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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Proportions in Male Patients
The proportions discussed so far generally apply to Caucasian
women. Generally, the male face tends to have a squarer, less
rounded appearance, with stronger, more pronounced features.
The key differences in the nose for men are as follows:
• The male dorsum tends to be straighter and wider, with
decreased concavity at the superciliary ridges.
• The male nasal dorsal profile should hug a line drawn from the
radix to the tip-defining points instead of falling 2 mm behind
and parallel to this line, as in women.
• There should be minimal to no supratip break, consistent with
the dorsal profile not falling behind the radix-to-tip line.
• Tip rotation in men is slightly less than in women (90ƒ to 95ƒ
versus 95ƒ to 100ƒ in women).
• In general, men have a broader, more bulbous nasal tip.
• Male skin is usually thicker, masking the amount of perceiv-
able change.
It is important to remember that these proportions are gen-
eral guidelines and can vary tremendously between different
individuals. In addition, it is important to consider the patient’s
ethnicity and culturally accepted aesthetic ideals, as rhinoplasty
is becoming increasingly popular among different ethnic groups.
Rhinoplasty in Patients of African Descent
Compared with the nasal ideals for Caucasians, the noses of
patients of African heritage typically feature a wide, low nasal
dorsum, decreased nasal length and tip projection, less nasal tip
definition, an acute nasolabial angle, and alar flaring (Fig. 61.27).
The goals of rhinoplasty in a patient of African descent include
achieving a narrower, straight dorsum, improved tip projection
and greater definition, and decreasing alar flaring and alar base
width (Fig. 61.28). Improvement of the typically low nasal dorsum
may require dorsal augmentation. Tip definition is improved by
suture techniques and cartilage grafting, as needed.
Fig. 61.25 The columellar–lobular angle is formed at the junction of
the columella with the infratip lobule. This angle is normally 30° to 45°.
Fig. 61.26 The alar–columellar relationship (ACR) is assessed in the
lateral view. A line is drawn through the long axis of the nostril, and a
perpendicular line is drawn from alar rim to columellar rim that bisects
this axis. The distance from the alar rim (point A) to the long axis line
(point B) should equal the distance between the long axis line to the
columellar rim (point C) if the alar–columellar relationship is normal
(AB = BC § 2 mm).

61 Primary Rhinoplasty
925
Rhinoplasty in Patients of
Middle Eastern Descent
The complex nasal morphology of the Middle Eastern nose war-
rants discussion. It demonstrates a combination of features seen
in individuals of African, Mediterranean, and Hispanic origin.
The Middle Eastern nose features thick, sebaceous skin and
is most prominent at the supratip. The radix may overproject,
the bony and middle vaults tend to be wide, and a significant
dorsal hump is common. The LLCs can feature malposition of
the lateral crura and weak middle and medial crura, resulting
in various characteristic deformities of the tip, including poor
tip definition, underprojection of the tip, or a droopy tip with
an acute nasolabial angle (Fig. 61.29). The tip deformities may
be exacerbated by hyperdynamic depressor septi nasi muscles.
Nasal deviation and nostril asymmetry are also common.
Achieving ethnic nasofacial harmony in a Middle Eastern patient
includes moderate dorsal hump reduction; narrowing of the wide
nasal bones; debulking of soft tissue, particularly at the supratip;
modest correction of underrotation and underprojection of the
nasal tip; improvement of tip definition; repositioning of the alar
bases; and correction of nostril asymmetries (Fig. 61.30).
These guidelines are meant only as a systematic method of anal-
ysis with general proportions and relationships. Each nose should
Fig. 61.27 Compared with the nasal ideals for Caucasians, the noses of
patients of African heritage typically feature a wide, low nasal dorsum,
decreased nasal length and tip projection, less well defined nasal tip,
an acute nasolabial angle, and alar flaring.
Fig. 61.29 The Middle Eastern nose features thick, sebaceous skin
and is most prominent at the supratip. The radix may overproject, the
bony and middle vaults tend to be wide, and a significant dorsal hump
is common. The lower lateral cartilages can feature malposition of the
lateral crura and weak middle and medial crura, resulting in various
characteristic deformities of the tip, including poor tip definition, under-
projection of the tip, or a droopy tip with an acute nasolabial angle.
Fig. 61.28 The goals of rhinoplasty in a patient of African descent often
include achieving a narrower, straight dorsum, improved tip projection
and definition, and decreasing alar flaring and alar base width.
Fig. 61.30 Achieving ethnic nasofacial harmony in a Middle Eastern
patient includes moderate dorsal hump reduction; narrowing of the
wide nasal bones; debulking of soft tissue; modest correction of
underrotation and underprojection of the nasal tip; improvement of
tip definition; repositioning of the alar bases, and correction of nostril
asymmetries.

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be individualized to the patient’s facial structure and tempered by
the patient’s desires to create facial harmony and balance.
61.5.3 Intranasal Examination
The final part of the preoperative analysis of the rhinoplasty
patient is the intranasal examination. This is performed with a
nasal speculum, headlight, and vasoconstriction. The septum,
turbinates, and external and internal nasal valves are evaluated
for obvious deformities or pathology.
Septal perforation or deviation should be identified. Septal devi-
ation can involve deviation of the septal cartilage, perpendicular
plate of the ethmoid bone, or vomer and can cause obstruction of
one or both of the nasal airways, along with external deviation of
the nose.
Guyuron et al classified septal deviation as follows (Fig. 61.31):
1. Septal tilt (40)
2. Anteroposterior C-shaped deviation (32)
3. Cephalocaudal C-shaped deviation (4)
4. Anteroposterior S-shaped deviation (9)
5. Cephalocaudal S-shaped deviation (1)
6. Localized deviation or septal spur (14)
Septal tilt is the most common type, where the quadrangular
cartilage and perpendicular plate of the ethmoid are straight but
the quadrangular cartilage is tilted to one side internally and to
the opposite side externally. Hypertrophy of the inferior turbinate
contralateral to the side of internal deviation is usually present.
If inferior turbinate hypertrophy is identified, the underlying
cause should be investigated. Turbinate enlargement can be con-
genital or acquired. If acquired, it may be the result of autonomic,
environmental, medical, or anatomic factors. A complete workup,
especially a detailed history, is essential.
The external nasal valve should be examined for patency
on normal and forced inspiration. Collapse of the alar rim from
weakness of the lower lateral crus should be evaluated.
A Cottle test should be performed to assess the internal nasal
valve. Septal deviation or midvault collapse can contribute to
airway obstruction in this area. Finally, nasal polyps or masses
may require further evaluation and treatment.
61.6 Preoperative Planning
After the initial history-taking and physical examination, the
procedure is fully discussed with the patient. The risks and
benefits of the procedure are detailed, and all questions are
answered. The patient is provided with a written, detailed
estimate of surgical charges with complete explanations by the
practice’s billing staff. :e ask the patient to return for a second
clinic visit to review the previous discussion and to assess the
patient’s psychological and emotional stability to ensure that he
or she is a good surgical candidate. :e also reiterate the defor-
mities we plan to correct and answer any further questions.
The consent form is reviewed again and signed. Our patients
sign a form accepting financial responsibility. A preoperative
instruction sheet and a list of medications to be avoided are also
provided.
Preoperative Instructions
Two Weeks Before Surgery
1. Some medications can interfere with anesthesia and cause
undesirable side effects that can affect your surgery. Please
read over the enclosed medication information list and let
us know if you take any of them. Aspirin or nonsteroidal
anti-inflammatory drugs (NSAIDs) should not be taken at
least 2 weeks before or after surgery. Acetaminophen (e.g.,
Tylenol) is a good medication to take for any aches or pains
you may have before surgery.
2. Smoking will affect how you heal. It is very important to
stop smoking 4 weeks before your surgery.
3. If you develop a cold, a facial sore, or any other illness before
surgery, please notify us.
4. If you are having surgery as an outpatient, please ensure
that arrangements have been made for a responsible adult
to drive you to the surgery center and pick you up after your
surgery and to stay with you for the first 24 hours.
Evening Before Surgery
5. Shampoo your hair and wash your face. Do not use condi-
tioner or hair spray after shampooing.
6. Make some Jell-O and/or soup for after surgery.
7. Get a good night’s rest.
8. Do not eat or drink anything after midnight.
Morning of Surgery
9. Arrive
at
the
surgery
center/hospital
by
__________________.
10. Do not eat or drink anything if your surgery is scheduled
before noon. If your surgery is scheduled after noon, you
may have coffee or tea and dry toast no later than 6 hours
before your scheduled surgery time.
11. Do not wear wigs, hairpins, hairpieces, or jewelry. Dress in
old, loose, comfortable clothes. Do not wear pullover tops
or pantyhose. Wear slip-on shoes.
12. Have someone drive you to the surgery center and make
certain a responsible adult will be available to take you home
and stay with you for 24 hours. Put a pillow and blanket in
the car for the trip home.
:e convert our operative plan into a graphic representation
(using Gunter Graphics; Austin, TX) to assist us in the operating
room. Any modifications to the plan are documented intraop-
eratively on a worksheet, transposed to the graphic depictions
afterward, and placed in the patient’s chart for future reference.
On the morning of surgery, any final questions are answered,
and the patient is taken to the operating room and positioned
supine on the operating table. 1oninvasive hemodynamic mon-
itoring devices are placed, and all pressure points are padded
appropriately. One gram of cefazolin is administered intravenously
for perioperative antibiotic prophylaxis. :e prefer general anes-
thesia for our patients, although local anesthesia with intravenous
sedation may certainly be used. After anesthetic is administered,
the nasal vibrissae are clipped and the nares are swabbed with
povidone-iodine (Betadine) solution.

61 Primary Rhinoplasty
927
:e mark a line for the anticipated incision (transcolumellar
stairstep, if using an open approach) and then inject approx-
imately 10 mL of 1 lidocaine with 1:100,000 epinephrine into
the intranasal mucosa, along the septum, and into the soft tissue
envelope. The inferior turbinates are injected if we anticipate
performing an inferior turbinoplasty (Table 61.3).
After the local anesthetic is injected, the nasal mucosa is shrunk
with cottonoid pledgets soaked in oxymetazoline. A drop of meth-
ylene blue is added to the oxymetazoline to differentiate this from
the local anesthetic and prevent inadvertent injection. :e do not
use 4 cocaine because comparable hemostasis can be obtained
using lidocaine with oxymetazoline, thus avoiding the use of a
controlled substance with potential cardiac effects that may be
seen with cocaine. A throat pack is placed in the oropharynx to
prevent possible ingestion of blood during surgery, which could
lead to postoperative nausea and vomiting. At this point the
patient is prepared and draped for surgery.
61.7 Operative Technique
61.7.1 Incision: Endonasal Approach
:hen deciding on what incision to use in the endonasal
approach, once again the surgeon must employ accurate preop-
erative nasofacial analysis. Because the objective is to minimize
incisions, any incision that can be used to access multiple areas
should be used so that separate incisions become unnecessary.
For example, if an alar contour graft will be needed as well as
rasping of a dorsal hump, the access incision can be made on the
same side as the alar contour graft.
There are two basic techniques for access in endonasal rhino-
plasty: nondelivery and delivery. The nondelivery approach can
use either a transcartilaginous (cartilage-splitting) incision or a
retrograde or eversion incision (Fig. 61.32). The transcartilaginous
Fig. 61.31 Septal deviation can be caused by: (a–c) septal tilt, anteroposterior C-shaped deviation, cephalocaudal C-shaped deviation, (d–f) antero-
posterior S-shaped deviation, cephalocaudal S-shaped deviation, or localized deviation or septal spur.
Table 61.3 Location and volume distribution of 1% lidocaine with
1:100,000 epinephrine
Location
Amount (mL)
Vestibules/aperture
2
Dorsum
1
Lateral walls
2
Tip/columella
2
Distal septum
2
Inferior turbinates
1
Total
10
a
d
c
f
b
e

