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

The patient is shown 8 months postoperatively. Her nose appears longer and its con-
tours are aesthetically pleasing.
One can also use a triangular caudal extension graft based anteriorly (8 to 10 mm)
and positioned within the membranous septum; its fixation to the caudal septum
can be achieved with figure-of-eight sutures, transmucosal mattress sutures, and ex-
ternal splints. An excellent fixation can be achieved by securely splinting (sandwich-
ing) the graft with two PDS battens.
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Part X  Rhinoplasty

Two PDS battens are sutured laterally to the caudal septum and then to the graft.
Because PDS resorbs in 6 months, it provides a scaffold for a good stabilization by
the fibrous tissue produced during the healing period.
Cartilage grafts to the tip may provide a lengthening effect by using multilayered
grafts placed caudally to the infratip lobule. These grafts must be thicker anteriorly
and feathered out posteriorly so as to decrease the angle of rotation. They can also
improve contour and projection if necessary. Infratip grafts allow the surgeon to
shift the tip defining points caudally and to provide a real lengthening. The recipi-
ent graft bed should be strong enough to resist the cephalic pull of the stretched skin
flap. This is achieved by the caudal extension graft placed within the membranous
septum and columella.
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Chapter 57  Secondary Rhinoplasty
After having undergone two rhinoplasties and septoplasty, this patient complained
of an overshortened nose with exposed nostril orifices and difficulty in breathing.
On lateral view, the dorsum was straight, but there was an overtip rotation, and
overshortening of the tip with an increased columellolabial angle at 130 degrees.
There was some a prominence on the right ala and a slight depression of the left
nasal bone and middle vault. Her soft tissues were quite thick.

On frontal view, the patient’s overexposed nostrils are evident, and her upper lip ap-
pears too long. Rhinoscopy revealed a septal deviation on the left side, and on pal-
pation of the septal mucosa with a soft instrument, it appeared that the septum had
been partially harvested previously. The goal was to decrease the angle of rotation
and correct the deformities. Because no septal cartilage was left after the previous
septorhinoplasties, the right concha was harvested using a retroauricular approach.
A transcolumellar approach was selected; a posteriorly based triangular resection
of the caudal septum, nasal spine, and mucosa was performed through a posterior
transfixing incision.
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Part X  Rhinoplasty

After skeletonization, direct visualization showed overresection of posterior portion
of lateral crus and a slight prominence of the left dome. Dissection of mucosal flaps
permitted to correct the septal deviation and harvest a small portion of septal car-
tilage. The domes were equalized by resection of the left dome. An alar graft was su-
tured to the remaining portion of the right lateral crus. A lateral low-to-low os-
teotomy was performed on the left side. A spreader graft was placed on the left side
and diced cartilage fragments were placed laterally to the upper lateral cartilage–nasal
bone junction to correct a depression. A triangular caudal extension graft based an-
teriorly was positioned in the membranous septum and stabilized with two PDS bat-
tens. A two-layered infratip graft was positioned and sutured, and a buttress graft
was positioned cephalad to the anterior portion of the graft and sutured to the domes.
A 2 mm alar base resection was then performed. The patient is seen 16 months post-
operatively.
An obtuse nasolabial angle with overexposure of the medial crura footplates may
be decreased by a resection of nasal spine and a triangular based resection of cau-
dal septum and mucosa. A composite graft harvested from the concha is indicated
if the gap between lower and upper lateral cartilage is large. The purpose of this
graft is to fill the void. The dressing is positioned while the nose is maintained in ex-
tension with a double hook instrument.
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Chapter 57  Secondary Rhinoplasty
Retracted Columella
Columellar retractions may be observed after an excessive resection of the antero-
caudal septum, the nasal spine, or the membranous septum. The columellar retrac-
tion can be located at the midcolumella or at the labiocolumellar junction, with an
acute nasolabial angle as a result of septal or nasal spine overresection.
Correction of a Short Nose
The short nose has always been a difficult challenge. Correction should resort to optical
illusion effects as well as true lengthening effects. Before grafting, three crucial points
should be considered:
 Undermine a large soft tissue cover.
 Perform a release of the alar columellar complex and mucosa.
 Graft so that the tip is in a more caudal position.

Gunter thoroughly described the alar-columellar relationship. On lateral view, the
outline of the nostril is an oval, which should be separated in two equal segments
by its long axis. The relationship of the columella to the long axis defines the re-
tracted columella. It can be combined with a hanging ala, decreasing the columellar
show.
Palpation with columellar mobilization allows evaluation of the nasal tip supports
and the suppleness or rigidity of the membranous septum. Anterior rhinoscopy with
palpation of the lining with a blunt instrument establishes the location of a septal
deviation, the location and extent of a caudal septal resection, and whether septal
material is available for grafting.
The open approach and transection of the upper lateral cartilage–septal junction af-
ter an extramucosal dissection allows a perfect exposure of the septum and facili-
tates assessment of the deformities or defects. Septal deviations are always corrected
before any further correction is performed.
Correction of the retracted columella must be graduated, taking into account the re-
traction extent, the suppleness or laxity of the lining, the tip, and the position of the
alae. Tip support has often been weakened and must be reinforced with sutures and
grafts.
Moderate Columellar Retraction With Supple Lining
A columellar strut is sufficient for the correction. It is preferentially harvested from
the septum, rectangle, measuring 15 to 20 mm long and 3 to 5 mm wide. It is placed
between the middle and intermediate crus, slightly extending in the membranous
septum. It is sutured with two or three 5-0 PDS stitches.
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A columellar onlay graft extended toward the nasal spine may sometimes improve the
columellar show.
An acute labiocolumellar angle caused by excessive trimming of the caudal septum,
of the nasal spine and sometimes of the membranous septum can be corrected with
a posterior-base triangular columellar strut. It leans against the nasal spine and ex-
tends into the membranous septum. Small pieces of cartilage can be added in the
premaxillary region to lower the labiocolumellar junction.
Significant Columellar Retraction With Scarred Lining
When the alar-columellar distance is less than 1 mm, lengthening of the caudal sep-
tum must be combined with lengthening of the lining.
Lining Lengthening
If possible, wide extramucosal bilateral undermining is first performed. Then stag-
gered horizontal incisions of the lining are made in the middle third. Transfixion
stitches are placed at the caudal edge of the septum while the lining is pulled inferi-
orly with hooks to keep the lining in a downward position.
When the scarred tissues cannot be undermined, a bilateral V-Y plasty can be done
during lining closure. If not possible, composite chondrocutaneous grafts can be
used. They are sutured in two hemitransfixion staggered incisions in the membra-
nous septum.
Caudal Septum Reconstruction
Columellar retraction is corrected by placing a graft that extends the missing cau-
dal septum (septal extension grafts). This graft must be aligned with the straight-
ened septum. If possible, it is harvested if possible en bloc at the posterior part of
the septum, preserving at least 8 to 10 mm above and in front of the defect. A stiff,
flat piece of cartilage is preferentially obtained at the posteroinferior part of the har-
vested graft, at the junction between the septum and vomer.
If the septum is not available for the septal extension grafts, the graft material can
be harvested from the conchae. It can become straighter and stiffer by suturing two
pieces of conchae with the concavities facing each other. A graft can also be har-
vested from the rib, especially if cartilage must also be used for dorsal augmenta-
tion or for other grafts. It is then taken in the central part of the rib and sutured af-
ter waiting at least half an hour to be certain that no late bending will occur.
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2078
Part X  Rhinoplasty
Different types of septal extension graft designs exist. The triangular caudal exten-
sion graft is stabilized with PDS battens (0.25 mm thickness). Fixation of the graft to
the nasal spine is made with 5-0 PDS after having placed the inferior edge of the
graft in a groove made behind the nasal spine. If the spine has previously been re-
sected, two converging drill holes are made in a V shape in the premaxilla to allow
a strong fixation of the graft. Fixation of the graft between the middle crura is done
only after having first temporarily closed the transcolumellar incision and assessed its
impact on the columella position.
Finally, an infracolumellar graft can be added before closure if more lengthening is
needed or if the columellar contour must be softened. Transfixion resorbable stitches
are made through the septum and graft to prevent dead space. An endonasal splint
and packing help to prevent fluid accumulation between the lining.
This patient underwent two rhinoplasties; the dorsum and caudal septum were over-
resected. On lateral view, a light fullness of the radix could be seen, with saddling
in the upper dorsum and a supratip convexity. The columella was retracted, partic-
ularly in its middle portion, highlighting the crooked aspect of the tip. Both alae
were markedly concave and collapsed.
Removal of
remnants of
lateral crus
Mucosal
lengthening
PDS 0.25 mm

