an open approach
was selected, exposing the deformities of the alar cartilages. The dorsum was slightly
rasped and the radix lowered with a beveled osteotome. The septum was approached
via the dorsal edge, and septal material was harvested. The deviation was corrected
by repositioning the caudal septum in the midline. The nasal spine was conserva-
tively resected, and the caudal septum was sutured to the soft tissues surrounding
the nasal spine.
2063
Chapter 57  Secondary Rhinoplasty

Endonasal and percutaneous medial osteotomies and endonasal lateral osteotomies
were performed. Two spreader grafts were positioned at different levels, taking into
account the configuration of the deformities. After placement of a columellar strut,
alar grafts (ear cartilage) were sutured to the lateral crura. The tip projection and
definition were improved with an onlay graft and a thin septal graft was positioned
in the infra columellar area. The patient is seen 1 year postoperatively.
Alar Deformities
Alar deformities and collapse may be caused by overresection of the cephalic por-
tion of weak, concave, long, or malpositioned lateral crura and by resection of the
domes, which may lead to medial movement of the lateral crura or by muscular dis-
ruptions, particularly disinsertion of the alar base. Resections of significant portions
of the lateral crura and postoperative soft tissue contraction can damage the exter-
nal valvular support and impair the airway. The external valve, which is caudal to
the internal valve, is composed of the cutaneous (external and vestibular skin cov-
erings) and skeletal (lateral crura) support of the mobile alar wall. The lateral walls
are observed for external abnormalities, such as an inward bowing of the alae on
inspiration, with or without alar collapse. One should look for mucosal scars in the
form of synechia or bands and deviations of the anterior septal border.
Potential Problems
2064
Part X  Rhinoplasty
Alar collapse may occur when the lateral crura are long, weak, and concave. Dome
resection and reduction of the height of the lateral crus exacerbate the condition if
these factors exist.

Depending on the appearance of the soft tissue cover, the shape, length, and elastic-
ity of the alar cartilages, and the extent of the collapse that is apparent on forced in-
spiration, the surgeon can reinforce the cartilaginous framework, modify its shape
or the shape of the domes, and reinforce the tip supports and the junction between
the lateral crura and the upper lateral cartilages. Careful external and endonasal ob-
servation of the motion of the ala is crucial, because it will show the affected area
and consequently show where to position the graft.
Correction
Exteriorization of the lateral crura by a marginal incision or, preferably, an external
transcolumellar approach allows these modifications to be made with accuracy. Lat-
eral crura that are very concave can be corrected by modifying their curvature with
light cartilaginous superficial incisions in conjunction with suture technique or thin
cartilage grafts. In thin skin, the cephalic portion of the lateral crura can be resected,
placed superficially to the concave lateral crura, and sutured to the remaining car-
tilage with apposition of the concave surfaces.
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Chapter 57  Secondary Rhinoplasty
A thick septal fragment can be spliced into two 0.5 mm thick alar grafts, which is
the average thickness of lateral crura. The fragment is placed in a groove 0.5 mm
deep. The graft is firmly pressed with the thumb and, with the use of a No. 11 blade,
it is meticulously split longitudinally. The procedure works well with septal and
costal cartilage, providing slightly convex strips of cartilage. In thick skin and weak,
concave cartilages, it is better to use more resistant cartilage, such as a fragment of
septal or conchal cartilage that has been modified as necessary.
A wide base of the columella may be caused by a thick septum that needs to be
thinned, or lateral edges of the nasal spine that need to be reshaped. The divergent
me dial crural footplates should be partially resected after the intervening soft tissue is
excised and transfixion sutures are placed to ensure narrowing of the columellar base.
An excess of mucosal tissue at the base of the columella can form a bulge. To pre-
vent this, the mucosa can be resected over the septum and the skin covering the col-
umellar base can be advanced, after partial resection of the tail of the medial crura.

After a primary rhinoplasty, this patient had a narrow nose, asymmetry, and col-
lapse of the middle vault (more noticeable on the left side), and a narrow nasal base
with exposed nostril orifices. On basal view, the nostril orifices were narrow with a
wide columella, and there was internal and external valve dysfunction. On lateral
view, there was a round nasal tip, a slight supratip excess, and bilateral alar retraction.
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The goal of secondary rhinoplasty was to improve her function by widening the mid-
dle vault and nasal base and to correct the alar retraction. A transfixing incision al-
lowed a shortening of membranous septum (2 mm) and caudal septum (4 mm high);
the nasal spine was conservatively resected. A transcolumellar incision provided full
exposure and allowed major harvesting of septal cartilage and vomer. Cartilage and
vomer grafts were placed in the middle vault and nasal base: two spreader grafts in
the middle vault, the left one being thicker, and two vomer fragments placed super-
ficially at the junction of the lateral and upper lateral cartilages. A cartilaginous alar
graft was then placed on the left side and a vomer graft on the right. A tip graft was
placed in the infratip to widen the tip lobule and provide better definition and pro-
jection. The patient is seen 13 months postoperatively. Her nose is more harmonious
and her ability to breathe has improved.
Short Nose
A short nose is defined as having a decreased distance from the radix to the tip and
an obtuse nasolabial angle of greater than 110 degrees with increased show of the
nostrils on frontal view. Whether primary or secondary, the foreshortened nose is
considered one of the most difficult for rhinoplasty surgeons to treat, particularly
when the covering tissues are scarred and adherent and there is a shortage of lining.
Causes
Why is the nose shortened? Assessing the causes of shortening may help to predict
the potential lengthening of the mucosal lining and covering soft tissues. A short
nose can result from excessive resection of the dorsum, the caudal and membranous
septum, the cephalic portion of the lateral crura, and the caudal portions of the up-
per lateral cartilages. Cephalic rotation of the nasal tip can be caused by a columel-
lar strut or by cephalic displacement of a tip graft, increasing the angle of rotation.
Diagnosis
A diagnosis of nasal foreshortening is based on different methods of measurement.
The nasal length depends on the size and proportions of the other facial features and
should be proportional to the forehead. Ideally, the nose lies within the middle third
of the face. However, in assessing the length of the nose, there are several anatomic
deficiencies and disproportions causing real as well as illusory perceptions of short-
ness. The optical illusion of nasal length is intimately related to the position of the
radix and to the nasolabial angle that determines the position of the subnasion.
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Chapter 57  Secondary Rhinoplasty