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incision is made several millimeters cephalad to the caudal
margin of the lateral/middle crura, thus preserving a rim strip to
support the ala. Double-hook retraction combined with digital
alar eversion provides the necessary exposure to facilitate this.
The vestibular skin is carefully dissected off the overlying
cartilage to expose the cartilage for resection. In the retrograde
approach, the vestibular incision is made at the most cephalic
margin of the LLC rather than through it (Fig. 61.33). Again, a
double-hook retractor and digital manipulation are used to facil-
itate exposure. The theoretical advantage to this incision is that
it maintains the caudal alar margins and prevents potential scar
contracture deformities in this area.
The delivery approach is used in cases in which moderate tip
modifications are necessary, especially if the angle of divergence
(as a measure of tip bifidity) is large. Again, using a double-hook
retractor in the ala and digital counterpressure to expose the
cartilaginous margins, a 1o. 15 blade scalpel is used to create
an intercartilaginous incision starting laterally just above the
cephalic margin of the lateral crus. It is extended medially
approximately 2 mm caudal and parallel to the limen vestibuli.
An infracartilaginous incision is then created along the caudal
margin of the L (from lateral crus to medial crus), ending at the
columellar–lobular junction (Fig. 61.34). Sharp scissors are then
used to dissect the soft tissue off the cartilage just above the
perichondrium, including over the dorsal cartilaginous septum.
The same incision is made on the contralateral side, and the two
incisions are connected in the midline over the anterior septal
angle, ending in a hemitransfixion incision. If necessary, this may
be extended to a full (complete) transfixion incision. The LLC is
then dissected free from the surrounding tissue and ´deliveredµ
outside the incision. If there is difficulty delivering the cartilages,
the incisions may be extended and the soft tissue undermined to
a greater extent. Once the cartilages (and domes) are delivered,
modifications may be made.
61.7.2 Incision: Open Approach
In the open approach, we use a stairstep transcolumellar incision
across the narrowest portion of the columella with a 1o. 15 blade
scalpel (Fig. 61.35). The stairstep is important because it helps
to provide landmarks for accurate closure, prevents linear scar
contracture, and camouflages the scar.
Bilateral infracartilaginous extensions are then performed (Fig.
61.36). These begin first from lateral to medial along the caudal
border of the lateral crus, then from medial to lateral, from the
level of the transcolumellar incision to the apex of the middle
crus, where it joins the lateral incision. A double-pronged skin
hook placed along the alar rim is used to perform this maneuver.
External digital pressure is used to evert the ala and facilitate
visualization of the lateral crus.
Important points during this step are as follows:
Fig. 61.32 Cartilage-splitting and transfixion incisions.
Fig. 61.33 In the retrograde approach, the vestibular incision is made
at the most cephalic margin of the lower lateral cartilage rather than
through it.
Fig. 61.34 In the delivery approach, the intercartilaginous incision is
started laterally just above the cephalic margin of the lateral crus. It
is extended medially approximately 2 mm caudal and parallel to the
limen vestibuli. An infracartilaginous incision is then created along the
caudal margin of the lower lateral cartilage (from lateral crus to medial
crus), ending at the columellar–lobular junction.

61 Primary Rhinoplasty
929
• Take your time³most mistakes are made trying to obtain
exposure.
• .eep the incisions superficial to prevent unnecessary injury to
the underlying cartilages.
• Identify the caudal border of the LLC before cutting.
61.7.3 Skin Envelope Dissection
Dissection of the skin envelope should be done meticulously. As
mentioned previously, it is important to perform the dissection in
the supraperichondrial/submusculoaponeurotic plane, because
this avoids injury to the arterial, venous, and lymphatic supply
to the nose. There should be no residual soft tissue remaining on
the LLCs if the dissection is performed properly. This dissection is
then continued in a superior direction, exposing the cartilaginous
dorsum and ULCs. At the level of the bony pyramid, the scissors
are traded for a Joseph periosteal elevator, which continues the
dissection in a subperiosteal plane to the radix (Fig. 61.37). It is
important to limit the extent of the subperiosteal dissection to
just the area of the bony dorsal hump that needs to be addressed;
otherwise, all the periosteal attachments to the nasal bones may
be disrupted, leading to prolonged wound healing and potential
nasal bone malposition, especially after osteotomy.
.ey points are as follows:
• Take your time³it is easier to go slowly through the correct
dissection than to spend more time fixing mistakes from
inadvertent mishaps resulting from haste.
• Stay just above the perichondrium in the submusculoaponeu-
rotic plane.
• Limit lateral subperiosteal dissection over the bony pyramid.
• Make certain the ULCs are not detached from the nasal bones by
accidental dissection under the nasal bones (rather than on top).
Fig. 61.35 In the open approach, we use a stairstep transcolumellar
incision across the narrowest portion of the columella with a No. 15
blade scalpel. The stairstep provides a landmark for accurate closure,
prevents linear scar contracture, and camouflages the scar.
Fig. 61.36 After the stairstep transcolumellar incision, bilateral inf-
racartilaginous extensions are then made, first from lateral to medial
along the caudal border of the lateral crus, then from medial to lateral,
from the level of the transcolumellar incision to the apex of the middle
crus, where it joins the lateral incision.
Fig. 61.37 At the level of the bony pyramid, the scissors are traded
for a Joseph periosteal elevator, which continues the dissection in a
subperiosteal plane to the radix.

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61.7.4 Nasal Dorsum
:e prefer to perform component dorsal hump reduction of
the osteocartilaginous hump instead of composite reduction
because component reduction offers incremental control and
greater precision. This process involves four basic steps, after the
skin envelope dissection just described:
• Separation of the ULCs from the septum
• Incremental reduction of the septum proper
• Incremental dorsal bony reduction (using a rasp)
• Three-point palpation test
Separation of the Upper Lateral Cartilages
From the Septum
To minimize mucosal trauma, which could result in internal
nasal valve stenosis or vestibular webbing, it is critical to create
bilateral dorsal submucoperichondrial tunnels before embarking
on reduction of the dorsal hump. This is done by elevating the
mucoperichondrium of the dorsal septum from caudal to cepha-
lad with a Cottle elevator until the nasal bones are reached (Fig.
61.38). The transverse processes of the ULCs are then sharply
separated from the septum using a 1o. 15 blade scalpel without
damaging the mucosa. If necessary, spreader grafts or dorsal
grafts can then be placed in this enclosed space, separated from
the nasal cavity (later in the case).
Incremental Component Cartilaginous Dorsal
Septal Reduction
At this point, the cartilaginous dorsum is separated into three
components: the septum centrally and the transverse portions
of the ULC laterally. The cartilaginous septum is addressed by
serially shaving down the dorsal hump deformity with a sharp
scalpel under direct vision. This maneuver is done carefully,
avoiding damage to the adjacent ULCs. The ULCs are then trimmed
incrementally to the desired height, taking great care to avoid
overresection. Overresection of the ULCs relative to the septum
may lead to an inverted-V deformity. Although reduction of the
ULCs may not be necessary in the case of small dorsal humps,
it may be necessary in the presence of larger hump reductions.
If so, it must be done after the septal cartilaginous hump and
bony dorsal hump are addressed. It is important to reiterate that
overresection of the ULCs must be avoided in order to prevent
internal nasal valve collapse and long-term dorsal irregularity.
Component Bony Dorsum Reduction
The method of reducing the bony dorsum depends on the amount
of deformity that requires resection. Large humps (generally
greater than 5 mm) are reduced either by a power burr with a
dorsal skin protector or a guarded 8-mm osteotome. For humps
smaller than 5 mm, a sharp rasp is used (we prefer a down-biting
diamond rasp). :hen rasping, it is important to maintain a
slightly oblique bias to minimize potential mechanical avulsion
of the ULCs from the nasal bones. The rasping is done in a con-
trolled, methodical fashion, proceeding along the left and right
dorsal aesthetic lines, and then centrally. The nondominant
thumb and index finger simultaneously stabilize the nasal bones
for maximum control during dorsal reduction (Fig. 61.39).
Three-Point Dorsal Palpation Test
The three-point dorsal palpation test is performed repeatedly
throughout the component dorsal hump reduction process,
after redraping the skin envelope. This test is performed with
a saline-moistened dominant index fingertip, which is used to
gently palpate the left and right dorsal aesthetic lines, as well as
centrally, to detect any dorsal irregularities or contour depres-
sions (Fig. 61.40).
61.7.5 Septal Reconstruction/
Cartilage Graft Harvest
If the septum is deformed, or if cartilage is needed for graft
material, the septum is harvested. The septum is ideal for car-
tilage graft harvest in rhinoplasty because of its close proximity
to the operating field and its minimal donor site morbidity. In
the endonasal approach, a .illian or hemitransfixion incision
is generally used because a full-transfixion incision can lead to
decreased tip projection, especially if dissected down over the
anterior nasal spine.
In the open approach, the cartilage harvest is begun by sep-
arating the middle crura, incising the interdomal suspensory
ligament, and exposing the anterior septal angle. A 1o. 15 blade
scalpel is used to incise the septal perichondrium, exposing the
distinct bluish-gray underlying cartilage. A Cottle elevator is used
to create a submucoperichondrial plane posteriorly to the perpen-
dicular plate of the ethmoid down to the nasal floor and across the
face of the septum (Fig. 61.41).
If the dissection is difficult at first, it may be because the
improper plane has been accessed, and a deeper plane should be
sought. The dissection should be more difficult at the junction
of the cartilaginous and bony septum, and therefore one should
proceed with caution in this area because perforation of the
overlying mucoperichondrium is more likely. It may be advanta-
geous to dissect two separate tunnels, one subperichondrial and
one subperiosteal, and then divide the junction sharply to help
avoid potential perforation in this area. The same dissection is
Fig. 61.38 Elevation of the mucoperichondrium of the dorsal septum
is carried out from caudal to cephalad with a Cottle elevator until the
nasal bones are reached.

61 Primary Rhinoplasty
931
then performed on the contralateral side. After this is complete,
a Vienna speculum is used to visualize both sides of the septum
directly to identify underlying deformity and to help achieve
exposure for the septal harvest.
:hen harvesting septal cartilage, it is necessary to preserve
an L-strut with 10 mm of dorsal septum and 10 mm of caudal
septum retained to support the lower nasal vault (Fig. 61.42).
After the cartilage is resected, it is preserved in saline solution.
Any residual deviations in the ethmoid or vomer are rongeured or
resected, and any mucosal perforations are repaired.
61.7.6 Correction of the Deviated Nose
Septal deviation, described previously in this chapter, can man-
ifest as external deviation of the nose. :e classify the deviated
nose into three basic types: caudal septal deviations, concave
dorsal deformities, and concave/convex dorsal deformities.
&ODVViÀFDWiRn RI WKe 'eYiDWed 1RVe
• Type I: Caudal septal deviation
̑ Straight septal tilt
̑ Concave deformity (C-shaped)
̑ S-shaped deformity
• Type II: Concave dorsal deformity
̑ C-shaped dorsal deformity
̑ Reverse C-shaped dorsal deformity
• Type III: Concave/convex dorsal deformity (S-shaped)
Correction of the deviated nose is based on the following
principles:
1. The open approach to expose all deviated structures
2. Release of all mucoperichondrial attachments to the septum,
especially the deviated part
3. Straightening of the entire septum while maintaining a 10-mm
caudal and dorsal L-strut
4. Restoration of long-term support with buttressing caudal septal
batten or dorsal spreader grafts
5. Outfracture or submucous resection of hypertrophied antero-
inferior turbinates, if necessary, for correction of the deviated
septum
6. Precisely
planned
and
executed
external
percutaneous
osteotomies
61.7.7 Inferior Turbinoplasty
In patients with symptomatic nasal airway obstruction caused
by inferior turbinate hypertrophy that is refractory to medical
management, an inferior turbinoplasty is performed. This can be
done by turbinate outfracture, submucous morselization of the
Fig. 61.39 The nondominant thumb and index finger are used simulta-
neously to stabilize the nasal bones for maximum control during dorsal
reduction.
Fig. 61.40 The three-point dorsal palpation test is performed with a
saline-moistened dominant index fingertip, which is used to gently
palpate the left and right dorsal aesthetic lines, as well as centrally, to
detect any dorsal irregularities or contour depressions.
Fig. 61.41 Cartilage harvest technique. (1) A No. 15 blade scalpel
is used to incise the septal perichondrium, exposing the distinct
bluish-gray underlying cartilage. A Cottle elevator is used to create a
submucoperichondrial plane posteriorly to the perpendicular plate of
the ethmoid (2) down to the nasal floor (3) and across the face of the
septum (4 ).