On frontal view, the dorsum was flat, with a rather narrow middle vault and a
pinched tip lobule. On basal view, the infratip segment was concave and the col-
umella appeared short. The objectives were threefold: correction of the retracted col-
umella, the depressed dorsum, and the collapsed alae. After harvesting the conchae
through a retroauricular approach, a transcolumellar approach was performed; dis-
section was tedious in the alar region because of adherent soft tissues. Operative
findings showed some rests of the right lateral crus and a concave lateral crus on the
left side. The radix was slightly reduced with a beveled osteotome.
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Chapter 57  Secondary Rhinoplasty

The septum was approached via its dorsal edge and an extramucosal dissection was
performed, allowing a large septal harvesting and conservative resection of nasal
spine. Two horizontal staggered incisions were made in the midportion of the dorsum
to provide some lengthening of the mucosal flaps. Mucosal lengthening was held in
caudal extension with two hooks, and sutures were placed a few millimeters above
the caudal border of the septum to stabilize the mucosal lengthening. Lateral low-
to-high and medial osteotomies were performed. A 5 mm wide columellar strut was
positioned between the caudal septum and the cephalic edges of the medial crura.
It was sutured to the nasal spine and to the caudal septum. The rests of the right lat-
eral crus were removed, and alar reconstruction was achieved with a conchal graft
sutured to the dome. The left concave lateral crus was corrected by suture technique.
Additional grafts were placed, caudally to the columella to provide additional ex-
posure of the columella, and in the infratip region to correct the depression in this
area. A two-layered dorsal septal graft was then placed on the dorsum. The patient
is seen 12 months postoperatively.
Nasal Tip Deformities: Problems Associated
With Soft Tissue Conditions
Secondary defects of the nasal tip are the most difficult to correct. The patient should
be advised that revisions are increasingly difficult and the outcome even more un-
predictable.
Secondary deformities of the nasal tip are often caused by excessive and asymmet-
rical resection of the alar cartilages, notably in the lateral portions and at the level
of the middle crura. Depending on the skin condition, overresection can cause var-
ious types of defects, but thick skin provides some support to the alar cartilages and
can also mask a projection or a cartilaginous defect. A wide range of deformities
may be seen in the nasal tip area. The most common nasal tip defects include the
following:
 Minor defects such as a slight asymmetry of the domes and lateral crura de-
spite perfect correction via an open approach and perfect symmetry at the end
of the procedure
 Malposition of the domes’ height and projection, nasal tip deviation, and a
tip lobule that is too narrow or broad
 Undercorrection that leaves an excess of tip projection, a wide lobule, tip pto-
sis, and cartilaginous projections
 Undertip projection of variable severity—from inadequate tip projection with
a round nasal tip, frequently observed after a loss of tip support, to a major
undertip projection caused by aggressive resection of the domes and lateral
crura
 Overrotation of the tip, with an increased angle of rotation
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2081
Chapter 57  Secondary Rhinoplasty
Overresection of the vestibular skin and mucosa can result in alar retraction that
exposes the columella. Secondary problems may be worsened by scarred soft tissues
that are very adherent to the underlying structures, making dissection very difficult.
Collapse and depression of the nasal ala are often associated with overresection of the
lateral crus: it weakens the cartilaginous support of the ala, creates alar notching or
retraction, and may impede the external nasal valve.
Correction
Deformities of the nasal base should be corrected taking into account the aesthetics
and the defects that are noted in other structures of the nasal pyramid, notably the
radix and dorsum, to reestablish an equilibrium between the subunits of the nasal
pyramid and to balance nasal harmony.
A transcolumellar approach is most often required to assess the deformities and the
remaining cartilages. This approach allows a larger array of suture corrections, bet-
ter positioning and accurate suture fixation of the grafts, and more accurate posi-
tioning of camouflage methods.
When after several surgeries soft tissues have become very scarred, a midcolumellar
incision can be used for easy placement of a tip graft.
This young postrhinoplasty patient complained of an unbalanced nose: a wide nasal
base, slight saddling of the dorsum, and bilateral alar retraction. On lateral view, the
upper dorsum was too low and the alar retraction was very marked on the anterior
portion of the alar rim.

The basal view showed an asymmetry of the nostril orifices. Soft tissues were mod-
erately thick and tip support was poor. On frontal view, there was a narrow bony
vault and a large, wide nasal base, with some irregularities on the surface of the tip
lobule; in addition, the nostril orifices were too exposed. These deformities were ob-
vious on oblique view, showing the flatness of the infratip. The objectives were to
balance the nose on lateral and frontal views, improve the tip configuration, defini-
tion, and width, and correct the alar retraction. After harvesting auricular cartilage
from the concha, a transcolumellar approach was selected. Dissection was difficult
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Part X  Rhinoplasty

because of a scarred supratip; defects were observed, particularly on the overresected
lateral crura, which were reduced to some unusable fragments of cartilage for correct
reconstruction and these were resected.
After rasping some irregularities of the dorsum, the supratip excess of septal carti-
lage was incrementally shaved, and a septal approach allowed for a major harvest-
ing. Reconstruction had started by strengthening the columella support with a sep-
tal columella strut. A multilayered dorsal graft was composed of a long fragment of
septal cartilage, a bruised fragment of the resected lateral crura placed superficial to
the main graft on its cephalic portion, and a bruised auricular cartilage placed under-
neath to augment the radix area. Alar reconstruction was achieved with two septal
battens positioned parallel to the alar rim and sutured to the vestibular skin. A tip
shield graft of ear cartilage was placed in the infratip lobule, and two buttress grafts
were positioned posterior to its anterior portion to decrease a large angle of rotation.
No osteotomies were performed. Results are shown 2 years postoperatively.
Scar Tissues
Difficulties are encountered when soft tissues are very scarred, and dissection should
be performed very careful to avoid dermal damage or skin perforation. This scar tis-
sue will sometimes be left on purpose. It can be sculpted to get a better tip and
supratip definition. It may also provide a solid foundation for graft placement and fix-
ation. A thin layer of scarred soft tissue can be left at the surface of the alar carti-
lages to facilitate suture techniques.
Excess width and tip projection can be controlled with a bloc sagittal wedge resec-
tion of scar tissue in the dome area, followed by approximation of the edges with
sutures.
An approach to the septum can be facilitated by sagittally splitting the section of
scarred tissue with a blade, starting from the inferomedial crura space up to the tip
and supratip.
Thinned Skin and Subcutaneous Tissues
From prior rhinoplasties, the superficial nasalis aponeurotic system (SMAS) and skin
may have been traumatized and may become thinner and more adherent to the un-
derlying structures. In those cases, sutures are favored to graft techniques whenever
they are usable. However, a camouflaging maneuver can be useful to hide small car-
tilaginous irregularities or the graft edges. Usually a sheath of deep temporal aponeu-
rosis is sutured on the top of the tip or the tip graft. Perichondrium can also be used
for this purpose.
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Chapter 57  Secondary Rhinoplasty

Reconstruction
Reconstruction involves strengthening of the tip supports. After having harvested
cartilage from the septum or other sites, the surgeon should, as in every rhinoplasty,
establish a solid, stable, symmetrical foundation and strengthen the medial leg of
the tripod. It is also essential to obtain a straight septum to correct any extrinsic tip
asymmetry.
The dome height, position, and symmetry can be corrected only after a stable foun-
dation has been established. If cartilage conditions are good, suture techniques may
be used to improve symmetry and projection and to narrow a broad tip lobule. Su-
tures can also enhance tip definition if the skin is not too thick.
If the columellar graft is too malleable (ear or soft cartilage), its rigidity can be im-
proved by assembling two grafts or sandwiching them with a thin fragment of vomer
or a PDS plate. When the columella is retracted, the columellar strut is positioned
within the membranous septum and medial crura. It should be wider than usual
struts to allow a caudal shift of the medial crura. When alar cartilages are too soft
or are unusable, it is sometimes better to resect and reconstruct them with cartilagi-
nous graft.
Tip asymmetry after a correct septal alignment sometimes requires asymmetrical re-
section of the domes or middle crura. An interdomal suture is then placed to equal-
ize the dome’s height.
Various types of tip grafts are used to reconstruct the nasal tip and improve its con-
tour, projection, position, and the alar-columellar relationship. The surgeon can use
onlay, shield, or buttress grafts. These grafts are often used in combination.
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Part X  Rhinoplasty
A tip graft should always be placed on a well-prepared, symmetrical recipient graft
bed. This can be created by judicious resection of the cartilaginous graft bed. The
caudal edges of the middle crura are equalized to provide a flat, symmetrical graft
bed, or an asymmetrical graft is placed (left). When it is difficult to obtain a flat,
symmetrical recipient graft bed, a small graft can be positioned on one side, above
the lateral portion of the shield graft, to compensate and correct an asymmetrical
recipient graft bed.

