The Art of Aesthetic Surgery_ Principles and Techniques -Foad Nahai, Farzad Nahai, Jeffrey Kenkel, Grant Stevens, William Adams Jr. (3 Volume Set)-Thieme (2020)

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IX Rejuvenation of the Cheeks, Chin, Lips, and Ears
8 to 9 years for carefully selected children, and we can avoid
general anesthesia in up to a third of the younger children and in
two-thirds of older children.
57.5.1 Head Positioning
Otoplasty is traditionally performed with the patient in the
supine position, with the head being turned from side to side
to approach each ear. This conventional approach has been the
preferred option and is certainly the only option for general-an-
esthetic procedures. However, for local anesthetic cases there are
some advantages to considering a prone position, with a number
of potential benefits for patient and surgeon.
A neurosurgical head support is used to allow the patient to lie
comfortably face down³more specialist equipment such as this
is preferred over makeshift strategies, mainly in terms of better
surgeon access to the operative site. Gamgee Tissue (Robinson
Healthcare Ltd., :orksop, U.) or gauze is padded around the
head to absorb any dripping blood. A platform can be fashioned
underneath the opening in the support to allow the patient
to rest reading material, a tablet, or a smartphone in view (Fig.
57.3). Patients should be made aware that they should inform the
surgeon should they wish to move at any point.
This approach allows two surgeons to operate, facilitating
training cases for a real-time ´follow my leadµ approach as well as
reducing operative time by operating on both ears simultaneously
(Fig. 57.4). Full exposure of the posterior approach to both ears is
available throughout without moving the head and without ear
retraction, which greatly facilitates the closure of the skin at the
end of the procedure. This position avoids blood accumulation
in the ear canal, which can be uncomfortable, disorienting, and
nausea inducing and limits hearing. The use of hand-held video
games, books, or tablets can improve the experience for young or
anxious patients and introduce an interesting element of fun into
the proceedings for them.
57.5.2 Hair Preparation
Hair preparation always proves difficult if hair is long. In the
prone position, plaiting of hair with or without antimicrobial gel
in the periauricular hair is often sufficient. In the supine position,
a combination of hair plaiting plus a swimming cap, which can
be cleaned and reused, and antimicrobial gel can usually deal
with the majority of offending stray hairs. Swimming caps are
difficult to put on without patient cooperation, so the advice is to
ask the patient to put the cap on prior to induction of anesthesia.
57.5.3 Access Incisions
Marking of the posterior access has traditionally been described
in the auriculocephalic sulcus. Ideal scar placement should there-
fore be geared toward adequate access to perform the procedure
as well as final scar visibility. Three-dimensional (3-D) analysis
of a range of posterior scar placements has demonstrated that a
scar in the helical rim has the smallest arc of visibility when the
patient is viewed from behind (Fig. 57.5).
Finally, optimizing the theater environment should be consid-
ered for performing otoplasty, particularly for young patients. The
use of on-table entertainment in the prone position has anecdot-
ally been very well received by patients. Even in the supine posi-
tion, young patients under local anesthetic can be encouraged to
bring their own music playlist to make the experience as relaxing
and as enjoyable as possible.
57.6 Operative Technique:
Using the Postauricular Fascia
to Enhance Otoplasty
The aim of this technique is an operation that provides consistent
good results, low complication rates, with good patient experi-
ence (no suture removal, no dressing changes, no head bandages,
and minimum number of hospital visits).
A posterior, elliptical skin excision is centered over the groove
of the antihelix measuring 8 to 10 mm in width, the length being
determined by the need to address the upper or lower pole.
Superiorly the excision should follow the curve of the antihelix
medially.
Fig. 57.3 Use of a neurosurgical head support to facilitate prone
otoplasty with the patient viewing a tablet screen during the
procedure. Use of a headpiece with a cut-out section is possible, but it
affords less access to the patient.
Fig. 57.4 Use of neurosurgical head support allows surgeons better
access, and the surgery can also proceed with two surgeons.

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Skin is excised at the subdermal level, leaving behind as thick a
fascial layer as possible over the posterior concha (Fig. 57.6). The
inferior border of the excision is then incised full-thickness down
to the chondral surface, and an anteriorly based fascial flap is then
raised toward the sulcus of the helical rim using blunt dissection
in the subfascial plane, facilitated by the curve of the tenotomy
scissors. The fascial flap is left in continuity with cartilage along
the entire length of the rim (Fig. 57.7). Dissection is completed
when adequate exposure is provided for suture placement.
In instances where a deep conchal bowl is evident, a concho-
mastoid suture using 4–0 poly(ethylene terephthalate) (Ethibond,
-ohnson -ohnson, 1ew Brunswick, 1-) is used to rotate the ear
posteriorly. This is the cornerstone for other aspects of the surgery
to have a more refined and natural look. In the presence of this
suture, the surgeon may demand much less of any other suture
placed. In the overwhelming majority of cases this maneuver will
negate the need to excise ´excessµ conchal bowl cartilage, which
is often described in the literature, and avoids the challenges and
potential complications associated with this excision. :e have
never needed to cut out cartilage.
:ide access to the mastoid can easily be achieved through blunt
dissection and indeed is necessary to allow the needle holder to
be maneuvered comfortably when placing the suture through
mastoid periosteum (Fig. 57.8).
This suture is first passed through mastoid periosteum at
roughly the midpoint of the ear. The auricularis posterior
muscle is an ideal anatomic landmark, and the suture can be
passed around the back of this muscle for consistency of suture
placement between cases and between ears. The strength of this
suture’s attachment to periosteum should be tested rigorously
(Fig. 57.9). The optimum position for the conchomastoid suture
on the concha is often at the midpoint in terms of height, but
superior or inferior placement can subtly lower or lift the ear,
respectively, as well as preferentially add to the correction of the
upper or lower pole if needed. Placement closer to the helical rim
will result in further posterior rotation, but placement too close
Fig. 57.5 The arc of visibility, when viewed from behind, of three potential scar placements: auriculotemporal sulcus (red), helical rim (blue), and in
between (green).

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IX Rejuvenation of the Cheeks, Chin, Lips, and Ears
to the rim can result in a ´telephoneµ deformity by constricting
the middle third. This should be judged on table, and these two
elements should be balanced when choosing the medial/lateral
position of the conchomastoid suture on the concha.
:e advise tying this knot first and leaving the needle attached
on an artery clip for use at the end of the procedure in reinforcing
this suture and providing Mustarde cover by picking up the fascial
flap in the same suture.
Accurate positioning of Mustarde sutures is paramount and will
make the difference between a natural and appropriately corrected
ear and an ´operated look.µ A fine-gauge needle can be used to
skewer the desired antihelical fold (Fig. 58.10) to facilitate suture
placement, but this step can often be omitted with sufficient expe-
rience. If the skewer technique is used, the needles can be removed
by an assistant one by one as each Mustarde suture is placed, or the
needle can be used to facilitate marking of proposed suture place-
ment points using ink, and all removed prior to suture placement.
Three Mustarde sutures addressing the inferior, central, and
superior pole are often sufficient, although, if required, there
should be no hesitation in using more.
Mustarde sutures should be tied from inferior to superior. The
reason for this is that manipulation of the ear inferiorly tends to
bring the superior portion along with it to a certain extent. This
means that by tying a superior suture in the desired position first,
subsequent sutures tied inferior to this can result in overcorrec-
tion of the superior pole. Often, superior pole position is the most
critical element, and the placement of this suture should be the
final step, using millimeter precision to position it perfectly.
Once all sutures have been placed, the long conchomastoid
suture is passed through the fascial flap and tied. This provides
cover to the Mustarde sutures and can also be used to tweak the
posterior rotation further by picking up the fascia more anteriorly
or address lobe prominence by picking it up inferiorly.
:e advocate the use of 4–0 Ethibond for conchomastoid/
Mustarde sutures, as we have found that these permanent braided
sutures hold well, handle well, and do not form the crystalline
´sharpµ knots of monofilaments, which can easily extrude or
cause discomfort.
The skin is then closed with a subcuticular running 5–0 absorb-
able monofilament poliglecaprone suture (Monocryl; -ohnson
-ohnson, 1ew Brunswick, 1-) with buried knots. The use of the
fascial flap that takes the tension off the suture repair and approx-
imates the skin edges, in addition to the use of glue as splint,
obviates the need for a strong suture for closure. This fine suture
Fig. 57.6 Thin skin excision exposing the postauricular fascia.
Fig. 57.8 Wide exposure of the mastoid fascia as medially as possible to
facilitate suture placement without obliterating the postauricular sulcus.
Fig. 57.7 Incision of the inferior border and blunt dissection of the
postauricular fascia to the helical sulcus.
Fig. 57.9 Testing the pullout strength of the mastoid suture.

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ensures hairline scars with limited potential for knot abscess or
issues (Fig. 57.11).
57.7 Ancillary Procedures
The earlobe is most easily corrected by a section of fascia dis-
sected from the inferior ear, used as a lever, and sutured pos-
teriorly to achieve the desired position. Alternatively, a suture
positioned inferiorly into the cartilage just above the lobe and
fixed posteriorly can achieve a very good result. A trial-and-error
strategy is simple to employ with minimal risk in this scenario
and, with experience, provides an easy option.
57.8 Dressings and Postoperative
Care
Head bandages are a significant cause of annoyance for patients
and surgeons alike. There is a high rate of accidental removal,
and this can cause distress, unplanned reattendance, and other
issues as outlined in the following subsections.
57.8.1 Disadvantages of Head Bandages
• Patient discomfort, itching and sweating; intolerable in hot
weather
• Patient embarrassment; delayed return to normal activities
(school or work)
• Restriction of bathing, showering, hair washing
• Stigma of surgery for those wishing to be discreet
• Hearing, balance, and nausea issues in some
• Reattendance due to bandages falling off
• Pressure necrosis to skin of ear
• Disguising early signs of postoperative problems (hematoma
or infection)
• Smell of blood retained in hair
Fig. 57.10 The use of fine-gauge needles to skewer the antihelical fold into position and provide reference points for suture positioning.

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IX Rejuvenation of the Cheeks, Chin, Lips, and Ears
57.8.2 Advantages of Skin Glue
:e first published the use of skin glue for postoperative splinting
in 2008, leading to widespread adoption of this safe and simple
technique that both ´dressesµ the wound and further de-tensions
any sutures holding the ear in position, among a number of other
benefits:
• Avoids use of head bandages
• Safe
• Simple and quick to apply
• Avoids one clinic appointment for removal of head bandage
and dressing
• Hides stigmata of surgery in those wishing to be discreet,
especially those with long hair
• Allows bathing and hair washing from the first postoperative
day
• Allows for immediate observation of potential complications
and early reattendance
The advantages of skin glue in otoplasty are best epitomized by
the disappointingly frequent request by patients for our services
specifically to avoid head bandages, rather than any perceived
surgical prowess or reputation
After skin closure, the skin is cleaned and dried and a cyano-
acrylate skin glue is applied to the helical rim from root to lobe.
This is then pressed firmly against the head for up to 10 seconds
(Fig. 57.12). In the awake patient, this can be carried out sitting
up, with the benefit that gravity will drip the glue down the rim
rather than onto the neck, which can be an issue in the asleep
patient. This procedure seals the wound and further retroverts the
ear, taking tension off the sutures. The glue usually holds for 1–3
weeks, and the ear is released through the process of desquama-
tion. Patients can shower and wash their hair from day 1 postop-
eratively. Patient with long hair can cover the ears immediately
and continue daily social interactions with no stigmata of surgery.
1o postoperative dressing clinic appointment is required for
removal of bandages. Patients should be counseled preoperatively
that they will have an overcorrected look until the skin glue comes
away and that one ear may be released before the other.
High-risk activities, including contact sports, should be avoided
for at least 6 weeks, and the use of a headband at night to avoid
shearing on the pillow is considered optional. Postoperative
Fig. 57.11 A hairline scar following otoplasty.
Fig. 57.12 Glue used to stick the helical rim to the head as dressing. (a)
Application of glue to the medial surface of the helix. (b) Pressing the
helix against the head. (c) Second application of glue to the helical rim.
(d) Adhesion of helical rim to head.

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review is at 2–3 months, at which time photographs are taken for
the medical record. :ith our technique only one postoperative
appointment is required, and the majority often end up being for
our own benefit to capture the ´afterµ photograph. Patients trav-
eling a long distance or from abroad can be discharged from the
operating room with appropriate advice and recourse to follow
up only as needed: there are no after-care tasks, head bandages,
dressings, or sutures.
57.9 Outcomes
:ith the myriad proven techniques available to choose from,
the discerning surgeon should now be asking which outcomes
can and should be optimized in order to maximize patient
satisfaction. A focus on antihelical angles and nuances of
technique does not necessarily translate into desirable expe-
riences and outcomes for patients. This struck home to me in
a consultation when one patient’s parent stated the reason for
choosing me as the surgeon was simply that ´you don’t use
head bandages.µ There are descriptions of techniques that
necessitate three postoperative clinic visits, not including
the obligatory impromptu return for a slipped head bandage.
Outcomes such as these are not routinely captured in eval-
uations of technique but form a major part of the decision
making process for patients when they are fully informed of
all of the options.
Technical outcomes may be taken as read to a certain extent
at this point, and surgeons should now be asking whether their
technique necessitates head bandages, suture removal, and more
outpatient appointments than other techniques. If so, can the
surgeon still justify this, and has the patient been given a choice"
57.10 Results
Fig. 57.13 shows the results of unilateral correction in a 7-year-
old boy presenting with prominence and underdevelopment of
the right antihelical fold.
Fig. 57.14 shows the results of bilateral correction in a 13-year-
old boy who presented with asymmetric, bilateral prominence,
deep conchal bowls, and a poorly developed left antihelical fold.
Fig. 57.15 shows the results of bilateral correction in a 16-year-
old girl who had an asymmetry amounting to only a few millime-
ters although it was noticeable.
57.11 Concluding Thoughts
Ear prominence is a significant cause of psychological morbidity
for adults and children alike. Timely intervention can resolve the
majority of this morbidity; however, an unfavourable outcome
will be obvious and, in the worst instances, deforming.
The importance of patient experience should not be under-
stated. In the pursuit of the optimal patient experience in oto-
plasty, we can now be asking ourselves questions such as ´Should
I be discharging patients from the operating room with perhaps
only a pro re nata follow-up appointment"µ ´:ould the patient
prefer to have a head bandage after surgery or not"’ and ´How
many times would the patient like to return to the hospital for
follow-up after surgery"µ
Fig. 57.13 This 7-year-old boy presented with unilateral prominence and underdevelopment of the antihelical fold on the right. The right ear is also
larger than the left. (a) Anterior, (b) lateral, and (c) posterior views are shown. (d,e,f) Three-months post-op. (d) After unilateral correction, the ears
have good symmetry in terms of prominence and contour and the size discrepancy is much less apparent. (e) The right antihelix is now well formed.
(f) The scar is subtle in the helical sulcus and has limited visibility from behind with the ear in its usual position.

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IX Rejuvenation of the Cheeks, Chin, Lips, and Ears
This chapter presents a simple, safe and reproducible approach
that produces consistently good results with a low complication
rate. If a suture comes undone, it can be revised, whereas once
tissue is lost or distorted, we step into the realm of reconstruction,
and our optimum aesthetic goal is often out of reach. As impor-
tantly, this technique allows for minimal downtime and stigma of
surgery, no head bandage, and minimal need for further hospital
visits, which, personal experience has demonstrated to me, can
be significant contributing factors to the development of the
reputation of the otoplasty surgeon.
Clinical Caveats
• Skin excision must be at the level of the dermis to allow
adequate thickness of the fascial flap—this can be achieved
by avulsing the skin having incised the edges and lifted one
end in the correct plane.
• Conchomastoid sutures must have sufficient traction on peri-
osteum to move the head of the patient off the table without
pulling out.
• Consider reinforcing Mustarde sutures with complementary,
supportive sutures holding the same position to halve the risk
of any given suture failure causing a recurrence.
• Bites through cartilage for Mustarde sutures must be deep
enough not to pull through but not so close to anterior
skin as to be visible. On table testing of pull out and visual
assessment of anterior skin can reveal an excessively deep
or shallow bite.
• Dissection down to the mastoid should be kept medial to
avoid obliteration of the postauricular sulcus.
Fig. 57.14 This 13-year-old boy presented with asymmetric, bilateral prominence with a present, but poorly developed, left antihelical fold and deep
conchal bowls bilaterally. (a) Anterior, (b) oblique, (c) lateral, and (d) posterior views are seen. (e,f,g,h) Three-months post-op. (e) A symmetrical and
aesthetically pleasing result is achieved. (f) Resection of the “hypertrophic” conchal bowl was not necessary. (g) The lateral view demonstrates the
soft and natural contour, which is achieved with cartilage sparing. (h) Posterior view shows inconspicuous scars.