932
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turbinate bone, or submucous resection of the anterior one-third
to one-half of the inferior turbinate. The submucous resection
is done by developing medial mucoperiosteal flaps, exposing
the conchal bone using a Cottle elevator, and sharply resecting
the proper amount. The flaps are replaced after this resection
without the need for suture repair (Fig. 61.43). It is important to
note that the extent of the conchal bone resection is limited to
the anterior portion. This is done mainly to avoid complications
of bleeding if the posterior portion is resected.
61.7.8 Cephalic Trim
In cases in which the tip is boxy or bulbous and requires better
refinement and definition, when the tip-defining points need
medialization, or when rotation of the tip is desired, a cephalic
trim is performed. This is done by using a caliper to measure
along the caudal margin of the LLC to preserve a 6 mm rim strip.
After this is demarcated, the cephalic portion of the middle and
lateral crura is resected (Fig. 61.44). The cartilage is preserved
for possible use later in the case.
61.7.9 Lower Lateral Crural
Turnover Flap
A lower lateral crural turnover flap is another useful technique to
address peridomal fullness while providing additional support
to the lateral crusra of the LLCs. It is beneficial for deformities,
weakness, and collapse of the lateral crura and can also be used
Fig. 61.43 Inferior turbinoplasty can be done by turbinate outfracture, submucous morselization of the turbinate bone, or submucous resection of
the anterior one-third to one-half of the inferior turbinate.
Fig. 61.42 When harvesting septal cartilage, it is necessary to
preserve an L-strut with 10 mm of dorsal septum and 10 mm of caudal
septum retained to support the lower nasal vault.

61 Primary Rhinoplasty
933
to improve lateral crural strength during tip reshaping. However,
there must be sufficient lower lateral crura to leave a 6-mm rim
strip. It can be used in combination with other external valve and
alar arch supporting techniques.
A horizontal line that bisects the cephalic aspect of the lower
lateral crus from the 6-mm rim strip is marked with methylene
blue. The cephalic aspect is dissected from the underlying ves-
tibular skin inferiorly to this horizontal line, and then the line
is scored with a 1o. 15 blade. 1ext, 2-mm full-thickness cuts at
the medial and lateral ends of the horizontal line are made. The
flap is turned over, and its caudal edge is secured with multiple
horizontal mattress sutures (Fig. 61.45).
61.7.10 Autospreader Flaps
Reduction of the nasal dorsum may compromise the internal
nasal valves. Even a slight decrease in the angle between the ULC
and the septum can lead to a significant increase in nasal airway
resistance. Patients who have a high, narrow dorsum, a weak
middle vault, short nasal bones, or a positive Cottle test preop-
eratively are at risk for developing postoperative internal nasal
valve dysfunction and, consequently, nasal airway obstruction.
In these cases, the use of autospreader flaps fashioned from the
dorsal aspects of the ULCs can maintain patency of the internal
nasal valves while preserving the dorsal aesthetic lines (Fig. 61.46).
After component dorsal hump reduction has been performed, the
overprojecting dorsal aspect of the ULCs is incised, leaving the
underlying mucoperichondrium intact. This dorsal portion of the
ULC is then rotated internally approximately 90ƒ to lie between
the septum and the medial edge of the ULCs, supported as a flap
by its attachment to the mucoperichondrium. The new dorsal
edges of the ULCs are then sutured with 5–0 polydioxanone
suture (PDS) at the midline to the rotated autospreader flaps and
secured along the septum.
Limitations using this technique include patients with a devi-
ated dorsal septum or asymmetric dorsal aesthetic lines. Spreader
grafts are indicated in these cases.
61.7.11 Spreader Grafts
Spreader grafts can be used to help stent open the internal valve,
stabilize the septum, and preserve the dorsal aesthetic lines (Fig.
61.47). These grafts usually are obtained from septal cartilage
and are designed to measure approximately 25 to 30 mm by 3
mm. Their cephalic ends can be trimmed obliquely to fit snugly
underneath the bony dorsum, and their caudal ends can be placed
either at the septal angle (if lengthening of the nose is not desired)
or extending past it (if lengthening is desired). Furthermore, the
grafts can be placed flush with the anterior septum or slightly
recessed. Placing the grafts flush with the septum will create a
wider- and flatter-appearing dorsum, while recessing the grafts
slightly will create a more rounded dorsum. :e secure the grafts
with 5–0 PDS in a horizontal mattress fashion.
Fig. 61.44 The cephalic trim is first marked using a caliper to measure
along the caudal margin of the lower lateral cartilage to preserve a
6-mm rim strip. After this is demarcated, the cephalic portion of the
middle and lateral crura is resected.
Fig. 61.45 Demonstration of the lower lateral crural turnover flap:
The cephalic aspect of the lateral crus is dissected from the underlying
vestibular skin inferiorly. A No. 15 blade is used to score the cartilage,
and 2-mm full-thickness cuts are made at the medial and lateral
ends of the horizontal line. The flap is turned over while maintaining
a minimum of a 6-mm width, and its caudal edge is secured with
multiple horizontal mattress sutures. (Reproduced with permission
from Janis JE, Trussler A, Ghavami A, Marin V, Rohrich RJ, Gunter JP.
Lower lateral crural turnover flap in open rhinoplasty. Plast Reconstr
Surg. 2009; 123:1830-1841.)

934
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61.7.12 7iS 0RdiÀFDWiRn
Altering Tip Projection
It is important to recognize the factors that contribute to tip pro-
jection in situ before embarking on a discussion on how precisely
to alter tip projection. The following are key anatomic elements
affecting tip projection:
1. The length and strength of the LLCs
2. The fibrous connections between the ULCs and LLCs (and
septum)
3. The abutment of the cartilages with the piriform aperture
4. The anterior septal angle
Alteration of any of these anatomic structures can result in
incremental changes in tip projection.
A graduated approach to tip projection is predicated on precise,
incremental, nondestructive changes made to the tip complex,
beginning with placement of a columellar strut graft, proceeding
with suture modification, and finishing with the use of tip grafts.
The algorithm begins with placement of a columellar strut graft.
This strut is usually fashioned from septal cartilage and measures
approximately 25 ð 4 mm. It can be placed in a ´fixedµ (secured
to the anterior maxilla) or a ´floatingµ (not secured to the max-
illa) fashion. This strut not only controls the columellar profile,
but also bolsters tip projection and unifies the tip complex. The
strut is placed by dissecting a pocket between the medial crura.
A double-pronged hook is then used to retract the middle crura
gently anteriorly to set the desired projection and symmetry. The
strut is positioned in the pocket, and a 25-gauge needle is used to
stabilize this configuration. Most struts are left floating on a soft
tissue pad between the base of the pocket and the nasal spine.
Medial crural sutures are placed in horizontal mattress fashion to
secure the complex. Further medial crural sutures can be placed
more caudally on the medial crura to control flaring, if necessary.
The next step in altering tip projection involves suture tech-
niques, which can increase tip projection by 1 to 2 mm. Suture
techniques are ideal for controlling cartilage in a precise, nonde-
structive fashion. Although the choice of a particular suture mate-
rial is surgeon dependent, the underlying premise is to choose a
material that one can easily work with and will hold the cartilage
in its altered position long enough to allow the natural fibrosis
to solidify the result. Although many suture techniques can be
performed in both open and closed rhinoplasty (with cartilage
Fig. 61.46 Demonstration of the autospreader flap. The dorsal portion
of the upper lateral cartilage is rotated internally approximately 90°
to lie between the septum and the medial edge of the upper lateral
cartilages, supported as a flap by its attachment to the mucoperi-
chondrium. The new dorsal edges of the upper lateral cartilages are
then sutured at the midline to the rotated autospreader flaps with 5–0
polydioxanone suture and secured along the septum.
Fig. 61.47 Spreader grafts approximately 25 to 30 mm are placed along
the dorsal septum and sutured in place to help stent open the internal
valve, stabilize the septum, and preserve the dorsal aesthetic lines.

61 Primary Rhinoplasty
935
delivery), we find them easier to place using the open technique
because it affords greater visualization and ease of placement.
:e commonly use four suture techniques to alter projection and
shape the nasal tip:
1. Medial crural
2. Medial crural-septal
3. Interdomal
4. Transdomal
Medial crural sutures serve to unify the medial crura of the LLCs
and are frequently used in conjunction with a columellar strut
(to help stabilize the strut) (Fig. 61.48). They can also be used to
reduce flaring of the footplates of the medial crura or to decrease
the angle of divergence between the middle crura, thereby effect-
ing an increase in projection, albeit to a limited degree. :e gener-
ally use 5–0 PDS in horizontal mattress fashion for this technique;
however, the suture choice can vary by individual preference.
Interdomal sutures are placed through the medial walls of the
domes in a mattress fashion and tied to narrow the interdomal
distance (Fig. 61.49). This results in both an increase in tip refine-
ment and an increase in projection.
Transdomal sutures are placed across the dome in mattress
fashion to narrow the arch of the dome and create more tip
definition (Fig. 61.50). Local anesthetic can be used to hydrodis-
sect a plane between the cartilaginous dome and the adherent
underlying mucoperichondrium to help prevent inadvertent
incorporation of the vestibular lining into the suture bite. :e
generally use 5–0 PDS in horizontal mattress fashion, placing the
knots on the medial aspect of the domes. These sutures can be
made asymmetric to correct anatomic asymmetries if necessary.
It is important, however, to prevent overtightening of this suture,
which can result in an unnaturally sharp tip-defining point.
If more tip projection or definition is desired after the maneu-
vers just described, tip grafts may be used. :e find it easier to
place these grafts using the open approach because it allows
direct visualization and precise placement and facilitates subse-
quent manipulation if necessary. It should be noted that grafts,
in general, have a tendency to become visible, so their use is
reserved only for the patient in whom the prior, more predictable
methods do not result in satisfactory tip projection. There are two
general types of tip grafts:
1. Onlay tip grafts
2. Infratip lobular grafts
The onlay tip graft can be fashioned from any type of cartilage,
although we find that the cartilage obtained from the cephalic
trim harvest works exceptionally well. This graft is placed in a
position overlying the domes and fixed in place (Fig. 61.51). :e
generally use 5–0 PDS for this, with the knots positioned under-
neath the dome.
The infratip lobular graft is positioned with its superior margin
overlying the dome and tip-defining points and extending infe-
riorly a variable distance, usually 10 to 12 mm (Fig. 61.51). It is
usually shield-shaped and has rounded graft edges to avoid a
Fig. 61.48 The medial crural suture.
Fig. 61.49 The interdomal suture.

936
X Rhinoplasty
visible and palpable stepoff. This graft increases infratip lobular
definition and projection and is secured with interrupted 5–0 PDS.
:hen trying to decrease nasal tip projection, once again it is
important to realize the anatomic factors that contribute to tip pro-
jection. If the support derived from the fibroelastic and ligamen-
tous attachments is disrupted, tip projection becomes primarily
dependent on the length and strength of the LLCs. Therefore, in
the open approach, if the skin envelope has been undermined and
these fibroelastic tissues have been severed, the primary means
of decreasing tip projection lies in altering these LLCs. This may
include techniques such as transection, setback, and resuturing of
the medial or lateral crura. Deprojection by affecting the medial
crura will slightly rotate the tip complex caudally, whereas affect-
ing the lateral crura will slightly rotate the tip cephalically. It is
also important to recognize that if the tip projection is decreased
significantly, alar flaring or columellar bowing may result, which
would necessitate correction (Fig. 61.52).
Altering Tip Rotation
Using the nasofacial analysis techniques described, rotation is
evaluated by the nasolabial angle. This angle, found by measur-
ing 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, should be
between 95ƒ and 100ƒ in women and between 90ƒ and 95ƒ in
men, as previously discussed.
To alter tip rotation, the extrinsic forces holding the tip at its
current angle must be released. This is generally done by severing
the connection between the LLC and ULC. This frequently takes the
form of a cephalic trim, as described previously. Furthermore, the
fibrous attachments of the medial crura and the caudal septum
can be transected to release tension on the nasal tip and allow
more cephalad rotation. This is generally achieved by resecting a
variable amount of the caudal septum (Fig. 61.53).
Depending on the amount of tip rotation, it may be necessary to
perform a limited resection of the nasal mucosa and membranous
septum to maintain proper nasal balance and harmony. After the
tip is rotated, its position is maintained with suture techniques
(medial crural septal sutures) and/or a columellar strut or septal
extension graft.
61.7.13 Alar Rims
Alar contour grafts are used as a simple and effective method to
correct and prevent alar notching or retraction. A subcutaneous
pocket below the infracartilaginous incision and parallel to the
alar rim is created with dissection scissors. The pocket should
span the length of the deformity and extend 3 mm to each side of
it. An alar contour graft is typically 3 ð 10 mm, but it may be need
to be larger, depending on the desired effect (Fig. 61.54).
61.7.14 Lateral Crural Strut Grafts
Lateral crural strut grafts are used to support weak lateral crura,
prevent collapse of the external nasal valve, address malposition
of the lateral crura, or increase tip projection. The vestibular skin
is dissected from the deep surface of the posterior surface of the
lateral crus. If the intention is to bolster or straighten the lateral
crus, the strut graft is simply placed behind the lateral crus and
fixed in position with 5–0 PDS horizontal mattress sutures (Fig.
61.55).
If caudal repositioning of the lateral crus is intended, the lateral
crus is separated from the accessory cartilages. A subcutaneous
pocket below and adjacent to the accessory cartilages is dissected
posteriorly to the piriform aperture. To correct malposition of the
lateral crura, the pocket is dissected below the infracartilaginous
incision and parallel to the alar rim. A 4 ð 25 mm lateral crural
strut graft is placed in the pocket and rests on the piriform aper-
ture posteriorly. The anterior aspect of the graft is placed deep to
the lateral crus and secured with two or three 5–0 PDS horizontal
mattress sutures.
Fig. 61.50 The transdomal suture.
Fig. 61.51 The onlay tip graft (left) and the infratip lobule graft (right).
Fig. 61.52 If the tip projection is decreased significantly, alar flaring or
columellar bowing may result, which will necessitate correction.