This patient had severe deformities and impaired breathing after a septorhinoplasty.
On lateral view, there was saddling of the upper dorsum and radix and a marked
supratip convexity. The columella was retracted in its posterior portion. The soft tis-
sue cover was thin, highlighting the deformities and projection of the cartilages.
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Chapter 57  Secondary Rhinoplasty

On frontal view, the bony vault was slightly broad in proportion to the width of the
middle vault and the collapsed alae. The nasal base was very asymmetrical, with sig-
nificant alar collapse on the left side. The tip and columella were deviated toward
the right. Cartilage was harvested from both conchae, and correction was achieved
with a transcolumellar approach and careful skeletonization in a subperichondrial
and subperiosteal approach to preserve sufficient thickness to the covering soft tis-
sues as much as possible. The deformities observed on direct view were marked, with
asymmetry of the resections and scar tissue in the supratip. A large posterior por-
tion of the right lateral crus had been resected, and the left lateral crus was very con-
cave and thin. Scarred supratip soft tissues were trimmed, as well as 3 mm of the
supratip dorsal edge.
Despite a previous septal surgery with its consequent scarred mucosa, harvesting of
the posterior septum was possible. Reconstruction was achieved with a spreader
graft on the left side and an autospreader graft with internal plicature of the dorsal
edge of the right upper lateral cartilage. After resection of the rests of the domes and
the left lateral crus, which was not usable, alar grafts (ear cartilage) were positioned
on the alae. Multilayered grafts composed of two septal fragments were placed on
2086
Part X  Rhinoplasty

the upper dorsum, and two fragments of the resected lateral crus were placed super-
ficial to the main dorsal graft in the radix area. Results are shown 2 years postop-
eratively.
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Chapter 57  Secondary Rhinoplasty
This 23-year-old patient had undergone two prior rhinoplasties. On the lateral view,
the nose was short and unbalanced, with a low upper dorsum, a high cartilaginous
dorsum, a round tip with no definition, and an increased angle of rotation. The
frontal and oblique views further demonstrated the bulbosity of the nasal tip and
low upper dorsum. On palpation, the soft tissues of the tip lobule were thick and
lacked suppleness.
A triangular posteriorly based resection of mucosa and caudal septum was performed
using a transfixion incision. After a transcolumellar approach and skeletonization,
the fibrous, scarred soft tissue of the supratip was resected and the dorsal border
trimmed by 2 mm. Operative findings showed the previously resected domes and a
slight tip deviation on the right side. A major harvesting of septal cartilage was then
performed using the hemitransfixion incision.

A two-layered, bruised cartilage was placed on the upper dorsum. The cut ends of
the previously resected domes were sutured after some adjustments. A columellar
strut was then placed within the medial crura and fixated with 5-0 PDS. A double-
layered shield graft was then placed in the infratip to augment tip projection and
the length of the nose. The patient is shown 18 months postoperatively.
2088
Part X  Rhinoplasty

In major undertip projection, multilayered grafts can be used. A long and stiff col-
umellar strut resting on or fixed to the nasal spine can be covered by multilayered
onlay grafts. All of these grafts (septal or ear cartilage) are accurately positioned and
sutured with 6-0 PDS.
Buttress Graft
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Chapter 57  Secondary Rhinoplasty
A long infratip shield graft projecting several millimeters above the domes can also
be used. However, the anterior extension of the tip graft should be buttressed with a
graft placed cephalad to the main graft and sutured to the anterior septal border or
to the domes to prevent the anterior portion of the graft from being folded cephal-
ically by an inelastic or rigid soft tissue cover.
When alar flaring is associated with an undertip projection, it should be corrected only
after nasal tip reconstruction. Any residual flaring can be assessed and then corrected.
Problems Associated With Soft Tissue Conditions
At the end of a rhinoplasty procedure, the result may appear satisfying. The dress-
ing often consists of adhesive tapes that put some pressure on the supratip. There
will be residual supratip fullness caused by edema, which can persist for several
weeks and will require massage or prudent injections of corticosteroids. After a few
months, one can assess the nose for a definitive polly-beak deformity.
Polly-Beak Deformity
Polly-beak deformity, one of the most obvious signs of a previous nasal operation,
is characterized by a supratip convexity that appears more pronounced when it is
associated with a lowered dorsum and underprojection of the nasal tip. It may re-
sult from a technical mistake or a lack of appreciation of the dynamics between skin
cover and the underlying skeleton, with inability of the soft tissue cover to redrape
properly over the new skeletal structures.

Causes of Polly-Beak Deformity
CARTILAGINOUS UNDERRESECTION
Cartilaginous polly-beak deformity is more
frequently caused by a lack of sufficient septal resection (anterior angle) than to in-
sufficient lateral crus resection (cephalic border at the dome junction). At the end of
the procedure, it is common to underevaluate the levels of difference between the
domes and the dorsal border of the septum in the supratip area; 5 to 6 mm is ap-
propriate in thin skin and up to 10 mm in thick skin. Any cartilaginous excess must
be resected if the nasal tip support and projection are appropriate and if skin elas-
ticity is good. Otherwise, more tip projection must be obtained, either through su-
tures (septocolumellar sutures are the most useful for this purpose) or through the
use of a long columellar strut on which the medial crura are shifted anteriorly, or a
tip graft.
CARTILAGINOUS OVERRESECTION
Excessive resection can lead to the same defor-
mity as underresection, although by different mechanisms. Two main preoperative
factors favor a cutaneous polly-beak deformity:
 Thick and loose covering tissues that will not retract in the supratip area.
 Preexisting tip with inadequate projection: incisions and resection will increase
the lack of tip projection. If not corrected, this lack of projection creates bulk
in the supratip area.
The common operative factor is a large resection of the cartilaginous hump with
loss of nasal tip support. This excessive hump removal occurs more frequently when
the radix is low and is not corrected. Poor redraping of the soft tissues over the os-
teocartilaginous skeleton remains the primary cause; in a patient with thick skin and
poor skin elasticity, the surgeon should not hope that the skin will redrape to the
new skeletal structures. Polly-beak deformity is often associated with a lack of defi-
nition of the tip lobule or a round tip.
Surgical Correction
It is easy to use morphing software to preview a pleasing nose for the patient, but
what really matters is that the patient leave the operating room with a satisfying
long-term result. This is achieved by establishing an adequate underlying skeleton
with good tip support, taking into account the dynamic balance that should exist
between soft tissue cover and the underlying skeleton.
In thin, elastic skin, excesses of the anterior dorsal border of the septum, upper lat-
eral cartilage, and cephalic edge of the lateral crura can be easily trimmed. In the
nasal tip, a single or multilayered onlay graft or a rigid infratip graft will provide
better projection and definition.
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Part X  Rhinoplasty

In thick skin, a conservative surgery should be performed with dorsal and nasal tip
augmentation that would make the supratip excess disappear. The tip supports should
be strengthened, and tip projection should be augmented. If a tip graft is positioned
in the infratip, it should pass 3 to 4 mm beyond the level of the domes and be ade-
quately buttressed to prevent folding of the graft under pressure from a rigid soft
tissue envelope.
The supratip subcutaneous tissues can sometimes be gently trimmed with scissors.
Caution is paramount, and preferably this resection is done without turning over
the supratip skin. Any dead space in the supratip area should be eliminated by ap-
proximation of the dermis to the underlying septum.
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Chapter 57  Secondary Rhinoplasty
This 20-year-old patient had undergone two previous rhinoplasties and septoplasty.
His main request was to have a thin, narrow tip lobule. On lateral view, there was
supratip fullness with a round nasal tip and a slightly depressed upper dorsum, as
clearly seen on the oblique view.