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Suggested Reading
[1] Adamson -E, Horton CE, Crawford HH. The growth pattern of the external ear.
Plast Reconstr Surg 1965;36(4):466–470
>2@ Bovill E, Boulton R, :harton S. Reply to: A clinical tip for prominent ear dress-
ings: a simple advice for prevention of slippage. -PRAS 2009;62(5):668. J Plast
Reconstr Aesthet Surg 2010;63(2):372
>3@ Farkas LG. Growth of normal and re-constructed auricles. In: Tanzer RC, Edgerton
MT, eds. Symposium on reconstruction of the auricle. St. Louis, MO: Mosby;
1974:24–31
>4@ Furnas D:. Correction of prominent ears by conchamastoid sutures. Plast Recon-
str Surg 1968;42(3):189–193
>5@ Gosain A., .umar A, Huang G. Prominent ears in children younger than 4
years of age: what is the appropriate timing for otoplasty" Plast Reconstr Surg
2004;114(5):1042–1054
>6@ .amburoùlu HO, Ozgr F. Postoperative satisfaction and the patient’s body
image, life satisfaction, and self-esteem: a retrospective study comparing adoles-
cent girls and boys after cosmetic surgery. Aesthetic Plast Surg 2007;31(6):739–
745
[7] Mathur BS, Shokrollahi .. Precision and suture positioning in otoplasty. Experi-
ence with 380 cases. J Plast Reconstr Aesthet Surg 2010;63(3):571–572
[8] McDowell A-. Goals in otoplasty for protruding ears. Plast Reconstr Surg
1968;41(1):17–27
[9] Mustarde -C. The correction of prominent ears using simple mattress sutures. Br
J Plast Surg 1963;16:170–178
>10@ Shokrollahi ., Manning S, Sadri A, Molajo A, Lineaweaver :. The prominent
antihelix and helix³the myth of the ´overcorrectedµ ear in otoplasty. Ann Plast
Surg 2015;74(Suppl 4):S259–S263
[11] Shokrollahi ., .aney S. Psychological considerations in patient selection for
pinnaplasty. J Plast Reconstr Aesthet Surg 2009;62(1):118
>12@ Shokrollahi ., Taylor -P, Le Roux CM, et al. The postauricular fascia: classifi cation,
anatomy, and potential surgical applications. Ann Plast Surg 2014;73(1):92–97
>13@ Shokrollahi ., Cooper MA, Hiew L<. A new strategy for otoplasty. J Plast Reconstr
Aesthet Surg 2009;62(6):774–781
>14@ Shokrollahi .. Request for treatment: the evolution of consent. Ann R Coll Surg
Engl 2010;92(2):93–100
>15@ Shokrollahi .. Otoplasty awake and in the prone position³a new perspective.
Ann Plast Surg 2013;70(1):1–3
>16@ Shokrollahi ., Au-discrete scar in prominent ear correction: a digital 3-dimensional analysis to
determine the ideal incision for otoplasty. Ann Plast Surg 2015;74(6):637–638
[17] Shokrollahi ., Tanner B. ´Glue earµ: beginning of the end for head bandages after
prominent ear correction" J Plast Reconstr Aesthet Surg 2008;61(9):1077
[18] Tas S. Prominent ear correction: a comprehensive review of fascial fl aps in
otoplasty. Aesthet Surg J 2018;38(7):695–704
[19] van :ijk MP, Breugem CC, .on M. 1on-surgical correction of congenital defor-
mities of the auricle: a systematic review of the literature. J Plast Reconstr Aesthet
Surg 2009;62(6):727–736
>20@ Vetter M, Foehn M, :edler V. A new postoperative otoplasty dressing technique
using cyanoacrylate tissue adhesives. Aesthetic Plast Surg 2010;34(2):212–213
Fig. 57.15 This 16-year-old girl presented with unilateral right-sided prominence which was subtle but noticeable. This case presents the unique
challenge of creating a noticeable change of a matter of millimeters. (a) Anterior, (b) lateral, and (c) posterior views are shown. The posterior rotation
of the conchomastoid suture provided most of the correction with subtle use of Mustarde sutures, achieving good symmetry with the unoperated
side. (d,e,f) Three-months post-op. (d) Postoperative anterior view. (e) Lateral view. (f) Posterior view showing inconspicuous scar.
a
d
b
e
c
f

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IX Rejuvenation of the Cheeks, Chin, Lips, and Ears
58 Rejuvenation of the Chin
Stephen E. Metzinger, Salvatore Lettieri, and Aldo B. Guerra
Abstract
Chin deformities are commonly encountered defects in patients
seeking profile plasty. Careful preoperative evaluation may
identify patients who could benefit from concurrent augmen-
tation or reduction mentoplasty. Alloplastic chin implants and
sliding genioplasty represent the main accepted methods of chin
augmentation, although fat grafting and fillers may be useful
adjuncts or primary tools for minor augmentations or asymme-
tries. Although many procedures may be used for retrognathia
or microgenia, sliding genioplasty may also be used in chin
asymmetry, prognathia, and vertical height discrepancies. This
chapter outlines the methods to analyze the chin and discusses
the treatment options available for correction of chin deformities
as an adjunct to profile plasty.
Keywords
genioplasty, chin augmentation, fat grafting, filler, deoxycholic
acid, profileplasty
58.1 Background
The chin, which is an area defined by the labiomental crease
superiorly, the oral commissures laterally, and the submental-
cervical crease inferiorly, is often overlooked when it comes
to the aesthetic alteration of the face. However, a chin with an
appropriate size, shape, and contour is important for a well-
balanced and harmonious face. :e often hear the terms ´weakµ
or ´strongµ chin to describe menta of certain morphologies
that have both emotional and psychosocial implications for our
patients. Therefore, the art and science behind the surgical alter-
ation of the chin, whether in isolation or as part of an integrated
facial rejuvenation or enhancement procedure, are an important
component of profile plasty.
Genioplasty³the alteration of the chin through either osse-
ous manipulation, implant augmentation, fat grafting, or filler
placement³is one of the more commonly performed cosmetic
procedures. However, alteration of the chin will cause both
predictable and unpredictable changes to the balance between
maxillomandibular morphology, dental relationship, and the
skin–soft tissue envelope that must be accounted for prior to per-
forming any proposed procedure. Pertinent anatomy and histor-
ical background have been described elsewhere in the literature.
:e present pertinent points on proper assessment and treatment
planning, present minimally invasive options, describe different
surgical and nonsurgical techniques, and discuss complications
and results to optimize outcomes.
58.2 Preoperative Assessment
Gender, ethnicity, age, and medical comorbidities are important
factors to consider in the overall treatment planning for profile
plasty. From a morphologic standpoint, men tend to have wider,
squarer faces, often with more projected chins and a two-point
light reflection. :omen, on the other hand, tend to have nar-
rower faces with a single-point light reflection on the chin (Fig.
58.1). Transgendered individuals may request a combination of
the two. Age can be a factor in the young and elderly popula-
tions. In younger patients, one must avoid performing mandible
surgery too early because the lower facial skeleton is not fully
developed. The dentition is not fully erupted until 15 years of
age, putting it at greater risk of injury during osteotomies. In
elderly or edentulous patients, on the other hand, one must
evaluate whether alloplastic augmentation, fat, or filler materials
might be more suitable due to poor bone stock or problems with
the skin–soft tissue envelope. Most importantly, profile plasty is
an elective procedure and should be performed only in patients
who are medically and psychologically fit. Smoking, though not
an absolute contraindication, increases the risk of complications,
including delayed wound healing and graft failure in both genio-
plasty and fat grafting.
Next, a complete analysis of the lower face and its relationship
to the rest of the face should be undertaken, taking into consid-
eration the dental relationship, maxillomandibular skeletal mor-
phology, deep fat pad volume, and the skin–soft tissue envelope.
The purpose is to determine whether genioplasty alone or formal
orthognathic surgery addressing maxillary and/or mandibular
dysmorphology would best fit the patient’s aesthetic goals.
Sometimes fat grafting or filler is all that is needed, or perhaps a
combination procedure such as genioplasty and fat, or alloplastic
implant with filler. The procedure must be customized to the
individual and the conditions at hand.
58.2.1 Dental Morphology
Evaluation of the occlusal and dental relationships is crucial in
determining whether a procedure is necessary, and if so, which
procedure would best address the patient’s dysmorphology.
Edward Angle’s classification is used to establish the relationship
between maxillary and mandibular dentition. In patients with
normal class I occlusion, any chin deformities can be managed
with isolated manipulation of the chin or overlying skin–soft
tissue envelope. However, patients with class II or III occlusion
require further evaluation to decide whether they will be better
served with a combination of mandibular and maxillary osteot-
omies with or without genioplasty. The presence of any dental
compensation or history of previous orthodontic treatment
is an important part of the patient’s dental history because

58 Rejuvenation of the Chin
883
underlying skeletal dysmorphology could be revealed upon
evaluation. Lastly, poor or infected dentition should be treated
prior to any discussion about profile plasty. Poor dentition can
lead to increased risk of infection, bone loss, malunion, and poor
outcome.
58.2.2 Skeletal Evaluation
Cephalometric analysis remains the primary guiding principle
behind any manipulation of the facial skeleton. A formal lateral
cephalogram may be useful in some cases. Most patients can be
adequately examined with a combination of proper soft tissue
and dental evaluation. 1otwithstanding, cephalometric princi-
ples remain central to guide treatment planning, as they form
the basis for many of the soft tissue relationships. In complex
cases, formal osseous cephalometric examination, such as the
Steiner analysis, is helpful in grasping the relationships among
the skull base, the maxilla, and the mandible. The relationship
between sella–nasion–subspinale (S1A in Fig. 58.2) and sella–
nasion–supramentale (S1B), as well as the relationship between
the maxilla and mandible (A1B), can help to ascertain whether
formal orthognathic surgery is necessary. Furthermore, adding
chin points pogonion (Pg) and menton (Me) to the analysis can
help determine whether concomitant genioplasty or soft tissue
manipulation is recommended.
Soft Tissue Analysis
Several tools exist to help with soft tissue analysis, and each
surgeon has a preferred set of methods he or she uses in
determining whether genioplasty or soft tissue manipulation
is needed and the level of movement required. Some of the
more commonly used analytical tools will be presented here,
but this is not comprehensive review of all available methods.
Three-dimensional (3-D) computer imaging and analysis may be
helpful as well as virtual modeling and virtual surgery (Crisalix,
Lausanne, Switzerland).
Every patient should be viewed from frontal, lateral, oblique,
and sagittal views. A life-size photograph to include bilateral
lateral, frontal, and bilateral oblique views can be helpful. From
the front, lip competence and facial height and symmetry can be
analyzed. In addition, the face should be analyzed with lips in
repose and while smiling to see the dynamic soft tissue changes
with animation. Video can be a useful tool in this evaluation. The
following parameters are particularly significance:
1. Lip competence: Patients with lip incompetence may prefer the
aesthetic outcomes of osseous genioplasty over implant aug-
mentation to correct this deformity.
2. Facial height: Facial proportion³the height of the lower third of
the face in relation to the middle third of the face³should be
measured to decide whether augmentation or reduction is rec-
ommended. Incisor show is a physical evaluation tool used as a
reasonable indicator of facial height dysmorphology. Increased
incisor show and/or mentalis strain can point to a long-face
syndrome pattern, whereas decreased incisor show can signal
a short-face pattern, both of which may be better corrected by
addressing the underlying maxillomandibular skeletal dysmor-
phology with orthognathic surgery.
3. Facial symmetry: Asymmetries of the mandible and chin may
require asymmetric movements and/or multiple osteotomies in
addition to incremental soft tissue adjustment with fat or der-
mal filler.
Fig. 58.2 Cephalometric analysis is the primary guiding tool in
manipulation of the facial skeleton. The relationship between sella–
nasion–subspinale (SNA) and sella–nasion–supramentale (SNB), as well
as the relationship between the maxilla and mandible (ANB), can help
to ascertain whether formal orthognathic surgery is necessary.
Fig. 58.1 Average proportions of the human face according to Da
Vinci’s rule of thirds and rule of fifths. Around these averages, men
tend to have wider, squarer faces and more projected chins, while
women tend to have narrower faces.

884
IX Rejuvenation of the Cheeks, Chin, Lips, and Ears
1ext, the profile view of the face is analyzed, and the following
points should be addressed:
1. Labiomental fold: The indentation between the lower lip and
lower portion of the mandible is an important characteristic to
recognize in chin aesthetics. In doing so, the vertical proportion
of the mandible to the facial length needs to be assessed, and
both the height and depth of the fold should be studied. Ideally,
the fold should fall at the junction of the upper and middle thirds
of the distance between stomion and menton. The fold should be
a 4 mm in men and a 6 mm in women. A deep fold may be ex-
aggerated in horizontal augmentation, whereas a shallow fold
may be effaced further by vertical augmentation. Patients with
a long lower face and a deep labiomental fold should not be of-
fered genioplasty, as these patients require formal orthognathic
correction with or without soft tissue filling.
2. Lip-chin relationship: A simple line connecting the most promi-
nent portions of the upper and lower lips (Riedel line; Fig. 58.3)
should touch the pogonion on a balanced face. Generally speak-
ing, the lower lip should be 2 to 3 mm posterior to the upper lip,
and the pogonion should never project beyond this line.
3. Cervicomental angle: The angle between the chin and the neck
should be 105ƒ to 120ƒ. Adjunctive treatments to enhance soft
tissue contour of the neck during genioplasty should be con-
sidered and are discussed further in the chapter. Surgical and
nonsurgical treatments such as submental lipectomy, neck
lift, high-intensity focused ultrasound (HIFU; e.g., Ultherapy,
Ulthera, Mesa, A=), lipolysis with deoxycholic acid (.ybella,
Allergan, Irvine, CA), and cryolipolysis (e.g., CoolSculpting, =eltiq
Aesthetics, Pleasanton, CA) can enhance chin aesthetics.
4. 1ose-chin evaluation: The aesthetics of the nose and the chin
should harmonize. Ideally, chin projection should lie a 3 mm
posterior to a line drawn in the nose–lip–chin plane (Fig. 58.4).
Lastly, the skin of the lower face should be examined in both
frontal and lateral views, noting the quality, thickness, and laxity
as well as any irregularities and/or aging signs. Because these
factors can impact outcome, a patient’s expectations should be
managed by discussing these findings in the preoperative setting.
Presence of ptosis of soft tissue caudal to the menton and an exag-
gerated submental crease (´witch’s chinµ) may require soft tissue/
muscle resection, alteration of volume, and/or repositioning of
the tissues. :ith this presentation, implant augmentation may
exaggerate the deformity. On the other hand, excess submental
skin can be addressed with a submental incision to remove an
elliptical segment around the incision to avoid skin ptosis. Video
analysis of facial animation can be helpful in documenting chin
fat pad deformities. Dynamic and static chin pad analysis can then
be used to address the proposed movements or augmentation
procedures of the mentum.
58.3 Treatment Approach
Once preoperative assessment is complete, it is important to
organize the information gathered to formulate an optimal
treatment plan. As expected, each surgeon’s subjective opinion
and previous experience will influence decision making. Further,
the patient’s desires and goals should be carefully considered in
the decision tree as well. As an example, a formal orthognathic
surgery is time consuming and costly and not something all
patients are willing to undertake. It is important in these situ-
ations to discuss with the patient whether genioplasty, alone or
Fig. 58.3 Riedel line: a line drawn vertically down the facial plane
connecting the most prominent portions of the upper and lower lips.
This line should touch the most prominent anterior portion of the chin
in a balanced face.
Fig. 58.4 Nose–lip–chin line: A line drawn vertically down the facial
plane connecting the most projecting point of the nose and the most
prominent portion of the upper lip. The most prominent anterior
portion of the chin should be ~ 3 mm posterior to this line.