61 Primary Rhinoplasty
937
61.7.15 Correcting the Alar–Columellar
Relationship
Class I Deformity
:hen the patient has a class I deformity, or when the long axis–
columellar rim distance (BC in Fig. 61.26) is greater than 2 mm
and the alar rim–long axis distance (AB in Fig. 61.26) is normal,
this is an example of a true hanging columella. Correcting this
involves resecting either the caudal septum, the caudal portion
of the medial crus, the caudal portion of the middle crus, or a
combination of these depending on which is responsible for the
deformity (Fig. 61.56).
Class II Deformity
A class II deformity, or a retracted ala (AB greater than 2 mm,
BC less than 2 mm), is treated in several ways. One method is
to insert an elliptically shaped composite graft from an access
incision made in the vestibular skin. The graft is made slightly
larger than is needed to compensate for secondary contraction.
If the retraction is mild and there is no tissue deficiency present,
an alternative technique can be used where the lateral crura are
detached from the accessory chain and repositioned inferiorly.
A final method is to place an alar contour graft (nonanatomic
position) in a pocket created along the vestibular rim to displace
the ala inferiorly (Fig. 61.57).
Class III Deformity
A class III deformity is a combination of a class I and class II
deformity and is therefore corrected with a combination of the
two procedures (Fig. 61.58).
Class IV Deformity
A class IV deformity is a hanging ala (AB less than 1 mm, BC less
than 2 mm). This is usually treated with an elliptical excision of
vestibular skin (Fig. 61.59). Care is taken to avoid overresection
of skin in this maneuver because an abnormal, rolled-in appear-
ance of the alar rim can result.
Class V Deformity
A class V deformity is a retracted columella (AB less than 2 mm,
BC less than 1 mm). The treatment of choice for this deformity
is placement of a columellar strut, which is positioned more
caudally to extend the caudal dimension of the columella. A
septal extension graft and a columellar onlay graft are additional
options to address a retracted columella (Fig. 61.60).
Fig. 61.53 Cephalic rotation of the tip can be achieved by cephalic trim of the lower lateral cartilages as well as resection of the caudal septum.
Fig. 61.54 Alar contour grafts.
Fig. 61.55 The lateral crural strut graft.

938
X Rhinoplasty
Class VI Deformity
A class VI deformity is a combination of class IV and class V and
is treated with a combination of the techniques described (Fig.
61.61).
61.7.16 Osteotomies
Osteotomies are a powerful technique in rhinoplasty. The indi-
cations to perform osteotomies, regardless of technique, are as
follows:
• To narrow the lateral walls of the nose
• To close an open-roof deformity (after dorsal hump reduction)
• To create symmetry by straightening the nasal bony framework
Contraindications to osteotomies can include patients with
short nasal bones; elderly patients with thin, fragile nasal bones;
and patients with heavy eyeglasses. There are several osteotomy
techniques, including medial, lateral, transverse, or a combination
of these. Furthermore, they can be performed through either an
external or an internal approach.
A lateral osteotomy may be performed as low-to-high, low-
to-low, or double-level (Fig. 61.62). They may be combined with
medial, transverse, or greenstick fractures of the upper bony seg-
ment as well. Regardless of the technique used in performing the
lateral osteotomy, it is important to maintain a smooth fracture
line by staying low along the bony vault, thereby preventing the
potential for a step-off deformity. The cephalic margin of the oste-
otomy should not be higher than the intercanthal line (the level of
the medial canthi); the thick nasal bones above this level increases
the technical difficulty, and it is possible to cause iatrogenic injury
to the lacrimal system (with resultant epiphora).
A low-to-high osteotomy is generally used to correct a small
open roof deformity or to mobilize a medium-to-wide nasal base.
It begins low at the piriform aperture and ends high medially on
the dorsum. The nasal bones are then ´greenstickedµ to medial-
ize them, with predictable fracture patterns obtained based on
nasal bone thickness. Occasionally, a separate superior oblique
osteotomy is necessary to mobilize thicker nasal bones enough
to be ´greensticked.µ A low-to-low osteotomy is generally a more
powerful technique in that it results in more medial movement
of the nasal bones and therefore is classically used when there
is a large open-roof deformity or if a wide bony base requires
Fig. 61.56 Class I deformity and methods for correction.

61 Primary Rhinoplasty
939
correction. It starts low along the piriform aperture and continues
low along the base of the bony vault to end in a lateral position
along the dorsum near the intercanthal line. As there is more bone
between the cephalic aspect of this osteotomy and the midline,
this type of osteotomy technique is frequently accompanied by
a medial osteotomy to mobilize the nasal bones better to achieve
the desired result.
:e have refined our preferred technique of external perforated
lateral osteotomies, which has proved to be well controlled, pre-
dictable, and reproducible. Furthermore, there are certain unique
advantages to this technique based on the preservation of the
periosteal attachments, namely:
• Decreased amount of dead space
• Reduced subluxation and subsequent airway compromise
• Greater overall stability after positioning
The technique is as follows:
1. Inject both intranasally and along the lateral nasal sidewalls
with 2 mL of 1 lidocaine with 1:100,000 epinephrine, allowing
5 to 7 minutes for the hemostatic process to take effect.
2. Introduce a sharp 2-mm osteotome percutaneously on the mid-
portion of the bony nasal pyramid at the level of the inferior
orbital rim and nasofacial junction. It must be held at a plane
parallel to the surface of the maxilla.
3. To avoid injury to the angular artery, sweep the osteotome down
the lateral nasal sidewall in a subperiosteal plane.
Fig. 61.57 Class II deformity and methods for correction.

940
X Rhinoplasty
4. Position the osteotome at an angle such that one edge is in con-
tact with the bone and strike with the mallet (Fig. 61.63). The
endpoints are a change in the feel and sound at that location.
5. Extend the osteotomy in an inferior, superior, and superi-
or-oblique manner at the level of the piriform. Leave a 2-mm
gap between individual osteotomies (Fig. 61.64).
6. Perform the same procedure on the contralateral nasal wall.
7. After the osteotomies are completed, use gentle pressure
between the thumb and forefinger to perform a greenstick
fracture of the nasal bones to position them in the desired
location.
8. Cover with flesh-colored Steri-Strips (3M, St. Paul, M1) and
apply a dorsal compression splint (Denver splint), which is kept
in place for 7 days to minimize postoperative edema (Fig. 61.65).
Medial osteotomies are used to facilitate medial positioning
of the nasal bones (Fig. 61.66). They are generally indicated in
patients with thick nasal bones or a wide bony base to achieve a
more predictable result, because greenstick fractures in these sub-
groups can sometimes be difficult and can lead to unpredictable
fracture patterns. Medial osteotomies can be used in conjunction
with lateral osteotomies; however, it is not necessary to use both
Fig. 61.58 Class III deformity.
Fig. 61.61 Class VI deformity.
Fig. 61.59 Class IV deformity and methods for correction.
Fig. 61.60 Class V deformity and methods for correction.

61 Primary Rhinoplasty
941
Fig. 61.65 Application of Steri-Strips and a dorsal compression splint (Denver splint).
Fig. 61.64 Lateral percutaneous low-to-low osteotomy.
Fig. 61.63 Most efficient cutting angle of the osteotome.
Fig. 61.62 Schematic depiction of lateral low-to-low, low-to-high, and double level osteotomies.

942
X Rhinoplasty
types in all cases. :hen both techniques are used, the medial
osteotomy is usually performed first because doing so makes it
technically easier to perform subsequent lateral osteotomies.
Although the cant of the medial osteotomy can be varied (such
as medial oblique, paramedian, or transverse), for the reasons
just stated, the cephalic margin should not cross the intercanthal
line. After the medial and lateral osteotomies are created, the
nasal bones are greensticked, as described earlier, to the desired
position.
Occasionally, a double-level lateral osteotomy is needed to
correct lateral wall convexities that are too great to be corrected
with a standard single-level lateral osteotomy or when significant
lateral nasal wall asymmetries exist (Fig. 61.67). This is done by
first making the upper (more medial) lateral osteotomy along the
nasomaxillary suture line. The lower (more lateral) of the two is
then created in standard low-to-low fashion.
Regardless of the operative technique, there are potential com-
plications associated with osteotomies (Table 61.4).
61.7.17 Closure
After excellent hemostasis is achieved and the wound is irrigated
to remove any excess debris, the skin envelope is redraped. If the
patient has thick skin, and especially if the patient is a woman,
we may choose to place a single 6–0 polyglycolic acid (Vicryl,
-ohnson -ohnson, Somerville, 1-) suture from the dermis
(underside of the skin envelope) to the underlying cartilaginous
framework in an attempt to recreate a supratip break.
The transcolumellar incision is then closed using 6–0 nylon
suture in simple interrupted fashion, making sure the coaptation
of the incision margins is precise (Fig. 61.68). The stairstepping
of the original incision facilitates accurate closure. The infracarti-
laginous incisions are reapproximated using 5–0 chromic suture
in a simple interrupted fashion. :e take special care to prevent
overbiting with the suture, which can create contour irregularities
and notching, especially in the soft triangle area.
If septal work has been performed, we place intranasal Silastic
(Dow Corning, Midland, MI) splints coated with antistaphylo-
coccal antibiotic ointment. These are secured with a transseptal
3–0 nylon suture. The nasal dorsum is then carefully taped, and
a malleable metal splint is applied over the dorsum (Fig. 61.69).
A drip pad is fashioned from a 2 ð 2 gauze and secured under
the nose with 0.5-inch paper tape. The throat pack is removed,
and the oropharynx and stomach are carefully suctioned to help
evacuate any blood, which may result in postoperative nausea and
vomiting.
61.7.18 Alar Base Surgery
In cases in which alar base surgery is necessary, it is generally
performed after closure of the transcolumellar and infracarti-
laginous incisions but before intranasal and external splints are
placed.
Analysis of the alar base was discussed earlier in the chapter.
Based on proper and precise nasofacial analysis, alar base abnor-
malities may be diagnosed, which may include wide or excessive
nostril sills, a wide alar base, asymmetric or malpositioned alar
bases, or any combination of these.
:ide nostril sills, or alar flaring, are a relatively common prob-
lem. This is corrected by performing a small crescentic resection
of the alar base, making sure to avoid extending the incision into
Fig. 61.66 Medial osteotomies.
Fig. 61.67 Double-level osteotomy.

61 Primary Rhinoplasty
943
the actual vestibule (Fig. 61.70). The incision is placed approxi-
mately 1 to 2 mm above the true alar base. The soft tissue at the
base is mobilized with judicious use of electrocautery and then
transposed medially to the desired aesthetic endpoint, where it
is sutured in place. :e suture using the ´halving principleµ in this
region because the interior incision is shorter than the exterior
incision.
A wide alar base is corrected in a similar fashion; however,
the crescentic excision assumes a more wedge-type geometry
and may include a small portion of the nostril sill (Fig. 61.71). If
a transcolumellar incision was used at the start, it is crucial that
the alar base excision stay within 3 mm of the lateral alar groove,
because the blood supply to the nasal tip can be jeopardized if the
lateral nasal artery is inadvertently injured.
Although some have advocated suture techniques for narrow-
ing the nasal base, we generally accomplish this with excisional
techniques, as just described.
61.8 Postoperative Management
All preoperative and postoperative instructions are given to
the patients in writing before as well as on the day of surgery.
Postoperatively, we routinely prescribe the following:
• Methylprednisolone (Medrol Dosepak, Upjohn, .alamazoo,
MI) for 7 days (to minimize postoperative edema)
• Hydrocodone/acetaminophen 5:500 for postoperative pain
every 4 to 6 hours as needed
Table 61.4 Potential complications of lateral nasal osteotomies
Infections
Operative trauma
Cosmetic problems
• Local
̑ Abscess
̑ Cellulitis
̑ Granuloma
• Systemic
• Intracranial
• Hemorrhage (hematoma, ecchymosis)
• Edema
• Nasal cyst formation
• Anosmia
• Arteriovenous fistula
• Epiphora
• Canalicular bleeding
• Neuromuscular injury
• Intracranial injury
• Excessive narrowing or convexity
• Insufficient mobilization of lateral bony walls
• Unstable bony pyramid
• Redundant soft tissue
• Stairstep deformity
• Nasal bone asymmetry
Fig. 61.68 Closure of the transcolumellar incision.
Fig. 61.69 If septal work has been performed, intranasal Silastic splints coated with antistaphylococcal antibiotic ointment are placed and secured
with a transseptal 3–0 nylon suture. The nasal dorsum is then carefully taped, and a malleable metal splint is applied over the dorsum.