The frontal and basal views showed a broad tip lobule with no definition and the
alae looked flared. On palpation, the soft tissue cover was thick and difficult to pinch,
precluding any tip reduction. The objectives were to augment the upper dorsum and
to give the tip more definition.
After skeletonization through an open approach, the supratip dorsal excess was
trimmed. The radix was slightly deepened with an osteotome, and the upper dor-
sum was rasped for removal of soft tissues and placement of a dorsal graft. A large
septal harvesting was performed through a hemitransfixion incision, and the grafts
were positioned. On the upper dorsum, a two-layered graft composed of one piece
of cartilage and vomer was placed. An additional graft was placed superficially.
A columellar strut (fragment of vomer) was placed within the medial crura, and the
tip was grafted with a rigid infratip graft extending 5 to 6 mm above the domes. The
pressure of the soft tissue cover was pushing the tip graft cephalically. A buttress
graft was placed above the tip graft and was sutured to the dorsal septal edge to pre-
vent cephalic displacement and provide the graft with strong anterior projection.
Because of the soft tissue thickness, there was no risk that the graft would be vis -
ible. A 3 mm alar base resection was performed. The patient is seen 2 years postop-
eratively.
2092
Part X  Rhinoplasty

In a large nose with thick skin, sometimes the only alternative is a vertical fusiform
resection in the supratip area. This provides the tip with better definition, but at the
price of a scar. Would the patient prefer a scar that is often not noticeable to a
supratip convexity with lack of harmony? The decision lies with the patient.
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Chapter 57  Secondary Rhinoplasty
After having undergone two previous rhinoplasties, this patient presented with a
long nose and a polly-beak deformity, as seen on the lateral view. On the frontal
view, the tip was bulbous with no definition.

Sequelae of radiation therapy prescribed by a previous surgeon for correction of the
polly-beak deformity were observed in the supratip area. On palpation, there was
significant laxity of the tip and supratip soft tissue cover. Because this patient was
tall and had a long, large nose, a reduction rhinoplasty was contraindicated, so a
skin resection was planned to reduce the supratip skin excess. This patient was a
participant in this decision, taking into consideration the poor quality of the skin
surface and a horizontal scar at the superior limit of the supratip.
After a horizontal, full-thickness resection of the supratip soft tissue cover and skele-
tonization, the hump was resected with an osteotome. Septal cartilage was then har-
vested through a hemitransfixion incision, and an onlay tip graft was positioned
2094
Part X  Rhinoplasty

through the supratip opening. After lateral osteotomies and alar base resections, sub-
dermal and running sutures were carefully placed. The patient is shown 32 months
postoperatively; the horizontal scar is scarcely visible.
In a patient with loose skin without elasticity that can be easily pinched because the
subcutaneous layers are very loose, correction also includes a nasal tip augmenta-
tion and, when possible, dorsal augmentation with cartilage grafts.
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Chapter 57  Secondary Rhinoplasty
Complications
The term secondary rhinoplasty in this chapter is taken to mean surgery on a post-
surgical nose. This frequently includes patients who have undergone three, four, or
more extensive operations on their noses. As the catalog of previous procedures
lengthens, the proportion of cicatrix in the nose increases, and the flexibility of the
tissues diminishes for further reshaping. It is not easy to separate unfavorable re-
sults and complications, because they overlap to a certain extent, a complication be-
ing considered an unexpected sequela.
A surgical complication means a mishap that occurs during the operative or heal-
ing phase of surgery that could possibly have been avoided by the surgeon. In sec-
ondary rhinoplasty, however, it describes any unfavorable outcome. Failure to meet
the goals set out before surgery is almost always interpreted by the patient as a com-
plication, despite a repeated and meticulous process of informed consent. Allied with
the unfavorable anatomic and psychological terrain, the inevitable postoperative
Polly-Beak Correction
Assessment
Soft tissue thickness and scarring
Tip supports
Septal alignment
Tip asymmetry
Reconstruction
Septal alignment and harvesting
Strengthening of tip supports
Providing balance with other subunits
Ensuring tip symmetry with resections, suture techniques, and grafts
Use of tip grafts for contour, projection
Use of alar grafts

scrutiny that accompanies secondary rhinoplasty makes it inherently prone to func-
tional and aesthetic complications. The most common complication is postopera-
tive bleeding. Infection usually responds well to antibiotic therapy. Severe compli-
cations during and after rhinoplasty are rare. Some are anecdotal.
Hemorrhage
Excessive bleeding may occur during or after surgery and is said to occur more com-
monly when associated septal or turbinate work has been done. Overall, it occurs
in approximately 2% to 3% of rhinoplasties. Intraoperative bleeding may become
problematic during inferior turbinectomy unless excision of the bone is carried me-
dially at its posterior end to avoid the vascular pedicle that arises from the lateral
nasal artery. This, and septal bleeding, usually respond to anterior nasal packing if
the source of bleeding cannot be identified; the use of pressure balloons, posterior
packs, and, very rarely, vessel ligation may become necessary. Postoperative hemor-
rhage usually stems from anterior septal ulcerations, which are cauterized with silver
nitrate sticks in a setting with good lighting and suction available.
The removal of packs in itself may unveil septal ulcerations and cause bleeding, thus
throwing into question the need for routine packing in the nose. The use of a head-
light and absorbable transeptal sutures after septal harvest (septoplasty), with splints
as necessary, obviates the need for bulky, uncomfortable intranasal dressings, which
are a source of sinusitis as well as bleeding.
Infection
Infection after rhinoplasty is rare, as would be expected of clean elective surgery in
such a richly vascularized territory. Routine administration of antibiotics is not ad-
vised, but some surgeons feel more comfortable giving them if grafts have been used.
Although rarely indicated in secondary rhinoplasty, any alloplastic material would jus-
tify preoperative antibiotic cover with a single intravenous dose. The most common
organisms are staphylococci, especially Staphylococcus aureus. When infection does
occur, the consequences can be serious. There may be an extremely bothersome, lo-
calized graft infection that necessitates removal of the graft. Rarely, infection can
spread to become severe cellulitis, sinusitis, or even intracranial sepsis. Nasal pack-
ing and splintage incurs a small (16.5 per 100,000) risk of toxic shock syndrome in
susceptible patients, with a mortality risk of 5% to 10%. Although one may culture
nasal flora preoperatively for TSST-1, the staphylococcal toxin responsible, these
statistics further underscore the argument for avoiding the use of foreign material
in the nose if at all possible.
Localized infections respond to routine measures, such as using targeted antibiotics
and direct incision and drainage. Systemic signs of hypotension, rash, and pyrexia
with late desquamation signify toxic shock and should be treated aggressively. Menin-
2096
Part X  Rhinoplasty