58 Rejuvenation of the Chin
885
in conjunction with treatments other than orthognathic surgery,
can achieve some of the desired goals, and if so, whether to
proceed with an alternative surgical intervention. For example,
genioplasty combined with fat grafting and/or submental lipec-
tomy can make a significant difference with very high patient
satisfaction.
Surgical technique for genioplasty falls into five broad catego-
ries: osseous genioplasty, alloplastic augmentation, structural fat
grafting, filler augmentation, and combination therapy. Generally
speaking, most surgeons are more comfortable with inserting
an implant than with performing osteotomies. Fillers are easier
than alloplastic augmentation, and fat grafting requires finesse
and experience with the complexity level, somewhere in between
implants and fillers. :ith proper patient and implant selection,
implant augmentation achieves desirable results and is relatively
easy to execute. However, osseous genioplasty, contrary to some
surgeons’ beliefs, is not a difficult procedure to perform; moreover,
it is a highly versatile procedure that can allow movement in all
dimensions. It can ameliorate conditions that an implant cannot,
such as a chin that is too long, too short, or asymmetric. In addi-
tion, patients who have had one or more failures of an alloplastic
chin implant are perhaps best treated by an osseous genioplasty.
The skin–soft tissue envelope can be further manipulated by
adding fat or filler to the genioplasty.
Osseous genioplasty, alloplastic augmentation, fat grafting, and
filler usage involve different levels of anesthesia; therefore, each
patient’s overall health, tolerance to anesthesia, and anesthetic
preference should be acknowledged in the analysis, as they may
dictate the patient’s personal preference in selecting a procedure.
The majority of implant augmentations can be performed under
local anesthesia, with or without sedation. Fat grafting can be
performed under local or general anesthesia. Most fillers require
topical anesthesia alone. Osseous genioplasty, however, should
be performed with at least intravenous sedation in a controlled
setting for both optimal pain and airway control. Most patients
undergoing osseous genioplasty, in fact, choose general anesthe-
sia, which in many ways make the operative steps easier for the
surgeon and can shorten surgery time.
58.4 Surgical Techniques
58.4.1 Osseous Genioplasty
Incision
An intraoral incision is used and preferred for osseous genio-
plasty. After appropriate sedation or anesthesia is achieved, the
chin is injected with a mixture of lidocaine containing 1:100,000
epinephrine and bupivacaine containing 1:200.000 epinephrine
in and around the proposed incision as well as areas of dissec-
tion and osteotomy. Next, the lower lip is stretched outward to
allow visualization of the mental nerve through the mucosa. The
incision should remain between the visible nerves. An incision
is made, leaving a generous cuff of mucosa and muscle that will
allow a watertight closure. The incision is carried down through
the mucosa and muscle with electrocautery.
Dissection
Dissection is then performed in the subperiosteal plane with
a periosteal elevator to expose the anterior surface of the chin
while visualizing and protecting the mental nerve coming
out of the mental foramen. It is important to avoid extensive
dissection, as the soft tissue attachments help to stabilize the
skeletal alteration, minimize unpredictable soft tissue changes,
and lessen postoperative osseous resorption. As much tissue as
possible should be left on the anterior surface of the symphysis
to prevent ptosis of the chin pad. There is also no need to dissect
above the mental nerve on either side, as that can increase the
chances that the nerve will be excessively stretched or avulsed.
Osteotomy
After proper retraction, a sterile marking pen is used to mark the
location of the osteotomy, which should lie at least 5 mm below
the apices of the canine teeth and 6 mm below the mental fora-
men to reduce the chance of injuring the tooth roots or nerves.
The exact location and angle of the osteotomy will depend on the
planned movement (Fig. 58.5). First, an oscillating saw is used
to make a vertical groove in midline perpendicular to planned
osteotomy that will be used as a midline reference point. A drill
hole can be placed at this point in the midline within the distal
chin, where a screw can be partially inserted later to be used
as a convenient retractor for the osteotomized chin segment. A
wide saw is preferred, as it tends to maintain orientation and
limit canting while performing the osteotomy of the central
portion. An osteotomy of the lateral segments is then performed
with a narrow saw. It is important to make complete cuts, and
particular attention should be paid along the posterior lingual
cortex to prevent an incomplete osteotomy. If a wedge resection
is planned, the caudal cut should be made first so that the second,
cephalad cut can be made on stable bone that remains attached
to the mandibular symphysis. An ample amount of contact
irrigation is recommended throughout the osteotomy to prevent
burning the bone and focal osteomyelitis.
Planned Movement and Fixation
The distal chin is then moved into the desired position, with the
direction and amount of movement dependent on preoperative
planning (Fig. 58.5). For positioning of the distal segment, a screw
can be partially inserted into a predrilled hole (as described in
the preceding subsection), and a wire twister can be used to hold
this screw as a retractor. A three- or four-hole straight titanium
plate can be contoured and secured to both proximal and distal
segments on either side of the osteotomy (usually inferior and
in between the lateral incisor and canine on each side). Prebent
genioplasty plates can also be used, with size dependent on
degree of advancement. At this point, the positioning screw can
be removed.
5eÀnemenWV
If significant vertical or horizontal lengthening is planned (! 5
mm), then an interpositional graft (autograft, allograft, or off-
the-shelf material such as hydroxyapatite) is shaped and placed
in the defect.

886
IX Rejuvenation of the Cheeks, Chin, Lips, and Ears
The greater the angle of osteotomy from the occlusal plane, the
shorter the chin will be. Moreover, a greater angle also leads to
a larger stepoff along the inferior border of the mandible as the
osteotomized segment is advanced, which may be visible and pal-
pable in some patients. A rasp can be used to soften the contour if
there is any doubt.
Lastly, an attempt can be made to improve on contour irregular-
ities and pre-existing asymmetry with a bur. However, multiple
osteotomies or asymmetric osteotomies may be better in provid-
ing more predictable and symmetric results.
Closure
The wound is copiously irrigated to remove any debris. The
muscle is then reapproximated with resorbable suture and the
incision is closed using 4–0 chromic mattress sutures.
SNin²SRIW 7iVVue 0RdiÀFDWiRn
Contour irregularities or volume discrepancies can then be
addressed with fat grafting or filler in the subcutaneous and/
or dermal plane. Caution should be exercised with overfilling
secondary to vascular compromise and pressure necrosis.
Fig. 58.5 Horizontal osteotomy techniques. (a) Sliding oblique horizontal osteotomy; (b) step horizontal osteotomy; (c) horizontal osteotomy for
asymmetry; (d ) sandwich horizontal osteotomy; (e) horizontal osteotomy with ostectomy; (f) correction of macrogenia by horizontal osteotomy.

58 Rejuvenation of the Chin
887
58.4.2 Alloplastic Chin Augmentation
Implant Selection
Silicone (Silastic, Dow Corning, Midland, MI), polytetrafluoroeth-
ylene (Gore-Tex, Implantech, Ventura, CA), polyester (Mersilene,
-ohnson -ohnson, 1ew Brunswick, 1-) mesh, and porous poly-
ethylene are the most commonly used implants for genioplasty
today (Fig. 58.6, Fig. 58.7). The type of implant, for the most part,
is dependent on each surgeon’s preference and experience. Porous
polyethylene and Mersilene implants may be more difficult to
place and remove due to soft tissue adherence and tissue ingrowth,
respectively. A myriad of implant shapes and sizes are available
depending on the magnitude of deficiency. Some chin implants
extend beyond the chin territory to contour the mandibular body.
Incision
Although both intraoral and submental incisions can be used,
we prefer to use the submental incision, as it allows better
visualization and more accurate contouring and placement of
the implant. It also provides a slightly lower risk of infection and
a lower rate of nerve injury. Intraoral incisions are an alternative
and can be placed either vertically or horizontally. The disadvan-
tage of external incisions are visible scars and the possibility of
hypertrophy.
Dissection
Dissection is performed in the subperiosteal plane. :ide dissection
is performed to improve visualization and allow more accurate
implant placement. Dual-plane dissection can be supraperiosteal
in the midline to theoretically reduce bone resorption. Silastic
implants have higher propensity to erode the underlying bone, so
consideration should be given to placing this type of implant in a
supraperiosteal plane. However, the chances of soft tissue injury
and skin irregularities are increased in the supraperiosteal plane,
so this approach should be performed with caution. :e tend to
prefer subperiosteal laterally and supraperiosteal centrally. This
approach may offer additional stability and fixation.
Implant Placement and Fixation/Closure
A one- or two-piece porous polyethylene implant is shaped and
contoured to fit as closely as possible to the native contour of the
symphysis and, if desired, the body of the mandible. Decreasing
the dead space between the implant and the underlying bone
is important to prevent complications. The implant is fixed to
the mandible with titanium screws. The wound is irrigated and
closed in layers. Mesh material is easier to contour and can be
suture-fixated to the periosteum. Gore-Tex and silicone can
use screw or suture fixation. All implants should be fixated to
prevent migration and distortion. Fixation must be accurate and
unobtrusive.
Fig. 58.8 and Fig. 58.9 show pre- and postoperative images
for implant augmentation using silicone and Mersilene mesh,
respectively.
58.4.3 Autologous Fat
Background
Autologous fat is a filler with ideal properties, which were
recognized by surgeons over a century ago and proposed by
many for the treatment of congenital deformity, traumatic
wounds, and tissue loss from oncologic resection. The actual
procedure of fat transfer, however, did not become popularized
until the 1980s with the introduction of several advancements
in liposuction anesthesia and small-bore cannulas. In 1987,
Coleman introduced a new technique for fat transfer involving
three important steps to minimize traumatic handling of fat
during liposuction. The three steps are manual lipoaspiration
under low pressure; centrifugation at 3,400 rpm for 3 minutes;
and a 3-D reinjection approach. Less traumatic methods for
lipoharvesting result in improved adipocyte viability and fat
graft survival. The quest for an ideal harvest and lipofilling
technique is motivated by the observed long-term resorption
rates of 30–70, often making the outcome of fat transfer as
a stand-alone procedure unpredictable, operator dependent,
and variable. These variabilities have led to many significant
modifications of Coleman’s technique that are often operator
specific and can include fat washing, filtering, sedimentation,
incubation with bioactive agents, core graft, block harvesting,
and many others too numerous to list.
Despite the many challenges seen with fat transfer, adipocytes
are noteworthy as fillers because they naturally integrate into
Fig. 58.6 (a) Skull with Mersilene implants. (b) Mersilene mesh
implants.
Fig. 58.7 (a) Skull with silicone implants on the cheekbones.
(b) Anterior view.

888
IX Rejuvenation of the Cheeks, Chin, Lips, and Ears
tissues, are autologous, and exhibit 100 biocompatibility.
Furthermore, adipocytes are transferred into the recipient site as
parcels of cells and supporting connective tissue serving to pro-
vide additional functions in lipofilling. These parcels also deliver
fibroblasts, endothelial cells, and adipogenic progenitor cells,
which may provide additional long-term benefits for patients.
:e present our technique in the following subsections, which has
been modified based on our observations of improved fat graft
survival in our series of patients. However, we believe there are
many effective methods, and our descriptions are neither all-in-
clusive nor dismissive of alternative techniques. The technique for
autologous fat transfer can be divided into three parts: harvesting
the graft, processing of the graft, and reinjection of the graft. Each
is equally important to the success of the procedure.
Preoperative Planning
Preoperative photographs are taken with and without a flash. The
photographs taken without a flash will often accentuate areas
of volume loss not apparent in standard flash photography. It is
helpful to compare preoperative photographs to pictures taken
of patients in their teens or early twenties, preferably full-face,
nonsmiling views, to appreciate better the degree of volume loss
presentable at the time of consultation. The patient is marked
preoperatively sitting upright in an area with direct overhead
lighting, often supplemented with side lighting as needed to
identify the areas of volume deficiency to be grafted.
Donor Site
Several donor sites have been advocated for harvest of autoge-
nous fat. For convenience, the abdomen is preferred, as it is
easily accessible, and incisions can be hidden in the umbilicus or
hair-bearing pubic area. Other common sites include the thighs,
knees, and arms. Some prefer the flank and buttocks, because
these areas seem resistant to alterations in body weight, or the
gluteal-femoral region, as these cells are larger and demonstrate
a higher lipogenic activity. Adipocytes harvested from the thigh
have been felt to have less resorption when transplanted.
Tumescent Solution
Sterile technique is employed for fat harvesting and reinjection.
:e recommend prophylactic antibiotics. Local anesthesia is used
for a small stab incision. Then a long injection cannula is used to
introduce tumescent fluid to the region. Our standard solution
consists of 1 mg of epinephrine, 200 mg of lidocaine, and 5 mEq
of sodium bicarbonate in 1 L of normal saline.
Fig. 58.8 Chin augmentation with silicone implant. (a) Preoperative
anterior view. (b) Postoperative anterior view. (c) Preoperative lateral
view. (d) Postoperative lateral view.
Fig. 58.9 Chin augmentation with Mersilene mesh implant. (a)
Preoperative anterior view. (b) Postoperative anterior view. (c)
Preoperative lateral view. (d) Postoperative lateral view.

58 Rejuvenation of the Chin
889
Low Negative Pressure
Trauma to the adipocytes in the process of harvesting affects
survival of the graft. Fat consists of adipose cells with thin cell
membranes enmeshed in a fibrous network. Harvesting fat while
retaining as much supporting structure as possible preserves the
integrity of the cells. In Coleman’s technique, a small (17-gauge)
cannula harvests parcels of fat with intact architecture. :e
typically attach a 10-mL Luer lock syringe to the cannula and
withdraw the plunger to provide a low level of negative pressure,
minimizing trauma to the adipose tissue.
Processing
After fat harvesting, the next step is preparation. Our strategies
have included systems such as LipiVage (Genesis Biosystems,
Lewisville, TX) or Viafill (Lipose Corporation, Greenwich, CT),
centrifuge, or gravity separation. There are advantages and
disadvantages to all techniques. Both the LipiVage and Viafill kits
offer closed filtration systems, reduce exposure to excessive g
force, and provide sterility and protection from exposure to air.
Our current technique uses filtration and gravity separation.
After fat is harvested, it is filtered using the LipiVage system and
transferred to 60-mL syringes, where it is allowed to separate by
gravity for 30 minutes. The excess blood, fluid, and serum are
then removed, and the fat is transferred to a 1-mL syringe for
reinjection.
Reinjection
:ith reinjection, the goal is to place each graft in a well-
vascularized bed to maximize survivability. Each graft should
be within 1.5 mm of vascularized tissue. Grafted adipocytes most
removed from the blood supply may not survive. The compacted
most viable fat cells are transferred to a 1-mL syringe. A Coleman
2 (Byron Medical, Tucson, A=) 7-cm straight injecting cannula is
used for microaliquot placement. The cannula should be inserted
through a 2-mm stab incision made with a 1o. 11 blade scalpel.
The cannula is guided into the target region while a tunnel is
created by advancing the cannula, and the fat is injected 0.1–0.2
mL at a time in retrograde fashion. The small channels for the
grafts help keep them adherent to the recipient site. Care should
be taken not to overfill the tract, as this can adversely affect graft
survival. The fat should be injected only while withdrawing
the cannula. One should always avoid high pressure, as this
will deposit an uncontrolled graft, which is unlikely to survive.
However, feeling a small amount of resistance while injecting is
important. If the aspirate injects too easily, it is likely that fat
has already been placed in this location and additional injection
would be detrimental to graft survival. Slight overcorrection
is important to compensate for some absorption of the liquid
carrier that occurs. A general recommendation is for a 30 over-
correction. After the fat is deposited, gentle digital pressure is
used to check for placement and contour irregularity.
Pearls for Fat Reinjection in the Chin
and Jawline
The chin and the jowl are intimately related, as they both become
accentuated in aging by the development of the prejowl sulcus.
This sulcus can be caused by osteoporosis of the mandible,
age-related facial volume loss, and laxity of the overlying skin
envelope. In combination with regional lipoatrophy, the patient
can develop the appearance of prominent jowls as well as loss of
chin prominence. Volume restoration to this area can lessen the
effects of aging to both the chin and the jowl. Overapplication of
fat grafting to the chin in isolation can lead to an unaesthetic fatty
chin. Fat transfer to the chin might be done with orthognathic
surgery as a means to camouflage any bony ridges. -ust as the
prejowl sulcus can contribute to the appearance of prominent
jowls, volume loss in the area of the mandibular angle can also
produce this effect. This effect can be reduced by facelift, and
one of the most common indications for autologous fat grafting
in this area is postrhytidectomy volume loss and persistent
jowls. :hen volume replacement in this area is combined with
treatment of the prejowl sulcus, the jowls can be concealed and
a smooth mandibular contour obtained.
Postoperative Care
Massage and excessive facial animation are discouraged imme-
diately following fat reinjection. These restrictions are in place
to reduce the risk of fat graft migration away from the desired
treatment sites. Ice compresses are applied for 48 hours to mini-
mize swelling, improve pain, and reduce inflammation.
Results of this technique are demonstrated in Fig. 58.10 and
Fig. 58.11.
58.5 Nonsurgical Techniques
58.5.1 Dermal Fillers
Rationale for Use
1onsurgical chin and submental enhancement techniques have
become more acceptable to a growing population of patients
seeking the least invasive approaches for facial rejuvenation and
for those looking to achieve more subtle results. Some patients
seek nonsurgical chin enhancement because they are not willing
to commit to a permanent change in their profile. Dermal filler
injections can offer a ´trial runµ for the new profile and a period of
time between 6 and 18 months (depending on filler selection) for
the patient to evaluate the results and possibly to pursue a more
permanent solution via surgery. For injectables, serious com-
plications are uncommon and manageable, in most situations,
with nonsurgical modalities. For the practitioner, many of these
nonsurgical approaches have the advantage of adjustability, even
with small increments of improvement, empowering the injector
to deliver small but reliable changes in facial appearance.
Dermal Filler Selection
Generally speaking, dermal fillers with high G´ (see Chapter 16)
tend to be also highly crosslinked (making them heavier with
higher viscosity and cohesivity) and are better suited for volumiz-
ing and tissue lifting in the chin. Highly crosslinked, high-G fillers
are also better suited for deeper soft tissue injection (away from
the dermis), including the subperiosteal plane. These types of fill-
ers, such as Restylane Lyft (Galderma, Lausanne, Switzerland), are