944
X Rhinoplasty
• 1ormal nasal saline solution for postoperative nasal congestion
• Antibacterial ointment to incisions three times daily
The patient is instructed to keep the head of the bed elevated
at an angle of 45ƒ beginning immediately after surgery to help
minimize postoperative swelling. Cool compresses are used
periorbitally during the day for the first 48 hours. Antibacterial
ointment is applied three times daily to the incisions after gentle
cleaning with a half-strength hydrogen peroxide–saline solution.
The patient is instructed to change the drip pad under the nose
as necessary until the drainage stops, at which time the pad and
tape can be discontinued. Any manipulation of the nose, including
rubbing, blotting, or blowing, is discouraged for the first 3 weeks
postoperatively. Sneezing should be done through the mouth
during this time. It is imperative to keep the nasal splint dry, and
the patient’s hair should be washed as in a beauty salon, with the
patient leaning the head backward over the sink.
:e maintain our patients on a liquid diet on the day of surgery,
which is subsequently advanced the following day to a soft regular
diet. Any foods that require excessive lip movements, such as
eating apples or corn on the cob, should be avoided for 2 weeks
after surgery.
During the first 2 weeks, nasal congestion may be minimized by
the use of normal saline nasal spray and over-the-counter nasal
decongestant sprays such as Afrin (oxymetazoline). However,
the use of Afrin should be limited because cessation can cause
rebound nasal congestion. If patients have difficulty with the
passage of air through the intranasal splints, they are encouraged
to breathe through their mouth. If the patient is very congested,
in-office suctioning may be warranted.
:e ask the patient to return on postoperative day 5 to 7, at
which time the sutures and nasal splints are removed. The nose
(especially the tip) may appear swollen and turned up, and the
tip may feel numb, but the patient is reassured that this is to
be expected and will resolve with time, with normal sensation
returning within 3 to 6 months. The patient cannot let anything,
including eyeglasses, rest on the nose for at least 4 weeks. Glasses
should be taped to the forehead. Contacts can be worn as soon as
the swelling has diminished enough to allow easy insertion (usu-
ally less than 5 to 7 days postoperatively). Patients are instructed
to avoid direct sunlight and to wear sunscreen of SPF 30 or higher
to prevent possible hyperpigmentation of the scar.
:e ask our patients to restrict strenuous activity that increases
their heart rate (above 100 beats/min) or blood pressure for 3
weeks after surgery. After that, they can gradually resume normal
activity. Obviously, any contact sports or activities that may cause
direct trauma to the nose are prohibited for at least 4 weeks after
surgery. Although some patients’ noses look excellent within 6 to
8 weeks, some may remain swollen for up to 1 year, but after 3 to
4 weeks such swelling will generally not be obvious to anyone but
the patient.
After the first postoperative visit (within the first week), we
ask the patient to return to the clinic at 3 and 8 weeks after the
operation. :e continue to follow the patient 3, 6, and 12 months
after surgery, and then annually thereafter.
61.9 Outcomes
Although it is difficult to determine an exact revision rate fol-
lowing primary rhinoplasty, a survey of plastic surgeons and
otolaryngologists revealed that 58 of those surveyed cited their
revision rate less than 5. This survey also revealed that the open
approach was preferred by 73 compared with 20 preferring
the closed approach for revision rhinoplasty.
In the senior author’s practice, approximately one in 25 primary
rhinoplasty patients requires revision. The most frequent reasons
for reoperation include further tip refinement or correction of
tip asymmetries (lower third), ´polly beakµ or pinched supratip
Fig. 61.70 Wide nostril sill, or alar flaring, is corrected by performing
a small crescentic resection of the alar base, making sure to avoid
extending the incision into the vestibule.
Fig. 61.71 A wide alar base is corrected in a similar fashion to alar
flaring, but the crescentic excision assumes a more wedgelike geome-
try and may include a small portion of the nostril sill.

61 Primary Rhinoplasty
945
deformity (middle third), and excessive dorsal reduction or dorsal
irregularities (upper third).
Functionally, continued nasal airway obstruction after primary
rhinoplasty has, in our experience, usually been from excessive nar-
rowing of the internal valve (without placement of spreader grafts).
:e used to see this more frequently when we performed more
aggressive resection of the transverse processes of the ULCs. Once
we adopted the component dorsal hump reduction technique with
preservation of the ULCs, the incidence of internal valve obstruction
decreased and the need for spreader grafts greatly diminished.
61.10 Results
61.10.1 Patient Example 1
The healthy 24-year-old woman shown in Fig. 61.72 presented
for cosmetic rhinoplasty without nasal airway obstruction. She
was unhappy with the appearance of her boxy tip and desired
correction. The frontal view demonstrates adequate dorsal
aesthetic lines, but asymmetric fullness of her supratip. Her left
LLC segment is more obliquely rotated than the right LLC. She
has excess lateral alar convexity with preoperative alar notching.
Operative Goals
1. Drastically refine the tip and narrow the tip-defining points.
2. Correct the lateral alar convexity and alar notching.
Surgical Plan
1. Open approach with transcolumellar stairstep incision connect-
ed to bilateral infracartilaginous incisions
2. Cephalic trim of lateral and middle crura leaving a 6-mm rim
strip
3. Medial crural, interdomal, and transdomal suturing
4. Bilateral alar contour grafts to correct lateral alar convexity and
prevent alar notching
This surgical plan is shown in Fig. 61.73.
Results
Comparison of preoperative and 15-month postoperative views
(Fig. 61.74) demonstrates improvement of dorsal aesthetic lines
and correction of her boxy tip. She has dramatic tip refinement,
with reduction of supratip fullness and narrowed tip-defining
points. Placement of alar contour grafts has corrected the lateral
alar convexity and prevented alar notching.
61.10.2 Patient Example 2
The healthy 24-year-old woman shown in Fig. 61.75 had aes-
thetic as well as functional concerns. Aesthetically, she did not
like her dorsal nasal contour and boxy, asymmetrical nasal tip.
Functionally, she complained of left nasal airway obstruction.
The lateral view demonstrates a slight dorsal hump, supratip
fullness, decreased tip projection, and a columellar–labial angle
Fig. 61.72 Patient example 1, preoperative. (Reproduced with permis-
sion from Rohrich, RJ, Adams WP Jr. The boxy nasal tip: classification
and management based on alar cartilage suturing techniques. Plast
Reconstr Surg. 2001; 107:1849-1863.)
Fig. 61.73 Patient 1, surgical plan. (Reproduced with permission from
Rohrich, RJ, Adams WP Jr. The boxy nasal tip: classification and man-
agement based on alar cartilage suturing techniques. Plast Reconstr
Surg. 2001; 107:1849-1863.)

946
X Rhinoplasty
of 100ƒ. Her basal view confirms an asymmetrical tip with left-
sided alar collapse. The left LLC is concave; the right is convex.
Her intranasal examination revealed left-sided deflection of the
caudal septum.
Operative Goals
1. Remove the small dorsal hump.
2. Decrease the tip rotation.
3. Correct the tip asymmetry.
Fig. 61.74 Patient example 1. (a,c,e,g,i,k) Preoperative and (b,d,f,h,j,l) 15 months postoperative. (Reproduced with permission from Rohrich,
RJ, Adams WP Jr. The boxy nasal tip: classification and management based on alar cartilage suturing techniques. Plast Reconstr Surg. 2001;
107:1849-1863.)
a
e
i
b
f
j
c
g
k
d
h
l

61 Primary Rhinoplasty
947
4. Refine the tip and reestablish tip-defining points.
5. Correct the left external nasal valve collapse and concave left
LLC.
6. Prevent postoperative alar retraction.
Surgical Plan
1. Open approach with transcolumellar stairstep incision connect-
ed to bilateral infracartilaginous incisions
2. Component reduction of dorsum (2 mm)
3. Caudal septal resection with medial crural setback sutures to
decrease tip rotation
4. Septal cartilage harvest leaving a 10-mm L-strut
5. Left lower lateral crural turnover flap to correct concave left LLC
6. Right cephalic trim leaving a 6-mm rim strip
7. Bilateral spreader grafts
8. Medial crural, interdomal, and transdomal suturing
9. Columellar strut
10. Lateral osteotomies (external perforated)
11. Bilateral alar contour grafts to prevent alar retraction
This surgical plan is shown in Fig. 61.76.
Results
Comparison of the patient’s preoperative and 12-month postoper-
ative appearance (Fig. 61.77) demonstrates a straight dorsum and
a unified tip complex with correction of her tip asymmetry. The
lateral view confirms the straight dorsal profile with a supratip
break, normal tip projection, and a nasolabial angle of 95ƒ. There is
an improved alar–columellar relationship. The basal view confirms
correction of her tip asymmetry and shows restoration of the
columellar–infratip lobular relationship. The left-sided external
valve collapse was corrected with the lower lateral crural turnover
flap, while alar contour grafts prevent postoperative alar retraction.
61.10.3 Patient Example 3
The healthy 41-year-old woman with Fitzpatrick type III thick
nasal skin shown in Fig. 61.78 presented for cosmetic rhinoplasty
without nasal airway obstruction. She was unhappy with the
appearance of her dorsal hump and unrefined tip. This patient
demonstrates the classic Middle Eastern nasal morphology. The
frontal view demonstrates nasal deviation and a plunging tip
with infralobular deficiency. Her lateral view demonstrates a
large dorsal hump and a severely underprojected, underrotated,
amorphous, and plunging tip as well as absence of a supratip
break. She has an alar–columellar discrepancy with a retracted
columella. Her basal view demonstrates nostril–tip imbalance
with ´short nostrils.µ Intranasal examination was normal. Her
dynamic examination revealed a hyperdynamic tip. Following
primary rhinoplasty, she requested a more dramatic change
in her tip, and this required a secondary soft tissue debulking
operation.
Fig. 61.75 Patient example 2, preoperative. (Reproduced with permis-
sion from Janis JE, Trussler A, Ghavami A, Marin V, Rohrich RJ, Gunter
JP. Lower lateral crural turnover flap in open rhinoplasty. Plast Reconstr
Surg. 2009; 123:1830-1841.)
Fig. 61.76 Patient 2, surgical plan. LLC, lower lateral cartilage.
(Reproduced with permission from Janis JE, Trussler A, Ghavami A,
Marin V, Rohrich RJ, Gunter JP. Lower lateral crural turnover flap in open
rhinoplasty. Plast Reconstr Surg. 2009; 123:1830-1841.)