gitic symptoms occurring shortly after rhinoplasty should also be linked to the sur-
gery until proved otherwise, and prompt medical attention must be sought from a
medical team.
Columellar Scarring
Secondary rhinoplasty may present an opportunity to revise an unfavorable transcol-
umellar scar. Any one of the numerous patterns for this incision (chevron, stairstep,
curved) may become thickened, hyperpigmented, or, most commonly, depressed,
with a visible shadow that interrupts the smooth lines of the columellar pillars.
Depressed horizontal scars can usually be excised at the beginning of the secondary
rhinoplasty, with the contours restored by bringing the healthy skin borders together
at the end of the operation. Eversion of the columellar skin with carefully placed
mattress (6-0 nylon) sutures affords a certain degree of protection from future in-
dentation.
Occasionally fullness is seen at the angles of the scar as it turns into the vestibular
incision. This causes the columellar flap to resemble a pincushion, which is evident
on the oblique view. When the elevated corner is resutured, it should be delicately
thinned of scar tissue with curved Iris scissors and inset under mild tension to flatten
the columellar flap over the outer aspect of the medial crus.
Vestibular Scarring
Because nature abhors empty spaces, fresh scars in a multioperated nose are prone
to contraction across the vestibule. Webs distort the normal relationship between
vestibular skin and nasal mucosa, creating stenosis and synechia. There is usually
little choice other than to use standard approaches when reoperating in these cases,
releasing any contractures as they are encountered. Some of the more obstructive
bands of scar may be resected and resurfaced using adjacent skin or mucoperichon-
drium, but in the apex of the dome this becomes difficult. Wide release of scar tis-
sue and reapposition of the nasal lining using peanut packs sutured together and
placed high against the undersurface of the domes is a useful maneuver in such cases.
In refractory cases, perforated nasal splints made of silicone that fill and shape the
vestibule are custom made and fitted for as long as the patient will tolerate them.
Severe vestibular scarring in the mucosal lining warrants the use of buccal mucosal
grafts, taken from the midlateral cheek and secured with Vicryl sutures. Petrolatum
gauze impregnated with antibiotic ointment is necessary for 5 days. Rarely, hinged
septal mucoperichondrial flaps based anteriorly on the anterior septal branch of the
superior labial artery may be required to resurface a severely scarred dome (Burget),
with care taken not to draw the mucocutaneous junction too far caudally below the
leading edge of the septum.
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Chapter 57  Secondary Rhinoplasty

2098
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Septal Perforation
Septal perforation is a late complication characterized by a complete breach across
the septum and its mucosa in the same place. Unless such a tear is meticulously re-
paired under direct vision and without tension, sometimes with the help of septal
splints (using x-ray film or a similar material), a small perforation will result. This
may crust and bleed, and whistle during inspiration. It may then be enlarged, re-
paired using advancement flaps and cartilage grafts, or closed using a septal button
if all else fails. Superinfection compounds the problem of trauma.
Traumatic Complications
Traumatic complications result from trauma to the nose itself and adjacent areas,
namely, the orbital region, where significant but rare complications may be observed.
By the nature of its scarred planes and altered anatomy, the secondary nose is neces-
sarily prone to inadvertent tearing of the SNAS and skin during undermining. Thick-
ening the soft tissue envelope immediately before its dissection by injecting saline
solution or a local anesthetic percutaneously can reduce the risk of tearing. Scarring
after buttonholing is made more conspicuous if it becomes adherent to the under-
lying structural framework. It is essential to anticipate this scarring by repairing the
SNAS layer if it is identifiable, and by everting the cutaneous sutures.
Osteotomies can damage the lacrimal sac. Intracranial injury and blindness have
been described, caused by direct mechanical trauma to the frontal lobe or the optic
nerve. Fracture through the cribriform plate may occur after aggressive manipula-
tions with twisting motions on the perpendicular ethmoid plate during a septoplasty.
Concluding Thoughts
The outcome in revision and secondary rhinoplasty depends on many factors, in-
cluding difficulties of correction that cannot always be predicted. These difficulties
may not reflect the severity of the defects. Thus a severe defect may be easier to cor-
rect than a very minor one when there is no shortage of graft material and soft tis-
sues conditions are favorable.
Because the nose is positioned in the center and midline of the face, minor defects
or asymmetry always bother a more observant and demanding patient. The diffi-
culty frequently lies in convincing a patient who has had a significant improvement
with prior surgery to avoid any revision for very minor defects.

2099
Chapter 57  Secondary Rhinoplasty
If most defects are caused by overbalanced and unbalanced resections and unrecog-
nized anatomic variants, some well-performed rhinoplasties with no apparent de-
fects may still be found to lack harmony and finesse.
In past decades, the open approach and cartilage grafting have been used more fre-
quently. Thus a new set of deformities is emerging, with scarred soft tissues making
the external approach more difficult, if not impossible, along with frequent short-
ages of graft material.
Before undertaking a primary and, a fortiori, a secondary rhinoplasty, the surgeon
must ask two questions: (1) Am I able to improve the appearance and/or function
of the patient’s nose? and (2) Will the patient be satisfied?
Clinical Caveats
 The patient and surgeon should make the journey as a team, and any problems
encountered along the way are best dealt with as a team.
 Secondary rhinoplasty defects require an accurate preoperative analysis of the de-
formities and assessment of the functional problems.
 An aesthetic sense and good knowledge of dynamics and skeletal support are es-
sential to achieve the goals of secondary rhinoplasty.
 The open approach provides excellent visualization of the deformities and facili-
tates graft placement and fixation.
 A large skin sleeve cannot redrape over the reduced skeleton.
 Because grafting is frequently performed for correction of secondary rhinoplasty
defects, harvesting and preparation of grafts are of crucial importance.
Annotated Bibliography
Aiach G, Gerbault O, Gomulinski L, eds. Rhinoplastie: Voie d’Abord Externe, 3rd ed. Paris:
Elsevier Masson, 2008.
This book is a comprehensive textbook on the primary and secondary rhinoplasties per-
formed through an open approach with its specific philosophy and strategy. A chapter
is dedicated to the secondary rhinoplasties, the preoperative analysis, the up-to-date cor-
rections with an emphasis on the grafts and the sutures.

Constantian MB. Rhinoplasty: Craft & Magic. St Louis: Quality Medical Publishing, 2009.
Much of the second volume of this two-book set is dedicated to secondary rhinoplas-
ties. Unlike the majority of plastic surgeons, Mark Constantian advocates a closed en-
donasal approach for all cases, with strategic choices completely different from those
used for the open approach. The impressive results prove that different ways can be used
to achieve good results in secondary rhinoplasty and that mastering both approaches
and their specific strategies is important when performing secondary rhinoplasties.
Gruber RP, Aiach G. Open rhinoplasty. In Goldwin R, Cohen MN, eds. Unfavorable Results
in Plastic Surgery: Avoidance and Treatment, 3rd ed. Philadelphia: Lippincott, Williams
& Wilkins, 2001.
This chapter considers the complications of rhinoplasty, with an emphasis on those re-
lated to the open technique.
Guyuron B. Secondary rhinoplasty. In Guyuron B, ed. Plastic Surgery—Indications, Opera-
tions, and Outcomes. St Louis: Mosby–Year Book, 2000.
A concise yet in-depth review of postrhinoplasty defects and their correction using in-
novative techniques.
Rohrich RJ, Sheen JP, Teotia SS. Secondary rhinoplasty. In Grotting JC, ed. Reoperative Aes-
thetic & Reconstructive Plastic Surgery, 2nd ed. St Louis: Quality Medical Publishing,
2007.
This book covers many problems commonly found in secondary rhinoplasty and nasal re-
construction, presenting both endonasal and open approaches to reoperative rhinoplasty.
Suggested Readings
Constantian MB. Differing characteristics in 100 consecutive secondary rhinoplasty patients
following closed versus open surgical approaches. Plast Reconstr Surg 109:2097-2111,
2002.
Daniel RK. Diced cartilage grafts in rhinoplasty surgery: current techniques and applica-
tions. Plast Reconstr Surg 122:1883-1891, 2008.
Daniel RK. The role of diced cartilage grafts in rhinoplasty. Aesthet Surg J 26:209-213, 2006.
Daniel RK. Septal saddle nose deformity and composite reconstruction. Plast Reconstr Surg
119:1029-1043, 2007.
Gerbault O, Aiach G. [Diced cartilage wrapped in deep temporal aponeurosis (DC-F): a new
technique in augmentation rhinoplasty] Ann Chir Plast Esthet 54:477-485, 2009.
Gruber RP, Weintraub J, Pomerantz J. Suture techniques for the nasal tip. Aesthet Surg J
28:92-100, 2008.
Gubisch W, Eichhorn-Sens J. Overresection of the LLC: a common conceptual mistake with
functional and aesthetic consequences. Aesthetic Plast Surg 33:6-13, 2009.
Gunter JP, Rohrich RJ, Friedman RM. Classification and correction of alar-columellar discrep-
ancies in rhinoplasty. Plast Reconstr Surg 97:643-648, 1996.
Sheen JH. Anatomic reconstruction of the nasal tip cartilages in secondary and reconstruc-
tive rhinoplasty. Plast Reconstr Surg 104:2199-2201, 1999.
2100
Part X  Rhinoplasty