890
IX Rejuvenation of the Cheeks, Chin, Lips, and Ears
our preference when addressing aesthetic chin deficiencies that
are related to volume loss or to a lack of projection (Fig. 58.12).
However, familiarity with hyaluronic acid (HA) fillers better
suited for dermal plane injection will be important when a lack
of chin prominence is addressed simultaneously with treatment
of marionette lines and other surface creases in and around the
oral commissure (Fig. 58.13). For chin projection enhancement,
the preferred depth of injection will be the periosteal plane, but
filler material can also be placed in the subcutaneous and up to
the subdermal plane. Practitioners should avoid the temptation
to place high-viscosity fillers in the dermal plane; instead, they
should rely on an armamentarium of filler combinations to
address most associated fine lines and other deformities in the
chin and jawline. For volume enhancement, we prefer a highly
viscous filler such as Radiesse (calcium hydroxyapatite; Merz
Pharmaceutical) or Sculptra (poly-L-lactic acid; Galderma,
Lausanne, Switzerland). However, more subtle results and ´trialµ
chin enhancements are best accomplished with high-G´ HA fillers.
Fig. 58.10 Autologous fat grafting to chin. (a) Preoperative anterior. (b) Postoperative anterior. (c) Preoperative lateral. (d) Postoperative lateral. (e)
Preoperative oblique. (f) Postoperative oblique.
a
d
b
e
c
f

58 Rejuvenation of the Chin
891
58.6 Complications and Outcomes
58.6.1 Surgical Techniques
Both early and late complications can occur after profile plasty,
including poor aesthetic results, hematoma, infection, malposi-
tion, and nerve injury. Guyuron and Raszewski retrospectively
reviewed their genioplasty outcomes and found that patients
had a high satisfaction rate after genioplasty, with osseous
genioplasty having a slightly higher satisfaction rate (90–95)
than alloplastic augmentation (85–90). Morbidity was the same
for both types of procedure. The incidence of reoperation after
genioplasty is extremely low and usually involves replacement
of implant or removal of implant and conversion of alloplastic
genioplasty to an osteotomy. Fat grafting and filler can help
with small contour irregularities and can be used to enhance
results. The rate of relapse is low, and the ratio of soft tissue to
hard tissue advancement on long-term follow-up has been found
to be stable over time. However, surgical efforts to correct an
excessively prominent chin are less predictable and should be
approached with caution, as the soft tissue response to posterior
repositioning of the chin is, at best, unpredictable.
The major complications and concerns of fat grafting are under-
correction and overcorrection. Undercorrection results from
placing less than the required amount of fat, from resorption, or
from graft loss. Excessive resorption of the graft can occur even
with overcorrection. Although placing too little fat obviously fails
to correct the defect, increasing the volume of injected fat may
actually exacerbate graft loss. Overfilling can also lead to increased
graft necrosis, resulting in palpable irregularities and eventual
disappearance of the grafted material. Coleman described about
a 40 resorption rate for fat graft augmentation in the chin pad.
Undercorrection is generally easier to treat than overcorrection.
Once the patient is judged to be fully healed, additional fat may
be grafted at a separate sitting to complete correction. Removing
excess graft is more difficult. If overcorrection is the diagnosis, then
waiting the appropriate period of time for resolution of edema is
recommended. If the overcorrection persists, microliposuction
can be performed. Transient mild ecchymosis, tenderness, and
swelling are more common complications of fat injections. Small
hematomas are more unusual and are sometimes associated with
the use of sharp needles for graft placement. Donor site scarring
is a potential concern, but with care during the procedure most
issues at the donor site can be avoided.
Although rare, infections can occur wherever the skin envelope
is violated. The most common source of infection is the oral
mucosa. Importantly, atypical mycobacterial infections have been
associated with inadequately sterilized surgical instruments.
Low-cost, single-use systems should eliminate the risks of
atypical mycobacterial infections from the use of contaminated
instruments. Severe systemic infections are rare with fat grafting
but have been recently reported in association with large-volume
fat injections and can lead to life-threatening sepsis and residual
postoperative deformity.
Embolization and arterial occlusion can be seen with a variety
of injectable fillers including autologous fat. Tissue necrosis,
blindness, and fatal stroke can result. Cases of blindness by central
retinal artery occlusion often involve injection into the glabellar
area, but there are reports of cases resulting from injection into the
nasolabial folds and lower lip as well. The risks of embolization can
be minimized by using a low-volume, low-pressure, blunt cannula
and injecting only while withdrawing the cannula from the area.
Avoidance of sharp needles for injection is also recommended.
58.6.2 Nonsurgical Techniques
Filler injections to the chin and for the face are becoming more
popular, and practitioners should be able to recognize the
complications associated with their usage. The vast majority
of complications seen with dermal fillers are self-limiting and
can include localized bruising, erythema, swelling, and small
bumps underneath the skin and mucosa (Table 58.1). However,
serious sequelae, such as vascular penetration with or without
embolism, permanent visual loss, biofilm infections, and nerve
paralysis, are not uncommonly reported, and practitioners
should be familiar with the process of making these diagnoses
and delivering appropriate treatment.
Fortunately, HA fillers account for approximately 80 of the
facial fillers in current use, and such fillers can notably be dis-
solved with hyaluronidase in case a serious complication arises.
Importantly, it should be noted that while hyaluronidase has
been approved as a dispersion agent, its use to dissolve HA fillers
currently remains an off-label procedure, and appropriate patient
Fig. 58.11 Autologous fat grafting to chin. (a) Preoperative anterior.
(b) Postoperative anterior. (c) Preoperative lateral. (d) Postoperative
lateral.

892
IX Rejuvenation of the Cheeks, Chin, Lips, and Ears
consent should be obtained. The recommendation on dosage sug-
gests that approximately 30 units of hyaluronidase are required to
dissolve 0.1 mL of HA. :e prefer to use the human recombinant
form of hyaluronidase (Hylenex, Halozyme Therapeutics, San
Diego, CA), and once we confirm the need to dissolve the product,
we commit to dissolving all of it within 24 hours.
The most common reason to dissolve HA fillers in clinical
practice is related to overcorrection or patient dissatisfaction.
Overfilled lips, laugh lines, and chins do not convey an attractive
appearance postinjection. 1odules and lumps in the first few
weeks after injection are most likely from overfill and not inflam-
matory in nature and may be treated with vigorous massage,
extruded with a needle, or dissolved. Most commonly, if a lump
is noted for longer than 2 to 3 weeks, the option to dissolve with
hyaluronidase is offered to the patient. Delayed edema in the area
of injection is likely the result of the HA filler tendency to draw
water and osmolality. Chronic prolonged edema, on the other
hand, may be treated as a hypersensitivity reaction with antihis-
tamines and possibly steroids.
Vascular injury and infection are more serious complications
associated with all dermal fillers. Vascular injury can involve pen-
etration, embolic events, and/or compression of arteries and veins.
Generally speaking, arterial injury presents with a rapid onset of
ischemic pallor and pain. However, in some patients, pain can be
variable and is not always a reliable sign. Embolization typically is
seen antegrade down the distribution of the injured vessel. Venous
occlusion due to direct injury or compression typically presents in
a more delayed fashion as a venous mottling, termed livido. :hile
serious vascular and embolic events have been reported to arise
in all parts of the face, there are certain regions, such as the gla-
bella, nasal dorsum, nasolabial folds, and lips, where retrograde
embolization has been reported more frequently. Prevention of
vascular events by patient and filler selection and avoidance of
danger zones is the best approach. However, it is impossible for
the busy injector to avoid these complications in all cases, and we
therefore recommend keeping a vascular injury emergency kit in
the office (Table 58.2).
Infections can occur with dermal filler injections. Most infections
are thought to be related to breaks in sterile technique. Adherence
to the methods described in the section on injections and sterile
techniques is recommended. It is also recommended not to apply
makeup for 4 hours after dermal filler injection. :hen infection is
suspected, a broad-spectrum antibiotic with activity against atyp-
ical mycobacteria should be prescribed. Clarithromycin (Biaxin;
AbbVie, 1orth Chicago, IL) is usually a good choice and well tol-
erated. Herpetic outbreaks are a more frequent type of infection
seen with dermal fillers. Reactivation of the virus can be treated
with oral valacyclovir. Delayed infection presenting several weeks
after injection can be more difficult to treat and can be caused by
a biofilm: an aggregate of encapsulated microorganisms, possibly
including bacteria, protozoans, and fungi, that are permanently
attached to an implant or other inert biomaterial. These can
Fig. 58.12 Restylane Lyft chin augmentation/Restylane lip augmentation. (a) Preoperative anterior view. (b) Postoperative anterior view. (c)
Preoperative right lateral view. (d) Postoperative right lateral view. (e) Preoperative left lateral view. (f) Postoperative left lateral view.

58 Rejuvenation of the Chin
893
present as a painful nodules that tend to resist oral antibiotics.
Some nodules can be due to foreign body reaction granulomas.
Granulomatous reactions can present months or even years after
injection and may require intralesional steroids and 5-fluorouracil
for treatment.
58.7 Concluding Thoughts
Genioplasty using implant augmentation, fat grafting, filler
placement, or osteotomy, whether performed in isolation or as
a component of formal orthognathic surgery or as an integral
component of the aesthetic alteration of the face, can lead to an
extremely high level of satisfaction for both patients and surgeons.
:hen performed with proper preoperative assessment and
precise execution, the results can harmonize and restore balance
among skeletal, soft tissue, and dental components of the lower
face. Both implant and osseous genioplasty, along with fat grafting
and/or filler placement with proper understanding of underlying
dysmorphology, preoperative assessment, and surgical technique,
Table 58.2 Filler crash cart contents and procedure
• If the filler site has severe pain (or no pain) and blanching or mottled
skin discoloration, immediately administer:
̑ Warm compresses
̑ Nitropaste
̑ Baby aspirin
̑ Supplemental oxygen
̑ Hyaluronidase
For hyaluronidase, Inject 300 units (2 vials) with 0.2 mL of lidocaine
(2%) using a 27-gauge needle into area of injection and area of
discoloration. Repeat every 40 to 60 minutes until the skin circulation
is restored to a bright red color. Restock hyaluronidase after usage.
Always keep 12 vials on hand.
• In the event of blindness, immediately consult an ophthalmologist
and retinal specialist for retrobulbar injection. (It is important to
establish a relationship before any event and agree to a referral
pattern with ophthalmologists.)
Known Àller complication risk factors:
• Deep injection (nasal radix and lateral nasal wall)
• Upper lip philtrum (vessel is surperficial)
• Large-volume bolus (greater than 0.1 mL)
• High-pressure injection
• Small, sharp needles
Table 58.1 Common adverse events of dermal filler injections
• Tenderness (most common)
• Swelling
• Pain
• Headache
• Bruising
• Redness
• Skin irregularities
• Chewing complaints
• Jaw ache
• Hyperpigmentation (least
common)
Fig. 58.13 Restylane Lyft chin augmentation. (a) Preoperative anterior view. (b) Postoperative anterior view. (c) Preoperative right lateral view.
(d) Postoperative right lateral view. (e) Preoperative left lateral view. (f) Postoperative left lateral view.

894
IX Rejuvenation of the Cheeks, Chin, Lips, and Ears
can be relatively easy to perform and should be an integral com-
ponent of the surgical approach to chin enhancement.
Clinical Caveats
• Proper evaluation is paramount including occlusion, skin–soft
tissue envelope characteristics, bony architecture, tensegrity,
and patient desire.
• Selection of approach is determined by the conditions at hand.
• Always finish with a two-layer watertight closure for genio-
plasty or implant. Barbed sutures are useful for closing a
muscle layer without a knot.
• Sterile technique, intentional mildness, and three-dimen-
sional thinking is imperative for fat grafting in the chin.
• Always have a filler crash cart available and nearby.
Suggested Reading
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>12@ Dessy LA, Mazzocchi M, Fioramonti P, Scuderi 1. Conservative management of
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>13@ Flaharty P. Radiance. Facial Plast Surg 2004;20:165–169
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ment of the perioral region. Facial Plast Surg Clin North Am 2007;15(4):461–470, vi
>15@ Glasgold RA, Glasgold M-, Lam SM. Complications following fat transfer. Oral
Maxillofac Surg Clin North Am 2009;21(1):53–58, vi
>16@ Greene --, Sidle DM. The hyaluronic acid fillers: Current understanding of the
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[17] Guyuron B. MOC-PS(SM) CME article: genioplasty. Plast Reconstr Surg
2008;121(4 Suppl):1–7
[18] Guyuron B. Genioplasty. Boston, MA: Little, Brown; 1993
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>20@ Guyuron B, Raszewski RL. A critical comparison of osteoplastic and alloplastic
augmentation genioplasty. Aesthetic Plast Surg 1990;14(3):199–206
>21@ Haack -, Friedman O. Facial liposculpture. Facial Plast Surg 2006;22(2):147–153
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>23@ Hoffmann .; -uvpderm Voluma Study Investigators Group. Volumizing effects of
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>30@ Lehocky B. Anthropometry and cephalometric facial analysis. In: Mathes S-.
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>31@ McCollough EG, Mangat DS. Augmentation mentoplasty. Laryngoscope
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1861–1862

Part X
Rhinoplasty
X

(Trang không có chữ)

59 Applied Anatomy of the Nose
897
59 Applied Anatomy of the Nose
Rod J. Rohrich, Paul N. Afrooz, William P. Adams Jr., and Joel E. Pessa
This chapter is dedicated to the memory of Dr. Jack P. Gunter.
Abstract
The nose consists of bone, cartilage, muscle, connective tissue,
soft tissue, and skin. Successful rhinoplasty begins with a thor-
ough understanding of each of these individual components of
nasal anatomy. Manipulation of any one of these components
requires a thorough knowledge of their interrelationships and
dynamic interplays. In addition, accessing the underlying anat-
omy of the nose requires an understanding of nasal blood supply.
This chapter discusses the pertinent anatomy of the nose and the
significance of the anatomy in rhinoplasty.
Keywords
nasal anatomy, rhinoplasty, open rhinoplasty, closed rhinoplasty,
nasal blood supply, nasal framework, nasal bones, nasal cartilage
59.1 Dedication
The authors would like to dedicate this chapter to Dr. -ack P.
Gunter. Dr. Gunter was a true rhinoplasty pioneer. His pursuit of
excellence and contributions to our understanding of rhinoplasty
have paved the way for generations of rhinoplasty surgeons.
59.2 Introduction
The nose consists of three elements: framework, support, and
external cover. The nasal framework consists of the skeletal
components of bone and cartilage (Fig. 59.1). Support is provided
by connective tissue and ligaments that hold the framework
together. The skin and soft tissue provide the external covering
of the nose. These components are intricately related and must
be anatomically visualized in every step of the rhinoplasty
sequence. In this chapter we will review the clinically relevant
anatomy encountered in rhinoplasty.
Principles in the anatomic sequence of a rhinoplasty include
the following:
1. Precise definition of anatomic goals preoperatively
2. Adequate anatomic exposure of the nasal deformity
3. Preservation/restoration of the normal anatomy
4. Correction of the specific deformity with precise and incremen-
tal control
5. Maintenance/restoration of the nasal airway
The skin is thinner and more mobile in the upper two-thirds of
the nose and thicker and more adherent in the distal third in the
nasal lobule (Fig. 59.2).
Fig. 59.1 Illustration of the nasal framework, consisting of the paired
nasal bones, the paired upper lateral cartilages, the nasal septum, and
the paired lower lateral cartilages.
Fig. 59.2 Variations in skin thickness along the length of the nose.