Tip
Angle of rotation
Nasion
Nasal length
Subnasale
The position of the nasion is critical; the “ideal position” is a specific point at the
deepest portion of the nasofrontal concavity. It is normally situated between the level
of the supratarsal fold and the lower eyelashes. Surgical maneuvers can alter the po-
sition of the nasion. Grafting the dorsum may shift the position of the nasion up-
ward, creating an illusion of lengthening. An obtuse columellolabial angle greater
than 110 degrees with an increased nostril show on the frontal view increases the
optical illusion of shortness. Infratip grafts decrease the angle of rotation, shifting
the tip-defining points caudally.
Correction
The short nose has always been a difficult challenge. The foreshortened nose is caused
by overresection, with retraction of the soft tissue envelope covering the overreduced
and unsupported skeleton, thus moving the mobile nose (alar complex) cephalically.
The principle of lengthening is to caudally extend the mobile nose. This requires
large soft tissue undermining and extramucosal dissection, followed by releasing
mucosal incisions and a lengthening of the underlying skeleton. Various procedures,
grafting in particular, can be used to produce a real or optical illusion of lengthen-
ing. Significant improvement, including optical illusion as well as real lengthening,
can be achieved by adequate soft tissue release, alar columellar complex release, and
grafting to hold the tip in a more caudal position.
Approach
The transcolumellar approach is best for correction of overshortening of the nose,
affording a wide and better access to external soft tissues and facilitating safe mu-
cosal dissection. In correcting a foreshortened nose, there is no risk of overcorrec-
tion because of the limiting factors: a most important factor is the suppleness of the
soft tissue envelope and the importance of lining contracture. The surgeon can also
produce an optical illusion by shifting the radix cephalad, either by deepening a shal-
low radix or by grafting the dorsum and radix. This can also be done by decreasing
a high tip projection and deepening an obtuse nasolabial angle by resection of a pro-
truding nasal spine and caudal septum.
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Part X  Rhinoplasty

Soft Tissue Release
Wide undermining of the soft tissue cover should extend upward to the radix and
widely over the lateral walls if a lateral osteotomy is not planned. The advantage of
this undermining is that one is able to use the elasticity of the skin in the hope that
it will adapt itself to the newly lengthened infrastructure. Good skin elasticity al-
lows better adaptation of the undermined soft tissues.
In severely foreshortened noses, the undermining can be carried out beneath the
nasal bones, the frontonasal apophyses, and the margin of the piriform aperture.
Thus the cartilaginous vault is dissected off the bony vault, making it possible to ex-
tend the entire cartilaginous nose downward.
Release of the Mucosal Lining
Release of the mucosal lining and laxity of the membranous septum are essential.
Dissection of the mucosa is possible when the mucosa is supple and nonscarred and
when it has previously been easily dissected. Medially, bilateral mucosal undermin-
ing is performed as in an extramucosal dissection, beneath the upper lateral carti-
lages. This undermining extends up to the level of the piriform aperture.
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Chapter 57  Secondary Rhinoplasty
The lateral crus is separated from the upper lateral cartilage by spreading motions
of the scissors, followed by placement of a graft in the gap that has been created.
The upper lateral cartilages are separated from the septum and, after traction has
been applied to the tip with a hook, staggered and horizontal mucosal releasing in-
cisions are made in the mucoperichondrium of the newly developed mucosal sleeve
at the level of the middle third; this allows the lower lateral cartilage complex to be
pulled caudally. Mattress sutures are then placed while traction is applied to the alar
complex in a caudal direction above the caudal septal border to stabilize the new
position of the mucosa. In severe cases, a significant tear of mucosal lining may oc-
cur that necessitates a composite conchal graft to fill the void.

Grafting
The osteocartilaginous framework can be lengthened by grafting after the previously
described preliminary but crucial maneuvers are performed, producing a real and/or
optical illusion of lengthening. Dorsal grafts allow correction of saddle deformity
and provide an illusory lengthening by shifting the nasofrontal depression upward.
A long dorsal graft (as a bone or costal graft) extending to the tip can provide real
lengthening by a forceful downward pull of the alar lobular complex, moving the
tip and defining points caudally.
Caudal extension grafts can also be used. A long, rigid batten septal extension graft
can be sutured along the lateral edge of the septum. This graft should be 3 cm long,
its stiffer portion protruding caudally by 6 to 10 mm.
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This patient was very depressed after a rhinoplasty that resulted in overshortening
of her nose; the nostril orifices could be seen on frontal view, and the nasal base was
flat and widened. Her principal request was correction of the shortening as well as
widening of the nasal base, yet she wanted her dorsal hump preserved. On lateral
view, she had a slight dorsal hump and a round tip without definition. The nasolabial
angle was increased, and the facets were too visible on both sides. On basal view,
one could note the signs of the loss of tip support: a short columellar distance, widen-
ing of the medial crural footplates, and alar flaring with soft tissue facet ptosis re-
sulting from a loss of support that was more noticeable on the right.