Ethnic Rhinoplasty

WILLIAM D. LOSQUADRO, DEAN M. TORIUMI
CHAPTER 58

T
he term ethnic can be applied to a group of people who share a common racial,
cultural, national, religious, or linguistic heritage. It is commonly used in the
United States to describe nonwhite minority groups. According to the American So-
ciety of Plastic Surgeons, cosmetic procedures for ethnic patients increased 11% in
2008, with Hispanics, those of African descent, and Asians leading the list, respec-
tively. The American Academy of Facial Plastic and Reconstructive Surgery reported
that rhinoplasty was the most common facial cosmetic procedure for both Hispan-
ics and individuals of African heritage and was second only to blepharoplasty in Asian
patients. Multiple factors have been attributed to this rise, including the increased
socioeconomic status and improved social acceptance of plastic surgery among these
ethnic groups. As the populations of United States and other industrialized nations
continue to diversify, the number of ethnic rhinoplasties will surely increase.
Pertinent Anatomy
Anatomic descriptions in the plastic surgical literature, such as high dorsum, and
low radix, traditionally refer to the ideal white (European) nose. However, this cus-
tom does not mean that characteristics described for a white individual’s nose are
the universal aesthetic ideal. Cultural norms and preferences dictate aesthetics: the
model Asian nose differs from the model white nose. Nevertheless, the global per-
vasiveness of Western popular culture has made the ideal white nose a frequent goal
for ethnic rhinoplasty patients.
Long ago, the term Hispanic described all people from the Iberian peninsula. Mod-
ern usage, however, describes only people from countries formerly colonized by
Spain, including Mexico and various Caribbean, Central American, and South Amer-
ican countries. The term mestizo represents a subset of Hispanics with mixed Euro-
pean and American Indian ancestry. Neither term is fully inclusive of the other (His-
panics may be of pure Spanish ancestry, whereas mestizos may be of Portuguese
ancestry), although the difference is semantic rather than clinically relevant. Never-
theless, Hispanic patients exhibit varied anatomic features unique to their individ-
ual Spanish and American Indian heritages.
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Part X  Rhinoplasty

At one end of the Hispanic spectrum is the so-called Castilian nose, with long nasal
bones, a high dorsum, and normal tip projection. This represents primarily Spanish
ancestry and is essentially a white nose. At the other end of the spectrum is the mes-
tizo nose, with thick skin, wide alae, a retracted columella, an overall short nose,
and a broad, underprojected tip. Any anatomic combination along this continuum
may be seen, depending on the patient’s specific genetic makeup.
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Chapter 58  Ethnic Rhinoplasty

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Part X  Rhinoplasty
The nose of a person of African heritage is characterized by a wide, low dorsum and
a broad, underprojected tip. A wide piriform aperture splays the upper lateral car-
tilages and creates a broad middle vault. Thick skin and interdomal fat contribute
to the bulbous tip. The medial and lateral crura are often short, thin, and weak. An
acute nasolabial angle is caused by both an underrotated tip and bimaxillary pro-
trusion. The nasal base is often wider than the interalar distance, and the under-
projected tip contributes to excessive alar flaring.
The Asian nose typically has a low radix, low dorsum, and broad, underprojected
tip. Thick, sebaceous skin contributes to a round tip with poor definition and blunted
soft tissue triangles. The columella is commonly retracted. Asian patients frequently
exhibit an acute nasolabial angle and retrusive premaxilla. Cartilages within the Asian
nose tend to be weak, especially the caudal septum. The cartilaginous septum is fre-
quently very small, necessitating the harvest of cartilage from a secondary location.

Preoperative Assessment
The surgeon elicits specific reasons for seeking rhinoplasty at the initial consultation
and reviews the patient’s cosmetic and functional concerns. It is vitally important to
understand an ethnic patient’s aesthetic goals. Some request cosmetic enhancements
that preserve their unique ethnic characteristics; others will seek a more Western or
white/European standard. Fastidious patients may voice their concerns using accurate
terminology, whereas others will have difficulty identifying features they like and dis-
like. For the latter, photographs of desirable noses will help to focus the conversation.
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Chapter 58  Ethnic Rhinoplasty
Computer imaging is particularly helpful in these situations. A consensus can quickly
be reached based on the visuals, and imaging facilitates discussion of realistically
achievable results. For example, a petite nose will be unattainable in a black or mes-
tizo patient with thick skin and a broad, underprojected tip. Imaging can demon-
strate realistic, balanced results that will help the patient and surgeon develop an ap-
propriate surgical plan.
Some patients express the desire to maintain their ethnicity, yet present photographs
of a white person’s nose. In the senior author’s (D.M.T.’s) practice, Asian patients
frequently provide photographs of Asian actresses, many of whom who have un-
dergone prior augmentation rhinoplasties, rendering their nose more Western. Al-
though they may ask for modest, ethnicity-preserving changes, they may be dissat-
isfied postoperatively if their dorsum has not been fully raised or their tip is left
rounded and less refined.

Ethnic patients who request revision procedures must be screened for prior implants.
Alloplastic implants are frequently used in Asia for augmentation rhinoplasty, par-
ticularly silicone L-strut implants. Implants can damage skin, particularly of the
dorsum, leaving it thin, irregular, and telangiectatic. Silicone L-strut implants may
also thin the tip skin, because the implant genu is the point of greatest tension. Im-
plant removal frequently requires replacement with an autologous costal cartilage
graft. This greatly increases the complexity of surgery and must be fully discussed
with the patient.
The potential use of autologous grafting materials such as auricular or costal carti-
lage must be discussed with the patient preoperatively. If harvesting of costal cartilage
is anticipated, knowledge of prior breast augmentation is important for both oper-
ative counseling and intraoperative technique. The scar from inframammary implant
placement or breast reduction may be useful for costal cartilage harvest if it is still
located within the inframammary fold.
The risks of costal cartilage harvesting and implantation should be carefully ex-
plained to the patient. In addition to the standard risks of pneumothorax, scarring,
and graft warping, the patient should understand that he or she will have increased
nasal stiffness postoperatively. This will soften over time, but the nose will always re-
main more rigid than it was preoperatively. Chest pain may range from nonexistent
to moderate for 3 or 4 days postoperatively. Discomfort when lifting heavy objects
may persist for 1 to 2 months before it subsides completely. Dorsal augmentation
with costal cartilage in Asian patients stretches skin near the medial canthus, and
changes to the epicanthal fold may occur.
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Part X  Rhinoplasty

Donor cartilage
Rib 6
Preoperative Planning
2107
Chapter 58  Ethnic Rhinoplasty
Multiple factors must be considered when designing the incision for costal cartilage
harvest. The senior author preferentially harvests the sixth rib because of its posi-
tion at the inframammary fold and less acute genu, which permits harvest of longer
straight segments. Ribs five and seven may be accessed through the same incision
when additional grafting material is needed. Fifth rib harvest can be more difficult,
because it requires dissecting under the breast tissue in women and through the pec-
toralis muscle in men. The fifth rib has a more continuous curve than the sixth rib,
making it difficult to harvest a long, straight segment. Seventh rib dissection fre-
quently increases postoperative pain, because it constitutes a variable portion of the
rib cage free margin, depending on the length of the eighth rib. Removal may cause
a slight but noticeable depression and can potentially produce a less stable rib cage.
In women the incision is ideally placed in the inframammary fold. The right side of
the chest is preferred for a right-handed surgeon; thus the patient’s rib pain will not
be confused with cardiac pain. In larger-breasted women, an incision can easily be
hidden in the inframammary fold. If future breast augmentation is a consideration,

2108
Part X  Rhinoplasty
the incision should be made lower to anticipate the new inframammary fold. In some
women the incision should be placed slightly more lateral so that it is not visible
when the woman is wearing a dress with a low neckline. In patients with breast im-
plants, the inferior extent of the breast pocket must be determined before the inci-
sion is made to prevent implant injury or violation of the implant capsule.
The size of the incision depends on a number of factors. Asian patients scar poorly on
the chest, so incision length and placement are critical to a favorable outcome. Mus-
cular or obese patients and those with pectus excavatum require larger incisions to ac-
commodate the greater depth of dissection needed; in thin patients with superficial
ribs, smaller incisions are required. Longer incisions are necessary for harvesting
longer pieces of rib. Incisions as small as 1.2 cm can be used to harvest 4 or 5 cm of
rib in patients with the appropriate chest characteristics. Harvesting rib through a
small incision is more difficult and time consuming but is a cosmetically superior
approach. Surgeons with less experience harvesting costal cartilage should use a
larger incision to avoid damaging the pleura.
Operative Technique
The procedure is typically performed with the patient under general anesthesia in
the supine position; the patient’s head is placed on a small soft support, such as a
doughnut. We prefer to use general anesthesia with endotracheal intubation to pro-
tect the airway from blood that may drip down to the larynx during the septoplasty
portion of the operation. We typically prepare the ear in case additional cartilage is
needed. With secondary rhinoplasty or augmentation rhinoplasty, we will prepare
the chest to allow costal cartilage harvesting if needed.