898
X Rhinoplasty
Vessels and nerves pass within the subcutaneous tissue above
the muscle. It is important to note the type, texture, and sebaceous
content of the skin., because these factors will affect the final
result. Overzealous alteration of the underlying framework in a
thin-skinned tip may have a long-term undesirable outcome. In
contrast, in a patient with thick sebaceous skin, more aggressive
alteration of the underlying framework is possible, and necessary,
to obtain significant tip definition and refinement of the nose.
59.3 Muscles
Although several muscles affect the nose, the two most clinically
significant are the levator labii alaeque nasi and depressor septi
muscles (Fig. 59.3). The levator labii alaeque nasi assists in
keeping the external nasal valve open and can cause functional
nasal obstruction with facial paralysis if alar flaring is impaired.
The depressor septi nasi, when clinically significant, shortens the
upper lip and can decrease tip projection on animation.
The nasal muscles interconnect so that animation of one affects
the others (Fig. 59.4). For example, contraction of the lip elevators
pulls the transverse nasalis. This has the effect of opening the
internal valve by distracting the upper lateral cartilages. 1asal
airway patency is therefore also a function of dynamic muscle
activity, in addition to proper skeletal and cartilaginous support.
In a cadaver study to define the anatomic variations of the
depressor septi muscle, we identified three types of depressor
septi muscles (Fig. 59.5). Type I depressor septi muscles (62) are
visible and identifiable and can be traced to full interdigitation
with the orbicularis oris from their origin at the medial crural
footplate. Type II muscles (22) are visible and identifiable, but
unlike the first group, these muscles insert into the periosteum
and demonstrate little or no interdigitation with the orbicularis
oris. In type III muscles (16), no muscle or only a rudimentary
depressor septi muscle is visible.
Routine preoperative examination of rhinoplasty patients
should easily identify those who demonstrate a drooping nasal
tip and shortened upper lip on animation, particularly when smil-
ing. In such patients (types I and II), transection of the depressor
septi muscles reliably and effectively corrects this dynamic facial
deformity. Follow-up of up to 2 years shows well-maintained aes-
thetic results without signs of relapse. Specifically, the technique
achieves the following goals:
• Enhancement of the tip-lip relationship
• Relative upper lip lengthening
• Maintenance of tip rotation/projection on animation
59.4 Blood Supply
There has been concern, especially with the growing popularity
of the external approach to rhinoplasty, that a transcolumellar
incision may compromise the blood supply to the nasal tip.
However, one must take into account the considerable blood
supply to the nose, with contributions from both the internal and
external carotid arteries (Fig. 59.6).
The ophthalmic artery and its branches, anterior ethmoids,
dorsal nasal, and external nasal arteries supply the proximal
portion of the nose. The nasal tip area is supplied primarily by
branches of the facial artery, including the superior labial and
angular vessels, with the lateral nasal branch coursing above the
alar groove, and the columellar branches, which are branches of
the superior labial vessels. In the dissection shown in Fig. 59.7,
one can see that even the infraorbital artery provides collateral
supply to the tip via the nasal arcades.
This vasculature has been confirmed by an angiographic study
in 22 fresh cadaver heads injected with lead oxide dye (Fig. 59.8).
The lateral nasal vessels were consistently identified 2 to 3 mm
above the alar groove in this study. The columellar and lateral
nasal arteries arise deep at the nasal base and end in the sub-
dermal plexus at the nasal tip area. The lateral nasal artery was
consistently present either bilaterally or unilaterally (100). The
presence of the columellar branches was noted 68.2 of the time;
however, there was a predictable crossover arcade between the
lateral nasal and columellar branches in 10 specimens in which
a transcolumellar incision was made before the dye was injected.
The clinical relevance of this study is twofold. First, it is excessive
defatting that jeopardizes the nasal tip supply. In nasal tip proce-
dures the surgeon should reconstruct the underlying framework
to redefine the tip rather than defatting the nasal tip, which is
anatomically dangerous. The other clinical point is that collateral
blood supply enters the nose via the alar arcades. Prior incisions
in this region can jeopardize collateral supply to the nasal tip in
secondary procedures.
Fig. 59.4 Cadaveric demonstration of the interconnection of nasal
musculature.
Fig. 59.3 Depiction of the levator labii aleque nasi and depressor septi
nasi muscles.

59 Applied Anatomy of the Nose
899
Fig. 59.5 Anatomic variations of the depressor septi nasi muscle.
Fig. 59.6 Illustration of nasal blood supply with contributions from
both the internal and external carotid arteries.
Fig. 59.7 Cadaveric depiction of nasal blood supply.

900
X Rhinoplasty
59.5 Nasal Vaults
There are three nasal vaults: the bony, upper cartilaginous, and
lower cartilaginous vaults (Fig. 59.9).
59.5.1 Bony Vault
The bony vault consists of paired nasal bones as well as the
ascending frontal process of the maxilla, which make up the
proximal third to half of the nose (Fig. 59.10).
The bones are comparatively narrow and thick above the can-
thal level. The clinical correlation is that osteotomies are rarely
indicated above the canthal level because it is quite narrow and
the bone is thick.
59.5.2 Upper Cartilaginous Vault
The upper lateral cartilages underlie the nasal bones for 6 to
8 mm as well as the lower lateral cartilages in the scroll area
between the upper and lower lateral cartilages (Fig. 59.11).
The keystone area is defined by the junction of the upper lateral
cartilages with the nasal bones and the septum (Fig. 59.12). It is
important to stress the relationship of the upper lateral cartilages
to the septum, especially at the keystone area, where the contour is
T-shaped (Fig. 59.13). Loss of these intricate relationships results
in the loss of the dorsal aesthetic lines and a potential inverted-V
deformity, as seen on frontal view.
59.5.3 Lower Lateral Cartilaginous Vault
The lower cartilaginous vault comprises the medial, middle,
and lateral crura of the lower lateral cartilage (Fig. 59.14). The
support factors for tip projection are:
• Length and strength of lower lateral cartilage and piriform
abutment
• Fibrous connections between the upper lateral and lower
lateral cartilage
• Medial crural ligaments
• Anterior septal angle
In a fresh-cadaver study, Adams et al reported the clinical sig-
nificance of different structures for nasal tip support using open
versus closed rhinoplasty techniques. Multiple nasal manipula-
tions using fresh cadaver heads, including cephalic trim, cephalic
trim and interruption of the lower lateral cartilages, dorsal hump
resection (1–4 mm), submucous resection of the septum, and
complete septal removal, were performed using both the open
and closed rhinoplasty approaches. Changes in nasal tip support
were recorded. Comparing similar procedures, the mean loss of
tip projection for the open approach was 3.43 mm versus 1.98
mm for the closed approach (p  0.001). There was a significantly
larger loss of tip projection for the open versus the closed pro-
cedure for cephalic trim, cephalic trim plus interruption of the
lower lateral cartilage, and cephalic trim/interruption of the lower
lateral cartilage/septum removal (all three p  0.001). The differ-
ences between the open and closed approaches were attributed
to an increase in ligamentous disruption using the open approach.
Fig. 59.8 Angiographic demonstration of nasal blood supply.
Fig. 59.9 Cadaveric depiction of the three nasal vaults: the bony vault,
the upper cartilaginous vault, and the lower cartilaginous vault.

59 Applied Anatomy of the Nose
901
Manipulation of the septum in general resulted in greater losses of
tip support for both the open and closed approaches.
The combination of skin, ligaments, and cartilage ultimately
provides tip support (Fig. 59.15). As progressively more of these
structures are disrupted, greater loss of tip projection occurs.
Sheen subdivided the lower lateral cartilage into the medial,
middle, and lateral crura. The angle of divergence is formed by
the domal angulation of the middle crus (Fig. 59.16). This is an
important factor in determining tip type, specifically whether
there is a bulbous or a boxy tip. The tip-defining points are
important: these consist of two equilateral triangles from the
supratip area to the apex of the domes to the columellar lobule
angle. The surgeon must use these reference points in assessing
tip definition and identifying tip asymmetries. Furthermore,
a classification system based on the angle of divergence of the
middle crura and the width of the domes can aid in the diagnosis
and treatment of nasal tip deformities (Fig. 59.17).
59.6 Nasal Function
The functional portion of a nose comprises three areas: the
septum, nasal valve areas, and turbinates. The septum includes
three primary components: the quadrangular cartilage, the
perpendicular plate of the ethmoid, and the vomer (Fig. 59.18).
The bony septum is made of the perpendicular plate of the
ethmoid, which is in continuity with the cribriform plate. :hen
performing a septal reconstruction and removing posterior septal
deviations, the surgeon must perform a sidewise fracture/sepa-
ration removal of the bony part of the perpendicular plate of the
ethmoid so as not to remove or dislodge the cribriform plate, which
can cause cerebrospinal fluid rhinorrhea. The most projecting part
of the premaxilla is the nasal spine, and it very infrequently needs
to be removed or altered. In contrast, the caudal portion of the
septum is the most protruding part of the columella and may
need to be altered if there is an alar–columellar discrepancy.
The internal nasal valve is defined as the junction between
the septum and the caudal border of the upper lateral cartilage
Fig. 59.10 The bony vault consists of the paired nasal bones (outlined)
and the ascending frontal process of the maxilla.
Fig. 59.11 Cadaveric demonstration of the upper cartilaginous vault.
Fig. 59.12 Schematic illustration of the keystone area. The keystone
is defined by the junction of the upper lateral cartilages with the nasal
bones and septum. The relationship of the upper lateral cartilages and
septum creates a T-shaped configuration.

902
X Rhinoplasty
Fig. 59.13 Cadaveric illustration of the keystone area. The keystone
is defined by the junction of the upper lateral cartilages with the nasal
bones and septum. The relationship of the upper lateral cartilages and
septum creates a T-shaped configuration.
Fig. 59.14 Depiction of the lower cartilaginous vault containing the
paired lower lateral cartilages.
Fig. 59.17 Anatomic classification of nasal tip anatomy based on the angle of divergence and domal width.
Fig. 59.15 Cadaveric depiction of the combination of skin, ligaments,
and cartilage providing nasal tip support.
Fig. 59.16 The lower lateral cartilages are subdivided into the medial,
middle, and lateral crura. The angle of divergence is defined by the
angle between the middle crura.

59 Applied Anatomy of the Nose
903
(Fig. 59.19). This angle is usually 10ƒ to 15ƒ. This must be pre-
served or reconstructed with a spreader graft in a primary or
secondary rhinoplasty.
Of the three turbinates (nasal conchae), the inferior turbinates
are the most significant functional component in nasal airway
breathing, and this occurs in the lower third of the nasal airway.
Submucous resection of the turbinate is indicated for airway
correction and yields excellent functional results.
59.7 Concluding Thoughts
1asal anatomy is well defined, and knowledge of this anatomy
enables the surgeon to analyze nasal form and shape precisely.
Operative goals can be defined to restore normal anatomic rela-
tionships, preserving function while improving nasal aesthetics.
Clinical Caveats
• Excellent rhinoplasty results can be obtained only if the
surgeon has a thorough knowledge of nasal anatomy and
understands the surgical relevance of alteration of the ana-
tomic structures.
• The type of framework modification is closely related to the
skin type.
• An active depressor septi muscle can be identified on preop-
erative clinical analysis, and its modification intraoperatively
can enhance the tip–lip complex.
• Following the open rhinoplasty approach, the blood supply to
the nasal tip is derived primarily from the lateral nasal arteries
2 to 3 mm above the alar groove.
• Multiple structures contribute to nasal tip support, including
the strength of the lower lateral cartilage, anterior septal
angle, upper lateral cartilage/lower lateral cartilage liga-
ments, medial crural ligaments, and nasal skin. Clinically
one must account for surgical disruption of these structures,
taking specific measures to provide nasal tip support, partic-
ularly in open rhinoplasty.
• The most common cause of functional nasal airway obstruc-
tion is inferior turbinate hypertrophy; however, septal devia-
tion and internal or external nasal valve abnormalities must
also be considered.
Suggested Reading
[1] Adams 😛 -r, Rohrich R-, Hollier LH, Minoli -, Thornton L., Gyimesi I. Anatomic
basis and clinical implications for nasal tip support in open versus closed rhino-
plasty. Plast Reconstr Surg 1999;103(1):255–261, discussion 262–264
>2@ Afrooz P1, Rohrich R-. The keystone: consistency in restoring the aesthetic
dorsum in rhinoplasty. Plast Reconstr Surg 2018;141(2):355–363
>3@ Beekhuis G-. 1asal septoplasty. Otolaryngol Clin North Am 1973;6(3):693–710
>4@ Bernstein L. A basic technique for surgery of the nasal lobule. Otolaryngol Clin
North Am 1975;8(3):599–613
>5@ Dingman RO, 1atvig P. The infracartilaginous incision for rhinoplasty. Plast
Reconstr Surg 1982;69(1):134–135
>6@ Ford C1, Battaglia DG, Gentry LR. Preservation of periosteal attachment in lateral
osteotomy. Ann Plast Surg 1984;13(2):107–111
[7] Gunter JP, Rohrich RJ. External approach for secondary rhinoplasty. Plast Reconstr
Surg 1987;80(2):161–174
[8] Gunter -P, Rohrich R-. Management of the deviated nose. The importance of
septal reconstruction. Clin Plast Surg 1988;15(1):43–55
[9] Hewell TS, Tardy ME. 1asal tip refinement³reliable approaches and sculpture
techniques. Facial Plast Surg 1984;1(2):87–124
>10@ Hilger -A. The internal lateral osteotomy in rhinoplasty. Arch Otolaryngol
1968;88(2):211–212
Fig. 59.19 Cadaveric illustration of the internal nasal valve. The
internal valve is defined as the junction of the septum and the caudal
border of the upper lateral cartilages.
Fig. 59.18 Schematic illustration of the nasal septum composed of the
quadrangular cartilage, the perpendicular plate of the ethmoid, and
the vomer.

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[11] -aneke -B, :right :.. Studies on the support of the nasal tip. Arch Otolaryngol
1971;93(5):458–464
>12@ McCollough EG, Mangat D. Systematic approach to correction of the nasal tip in
rhinoplasty. Arch Otolaryngol 1981;107(1):12–16
>13@ Millard DR -r. Alar margin sculpturing. Plast Reconstr Surg 1967;40(4):337–342
>14@ Peck GC. The onlay graft for nasal tip projection. Plast Reconstr Surg
1983;71(1):27–39
>15@ Pollock RA, Rohrich R-. Inferior turbinate surgery: an adjunct to successful treat-
ment of nasal obstruction in 408 patients. Plast Reconstr Surg 1984;74(2):227–
236
>16@ Sheen -H. Achieving more nasal tip projection by the use of a small autoge-
nous vomer or septal cartilage graft. A preliminary report. Plast Reconstr Surg
1975;56(1):35–40
[17] Rohrich R-, Gunter -P, Friedman RM. 1asal tip blood supply: an anatomic study
validating the safety of the transcolumellar incision in rhinoplasty. Plast Reconstr
Surg 1995;95(5):795–799, discussion 800–801
[18] Rohrich R-, Afrooz P1. Rhinoplasty refinements: the role of the open approach.
Plast Reconstr Surg 2017;140(4):716–719
[19] Rohrich R-, Huynh B, Muzaffar AR, Adams 😛 -r, Robinson -B -r. Importance
of the depressor septi nasi muscle in rhinoplasty: anatomic study and clinical
application. Plast Reconstr Surg 2000;105(1):376–383, discussion 384–388
>20@ Sheen -H. Spreader graft: a method of reconstructing the roof of the middle nasal
vault following rhinoplasty. Plast Reconstr Surg 1984;73(2):230–239
>21@ Sheen -H, Sheen AP. Aesthetic Rhinoplasty, 2nd ed. St Louis, MO: 4uality Medical
Publishing; 1998
>22@ Tardy ME, Denneny -C. Micro-osteotomies in rhinoplasty³a technical refine-
ment. Facial Plast Surg 1984;1(2):137–145

60 Clinical Decision Making in Rhinoplasty
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60 Clinical Decision Making in Rhinoplasty
Farzad R. Nahai
Abstract
Rhinoplasty is a uniquely challenging endeavor and significantly
benefits from detailed analysis and planning. The author would
argue that of all the procedures in plastic surgery, successful
rhinoplasty is the most dependent on thorough analysis and
planning. Time spent on understanding your patient’s goals and
motivations, analyzing the nose, imaging the nose, formulating a
plan, then executing that plan to the best of your ability is more
likely to be rewarded with a happy patient and therefore a happy
surgeon. This chapter illustrates the author’s method of analysis
and planning in rhinoplasty from consultation to operation.
Keywords
rhinoplasty, analysis and planning, digital imaging, red flag
patient
60.1 Introduction
For those surgeons who enjoy rhinoplasty, it is the challenge and
reward that is appealing. The challenge exists in analysis, pre-
planning, attention to detail, and meticulous surgical technique,
which is often rewarded with the results that make our patients
happy and, in turn, us as well. The foundation of successful rhi-
noplasty is analysis and planning. I would argue that when con-
sidering the three aspects of rhinoplasty³analysis, planning, and
surgical technique³50 of a successful outcome rests with anal-
ysis and planning and the remaining 50 with surgical technique
(Fig. 60.1). This relationship may vary from surgeon to surgeon
and practice to practice, but the point cannot be overemphasized
that, if you want to achieve consistently excellent results, analysis
and planning are critically important in rhinoplasty. This chapter
will focus on the aspects of nasal analysis and surgical planning
for rhinoplasty, from consultation to the operation.
60.2 Basic Anatomy of the Nose
Basic clinical anatomy of the nose is covered in Chapter 59. For
the purposes of analysis and planning, the rhinoplasty surgeon
must have a clear and in-depth understanding of what gives the
nose its shape and what anatomic elements are responsible for
proper nasal function as it relates to breathing. The skin itself
is generally of two varieties: thinner and more mobile over the
dorsum and sidewalls, transitioning to thicker and more glabrous
skin with much less mobility on the tip and nostrils. At the tip,
a variable amount of fatty tissue can be found depending on the
genetic/ethnic background of the patient. A thin muscular layer
also exists, made up of paired nasalis muscles along the side-
walls, the procerus along the radix, and the depressor septi nasi
at the base of the columella. The extrinsic levator labii superioris
alaeque nasi elevates and dilates the ala, and the finer intrinsic
pars alaris muscles flare the nostrils.
The underlying bony and cartilaginous structures are the
principal features that give the nose its shape and are the areas
where the majority of the surgical effort is typically spent. Of
course, there are significant variations based on genetic/ethnic
background, but the paired nasal bones shape the upper third of
the nose on average, and the septum, upper laterals, and lower
laterals shape the lower two-thirds and tip especially. From a
functional standpoint the septum and its relationship to the nasal
bones, the vomer on which it rests the upper lateral cartilages,
and the inferior turbinates and the integrity of the ala dictate
nasal breathing function.
The qualities of the skin, muscle, bone, and cartilage that shape
the nose are clinically correlated to the shapes and contours of the
nose, some of which have their own descriptive labels or preferred
terminology when it comes to clinical correlations. More detail
can be found in the anatomy section, but a few key concepts are:
dorsal aesthetic lines, bony base, intercanthal distance, radix,
dorsal hump, supratip break, tip-defining points, infratip lobule,
nasolabial angle, columellar show, and alar rim contour; there are
many more.
60.3 Initial Consultation
60.3.1 Interview
The minute you meet the patient, your analysis of the nose (and
the patient) starts. :ith experience, the surgeon can often for-
mulate an initial plan for rhinoplasty within seconds of seeing
Fig. 60.1 The process of successful rhinoplasty can be broken down
into three aspects: analysis, planning, and execution. Analysis and
planning are the foundation on which a successful rhinoplasty can be
done. While it may differ from surgeon to surgeon, I would argue that
analysis and planning make up about 50% of what it takes to deliver
a successful procedure, with the remaining half being the actual
performance of the procedure.