948
X Rhinoplasty
Operative Goals
1. Remove the large dorsal hump.
2. Correct the nasal deviation.
3. Refine the tip and reestablish the tip-defining points (note thick
skin).
4. Drastically improve the tip rotation and projection.
Surgical Plan
1. Open approach with transcolumellar stairstep incision connect-
ed to bilateral infracartilaginous incisions
2. Component reduction of dorsum (5 mm)
3. Anterior septal angle reduction
Fig. 61.77 Patient example 2, (a,c,e,g,i,k) Preoperative and (b,d,f,h,j,l) 12 months postoperative. (Reproduced with permission from Janis
JE, Trussler A, Ghavami A, Marin V, Rohrich RJ, Gunter JP. Lower lateral crural turnover flap in open rhinoplasty. Plast Reconstr Surg. 2009;
123:1830-1841.)
a
e
i
b
f
j
c
g
k
d
h
l

61 Primary Rhinoplasty
949
4. Septal harvest (for cartilage grafting purposes) with 10-mm
L-strut
5. Bilateral spreader grafts
6. Cephalic trim leaving a 6-mm rim strip
7. Columellar strut graft with medial crural septal sutures
8. Medial crural, interdomal, and transdomal suturing
9. Combined infralobular and onlay tip graft
10. Lateral osteotomies (external perforated)
This surgical plan is shown in Fig. 61.79.
Results
Comparison views of preoperative and 2-year postoperative
appearance (Fig. 61.80) demonstrate a more balanced nose
after reduction of the dorsum and refinement of the tip
including improved tip rotation, projection, and definition. The
drastic improvement in overall nasal tip definition, including
enhancement of the supratip and infratip, required a secondary
operation with more soft tissue debulking and visible onlay
tip graft replacement secondary to early graft resorption. The
necessity for secondary tip refinement or soft tissue debulking is
not uncommon in the Middle Eastern population and should be
discussed during the initial informed consent.
61.11 Concluding Thoughts
Success in primary rhinoplasty is predicated on accurate preop-
erative analysis and clinical diagnosis, identification of both the
patient’s expectations and the surgeon’s goals, and a thorough
review of the plan of care and expected postoperative recovery.
Intraoperatively, adequate anatomic exposure of the nasal
deformity, preservation and restoration of the normal anatomy,
correction of the deformity using incremental control, mainte-
nance and restoration of the nasal airway, and recognition of
the dynamic interplay between these maneuvers will optimize
outcomes and lead to a successful experience for both the patient
and the rhinoplasty surgeon alike.
Clinical Caveats
• The key to a successful outcome begins with proper patient
selection.
• A thorough understanding of normal and abnormal nasal
anatomy is paramount.
• Accurate, precise, and complete nasofacial analysis is manda-
tory to help plan the operation.
• Full and complete disclosure of all risks and benefits, includ-
ing financial responsibilities, must be performed to both the
surgeon’s and the patient’s satisfaction. There is no substitute
for an informed patient.
• The surgeon should never enter the operating room without
a well-thought-out plan.
• The type of incision used is far less important than the
correction of the underlying problem. Choose appropriately
according to the deformity and your own experience.
• If performing an open approach through a transcolumellar
incision, one must avoid excessively debulking the tip and
Fig. 61.78 Patient example 4, preoperative. (Reproduced with
permission from Rohrich RJ, Ghavami A. Rhinoplasty for Middle
Eastern noses. Plast Reconstr Surg. 2009; 123:1343-1354.)
Fig. 61.79 Patient 4, surgical plan. (Reproduced with permission
from Rohrich RJ, Ghavami A. Rhinoplasty for Middle Eastern noses.
Plast Reconstr Surg. 2009; 123:1343-1354.)

950
X Rhinoplasty
maintain alar base incisions at least 3 mm inferior to the alar
groove to preserve blood supply to the tip.
• The procedure should proceed in an organized, stepwise
fashion from skin to skin, without rushing. Iatrogenic injuries
are difficult to correct.
• The dorsal reduction should always be performed before
harvesting septal cartilage, so that the 10-mm L-strut is
maintained.
• The dorsum should be reduced in component fashion to
prevent an inverted-V deformity.
• The surgeon should attempt to preserve the transverse
processes of the ULCs.
• Tip modifications should be performed using a graduated
approach.
• All incisions must be closed meticulously.
• The postoperative splints/tapes should be positioned care-
fully to prevent iatrogenic deformity.
• The postoperative course should be reviewed with the patient
and family before and after the operation.
Fig. 61.80 Patient example 4. (a,c,e,g) Preoperative and (b,d,f,h) 2 years postoperative. (Reproduced with permission from Rohrich RJ, Ghavami
A. Rhinoplasty for Middle Eastern noses. Plast Reconstr Surg. 2009; 123:1343-1354.)
a
b
c
e
h
d
g
f

61 Primary Rhinoplasty
951
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62 Tip Grafting for Nasal Contouring
953
62 Tip Grafting for Nasal Contouring
Jeffrey T. Steitz and Dean M. Toriumi
Abstract
Management of the tip in rhinoplasty is a challenging endeavor
that is managed in a variety of ways including cephalic trim,
dome sutures, and tip grafting, among others. All surgical
principles should build off a strong, stable nasal base to maintain
tip projection and rotation. Once base stability has been estab-
lished, tip grafting can be used to increase projection, reorient
malpositioned lower lateral cartilages, and create favorable tip
contour. Multiple techniques can be utilized, including shield
tip grafts and lateral crural strut grafts. Revision surgery may
require autologous cartilage harvest, which can complicate the
operation but, when the right material is selected, can create
astounding results.
Keywords
rhinoplasty, tip grafting, tip contouring, shield graft, lateral
crural strut graft
62.1 Introduction
1asal tip contouring is perhaps the most difficult rhinoplasty
skill to master. Seemingly isolated maneuvers can simulta-
neously affect multiple parameters on both the anterior and
lateral views. The degree of difficulty is compounded by the
relentless contraction of the skin–soft tissue envelope and the
resultant potential for late complications. Early techniques in
tip rhinoplasty were primarily reductive. The lower lateral car-
tilages (LLCs) were trimmed, scored, or divided to create smaller,
albeit weakened, noses. Current techniques in tip rhinoplasty
emphasize conservative LLC excision, suture reshaping, cartilage
repositioning, and cartilage grafting.
One of the earliest reports of nasal tip cartilage grafting was
by Peer in 1945. Through his histologic studies of grafts, he
refuted the prevailing belief that septal cartilage was resorbed
after transplantation, and he specifically described lengthening a
retracted columella with septal cartilage. Hage in 1964 detailed
the correction of dynamic alar collapse using auricular cartilage
through, presciently, an open transcolumellar approach. Modern
tip grafting techniques were first described by Sheen after he
keenly observed that ´polly-beakµ deformities resulted from an
overreduced nasal structure that was unable to accommodate a
large skin–soft tissue envelope; his solution was to augment the
tip with cartilage grafts placed through an endonasal approach.
These techniques were later popularized through the external
approach by Johnson and Toriumi.
Tip grafting is often performed in conjunction with conservative
reduction of the LLCs and suture contouring. Grafting significantly
increases surgical complexity and the potential for postoperative
complications and, thus, should not be used indiscriminately. A
graded surgical algorithm may effect modest tip changes, such as
narrowing and slight increases in projection, with conservative
cartilage trimming and suture reshaping alone. Tip grafting can
be used for greater changes, and grafting alone can lengthen
or enhance the projection of a short nose, straighten a severely
crooked tip, and reposition retracted alae. :hen used properly,
cartilage grafting is a powerful tool for nasal tip contouring.
62.2 Indications and
Contraindications
Indications for tip grafting in primary rhinoplasty include the
increase of tip projection, prevention of postoperative loss of tip
projection, nasal lengthening, straightening of tip deviations, and
correction of cephalically positioned LLCs. Mild increases in tip
projection may be successfully achieved with suture contouring
(such as dome-binding sutures, lateral crural steal, and so on);
increases greater than 1 or 2 mm frequently require tip grafts.
The degree of augmentation and refinement, the anatomy of the
existing nasal framework, and the skin thickness will further
dictate the type of tip grafting employed.
Patients with weak LLCs, short medial crura, and a deficient
caudal septum are at risk for postoperative loss of tip projection.
Extended columellar struts, caudal septal extension grafts, and
caudal septal replacement grafts can each be used to stabilize the
tip. These same grafts can also be used to lengthen short noses and
correct persistent caudal septal deviations. Costal cartilage may
be needed when lengthening a short nose to withstand the force
applied by the stretched, contracting skin–soft tissue envelope.
Cephalically positioned LLCs are another indication for grafting
techniques. Aesthetically, cephalically positioned cartilages con-
tribute to tip bulbosity, the “parentheses” tip deformity, and alar
retraction. Functionally, they facilitate lateral wall collapse and
decrease nasal valve patency. After dissection from both the nasal
skin and vestibular mucosa, only very strong, flat lateral crura
permit suture repositioning alone. Most cartilages lack adequate
strength to support the lateral wall and will require placement
of lateral crural strut grafts to prevent postoperative alar collapse
and retraction.
1o absolute contraindications to tip grafting exist, although
grafting is sometimes unnecessary. Primary rhinoplasty patients
with adequate projection, proper rotation, and minimal tip bul-
bosity may successfully be treated with conservative trimming
of the cephalic lateral crura and suture contouring. Overly long
noses may be better addressed by setting the medial crura back
on the caudal septum in a tongue-and-groove fashion. Desired
aesthetic changes must be balanced against the increased risk of
complications posed by grafting.

954
X Rhinoplasty
62.3 Pertinent Anatomy
The nasal tip proper is one of the nine aesthetic subunits of the
nose. :ithin the context of nasal tip contouring, the term ´tipµ
more accurately reflects the lower third of the nose, specifically
the tip, ala, soft tissue triangle, and columellar subunits. The
transition points between these subunits contribute substan-
tially to tip highlights and shadows.
The external appearance of the nasal tip is dictated primarily
by the anatomy of the LLCs and the caudal septum. Projection
and rotation are the primary metrics analyzed when viewing the
tip profile. Other important parameters are the alar–columellar
relationship, the columellar–lobular angle or double break, and
the supratip break. Ideal tip projection has been quantified by
assorted mathematical equations and anatomic relationships. adequate projection is often best determined by simple observa-
tion of each patient’s anatomy³particularly dorsal height, nasal
length, and chin projection. Ideal rotation in men is approximately
90ƒ to 100ƒ, compared to 100ƒ to 120ƒ in women. The perceived
rotation is affected by the position and contour of the nasolabial
angle. A gentle curve is desirable; a sharp transition makes the
angle appear more acute and unnatural.
The alar–columellar relationship can significantly affect the per-
ceived harmony of the tip profile. Alar retraction creates a snarled
appearance that mars an appropriately projected and rotated tip.
Approximately 2 to 4 mm of columellar show is generally consid-
ered aesthetic. Greater show may result from alar retraction or a
hanging columella; less show may be caused by hanging alae or
retracted columella. The alar rim contour should approximate a
gentle curve. :hereas alar retraction is characterized by a more
uniform arc of elevation, alar notching describes an acute, focal
retraction that interrupts the ideal contour.
The double break and supratip break are other important
components of an aesthetic tip. The double break is formed by
the natural divergence of the intermediate crura. The cephalic
break point corresponds to the tip-defining points on the anterior
view and represents the transition from the domes to the lateral
crura. The caudal break point represents the initial divergence of
the medial crura into the domes and can be difficult to appreciate
on anterior view. The area between these two points forms the
infratip lobule. The transition from the tip-defining point to the
dorsum forms the supratip break. The dome height over the
anterior septal angle and the skin thickness draping over it create
the break. A 1- or 2-mm supratip break is especially desirable in
women, whereas men may tolerate less or no supratip break.
The tip profile is primarily a two-dimensional relief against a
uniform background; subtle shadows and highlights compose the
anterior view. :hen using a single midline light source, the tip
highlight predominates. Ideally, it is a horizontally oriented ellipse
formed by the divergence of the intermediate crura and the paired
domes. The paired tip-defining points are more prominent when
two light sources are used. The average width between tip-de-
fining points is reportedly 8 mm, although this distance should
be individualized based on overall facial width, base width, and
cultural norms (Fig. 62.1).
Cephalic to the tip highlight there should be a subtle shadow
that represents the supratip break. Greater supratip breaks cast
darker shadows. The tip highlight should gradually transition to
the alae without a deep shadow. A concave transition between the
tip and alae isolates the tip with shadows and creates the “paren-
theses” deformity; this may be caused by bulbous or cephalically
positioned LLCs. An unnatural, single midline tip highlight may be
seen in patients whose domes have been pinched together. On the
basal view, a pinched tip will exhibit marked alar concavity.
Overall tip shape and size are crucial to tip aesthetics. A bulbous
tip interrupts a smooth brow-to-tip aesthetic line. Bulbosity may
result from both enlarged and cephalically positioned lateral
crura. The ideal lateral crural position can range from 35ƒ to 45ƒ
off the midline; more simply, they should point toward the lateral
canthus as opposed to the medial canthus.
Even after a cephalic trim is performed, cephalically positioned
lateral crura can leave residual tip fullness that tends to obliterate
the subtle sidewall inflection at the confluence of the sidewall, tip,
and ala.
The relationship of the infratip lobule to the ala is another
important component of the anterior view, and the ideal contour
is a gently curving V, or ´gull in flight.µ Prominence of the infratip
lobule, tip rotation, and alar position all contribute to this contour.
It is exaggerated by a prominent, ´hangingµ infratip lobule and
reduced by a hidden, flattened infratip lobule. An underrotated
tip also creates an unsightly shadow at the nasolabial angle.
62.4 Preoperative Assessment
The surgeon begins the preoperative assessment by eliciting the
patient’s functional and aesthetic concerns. Understanding the
patient’s surgical goals is crucial to a successful surgeon-patient
relationship. Some patients request correction of obvious defor-
mities, such as a dorsal hump or bulbous tip, whereas others
provide annotated photographs detailing a multitude of changes.
Some want to address a single deformity, such as male patient
who wants a less bulbous tip but is unconcerned with a slight
dorsal convexity. Ethnic patients may ask for subtle changes that
maintain their ethnicity, or they may desire a more refined nose.
Identifying patients with unachievable aims or goals beyond
the surgeon’s aesthetic range is paramount. Patients with goals
that are unattainable rarely have body dysmorphic disorder;
Fig. 62.1 (a) Anterior view highlighting ideal tip contours. There is a
horizontal ellipse at the tip, highlighting ideal underlying structure.
There is a subtle shadow in the supratip with a smooth transition from
tip lobule to alar lobule. (b) Lateral view shows the smooth transition
from tip lobule to alar lobule.