Harvest of Costal Cartilage
The septum is unlikely to provide sufficient grafting material for ethnic patients un-
dergoing augmentation rhinoplasty; invariably, auricular or costal cartilage har-
vesting is necessary. Graft warping is a potential complication when using costal car-
tilage, but the risk can be mitigated with meticulous technique. Early graft harvest
and sequential carving allows time for bending and warping tendencies to present
and be managed intraoperatively.
Harvesting of costal cartilage can often be performed before opening the nose in eth-
nic patients because of the insufficient septal cartilage and the obvious need for graft-
ing material to augment the nose. The skin is incised with a No. 15 blade, and the
subcutaneous fat is sharply dissected. Ragnell or Senn retractors are used to expose
the muscular fascia. Frequent palpation with a 27-gauge needle ensures a proper tra-
jectory of dissection and identifies the bony-cartilaginous junction. The rectus sheath
and pectoral fascia fuse to form the fascial sheath above the sixth rib. A cruciate in-
cision is made through the fascia, and any muscle is bluntly dissected to expose the
rib. Blunt dissection minimizes bleeding and postoperative pain.
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Chapter 58  Ethnic Rhinoplasty
The thick, fibrous rib perichondrium is excellent material for camouflaging grafts,
especially when performing tip grafting and dorsal augmentation. The outer layer of
rib perichondrium may be excised initially or removed once the rib is harvested.
Larger sheets can often be harvested by excising the perichondrium first. The peri-
chondrium is incised with a No. 15C scalpel; the smaller profile of the 15C blade
permits greater visualization through a small incision. The perichondrium is then el-
evated from lateral to medial with a Freer elevator, and the pedicle is divided with
scissors after sufficient material has been raised.

When freeing the perichondrium from the superior and inferior edges of the rib, it
is best to err slightly into the rib itself. Leaving a thin cuff of cartilage helps prevent
inadvertent transection of the often-attenuated deep perichondrium. There is fre-
quently an interchondral joint between the sixth and seventh ribs near the rib genu.
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Part X  Rhinoplasty
Shallow transverse incisions are made with a 15C scalpel near the bony-cartilaginous
junction and as far medial as the patient’s needs dictate. Leaving a thin rim of car-
tilage at the bony junction allows sharp edges to be rounded after the rib is removed.
The incisions should be superficial to avoid violating the inner perichondrium and
pleura. Costal dissection is easily performed with the sharp end of the Freer eleva-
tor. Younger patients have soft, white costal cartilage, whereas older patients have
yellow-brown cartilage with varying amounts of calcification. Often there are islands
of calcification at the rib periphery, and dissection must proceed around them. Rarely
is the entire segment calcified and unusable.

The attachment may be fibrous, a synovial joint, or a solid cartilaginous connection
that requires division with a Freer elevator. After the rib has been dissected circum-
ferentially, the Freer elevator is used to bluntly elevate the rib off the deep perichon-
drium. The undersurface of the rib and the deep perichondrial sleeve can be viewed
directly to ensure that the pleura is not violated. Significant resistance when trying
to bluntly elevate the rib often indicates incomplete dissection at one of the corners,
especially medially, where the rib is thicker. Care must be taken when elevating
an older, more brittle rib to ensure that it does not fracture. After the rib is freed, a
double-pronged skin hook facilitates removal from the pocket. The medial and lat-
eral rib edges are trimmed and smoothed with Takahashi forceps. The inner peri-
chondrial sleeve is inspected and irrigated with saline solution; a Valsalva maneuver
performed by the anesthesiologist confirms pleural integrity. The rib is placed in an
antibiotic-infused saline solution.
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Chapter 58  Ethnic Rhinoplasty
Carving often begins after opening the nose. Carving is best performed on a flat carv-
ing block with a No. 10 blade. Toothed forceps provide a secure grasp of the rib; non-
toothed forceps may eject grafts off the carving block. Carving the rib into three seg-
ments maximizes the number of useable grafts. The thickness of each segment varies
according to the patient’s needs. The central portion of rib often warps least. Outer
segments have a fibrous component that causes greater warping in younger patients
but helps maintain graft integrity in older, more brittle ribs. The segments are thinned
initially and placed back into the antibiotic-infused saline solution.
Final cuts are made just before the grafts are placed. Carving the grafts in this man-
ner allows warping tendencies to manifest intraoperatively and to be used for curved
grafts. For example, dorsal grafts placed concave side down will lie flat after skin–
soft tissue envelope compression, whereas lateral crural strut grafts can be placed
convex side up to better support the airway. Older calcified rib is more difficult to
harvest, carve, and suture but maintains the distinct advantage of warping very lit-
tle. Younger cartilage is easy to carve and suture but can warp dramatically and is
less predictable.

Incision Closure
Careful closure of the chest incision minimizes scarring and visibility of the scar. Un-
used pieces of costal cartilage are placed back within the perichondrial sleeve. The
muscular fascia is closed with 3-0 PDS sutures, and breast tissue or subcutaneous
fat is closed with 4-0 PDS. The breast is pushed medially and inferiorly in women to
assess for puckering that represents improper dermal tethering to the deep closure.
The epidermal edges in small incisions are often macerated by retraction. A No. 15
blade can be used to trim the wound edge up to, but not around, the incision apex;
trimming circumferentially elongates the incision. The skin is then closed deeply with
5-0 PDS and cutaneously with a running locking 6-0 nylon vertical mattress suture.
Local anesthetic is injected after closure is completed. Bacitracin ointment is applied,
and the wound is covered with nonadherent gauze and a transparent dressing.
Harvest of Auricular Cartilage
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Part X  Rhinoplasty
Auricular cartilage is easily harvested through a postauricular incision placed on the
pinna above the postauricular crease. This incision placement ensures that scars will
not be visible and prevents blunting of the postauricular sulcus. The incision is car-
ried down onto the posterior perichondrium, which may be harvested or left in situ.
The entire conchal bowl can be harvested without changing the external auricular
appearance; violation of the antihelix, however, will cause a cosmetic deformity.

Transauricular needles can help demarcate the area to be harvested. The cartilage is
incised with a No. 15 blade and bluntly dissected from the anterior perichondrium
with a Freer elevator.
Hemostasis of the anterior skin–perichondrial flap is obtained with bipolar cautery;
judicious use prevents damage to the flap. The skin incision is closed deeply with
6-0 Monocryl and superficially with 5-0 fast-absorbing gut suture. A Penrose drain
is trimmed and left exiting the inferior extent of the incision. A cotton bolster coated
in antibiotic ointment is sutured through and through the conchal bowl with 3-0 ny-
lon; the posterior bolster can be lassoed within the suture loop.
Elevation of the Skin Flap for an External Rhinoplasty
Approach
Details regarding the incision and dissection are discussed in Chapter 56. Ethnic pa-
tients frequently require increased projection, and it may be prudent to place the
transcolumellar incision slightly lower to accommodate eventual superior movement
of the scar.
Dorsal Augmentation
Most ethnic rhinoplasties require dorsal augmentation, although some patients may
present with dorsal humps that require reduction. The cartilaginous convexity is first
reduced with a No. 15 blade. If a bony component of the hump exists, the cephalic
extent of the reduction is perforated with a 2 mm straight osteotome placed perpen-
dicular to the nasal bones. This maneuver creates a weak point for the 12 mm Rubin
osteotome to exit through and counteracts the tendency for overreduction. Reduc-
tion of the dorsal hump often creates an open roof deformity that requires lateral
osteotomies to close. High-low-high lateral osteotomies are performed with a 3 mm
straight osteotome. Intermediate osteotomies are rarely needed, except for an ex-
tremely wide dorsum.
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Chapter 58  Ethnic Rhinoplasty
Thoughtful graft selection for dorsal augmentation can help minimize postoperative
complications. Septal cartilage is often preferred over auricular or costal cartilage
for dorsal augmentation, because it does not curl or warp. Unfortunately, the sep-
tum is often insufficiently thick or is depleted and harvesting auricular or costal car-
4
58-1 Nasal dorsal
augmentation
4
58-2 Dorsal hump
reduction:
high horizontal dorsal
oste ot omy for more
precise control