906
X Rhinoplasty
the patient. It is what happens during the interview, formal
exam, and imaging (which is highly recommended) that leads
to the final plan. Ask two questions of your patient: ´:hat is
it about your nose that you want to change"µ and ´How is the
breathing through your nose"µ Listen to the answers.
Two Principal Questions to Ask a New
Rhinoplasty Patient
• “What is it about your nose that you want to change?”
• “How is the breathing through your nose?”
questions, and by ´a lotµ I mean more than just the actual answers
to the actual questions. :hat do I mean" The detail or lack of
detail your patients report tells you not only the areas of the nose
you need to address during the consultation but also the degree of
their own understanding of their appearance and how their nose
interacts with the rest of their face. Furthermore, by listening, you
can tell the degree of concern the patient has with the features of
his or her nose and, by extension, what it is going to take to have
a happy patient should the patient choose to have surgery. For
minor patients, pay attention to what extent they themselves are
reporting on their nose versus their parents.
Once you have listened to your patient, review the pertinent
medical and surgical history; especially anything related to the
nose, such as trauma, previous rhinoplasty, seasonal allergies,
obstructive sleep apnea, frequent use of nasal sprays, epistaxis,
drug use, and smoking.
Sometimes you can gather information about the patient from
your staff. How did the patient interact with your front desk" How
is the patient with your clinical staff and back office staff" Often
patients are on their best behavior when the physician is around,
so if you are questioning your patient’s disposition or motivations,
you can look to your staff to fill in any gaps in the patient’s profile.
If a patient is rude or out of line with your staff, ask yourself how
that individual will behave toward you in the event of any difficul-
ties after surgery.
60.3.2 Exam
Examine the patient with them sitting up and facing you at eye
level. Before focusing on the nose, take into account the overall
facial appearance with attention to asymmetries and, in partic-
ular, to the relationship between the upper, middle, and lower
thirds of the face, with the nose being the dominant feature of
the middle third of that face. Ask yourself what the relationship
of the nose is to the upper and lower thirds of the face. Does it
dominate (as in a very large nose) or is it overshadowed (as a
small nose with low bridge or one that has been overoperated
on)" Once this is done, start your systematic exam of the nose,
looking at it from the anterior view and laterally, taking into
account all the shapes and contours (dorsal aesthetic lines, dorsal
hump, tip width, etc.). By asking the patient to smile and observ-
ing laterally, you can assess whether or not the tip dips down
due to the depressor septi nasi muscle. Furthermore, look at the
nose from both the right and left sides, as often the appearance is
different in the case of nasal deviations. Patients will sometimes
report that they prefer one side over the other when there is
a difference. Lastly, assess the function of the nose by asking
whether the patient breathes better through one nostril or the
other; then listen to the nasal breathing with both nostrils open
then with each one closed individually. This can clue you in to
internal obstruction issues and the function of the internal and
external nasal valves. I find Cottle’s maneuver only somewhat
helpful, as almost all patients breathe better when it is done.
Once the external exam is done, the internal nasal exam is
performed. :ith a speculum and a light, observe the base of the
nose, making note of the alar base width, position of the columella,
any asymmetries, and the position of the anterior septum. Often
an anterior septal deviation is easily noted here. Next, shine the
light into the nose; the remaining septum and inferior turbinates
are seen, along with any evidence of septal spicules occluding the
nasal airway. The occasional septal perforation is also identified. All
external and internal findings are recorded in the patient’s chart.
60.4 The Initial Conversation with
the Patient
Once the exam is done, an initial conversation takes place. A
brief review of your findings is done; then specifics of surgery
are presented. This includes a general discussion of the process
of rhinoplasty, the surgeon’s preferred approach and location of
incisions, the aspects of the nose that will be addressed, where
the surgery will take place, type of anesthesia used, the type of
dressings/splinting that will be used, and what kind of recovery
is anticipated. In addition to what kind of pain they will have,
patients are usually quite keen on when they can go back to
school or work without attracting too much attention. This can
be broken down several ways, but one way I like to do it is the
time it will take to go out without attracting a lot of attention (1
week with some sunglasses or makeup perhaps), 2 weeks until
minimal or no cover is needed, and 6 weeks until we see 95 of
the result. I tell patients that for the most part the nose will look
final to them at about 6 weeks, but it will take 6 to 12 months to
look final to my eye. At this point questions from the patient and
family are elicited and answered. Throughout the entire consul-
tation process, the surgeon is constantly assessing the patient
as a candidate for surgery by paying attention to the patient’s
maturity level, degree of concern with the nose versus degree
of findings of the nose, motivations for surgery, and ability to
understand what has been discussed to this point, and response
to the surgeon’s recommendations.
If the patient is a good candidate for fillers to the nose, this is
a good time to introduce that option. If the patient is not a good
surgical candidate, this is a good time to start dropping hints to
that effect. If the patient is likely to be a good surgical candidate,
the next step is digital imaging.
60.5 Digital Imaging
Imaging and morphing the nose in one manner or another (by
hand drawings or digital software) can be an incredibly useful
tool during the process of consultation. My preference is digital
imaging using software specifically made for aesthetic surgery

60 Clinical Decision Making in Rhinoplasty
907
(Mirror suite, Canfield Scientific, Parsippany, 1-). Before I used
digital imaging, I simply printed the patient’s photos and used
pens and pencils to morph the nose. Some patients, especially
millennials and younger, may present having imaged their nose
themselves using filters available on popular platforms such as
Snapchat or something similar. Rather than disregard this effort
by patients, you should take a look at what they have done, as it
is a window into their impression of themselves and rhinoplasty
goals; then it is up to you to decide whether they are realistic or
not and move from there.
In any event the imaging that is done in your office during the
consultation serves three primary purposes, plus one if you and
your patient agree to surgery:
1. It gets you and your patient on the same page as to what the goal
appearance is.
2. The imaging helps answer the questions of whether or not that
goal is in balance with the rest of the face.
3. Once the imaging is done, it helps you decide whether those
results are achievable through surgery in your hands (Fig. 60.2).
If the first three goals of imaging are met and favorable for
surgery, then the fourth purpose of imaging is to use it to make
your surgical plan (a more in-depth explanation of this will come
later). If the first, second, or third aspect of imaging is a stumbling
block for you or your patient, you must reassess the goals of the
consultation and whether or not rhinoplasty is recommended. All
imaging is done with the expressed understanding that it is not
a guarantee of a result but simply a tool used to help achieve a
desired outcome. The imaging portion of the visit is a great time
to make sure you and your patient are on the same page and that
you believe the patient is a good candidate for surgery. In a busy
rhinoplasty practice, you may identify one patient a month who is
not a good candidate for one reason or another and decide not to
operate on that patient, saving you and them a lot of distress and
heartache. Conversely, the imaging can cement the beginning of a
very good patient–doctor relationship and aid in the planning of
an operation that can meet all the goals set forth.
60.6 The Red Flag Patient
The entire spectrum of plastic surgery sees patients who, for one
reason or another, are not a good candidate for surgery. One term
applied to these patients is ´red flag patient.µ The red flag patient
is very present and evident within the pool of patients seeking
rhinoplasty. Identifying the red flag patient before the patient
has surgery is very important, and (as mentioned earlier) may
take the assistance of your staff to identify. The red flag patient
can present in many ways. One of the easiest to identify is the
patient who has excessively high concerns related to minimal
findings on exam. This observation was popularized by Mark
Gorney, who then coined the ´Gorney-Gramµ (Fig. 60.3). By
plotting where your patient is on the Gorney-Gram, you may be
able to ferret out the patient who will not be happy no matter
what you do, before you do it.
Another classic red flag patient is the single, immature, male,
overly narcissistic (SIMO1) patient. Should a SIMO1 patient have
surgery, you run the risk of not only an unhappy patient postoper-
atively but also one who can become angry and aggressive toward
the surgeon. Red flags can also be more subtle. The ´Debbie
Downer” type of patient is one to be wary of as well. This is the
patient who just never seems happy in your office, the one who
during imaging just never seems to be happy with any appearance
of the nose you generate or can’t seem to settle on one preferred
image. This type of patient will not be happy after a successful
procedure either. Another red flag is the patient who is rude or
abusive to your staff. Such individuals will not show this side of
themselves to you, so you have to empower and rely upon your
staff to inform you when this happens. In the right circumstances
it is possible they will turn their venom and meanness on to you.
Avoid taking these patients on; you will do yourself a favor and
your staff will greatly appreciate it.
Some information may be harder to come by. For example, some
patients may present having seen numerous other rhinoplasty
surgeons, and you may not know it. Having had multiple consul-
tations in and of itself is not necessarily a red flag, but it may be an
indicator of a patient who is in constant search of the ´oneµ surgeon
who can meet goals that in fact may not be realistic. Or, possibly
that patient saw numerous other surgeons who did not agree
to do the requested surgery, and now that patient is seeing you.
Sometimes these patients who have been rejected several times
by other surgeons alter their behaviors so as not to be identified
as a red flag patient. There are also grey areas here, meaning some
patients who may appear as red flag patients but perhaps are not.
Maybe that patient who is doctor shopping needs the time and
consultations to feel finally comfortable making the decision to
have surgery. Some patients may show up having done their own
imaging and spent hours online looking at noses and present their
findings to you with specific goals already laid out before you have
assessed them fully. I know that early in my carrier it was harder
for me to take on the very particular patients who brought in their
own drawings or exhibited very particular goals with the imaging,
but with time, better patient management skills, and frankly better
rhinoplasty skills, such patients have been less of a red flag for me.
your surgical skills, maybe even have a ´sixth sense,µ if you will,
about each situation, then make a decision. Lastly, remember that
you never regret the patient you did not operate on.
60.7 Formulating a Plan
:ith the consultation done and digital imaging in hand, a
surgical plan can be put together. The plan should take into con-
sideration the patient’s goals, your exam findings, your comfort
level, and the imaging. Every surgeon’s mind works differently,
and there is no one best approach to surgical planning that will
be universally applicable. :ith that in mind, what is presented is
one way that I have found to take something rather complex and
make it into something that is simple, very effective, repeatable,
documentable, and easy to teach.
By ´simple planning,µ I mean it’s as easy as creating an ´if . . .
then” proposition. For example, “if” there is a dorsal hump, “then”
perform a hump reduction. Or “if” there is a deviated septum,
“then” perform a septoplasty. This “if . . . then” formula can be
applied down the line as it pertains to all the maneuvers that were
done on the nose during the morphing process, so that eventually
a step-by-step multipoint plan is developed (Fig. 60.4). The plan

908
X Rhinoplasty
Fig. 60.2 This is a 19-year-old woman who presented with an interest in reduction rhinoplasty (a, left). During the imaging portion of her consulta-
tion two proposed images where made from the A/P view: one with doral hump reduction, nasal bone infracture, and tip defining work (a, middle).
The second image (a, right) shows the same work PLUS a bilateral weir excision. Morphing the nose with and without the weir really demonstrates
the improvement in the overall nasal balance to the patient and confirmed my suspicion that she would look good with it. Having done the weir on
the computer and confirming that both my patient and I liked it, the weir was incorporated into her procedural plan. (b) A similar situation where
the left photo is unmorphed, the middle photo shows morphing that includes a weir excision, and the photo on the right shows her result at 1 year.
Morphing can be very helpful when it comes to counseling a patient on your recommendations and (as in example b) a tool you use to measure your
own results against the morphing and learn from it.

60 Clinical Decision Making in Rhinoplasty
909
can be written and posted in the operating room and used as a
reference list during the procedure. This eases the burden on the
surgeon, who does not have to memorize what he or she intends
to do on any given case. :ith the plan/list up in the operating
room, each maneuver can be checked off as the case progresses so
that proposed maneuvers will not be missed or skipped (Fig. 60.5).
If additional procedures are performed, they are simply added to
the list so that by the end of the case a complete record exists of
what was done during the procedure. The same list can then be
used during the dictation process and eventually included as a ref-
erence in the patient’s chart. Furthermore, the list can be used as a
teaching tool for residents and for surgeons interested in assessing
and reviewing their own results over time. I have personally found
these lists and procedure plans incredibly helpful in my practice.
60.8 Performing the Procedure
Five Times
Looking back over this chapter and the process that it presents
for assessing and planning for rhinoplasty, the surgeon essen-
tially goes through the process of ´performingµ rhinoplasty on
any given patient fiYH times from beginning to end. To explain, as
it was to me by Robert Simon, MD, many years ago, the surgeon
repeats the procedure as follows (Fig. 60.5).
1. The first time you ´performµ the rhinoplasty is the minute you
walk into the exam room, meet your patient for the first time,
and think about what needs to be done. It is based on your initial
gut reaction to the nose and the patient’s appearance.
2. The second time you ´performµ the rhinoplasty is at the imaging ses-
sion: essentially doing the surgery on the computer with the software.
3. The third time you ´performµ the rhinoplasty is when coming up
with the point-by-point surgical plan that is written down. A good
time to do this is the night before or morning of the procedure.
4. The fourth time you “perform” the rhinoplasty is the actual pro-
cedure itself in the operating room.
5. Lastly, the fifth time you ´performµ the rhinoplasty is when you
review your notes from the operation and dictate the procedure.
This is the after review, if you will, when you take a moment to look
back at what you did and make the notes part of the patient’s record.
So, taking a look at this list and doing the procedure five times, one
“performs” the rhinoplasty three times before the actual procedure.
How does this help" :hat are the benefits" :ell, they are many.
Through the first three times the surgeon is given the opportunity
to assess the nose and make a plan each time, helping refine the plan
and lowering the chances of missing something. By the time you go
to the operating room, you have prepared yourself and had three dry
runs on the rhinoplasty before actually performing it. It stands to
reason that the more you prepare for any event, especially a complex
procedure, the higher the likelihood that procedure will go well.
Recording the procedure while performing it and keeping a
record for later reference are also very beneficial. By ´checking
the boxesµ during the procedure, you are making sure everything
that you intended to do is getting done. At the same time, you are
relieving yourself of having to commit a whole surgical plan to
memory, therefore allowing yourself more attention to the task of
performing the procedure. 1o two rhinoplasties are the same, so
detailed notes for later reference help you assess your own results
and are a permanent resource that can help you evolve your tech-
nique over time when you review your results.
60.9 Case Examples
60.9.1 Case 1
The patient shown in Fig. 60.7 presented when she was 16 years
old with an interest in reducing the size of her nose. Because she
is rather tall at 180 cm, it would not have been appropriate simply
to reduce the size of her nose as one might for someone shorter.
After the imaging was done, her surgical plan included dorsal
hump reduction, autospreader flaps, septoplasty, turbinate
outfracture, nasal bone infracture, caudal trim of the septum,
Fig. 60.3 The Gorney-Gram: Patients who are in the lower right-hand
corner of the graph demonstrate a lower degree of concern with a
nose that needs a lot of work. These patients are more likely to be
happy after surgery. Patients in the upper left-hand portion of the
graph have a high degree of concern for a nose that may not need
much done to it. These patients are at risk for being unhappy after
surgery. (Courtesy of Mark Gorney, MD.)
Fig. 60.4 Matching the maneuver with the problem.
Cosmetic
• Dorsal hump >>>>>>> hump reduction
• Open roof/wide base >>> osteotomies
• Wide tip >>>>>>> tip sutures ++
• NAO >>>>>>> septoplasty/turbs
• Tip over-projected >>>> set back
• Tip under-projected >>> columellar strut
Nasal airway obstruction
• Deviated septum >>>>>> septoplasty
• Crooked septal spine >>>>>> resect spine
• Enlarged turbinates >>>>>> outfracture or resect
• Support internal valve >>>>>> spreader graft
• External valve collapse >>>>>> alar batten graft +/- rim grafts

910
X Rhinoplasty
cephalic trim of the lower lateral cartilages, transdomal and
interdomal tip sutures, horizontal mattress sutures of the lower
laterals, tip defatting, tip setback with suture, columellar strut,
infratip lobule reduction, and bilateral modified weir excisions.
60.9.2 Case 2
The patient shown in Fig. 60.8 presented at age 22 years with
complaints of a dorsal hump and overall wide nose with a wide
and droopy tip. Her surgical plan originally contained 14 points,
indicating the advantage in displaying it in the operating room
as a checklist, which was further altered as a result of intraop-
erative findings. One year postoperatively, she was very pleased
with her results.
60.10 Concluding Thoughts
Rhinoplasty has its challenges and rewards. As one of the more
complex plastic surgery procedures, detailed preparation is of
enormous benefit to the surgeon and, in turn, the patient. Careful
analysis and planning are the foundation on which a successful
procedure is performed with benefits that extend beyond the day
of surgery (i.e., teaching, reference, and improving the surgeon’s
technique). A systematic approach to the patient and the use of
digital imaging can simplify the process of surgical planning
in rhinoplasty. Along the way the surgeon needs to be aware of
red flag patients and be judicious about patient selection. :hen
everything comes together, rhinoplasty can be very rewarding
and create a very positive change in your patients.
Fig. 60.6 Doing the surgery five times. (Credit to Robert Simon, MD.)
Fig 60.5 Surgical plan posted on the operating room wall during the procedure. (a) Preoperative photos and morphed images of patient. (b)
Procedure plan in the form of a checklist with boxes that are checked off as the maneuvers are done. This way the preop photos, morphed images,
and plan can all be referenced directly during the procedure. This helps the surgeon remember all the portions of the procedure to be performed and
helps when it comes to dictating the procedure and critiquing the results a year later.