62 Tip Grafting for Nasal Contouring
955
they more commonly request changes that are not anatomically
feasible. For instance, a finite reduction is achievable in a patient
with thick skin, a large dorsal hump, and overprojected nasal tip
without developing a polly beak deformity; however, a small,
petite nose is unrealistic. Other patients may desire changes that
are displeasing to the surgeon’s aesthetic sensibilities, such as a
scooped dorsum or arched alae. These goals may be surgically
attainable, and the patient may indeed be happy postoperatively.
However, a dissatisfied patient is both unhappy and aesthetically
worse. All of these patients are poor candidates, and the surgeon
should politely decline to operate.
62.4.1 Patient History
The patient’s past surgical history should be obtained. The
timing and number of prior septoplasties, rhinoplasties, and
cartilage-harvesting procedures are recorded. Proper preopera-
tive counseling requires that the surgeon be aware of available
grafting material and whether alloplastic implants or injectable
fillers have been used previously. In the case of previous inject-
able filler, it is important to know the material injected and the
frequency with which it was performed. Additionally, many
patients with previous filler to the nose may have intermittent
inflammatory change of the overlying skin, which may not be
evident on the day of examination. It is important to elicit this
history, as it may indicate the presence of chronic infection/
inflammation that may increase risk of postoperative infection.
The patient’s past medical history should also be elicited, partic-
ularly rhinologic complaints such as nasal obstruction, congestion,
epistaxis, and rhinorrhea. Patients with allergic rhinitis should be
counseled that medical intervention will be necessary to alleviate
their symptoms rather than surgery. A history of bleeding diathe-
ses, asthma, chronic obstructive pulmonary disease, diabetes, and
immune disorders is also important, because these will have an
impact on intraoperative management and postoperative healing.
The patient’s medication usage should be recorded, particularly
nasal decongestant sprays.
For most primary and secondary rhinoplasties, smoking is not
a contraindication, although the increased risk of infection, tissue
necrosis, and prolonged healing should be discussed. Complex
revisions of skin–soft tissue envelopes damaged by infection,
fillers, or alloplastic implants are at a much higher risk for com-
plications and should be delayed until the patient stops smoking
completely. Ideally, all patients should quit smoking 6 to 8 weeks
before surgery.
62.4.2 Physical Examination
The physical examination begins with visual inspection of the
anterior, lateral, and basal views. The external manifestations of
various anatomic irregularities were discussed in the previous
section. Palpation helps to assess the strength of the LLCs and
caudal septum. In revision patients, palpation will aid in differ-
entiating soft tissue from structural abnormalities and assessing
the elasticity of damaged skin.
Anterior rhinoscopy with a nasal speculum can identify caudal
septal deviations, internal nasal valve collapse, and inferior tur-
binate hypertrophy. It is prudent to perform nasal endoscopy in
any patient who complains of nasal obstruction. A rigid 0ƒ scope
can be introduced under direct visualization or with a camera and
monitor. The presence of a septal perforation, synechiae, polyps,
concha bullosa, or mucopurulent drainage necessitates additional
rhinologic workup.
62.4.3 Photography and Imaging
Photography is an integral component of the rhinoplasty con-
sultation. Standard views include anterior, lateral, oblique, and
basal views. Photographs are taken with two umbrella lights,
each positioned behind the camera at a 45ƒ angle to the patient.
An anterior photograph with a single midline umbrella light
positioned behind the camera improves the contrast between
light and shadow and provides better visualization of nasal con-
tours. Additional views include close-ups of all standard views,
an inspiratory basal view to assess external valve collapse, and
smile views. Patients with vertically oriented smiles (that is, the
corner of the mouth goes up instead of moving laterally) who
will be undergoing placement of an extended columellar strut
graft or caudal septal replacement graft with fixation to the nasal
spine may develop a transverse upper lip crease when they smile.
Imaging software is an excellent tool for demonstrating
operative goals. Modified photographs can help patients com-
municate their goals more effectively and provide the surgeon
with a visual surgical template. It is imperative, however, that
realistic imaging of an obtainable outcome be shown. In the senior
author’s practice, preoperative digital imaging is performed, and
copies of these simulated results are provided for the patient to
take home. He or she is encouraged to review the photographs
and schedule another visit if modifications or clarification is
necessary. However, producing virtual results with the patient
present should be performed only after considerable experience,
because it requires deft use of the software and knowledge of
what is surgically achievable. Likewise, photo imaging should not
be performed by ancillary staff, who may not have knowledge
of realistically achievable results. If used properly, photographic
imaging can be a powerful tool in the surgical practice.
62.5 Preoperative Planning,
Including Markings
Patients are positioned supine on the operating room table, with
the head supported by a foam pillow. Operative anterior, lateral,
and basal photographs are taken after intubation.
Convexities and concavities are marked before local anesthetic
is injected, so that deformities can continue to be identified
despite the inevitable edema from the injection and operative
manipulation (Fig. 62.2). Local injection of the tip, nasal spine,
dorsum, sidewalls, septum, and vestibular mucosa incision lines
is then performed with 1 lidocaine with 1:100,000 epinephrine.
Vigorous injection of the septum facilitates hydrodissection of the
mucoperichondrial flaps.
An inverted-V incision is outlined midway between the supe-
rior extent of the columella and the medial crural footplates. A
straight-line columellar incision should be avoided to prevent scar
contracture and columellar notching. In patients whose noses will
be deprojected, the incision should be outlined slightly higher to
accommodate its eventual inferior movement.

956
X Rhinoplasty
62.6 Operative Technique
62.6.1 Incision and Dissection
The various benefits and drawbacks of endonasal and open
rhinoplasty are a frequent topic of debate. Many advanced tip
grafting techniques require suture fixation and are best accom-
plished by the open approach. Flap elevation and closure warrant
close attention and meticulous technique.
The anterior columellar portion of the incision is made with a
No. 11 blade. For precise incision placement, the blade is moved
in a sawing motion. The lateral limbs are incised very superficially
to avoid transecting the medial crura. The vestibular portion of
the columellar incision is more easily completed with a 1o. 15
blade. Grasping and turning the tip with the left hand exposes the
columella. The incision is extended up toward the vestibular apex,
but not blindly into it.
The marginal incisions are performed next. Using a wide
double-pronged skin hook, the lateral crura are exposed. Gentle
palpation with the scalpel can help identify the caudal edges of
the lateral crura. The incision is then performed from lateral to
medial but is stopped short of the vestibular mucosa beneath
the dome. At this point the marginal incision has not yet been
connected to the columellar incision.
Elevation of the skin–soft tissue envelope over the medial crura
begins using Converse scissors, exerc ising care to avoid transect-
ing the medial crura. As the dissection approaches the intermedi-
ate crura, it is important to dissect within the supraperichondrial
plane. This plane is often identified by its wispy connective tissue
and lack of bleeding.
Once the skin flap has been elevated over the intermediate crura,
the marginal incisions can be completed. A wide double-pronged
skin hook is used to expose the vestibular apex, and the incision
is completed with the Converse scissors. Direct visualization
permits precise incision placement. Dissection over the domes
is facilitated by simultaneous caudal LLC retraction and cephalad
skin flap retraction. Careful dissection over the lateral crura
ensures that the caudal margin is not inadvertently transected.
Dissection continues in the supraperichondrial plane onto the
anterior septal angle and over the upper lateral cartilages (ULCs);
a Converse retractor facilitates visualization beneath the flap.
Once the rhinion is encountered, the nasal bone periosteum is
incised with the sharp edge of a -oseph periosteal elevator. The
periosteum is raised off the nasal bones with the -oseph elevator.
62.6.2 Septal Cartilage Harvest
Septal cartilage is the first choice for grafting material because
of its location, strength, and flexibility. There are multiple
approaches for septal cartilage harvest; the choice depends on
the work to be undertaken. A .illian incision may be used for
rhinoplasties in which repositioning of the tip, columella, or
nasal base is not necessary. If more extensive work is needed and
the nose requires shortening, lengthening, rotation, or deprojec-
tion, dissection between the medial crura to expose the caudal
septum may be beneficial. The interdomal space is divided,
and dissection is carried onto the anterior and posterior septal
angles; extended dissection requires division of the ULCs from
the dorsal septum. Entering the interdomal space and separating
the ULCs allow maximal septal exposure and precise control of
nasal base and tip position.
Mucoperichondrial flap dissection in the subperichondrial
plane ensures a relatively bloodless dissection. The proper plane
is entered by scoring the septum with a 1o. 15 blade and then
dissecting the flap with a Freer elevator. Dissection is carried back
to the bony–cartilaginous junction bilaterally. If the bony septum
is deviated, flap elevation continues posteriorly and the deviated
portion is resected.
In harvesting septal cartilage, it is important to leave a 1- to
1.5-cm L-strut intact to provide nasal support. Additional cartilage
may be left beneath the keystone area of the ULCs to ensure dorsal
support, particularly in patients with short nasal bones. Careful
dissection of posterior septal cartilage between the perpendicular
plate of the ethmoid bone and the vomer will ensure maximal
length to the septal graft (Fig. 62.3).
62.6.3 Costal Cartilage Harvest
Details of costal cartilage harvesting and carving are presented
in Chapter 63 . It is worth reiterating, however, that postoperative
warping can be avoided by early and sequential intraoperative
Fig. 62.2 Preoperative markings are performed prior to injection of
local anesthetic. This particular patient has marked bulbosity in the
tip with pinching in the left middle vault and subtle asymmetry of the
nasal bones.