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Part X  Rhinoplasty
tilage is necessary. Auricular cartilage can curl at the edges and create a deformity
when used for dorsal augmentation. The costal cartilage of older patients is typically
brown and more calcified and brittle; although carving and suturing are more diffi-
cult, older costal cartilage warps less. Conversely, younger costal cartilage is white,
softer, and easier to carve, but warps more.
Upper lateral cartilage
Lower lateral cartilage
Dorsal graft
Perichondrium
Perichondrium
Dorsal grafts are carved into a canoe shape: flat or slightly concave on the under-
surface, gently rounded on the edges, and tapered at both the caudal and cephalic
ends. The specific dimensions depend on the needs of the patient.
Ideally the dorsal graft is slightly curved so the graft can be set into position with
the concave surface facing downward. This orientation protects against any chance
that the graft will curve upward, leaving the patient with a prominence in the supratip
and radix.

Graft edges often need camouflaging to prevent visible postoperative step-offs, espe-
cially in thin-skinned patients. Dorsal palpation is critical, since intraoperative edema
will obscure minor irregularities. Perichondrium can be sutured along the graft edge
with 6-0 Monocryl. Alternatively, the entire graft can be covered in perichondrium.
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Chapter 58  Ethnic Rhinoplasty
Graft size and placement are individualized for each patient. Greater dorsal aug-
mentation creates a narrowing effect on the frontal view that must be balanced with
anticipated changes to the tip. Ethnic patients frequently have wide tips that resist
significant narrowing and necessitate restrained dorsal narrowing to preserve tip-
dorsum harmony.
The radix of white/European individuals commonly lies between the superior lash
line and the upper lid crease, whereas the radix of Asian patients typically lies at the
midpupillary level. Dorsal graft placement thus depends on the degree of ethnic char-
acteristics the patient wishes to maintain.

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Part X  Rhinoplasty
Nasal bone
(roughened by rasp)
Lower lateral cartilage
Upper lateral cartilage
Dorsal graft
Perichondrium
In primary augmentation rhinoplasties, dissection of a narrow dorsal pocket facili-
tates tight graft placement. For grafts extending over the bony dorsum, graft adher-
ence can be improved by roughly rasping the dorsum and suturing perichondrium
to the graft’s undersurface. This will create a bone-perichondrial interface that pro-
motes graft adhesion in the early postoperative period. The graft can be secured cau-
dally to the middle vault with 5-0 PDS.
Nasal spine with notch
Submucosal
spreader grafts
Caudal septal
extension graft
Upper lateral cartilage
Lower lateral cartilage
In complex revisions, the L-strut may need to be reconstructed. After building the
dorsal component of the L-strut with extended spreader grafts and a septal exten-
sion graft, a separate dorsal graft can be placed on top of the stable middle vault.
Placing the dorsal graft on top of extended spreader grafts permits minor movement
independent of the L-strut.

Removal of large alloplastic implants in patients undergoing revision procedures re-
quires wider dissection and often results in a large pocket. Grafts can be sutured to ad-
jacent soft tissue or transcutaneously using 6-0 Monocryl. In the rare patient in whom
graft stability cannot be obtained with suture fixation, a transcutaneous threaded
Kirschner wire can be drilled through the dorsal graft and into the underlying nasal
bone. On postoperative day 7, the wire can be removed or clipped at the skin surface.
Tip Contouring
The tip in ethnic patients is often bulbous and underprojected, and lacking in defi-
nition. Frequently used techniques include cephalic trim of the lateral crura, dome
binding and interdomal sutures, and shield tip grafting. Repositioning of the lateral
crura is seldom performed, because it can accentuate the hanging ala commonly
found in ethnic patients.
Slightly increased projection may be obtained with onlay tip grafts in selected ethnic
patients with thin skin. These rectangular or elliptical grafts are sutured horizontally
over the domes with 6-0 Monocryl to simulate the natural horizontal tip highlight.
Soft cartilage, such as auricular or trimmed lower lateral cartilage, is ideal for this
purpose, and approximately 1 to 2 mm of increased projection can be achieved.
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Chapter 58  Ethnic Rhinoplasty

Thick-skinned patients frequently require shield tip grafts with lateral crural grafts
to increase projection, stretch the skin, and refine the tip. The shape of the shield
graft simulates the divergent medial crura and domes. Shield grafts are sutured to the
medial crura with 6-0 Monocryl. Large grafts creating substantial increases in pro-
jection (greater than 2 mm) are often supported with buttress grafts and/or lateral
crural grafts. Both grafts maintain postoperative tip projection by preventing cephalic
rotation of the shield graft once the skin–soft tissue envelope is sutured closed. Lat-
eral crural grafts are sutured on top of the native lateral crura, whereas lateral crural
strut grafts are sutured to the undersurface of the lateral crura. In addition to sup-
porting the shield graft, lateral crural grafts smooth the transition from the tip to the
alae and preserve the natural tip-alar highlight. Shield tip grafts can be carved from
any type of cartilage, although stronger septal and costal cartilage is preferred to
weaker, more flexible auricular cartilage.
Tip refinement can often be obtained with dome binding and interdomal sutures.
When a shield tip graft is used, the tip width is set by the leading edge of the graft.
Soft tissue or perichondrium can be placed over and around the tip graft to provide
additional camouflage.
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Part X  Rhinoplasty

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Chapter 58  Ethnic Rhinoplasty
Patients of African descent in particular have a large amount of fibrofatty tissue
within the tip. This can be cautiously resected to increase tip definition; care is taken
not to injure the subdermal plexus of the skin flap.
Weak alae can be supported with alar rim grafts. Rim grafts are thin, sliver-shaped
grafts inserted into pockets dissected caudal to the marginal incision. They are se-
cured with a single 6-0 Monocryl suture, and the medial edge of the graft is crushed
with Adson-Brown forceps to prevent visibility within the tip. Rim grafts help form
a triangular base by straightening concave alae. Correcting alar concavities elimi-
nates shadows that isolate the tip and interrupt the tip-alar highlight.
The transcolumellar incision is closed deeply with a single 6-0 Monocryl to align
and reduce tension on the skin edges. The skin is then closed with interrupted verti-
cal mattress 7-0 nylon sutures oriented perpendicular to the incision. The marginal
incisions are closed with 5-0 chromic gut, and the septal mucoperichondrial flaps
are reapproximated with a 5-0 plain gut quilting suture.

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Part X  Rhinoplasty
Reduction of the Alar Base
Alar base reduction, if necessary, is the final step during rhinoplasty. Different in-
traoperative maneuvers have variable effects on the final alar position. For example,
increasing tip projection decreases flare, whereas lateral crural repositioning increases
flare. Regardless, ethnic patients frequently benefit from some form of base reduc-
tion. The degree of flare, nostril size, and native alar/sill anatomy determine incision
placement. The noses of thick-skinned mestizo patients or individuals (particularly
males) of African descent frequently have a smooth, rounded internal ala-to-sill tran-
sition. Base reduction incisions made across the nostril sill are at a high risk for vis-
ible scarring. These patients are better candidates for external alar reductions unless
the nostrils are very large. Patients should be counseled preoperatively that their
thick, sebaceous skin makes them more likely to scar unfavorably.
The amount to be resected is first outlined with a marking pen. Conservative exci-
sions are preferable, because additional ala can be excised postoperatively at a later
time. The ala is excised with a No. 11 blade. The incision is closed deeply with a sin-
gle 6-0 Monocryl suture, and the skin is closed with interrupted vertical mattress
7-0 nylon sutures. Meticulous technique is necessary to prevent visible scarring.