60 Clinical Decision Making in Rhinoplasty
911
Fig. 60.7 Case 1. (a,b,c) This patient presented when she was 16 with an interest in reducing the size of her nose. She is a model who is 5 feet 11 inches
(180 cm) tall with an interesting genetic background: a Caucasian mother and an Indian father. After the imaging was done, her surgical plan included
dorsal hump reduction, autospreader flaps, septoplasty, turbinate outfracture, nasal bone infracture, caudal trim of the septum, cephalic trim of the
lower lateral cartilages, transdomal and interdomal tip sutures, horizontal mattress sutures of the lower laterals, tip defatting, tip setback with suture,
columellar strut, infratip lobule reduction, and bilateral modified weir excisions. Keeping in mind that she is rather tall for a woman, it would not have
been appropriate to reduce the size of her nose to the same degree as one might for someone shorter. (d,e,f) Her 4-year result is shown.
a
d
b
e
c
f

912
X Rhinoplasty
Fig. 60.8 Case 2. (a,b,c) This woman presented at age 22 years with complaints of a dorsal hump and overall wide nose with a wide and droopy tip.
Her background is Egyptian, and she desired a smaller nose. (d) The actual plan from the operating room. This was originally a 14-point plan that
would be difficult to memorize and keep track of during surgery. Note the boxes that are checked off during the procedure by the circulating nurse,
who also recorded additions to the plan based on intraoperative findings. (e,f,g) She is seen 1 year postoperatively and remains very pleased with her
results. Note the balance with her face and maintenance of her Egyptian heritage.
a
e
b
f
d
c
g

61 Primary Rhinoplasty
913
61 Primary Rhinoplasty
Paul N. Afrooz and Rod J. Rohrich
Abstract
Rhinoplasty is one of the most complex and challenging oper-
ations in plastic surgery and also one of the most commonly
performed aesthetic surgery procedures. Successful rhinoplasty
begins with a thorough understanding of nasal anatomy, accurate
clinical analysis and definition of the anatomic deformity, and
precise surgical execution. This chapter discusses the history of
rhinoplasty surgery, nasal anatomy, clinical nasal analysis, and
operative approaches and principles as well as preoperative and
postoperative management.
Keywords
rhinoplasty; open rhinoplasty; endonasal rhinoplasty; closed
rhinoplasty; septoplasty
61.1 Introduction
Rhinoplasty is one of the most complex and challenging oper-
ations in plastic surgery. The rhinoplasty surgeon must have a
thorough understanding of the three-dimensional anatomy of
the nasal region, a proficiency in nasal and facial analysis, and
a firm grasp of the core concepts in manipulating nasal soft
tissues, cartilage, and bone. The surgeon must also be able to
appreciate the dynamic interplay between these structures and
have sound aesthetic judgement in order to create a result that
will produce a balanced, harmonious nose in relationship to the
rest of the face. The initial operation is critical to the long-term
result because the tissues are virginal and undistorted by prior
operative procedures.
61.2 Evolution of Technique
Aesthetic rhinoplasty has its roots in nasal reconstruction. The
first recorded treatment of nasal injuries dates back to approx-
imately 3000 BC, as recorded on the Egyptian Edwin Smith
surgical papyrus. Reconstructive surgery for nasal deformities is
described as early as 600 BC by Sushruta in India. After a long
period of quiescence during the Dark Ages, descriptions of nasal
reconstruction again appeared as the Renaissance brought forth
advances in science and medicine. The Indian methods for nasal
reconstruction with forehead and cheek skin were practiced and
modified by Italian surgeons into the Italian method, using arm
skin to reconstruct the nose. In the early nineteenth century,
German surgeons including Carl von Graefe and -ohann Friedrich
Dieffenbach continued to develop methods for nasal reconstruc-
tion; Dieffenbach was one of the first to describe surgery for
aesthetic improvement of the nose.
-ohn Orlando Roe, an American otolaryngologist, is credited
with describing the first aesthetic rhinoplasty and introducing
the endonasal approach. In 1887 Roe published ´The Deformity
Termed ¶Pug 1ose’ and Its Correction, by a Simple Operation,µ and
in 1891 ´The Correction of Angular Deformities of the 1ose by a
Subcutaneous Operation.µ Roe’s descriptions preceded those of
-acques -oseph, a German orthopedic surgeon often regarded as
the father of modern rhinoplasty, given his contribution to the
analysis, classification, and repair of various nasal deformities,
outlined in his two-volume textbook on plastic surgery of the
nose.
In the first half of the twentieth century, the emergence of
plastic surgery as a specialty was spurred forward by experience
gained reconstructing devastating war injuries. The second half
of the twentieth century saw significant contributions to the
rhinoplasty literature, with gains in preoperative assessment and
diagnosis, management of the nasal airway, cartilage-grafting
techniques, and popularization of the open approach to rhino-
plasty. The open approach was first described by Aurel Rpthi of
Budapest in 1921 but did not gain popularity. In the 1960s his
approach was rediscovered by Ante Sercer of =agreb and intro-
duced to 1orth America by his associate, Ivo Padovan, in 1970.
:illiam Goodman of Toronto was the first 1orth American to
adopt the open approach, and this technique has gained in popu-
larity since the 1980s.
61.3 Indications and
Contraindications
Rhinoplasty can be performed for many indications, which fall
along a spectrum from purely functional to purely aesthetic.
However, each individual’s nasal anatomy must be taken into
account when deciding whether the patient is a good surgical
candidate and what approach should be used to address the
problem. 1o single approach is appropriate for all situations.
Obviously, there can be great advantages for the patient when
rhinoplasty is properly performed. Patients who suffer from nasal
airway obstruction (1AO) can achieve significant amelioration, if
not total eradication, of their symptoms. Frequently these patients
have had difficulty breathing for several years. :hether the defor-
mity is congenital or traumatic, patient satisfaction is extremely
high after corrective surgery is performed.
Similarly, a patient who undergoes rhinoplasty for purely
aesthetic reasons stands to benefit significantly with respect to
self-image and self-esteem after a successful rhinoplasty. One
must be wary, however, of patients who perceive a significant
deformity in themselves when the deformity appears minor
to the surgeon. Such patients may never be satisfied with the
outcome, no matter how well the rhinoplasty is executed (see
Chapter 1). Multiple preoperative visits may be necessary, not
only to understand completely what the patient desires but also
to confirm whether the patient’s expectations are realistic.

914
X Rhinoplasty
61.3.1 The Open versus the
Endonasal Approach
In modern rhinoplasty, both the open and the endonasal (closed)
approaches have their staunch proponents. The open approach
continues to gain in popularity over the endonasal approach
for both primary and secondary rhinoplasty. There are advan-
tages and disadvantages to both techniques, with the correct
approach determined by the patient’s anatomic deformity and
the surgeon’s experience. Clearly, what is performed to alter
the underlying anatomy is far more important than the type of
incision used (Table 61.1).
Despite the disadvantages to the open approach, in our expe-
rience we have not had patient dissatisfaction related to these
specific factors, other than prolonged nasal tip edema. As long as
the expectation level is set preoperatively, this has not proved to
be a problem.
Those who favor the endonasal approach to rhinoplasty submit
that the advantages offered by the open approach are outweighed
by its disadvantages (Table 61.2).
:e prefer the open approach, in general, because it provides
full visualization of the nasal framework to diagnose the cause
of the nasal airway obstruction or the aesthetic deformity more
accurately. The various structures, from the dorsum to the septum
to the tip, can be manipulated with precision to yield reproduc-
ible results. :e strongly recommend the open approach when
addressing a posttraumatic deformity or in secondary/revisional
surgery, as well as when complex tip modifications are necessary.
:e find the endonasal approach to be advantageous in patients
with an isolated dorsal hump deformity or when minimal
modification of the tip is required. In these instances, we prefer
access through a marginal incision (approximately 1 mm cephalad
to the caudal margin of the lateral crus). :e combine this with
an intercartilaginous incision in cases of minor tip refinement
to allow adequate cartilage delivery and exposure. If the caudal
septum needs to be corrected as well, we perform a concomitant
hemitransfixion or transfixion incision.
61.4 Pertinent Anatomy
As in every other area in plastic surgery, thorough knowledge of
anatomy is paramount to obtaining a superior result. The nose is
divided into external skin and soft tissue, the underlying osseo-
cartilaginous framework, and ligamentous support. Rhinoplasty
surgeons must be familiar with each structure’s native mor-
phology and its variants and must have an appreciation for the
dynamic interplay between the components.
61.4.1 Skin
The thickness, mobility, and sebaceous character of the nasal
skin vary along its length, with the upper two-thirds being
thinner, more mobile, and less sebaceous than the inferior third
(Fig. 61.1). The nasal dorsum thickness averages approximately
1.3 mm, whereas the lobule skin thickness averages 2.4 mm. A
straight dorsum actually has a slight underlying convexity of its
osseocartilaginous framework in the cephalic area; therefore a
straight dorsal profile is actually produced by the combination
of this convexity in the osseocartilaginous framework with the
variation in dorsal skin thickness.
Some ethnic subgroups, such as those of African descent,
Hispanics, and those of Mediterranean descent, can have thicker,
more sebaceous skin. These differences are important because
the skin over the underlying nasal framework can either reveal
or mask changes depending on its characteristics. For instance,
it is advisable to err on the conservative side when operating on
Table 61.1 Open rhinoplasty approach rationale
Distinct advantages
Potential disadvantages
• Binocular visualization
• Evaluation of complete deformity without distortion
• Precise diagnosis and correction of deformities
• Allows use of both hands
• More options with original tissues and cartilage grafts
• Direct control of bleeding with electrocautery
• Suture stabilization of grafts (invisible and visible)
• External nasal incision (transcolumellar scar)
• Prolonged operative time
• Protracted nasal tip edema
• Columellar incision separation
• Delayed wound healing
Table 61.2 Endonasal approach
Advantages
Disadvantages
• Leaves no external scar
• Limits dissection to areas needing modification
• Permits creation of precise pocket so graft material fits exactly without
need for fixation
• Allows percutaneous fixation when large pockets are made
• Promotes healing by maintaining vascular bridge
• Encourages accurate preoperative diagnosis and planning
• Produces minimal postsurgical edema
• Reduces operating time
• Results in fast patient recovery
• Creates intact tip graft pocket
• Requires experience and great reliance on accurate preoperative
diagnosis
• Prohibits simultaneous visualization of the surgical field by a teaching
surgeon and students
• Does not allow direct visualization of nasal anatomy
• Makes dissection of alar cartilages difficult, particularly in cases of
malposition

61 Primary Rhinoplasty
915
a white woman with thin skin compared with a man of African
descent with thick, sebaceous skin. More dramatic manipulation
to the underlying nasal framework will be necessary in the patient
with thick skin to obtain an appreciable change in the external
appearance.
61.4.2 Muscle
Two muscles, in particular, are important in rhinoplasty³the
levator labii alaeque nasi and the depressor septi nasi (Fig. 61.2).
The levator labii alaeque nasi helps to maintain the patency of
the external nasal valve, whereas the depressor septi nasi, if
overactive, can shorten the upper lip, cause a transverse upper
lip crease, and alter tip projection.
Evaluation of the depressor septi nasi is routine in our pre-
operative assessment. Its effect on depressing the nasal tip and
shortening the upper lip can be appreciated in some patients on
animation, particularly when smiling. In the subgroup of patients
in whom this muscle significantly alters the nasal appearance, we
transect this muscle. By doing so, several goals are achieved:
1. Enhancement of the tip–lip relationship
2. Relative upper lip lengthening
3. Relative fullness to the upper lip
4. Maintenance of tip rotation/projection on animation
61.4.3 Blood Supply
The blood supply to the nose is derived from both branches of the
ophthalmic artery and branches of the facial artery (Fig. 61.3).
It is important to note the vascularity to the nasal tip because
an open rhinoplasty approach using a transcolumellar incision
will transect the columellar vessels (when present), leaving the
lateral nasal and dorsal nasal arteries as the remaining blood
supply. In our 1995 study, we found the lateral nasal arteries
to be present (either singularly or bilaterally) in 100 of cases,
with the columellar branches present 68.2 of the time. Since the
lateral nasal vessels are found approximately 2 to 3 mm above
the alar groove, extended alar resections to this level are pro-
hibited because injury to these vessels after the transcolumellar
approach would severely compromise blood flow to the nasal tip.
Furthermore, one must be extremely cautious when debulking
the nasal tip after an open approach, because the subdermal
vascular plexus connecting the dorsal nasal and lateral nasal
blood supplies may be damaged, leading to a similarly disastrous
result, with necrosis of the nasal tip skin.
Tardy and Toriumi studied the vascular and lymphatic anatomy
of the nose and determined that the transcolumellar incision
itself did not compromise major venous or lymphatic outflow.
Furthermore, they recommend dissection just above the perichon-
drium in the deep areolar plane, leaving the musculoaponeurotic
layer intact, which preserves the major arterial vascular supply
and avoids damage to the venous and lymphatic vasculature
that lies in a more superficial (subcutaneous) plane. In this way,
bleeding and postoperative edema are minimized.
61.4.4 Nasal Vaults
The osseocartilaginous nasal framework can be subdivided into
three separate vaults: bony, upper cartilaginous, and lower carti-
laginous. The bony vault constitutes the upper third to half of the
nose and is made up of the paired nasal bones and the ascending
frontal process of the maxilla (Fig. 61.4). It is important to note
that the nasal bones are narrowest and thickest above the level
of the medial canthi. As a result, osteotomies are rarely indicated
above this level.
Fig. 61.1 Variations in nasal skin thickness along the nose.
Fig. 61.2 The levator labii alaeque nasi and depressor septi nasi
muscles.

916
X Rhinoplasty
The upper cartilaginous framework begins where the nasal
bones overlap the upper lateral cartilages (ULCs) and septum
for 4 to 6 mm, creating what is known as the keystone area. This
area should be the widest part of the dorsum and resembles a T
shape in cross-section. The remainder of this vault is composed
of the paired ULCs and dorsal cartilaginous septum (Fig. 61.5).
Overresection during dorsal hump reduction in this area can lead
to deformities such as the inverted-V deformity or disruption of
the dorsal aesthetic lines. A component dorsal hump reduction is
advised to avoid these complications.
The lower cartilaginous framework begins where the ULCs
interdigitate with the lower lateral cartilages (LLCs) in what is
called the scroll area (Fig. 61.6). Each of the LLCs comprises the
medial, middle, and lateral crura. These cartilages are connected
to each other, the ULCs, and the septum by fibrous tissue and
ligaments. Disruption of these ligaments can result in diminished
tip projection during rhinoplasty. Thus, if these structures are
violated, maneuvers that increase tip support (for example, col-
umellar struts, extended spreader grafts, suture techniques) may
be necessary.
61.4.5 Nasal Function
The septum, turbinates, and internal and external nasal valves
serve as the anatomic functional foundation for the nose, con-
tributing to respiration, filtration, humidification, temperature
regulation, and protection.
The septum is made up of the septal cartilage, the perpen-
dicular plate of the ethmoid bone, the nasal crest of the maxilla,
and the vomer (Fig. 61.7). Deformities in the septum can lead to
significantly impaired airflow through the nose as well as com-
pensatory turbinate pathology. Restoration of a normal straight
septum will help reestablish laminar airflow. :hen addressing
septal deformities, it is important to assess all septal components.
:hen performing a septal resection, it is important to remem-
ber that the perpendicular plate of the ethmoid is contiguous
posterosuperiorly with the cribriform plate. Therefore, a sidewise
fracture of the perpendicular plate should be performed with care
to prevent iatrogenic damage to the cribriform plate, which can
lead to cerebrospinal fluid rhinorrhea, olfactory impairment, and
potential ascending infection/meningitis.
The turbinates help to guide the transport of air during res-
piration and condition/humidify inspired and expired air (Fig.
61.8). These structures are mucosa-lined extensions of the lateral
nasal cavity and undergo a normal autonomically mediated cycle
of expansion and contraction. Of all the turbinates, however, it
is the inferior turbinate that has the greatest impact on airway
resistance, providing up to two-thirds of the total airway resis-
tance from its most anterior aspect. However, overresection of the
anterior inferior turbinate can have a deleterious effect on its reg-
ulatory and physiologic functions and can lead to crust formation,
bleeding, and nasal cilia dysfunction.
The internal nasal valve can contribute up to 50 of the total
airway resistance and is the narrowest segment of the nasal airway.
It is composed of the angle formed by the intersection of the nasal
septum and the caudal margin of the ULC and is usually 10ƒ to
Fig. 61.4 The bony vault of the nose is made up of the paired nasal
bones and the ascending frontal process of the maxilla.
Fig. 61.3 Blood supply of the nose.

61 Primary Rhinoplasty
917
15ƒ (Fig. 61.9). In some cases, the anterior portion of the inferior
turbinate may be a significant contributor to the decrease in the
cross-sectional area of this region. Patients with short nasal bones
and long, poorly supported ULCs have a propensity to have collapse
at this area. Traditionally, improvement in airflow with lateral
traction on the cheek (positive Cottle’s sign) diagnoses collapse of
the internal nasal valve and signals the need for spreader grafts to
increase the patency of the valve and stent the airway open.
Fig. 61.5 The keystone area is the junction of the bony vault and the upper cartilaginous vault. The upper cartilaginous vault is composed of the
paired upper lateral cartilages and the dorsal cartilaginous septum.
Fig. 61.6 The lower cartilaginous framework is composed of the
paired lower lateral cartilages.
Fig. 61.7 The septum is made up of the septal cartilage, the perpen-
dicular plate of the ethmoid, the nasal crest of the maxilla, and the
vomer.
Fig. 61.8 The turbinates help to guide the transport of air during
respiration and condition/humidify inspired and expired air.
Fig. 61.9 The internal and external valves.

918
X Rhinoplasty
The external nasal valve is the cartilaginous vestibule bounded
by the nares and lateral alar sidewalls (Fig. 61.9). It is caudal to the
internal valve. Obstruction at this area may be caused by foreign
bodies, weak or collapsed LLCs, loss of vestibular skin, or scar
tissue. Several options are available to reestablish proper airflow
through this area, including alar contour grafts, lateral crural strut
grafts, lateral crural cephalic turnover flaps, lysis of adhesions,
scar revision, mucosal grafts, skin grafts, or composite grafts.
61.5 Preoperative Assessment
61.5.1 Initial Consultation
Before proceeding with a rhinoplasty, it is important to evaluate
the patient’s motivations and expectations for surgery com-
pletely to determine whether the patient is a suitable surgical
candidate. Gunter and Gorney have both commented on ´danger
signsµ that may be exhibited by certain patients. Patients that
meet these criteria should be approached with caution because
surgical intervention may not be in the best interests of either
the patient or the surgeon. Gunter identified the following 13
danger signs that may signify underlying psychological issues:
1. Minimal disfigurement
2. Delusional distortion of body image
3. Identity problem or sexual ambivalence
4. Confused or vague motives for wanting surgery
5. Unrealistic expectations of change in life situation as a result of
surgery
6. History of poorly established social and emotional relationships
7. Unresolved grief or currently in a crisis situation
8. Present misfortunes blamed on physical appearance
9. Older neurotic man who is overly concerned about aging
10. Sudden dislike for one’s anatomy, especially in an older man
11. A hostile, blaming attitude toward authority figures
12. History of consulting physicians and being dissatisfied with
them
13. Indication of paranoid thoughts
Similarly, Gorney uses two systems to identify potential prob-
lem patients. The first uses the acronym SIMO1 (single immature
males, overly expectant, narcissistic) to describe certain traits to
be wary of. The second method Gorney uses plots the patient’s
concern on one axis and the degree of deformity on the other (Fig.
61.10). Patients with an appropriate amount of concern relative to
their degree of deformity are excellent candidates for treatment.
However, those with minimal deformity but disproportionate
concern should be avoided, because frequently their expectations
exceed the amount of aesthetic improvement that is possible.
Furthermore, regardless of the degree of deformity, if the level of
skill and expertise required to perform the rhinoplasty exceeds
the surgeon’s ability, the patient should be referred to a more
proficient surgeon.
It should also be noted that men in general tend to have a poorer
understanding of their deformity than women do. Furthermore,
they tend to have a more difficult time articulating the desired
changes. Thus, for this subgroup of patients, during the initial
consultation the physician must determine the patient’s goals
and whether they are realistic. A second follow-up consultation is
recommended to reiterate the patient’s desires, develop a realistic
operative plan, and reaffirm the patient’s understanding of the
anticipated procedure.
Although there are different methods for integrating the
patient into the surgical process, we find that computer imaging
provides an excellent way for patients to gain a realistic under-
standing of the anticipated outcome. Although the images are not
meant to guarantee surgical results, they do provide a visual level
of understanding that may otherwise be lacking. These images,
combined with standardized anterior, lateral, oblique, and basal
photographs, serve as an integral element of the preoperative
surgical plan.
61.5.2 Facial Analysis
An essential element to proper preoperative surgical planning is
critical facial analysis. Each individual nose has different propor-
tions, morphology, and relative relationship with the surround-
ing face. To preserve nasofacial harmony, it is crucial to perform
a systematic and meticulous analysis of the nose and face to
diagnose the deformity accurately and then to determine the
optimal surgical plan to correct the problem. It is also important
to point out natural facial asymmetries to the patient preoper-
atively so the patient gains a better understanding of what is
actually present before any operative intervention is performed.
:e begin by evaluating the patient’s skin type, thickness, and
texture. As previously mentioned, this is important because
thicker, more sebaceous skin tends to camouflage changes made
to the underlying osseocartilaginous framework, whereas thinner
skin tends to show even minor changes.
:e then proceed with the remainder of the facial analysis.
There are some proportions and relationships of facial structures
that make up an ´attractiveµ face. Although more proportions
Fig. 61.10 Plot of patient concerns relative to deformity.

61 Primary Rhinoplasty
919
have been described, the following are some of the fundamental
relationships that we routinely use in our preoperative evaluation
of the rhinoplasty patient. :e will describe these relationships
briefly for Caucasian women and point out when the proportions
differ between men and women.
:e start by evaluating for disproportions and anomalies of the
underlying facial skeleton, including the maxillomandibular rela-
tionship. To do this, we divide the face into thirds using horizontal
lines adjacent to the hairline, brow (at the level of the supraorbital
notch), nasal base, and menton (Fig. 61.11). The upper third
(between the hairline and the brow) is the least important, as it is
the most variable (depending on the hairstyle). The lower third of
the face is then subdivided into thirds by visualizing a horizontal
line between the oral commissures (stomion). The upper third of
this subdivision lies between the nasal base and the oral com-
missures, and the lower two-thirds between the commissures
(stomion) and the menton. If there are significant deviations from
these proportions, the patient may have underlying craniofacial
disproportion (e.g., vertical maxillary excess) that may need to be
addressed in addition to rhinoplasty.
The nasal length (radix to tip, or RT) is verified against the
stomion-to-menton distance (SM), which should be equal, as was
described by Byrd and Hobar (Fig. 61.12).
For future reference, a natural horizontal facial plane is deter-
mined by drawing a line perpendicular to a plumb line superim-
posed over the head in repose and the eyes in straightforward
gaze (Fig. 61.13). As the external auditory canal position may
differ between patients, this line may or may not correspond to
Frankfort’s line.
The lip–chin relationship is assessed next. Byrd determines
ideal chin projection by dropping a vertical line from a point one-
half the ideal nasal length tangential to the vermilion of the upper
lip. The lower lip should be no more than 2 mm behind this line.
The ideal chin position varies with gender, with the chin lying
slightly posterior to the lower lip in women but even with the
lower lip in men. If there is a discrepancy in these relationships,
orthodontics, orthognathic surgery, or a chin implant may be
necessary to improve facial harmony.
1asal deviation is noted by drawing a line from the midglabel-
lar area to the menton, bisecting the nasal ridge, upper lip, and
Cupid’s bow (Fig. 61.14). This line will pass between the central
incisors in patients with normal occlusion. Any deviation of the
nose from this line will likely require septal surgery.
Fig. 61.11 The face is divided into thirds using horizontal lines adjacent
to the hairline, brow, nasal base, and menton. The lower third of the
face is then subdivided into thirds by visualizing a horizontal line
between the oral commissures (stomion). The upper third of this sub-
division lies between the nasal base and the oral commissures, and the
lower two-thirds between the commissures (stomion) and the menton.
Fig. 61.12 The nasal length (radix to tip, or RT) is verified against the
stomion-to-menton distance (SM), which should be equal.
Fig. 61.13 (Left) A natural horizontal facial plane is determined by
drawing a line perpendicular to a plumb line superimposed over the head
in repose and the eyes in straightforward gaze. (Right) Ideal chin position
is determined in reference to a vertical line dropped from one-half the
ideal nasal length and tangential to the vermilion of the upper lip.

920
X Rhinoplasty
The nasal dorsum is then assessed on frontal (anterior) view.
The curvilinear dorsal aesthetic lines are traced from where they
originate at the supraorbital ridges, and then follow along the
corrugators to converge at the medial canthal ligaments, from
which they begin to diverge slightly. From this point, they track to
the tip-defining points, slightly diverging from each other along
the dorsum during their course (Fig. 61.15). Ideally, the width of
the dorsal aesthetic lines should match either the width of the
tip-defining points or the interphiltral distance. These lines may
be ideal, narrow, wide, asymmetric, or ill-defined.
The widths of both the bony base and the alar base are then
assessed. The width of the bony base should be 80 of the normal
alar base width (which is typically equal to the intercanthal
distance) or the width of the palpebral fissure (Fig. 61.16). If the
bony base is greater than 80 of the alar base width (assuming
the alar base width is normal), it is likely that osteotomies will be
required to narrow the bony vault. Although men tend to have a
wider bony base than women, it is important not to narrow the
dorsum too much in males, since this could feminize the nose.
The alar base is analyzed, as is the geometry of the alar rims
(Fig. 61.17). If the alar base width is greater than the intercanthal
distance, it must be determined whether this is the result of a
narrow intercanthal distance, a true increased interalar width, or
alar flaring. If the intercanthal distance is smaller than the width
of the palpebral fissure, it is better to maintain a slightly wider
alar base. If there is true increased interalar width, a nostril sill
resection may be indicated. If the increase in width is secondary
to alar flaring (greater than 2 to 3 mm outside the alar base), an
alar base resection should be considered. Again, the alar rims
should also be assessed for symmetry and should flare slightly
outward in the inferolateral direction.
:hile still addressing the frontal view, the surgeon assesses the
nose tip to determine the supratip break, the tip-defining points,
and the columellar-lobular angle. These points serve as landmarks
to draw two equilateral triangles with their bases opposed (Fig.
61.18). If these triangles are asymmetric, the underlying reason
should be investigated, and the patient will likely require tip
modification.
The final assessment on frontal view is of the outline of the
alar rims and the columella, which should resemble a seagull in
gentle flight, with the columella lying just inferior to the alar rims
(Fig. 61.19). If the curve is too drastic, the patient may have an
increased infratip lobular height, or a hanging columella, which
will need correction. If, on the other hand, the curve is flattened,
the patient probably has decreased columellar show, which may
require columellar augmentation or alar rim modification.
Fig. 61.14 Nasal deviation is noted by drawing a line from the
midglabellar area to the menton, bisecting the nasal ridge, upper lip,
and Cupid’s bow.
Fig. 61.15 The dorsal aesthetic lines originate at the supraorbital
ridges and then converge at the medial canthal ligaments, from
which they begin to diverge slightly. From this point, they track to
the tip-defining points, slightly diverging from each other along the
dorsum during their course.

61 Primary Rhinoplasty
921
The basal view of the nose is addressed next, with the outline
of the nasal base described as an equilateral triangle with a
lobule-to-nostril ratio of 1:2 (Fig. 61.19). The nostril itself should
have a teardrop-like geometry, with the long axis from the base to
the apex oriented in a slight medial direction.
The lateral view is then analyzed, beginning with the position
and depth of the nasal root at the radix. The nasofrontal angle
connects the brow and the dorsum through a soft concave curve
at the radix. The apex of this angle should lie between the upper
lid eyelashes and the supratarsal fold, with the eyes in natural
horizontal gaze. Although this angle can vary from 128ƒ to 140ƒ,
Fig. 61.16 The width of the bony base should be 80% of the normal
alar base width or the width of the palpebral fissure.
Fig. 61.18 The supratip breakpoint, the tip-defining points, and the
columellar-lobular angle make up the landmarks of the nasal tip. These
points serve as landmarks to draw two equilateral triangles with their
bases opposed.
Fig. 61.17 The alar base should be analyzed for width and geometry.
Fig. 61.19 The outline of the alar rims and the columella should
resemble a seagull in gentle flight, with the columella lying just inferior
to the alar rims. In the basal view, the outline of the nasal base should
resemble an equilateral triangle with a lobule-to-nostril ratio of 1:2.

922
X Rhinoplasty
it is ideally 134ƒ in women and 130ƒ in men. Other important ref-
erence measurements from this view include the nasion–medial
canthal distance, which should be approximately 15 mm, and the
nasion–corneal plane distance, which is approximately 11 mm.
:hile still concentrating on the lateral view, it is important to
remember that the perceived nasal length and tip projection can
be altered by the position of the aforementioned nasofrontal angle.
For instance, if the nasofrontal angle is positioned more anteriorly
and superiorly than normal, the nose will appear elongated, the
nasofacial angle will be decreased, and the tip projection will
appear diminished (Fig. 61.20, yellow line). Conversely, if the
nasofrontal angle is too posteriorly or inferiorly positioned, the
nose will appear shorter, and the tip more projecting (Fig. 61.20,
red line). Ideally, the nasofacial angle (as defined by the junction
of the nasal dorsum with the vertical facial plane) should measure
32ƒ to 37ƒ.
Tip projection is addressed next, still from the lateral view.
Although several methods have been described to assess this, we
prefer the following two ways. In a patient with normal upper
lip projection, we begin by drawing a horizontal line from the
alar–cheek junction to the tip of the nose (Fig. 61.21). The tip pro-
jection is considered normal if 50 to 60 of this line lies anterior
to a vertical line tangent to the most projecting part of the upper
lip. The tip is considered to be overprojected if greater than 60 of
the horizontal line lies anterior to the vertical reference line and
may therefore require deprojection. Conversely, if less than 50
of the tip lies anterior to the line, the projection may need to be
augmented (in any number of ways).
The second method we use to help assess tip projection is by
comparing it to the alar base width (they should be equal) and
by comparing the ratio of nasal length (radix to tip, RT) to the tip
projection length (alar base to tip, as described in the preceding
paragraph). In the latter, the ideal tip projection is 0.67 ð RT (Fig.
61.22).
After the tip projection is assessed, the dorsum is analyzed. The
aesthetic nasal dorsum should lie approximately 2 mm behind
and parallel to a line from the radix to the tip-defining points in
women (Fig. 61.23). The norms for men are discussed in a later
subsection.
The degree of supratip break is appraised when the nasal tip
projection and dorsum are evaluated. A slight supratip break is
preferred in women (but not in men). This gives the nose more
definition and distinguishes the dorsum from the tip.
The nasolabial angle is used to determine the degree of tip rota-
tion (Fig. 61.24). This angle is obtained by measuring the angle
between a line coursing through the most anterior and posterior
edges of the nostril and a plumb line dropped perpendicular to
the natural horizontal facial plane. This angle should be between
95ƒ and 100ƒ in women.
The nasolabial angle should not be confused with the columel-
lar–lobular angle, which is formed at the junction of the columella
with the infratip lobule (Fig. 61.25). Increased fullness in this area
is usually caused by a prominent caudal septum. This angle is
normally 30ƒ to 45ƒ.
The alar–columellar relationship is then assessed in the lateral
and frontal views. A line is drawn along the long axis of the nostril,
and a perpendicular line is drawn from alar rim to columellar rim
Fig. 61.20 The perceived nasal length and tip projection can be
altered by the position of the nasofrontal angle. If the nasofrontal
angle is positioned more anteriorly and superiorly than normal, the
nose will appear elongated, the nasofacial angle will be decreased, and
the tip projection will appear diminished (yellow line). Conversely, if the
nasofrontal angle is too posteriorly or inferiorly positioned, the nose
will appear shorter, and the tip more projecting (red line).
Fig. 61.21 The tip projection is considered normal if 50–60% of the tip
lies anterior to a vertical line tangent to the most projecting part of the
upper lip.