62 Tip Grafting for Nasal Contouring
957
graft carving. Somewhat counterintuitively, bent pieces are
often preferred to straight pieces, because the warping has com-
menced in the operating room and can be used to the surgeon’s
advantage.
62.6.4 Nasal Base Stabilization
The nasal base is the foundation of the lower third of the nose and
maintains tip position; anatomically, it is composed of the caudal
septum and its soft tissue attachments to the LLCs. Stabilization
of the nasal base is a prerequisite for tip contouring. A weak
nasal base requires overcorrection of projection and rotation
in anticipation of postoperative loss of projection. Consistent
results require precise intraoperative tip positioning on a stable
base that is resistant to postoperative skin–soft tissue envelope
contraction.
A graduated approach to nasal base stabilization is prudent.
Patients at risk for postoperative loss of tip projection are those
with weak LLCs, a short caudal septum, and short medial crura.
The nasal base of patients with long, strong medial crura can be
stabilized with a columellar strut placed into a pocket dissected
between the medial crura. In patients requiring rotation or short-
ening, the medial crura can be fixed to the overly long, midline
caudal septum in a tongue-and-groove fashion.
Patients requiring nasal lengthening or significant projection
need strong support to resist the skin–soft tissue envelope
contractile forces. Lengthening is accomplished with a caudal
septal extension or replacement graft (Fig. 62.4). Caudal septal
extension grafts can be placed end to end or overlapped, depend-
ing on the position of the caudal septum. End-to-end grafts are
stabilized with two sets of bilateral splinting grafts sutured with
5–0 polydioxanone sutures (PDS) or with extended spreader
grafts. A slightly deviated caudal septum can be lengthened with
an overlapping graft if the caudal margin of the graft is midline.
The graft is secured with horizontal mattress 5–0 PDS. The over-
lapping cephalic edge of the graft is beveled so that the airway is
not obstructed. End-to-end grafts are preferred because they are
less likely to cause deviation or airway obstruction.
Patients with a severe caudal septal deviation, deficient septum,
or nasal cant may benefit from a caudal septal replacement graft
(Fig. 62.5, Fig. 62.6). In these cases, the caudal septum is removed
while a strong dorsal strut is left intact. Spreader grafts are inserted
up to the osteocartilaginous junction and extend beyond the end
of the dorsal strut to stabilize the caudal septal replacement graft.
Dissection is carried down through the interdomal space onto the
nasal spine. After removal of the caudal septum, a straight 5-mm
osteotome is used to make a notch in the nasal spine and set the
midline of the nasal base (Fig. 62.7). Creation of a wedge-shaped
notch acts as a graft fixation point and allows precise and stable
graft placement. The nasal spine may not be centered, such as in
deviated noses, and the notch may need to be set off of the nasal
spine midline. Before graft placement, two 4–0 PDS sutures are
placed through the periosteum on each side of the notch and left
untied. If no tissue is available for suture placement, a hole can be
drilled through the nasal spine with a 16-gauge needle. Once the
graft is placed within the notch, the suture is passed back through
the graft and tied.
Cartilage from the septum or rib is preferred for caudal septal
replacement and extension grafts. Equivalent strength with auric-
ular cartilage requires thicker grafts, which can excessively widen
the columella and block the airway. Costal cartilage is strong
enough to resist postoperative contractile forces in complex revi-
sions where scarred skin–soft tissue envelopes need lengthening
and projection.
62.6.5 Tip Projection
Multiple techniques are available to increase tip projection.
Minor increases in projection can be obtained with suture
contouring alone. Dome-binding sutures can be placed within
the native domes or used to recruit lateral crura (Fig. 62.8). The
lower lateral cartilages may also be advanced on a stable nasal
base and fixed with transeptal 4–0 plain gut sutures. This tech-
nique will blunt the nasolabial angle, which may or may not be a
beneficial change. :hen these techniques prove insufficient, tip
grafting is required.
Mild increases (1 or 2 mm) in tip projection can be attained
with tip onlay grafts. These grafts are trimmed into a rectangular
or elliptical shape to simulate the ideal tip highlight and are
sutured directly over the domes in a horizontal orientation (Fig.
62.9). Any type of cartilage may be used, although the cephalic
trim of the lateral crura is ideal for mild increases, because its soft
edge blends easily with the native cartilages. For greater increases
in projection, thicker or multiple pieces of septal cartilage or soft
tissue may be necessary.
Larger increases in projection can be obtained with shield
tip grafts. The graft shape simulates the divergent intermediate
crura and paired tip-defining points. Beveled edges facilitate graft
Fig. 62.3 Harvested septal cartilage.

958
X Rhinoplasty
Fig. 62.4 Surgeon’s view showing a caudal septal extension graft
fixated with extended spreader grafts.
Fig. 62.5 Caudal septal replacement graft prior to implantation. Graft
was created from septal cartilage graft.
Fig. 62.6 Caudal septal replacement graft fixated in place to the
anterior nasal spine and spreader grafts.
Fig. 62.7 5-mm osteotome creating a notch in the anterior nasal
spine. Osteotomy may be performed off midline depending on
whether or not deviation of the nasal base is present preoperatively.

62 Tip Grafting for Nasal Contouring
959
camouflage. The shield tip graft is sutured to the intermediate
crura and projects above the domes (Fig. 62.10, Fig. 62.11). The
additional projection carries an increased risk of graft visibility,
particularly in patients with thin skin. However, the graft’s lead-
ing edge stretches and thus refines the thick-skinned tip. Slight
graft flexion, often caused by compression from the skin–soft
tissue envelope, helps preserve the double break. Support grafts
(cap or buttress grafts) can be placed behind the shield graft to
resist excessive cephalic pressure.
Smoothing the transition from the shield graft to the lateral
crura is crucial to preserving a smooth tip–alar lobule junction
and preventing shadows that isolate the tip. Lateral crural grafts
extend from the existing LLCs to the posterosuperior aspect of the
shield graft and are secured with 6–0 PDS. They are used primarily
when the shield graft projects more than 3 mm above the existing
dome structures.
Skin thickness dictates the amount of camouflage necessary to
prevent graft visibility. Thick skin may require none, whereas thin
skin requires several layers. Perichondrium is an excellent tissue for
this purpose, especially thick, fibrous, costal perichondrium. Gently
crushed septal cartilage, auricular cartilage, or scar tissue is also
useful. These materials can be sutured over or around the leading
edge of the shield graft to prevent graft visibility (Fig. 62.12).
Greater tip projection increases the distance between the domes
and anterior septal angle, thus increasing the supratip break. The
visible supratip break reflects the skin thickness draped over this
height. In a projected tip on a stable base, 4 to 6 mm between the
dome and the anterior septal angle is appropriate for thin skin,
whereas 8 to 12 mm may be needed for thick skin. Too large a
supratip break may appear as a scooped dorsum or mild saddle
deformity. Supratip grafts can be sutured to the cartilaginous
dorsum to ease the transition and improve the overall nasal profile.
62.6.6 Tip Rotation
Smaller degrees of tip rotation can be achieved simply by placing
a columellar strut and dome-binding sutures. This maneuver
will increase tip projection and often produce moderate tip rota-
tion; the amount of rotation depends on the prominence of the
caudal septum and its contribution to the ptotic tip. Trimming
the caudal septum can result in tip rotation but is unreliable. Tip
rotation can also be achieved by shortening the lateral crura or
by performing a lateral crural division and overlay (the lateral
crural steal technique described by .ridel and colleagues).
Alternatively, tip rotation can be controlled by setting the medial
crura into position about the native or extended caudal septum.
:hen excessive nasal length is caused by a redundant caudal
septum, tip rotation can be achieved by dissecting between the
medial crura and suturing them to the existing caudal septum.
This maneuver will result in shortening of the nose and rotation
of the nasal tip. The caudal septum is not trimmed but rather used
as a fixation point to create tip rotation. The degree of rotation
can be increased by moving the domes more cephalad than the
lower segment of the medial crura. Once rotation is achieved
using this method, there may be redundancy of the lateral crura
that may require dissection of the lateral crura and repositioning.
Maneuvers used to rotate and project the tip may also flatten the
infratip lobule. Lack of a double break on tip profile will give the
nose an unnatural, beaklike appearance. Infratip grafts can be
sutured to the medial crura to recreate the ideal contour.
62.6.7 7iS 5eÀnemenW
Tip refinement refers to the overall size, shape, and definition
of the tip. The shape and width of the domes and the size and
position of the lateral crura determine whether the tip is
aesthetically pleasing. Large lateral crura should be trimmed
cephalically; leaving behind 8 to 10 mm of width is advisable,
although the precise amount resected depends on the shape and
intrinsic strength of the cartilages. Dome-binding sutures refine
Fig. 62.8 Rendering of dome sutures and caudal septal extension graft
for nasal tip contouring. This is generally reserved for patients with
inherently strong and caudally oriented lower lateral cartilages.
Fig. 62.9 Soft tissue grafting to the nasal tip assists in maintaining a
higher orientation of the caudal margin of the lateral crus (in compari-
son to the cephalic margin) as well as camouflage.

960
X Rhinoplasty
and narrow the tip. Residual tip bulbosity after trimming and
suture contouring is often caused by cephalically oriented lateral
crura or residual deformity of the lateral crura. Dome-binding
sutures may also deform the lateral crura by leaving an unnat-
ural bulge lateral to the dome sutures or near the alar groove.
Lateral crural strut grafts can be used effectively to reposition
the LLCs, refine the tip, and enlarge the nasal airway. Lateral
crural strut grafts are sutured to the undersurface of the lateral
crura to position the cartilages in a flatter, stiffer orientation; they
can then be effectively narrowed without bulging laterally (Fig.
62.13). The lateral crura are freed from the underlying vestibular
mucosa (Fig. 62.14, Fig. 62.15, Fig. 62.16); local anesthetic is
injected to facilitate the dissection. Septal cartilage is strong and
flexible but not always available. The strength of costal cartilage
permits reduced graft thickness at the expense of increased tip
rigidity. Auricular cartilage is often too thick for this application.
Grafts are generally 1 to 1.5 mm thick, 5 mm wide, and 25 to 30
mm long, although the exact length depends on the degree of
airway collapse and alar retraction.
The position of the domes can be altered with lateral crural
strut grafts (Fig. 62.17). This technique is applied primarily in an
overprojected nose to decrease tip projection and counterrotate
the tip. Precise positioning of the medial graft edge creates a new
tip-defining point along the intermediate crura or medial to the
original dome. Positioning the lateral crural strut graft medially
moves the old dome lateral to the new one and deprojects and
counterrotates the tip. The new dome’s position is fixed by placing
Fig. 62.10 Anterior view of a shield tip graft (prior to placement of
additional grafts).
Fig. 62.11 Basal view of a shield tip graft.
Fig. 62.12 Shield tip graft with soft tissue camouflage and articulated
rim grafts.

62 Tip Grafting for Nasal Contouring
961
Fig. 62.13 Basal view of lateral crural strut grafts prior to repositioning
into a caudally oriented pocket. Note the flattening of the lateral crus.
Fig. 62.15 Basal view of released lateral crura.
Fig. 62.14 Anterior view of released lateral crura.
Fig. 62.16 Surgeon’s view of released lateral crura.

962
X Rhinoplasty
transdomal sutures of 5–0 PDS through the medial margin of the
graft and native LLCs; the suture is tied between the new domes
to hide the suture knot. A limited increase in tip projection can
be obtained by moving the medial margin of the lateral crural
strut graft lateral to the existing dome. Tip projection is more
commonly increased by advancing the nasal base on a stable strut
or extension graft or with a shield tip graft.
Cephalically oriented lateral crura can be repositioned once lat-
eral crural strut grafts are in place. A pocket is dissected caudally
in the alar skin–soft tissue envelope with Converse scissors. The
pocket is typically placed just caudal to the alar groove. Placement
of the strut graft within this pocket will decrease the cephalic
tip bulbosity and improve retracted alae. Precise placement of
the pockets is critical to producing symmetrical alar margins
and nostrils. If the nostril shapes or alar margins are asymmet-
ric preoperatively, the two pocket locations must be altered to
compensate for these differences. It is also paramount to leave
the remainder of the alar lobule, caudal to the placement of the
pocket, undissected to allow precise placement of the strut graft
with minimal mobility. A common mistake is placement of the
pocket at the caudal margin of the ala similar to the placement of
an alar rim graft. This can cause visibility of the graft, distortion
of the alar margin, and minimal improvement in lateral wall
collapse. Repositioning of the lateral crura with lateral crural strut
grafts increases the need for alar base reduction due to increased
alar flare.
In complex revision cases, the native domes and lateral crura
may be severely deformed by scar tissue, multiple grafts, and
overresection. If no usable intermediate or lateral crura exist, new
ones can be shaped from lateral crural replacement grafts.
Lateral crural replacement grafts are sutured to the caudal
septal extension or caudal septal replacement graft (Fig. 62.18).
Soft, flexible tissue is ideal for the lateral crural replacement grafts.
Thin septal cartilage, scar tissue, and rib perichondrium are good
options, although a remnant lateral crural graft with attached scar
tissue is ideal because of its flexibility and strength. Lateral crural
strut grafts can be sutured to the lateral aspect of the lateral crural
replacement grafts to provide lateral wall support. They should
measure 25 to 32 mm in length depending on the size of the nose
and the amount of lateral wall support needed. Ideal lateral crural
strut grafts are slightly curved, and the concave side is oriented
toward the nasal airway to ensure airway patency. Once the
lateral crural strut grafts are in place, domes can be created by
placing 5–0 PDS dome sutures bilaterally.
62.6.8 Nostril Reshaping
In addition to base reduction techniques, nostrils can be reshaped
with grafting. Lateral crural repositioning is perhaps the most
powerful method of pulling down retracted alae and recreating
nostril shape on anterior view. Lateral crural overresection
in traditional reductive rhinoplasties often led to alar collapse
that isolated the tip in circumferential shadows. Alar retraction
exaggerates the ´gull in flightµ contour on anterior view and
contributes to the abnormal alar–columellar relationship on
profile. As previously described, lateral crural strut grafts can
be used to reposition the alae more caudally. It is essential to
make the pockets for the repositioning caudally and down to
the piriform aperture to ensure adequate alar movement. :hen
moving the ala caudally, the pocket created for the lateral crura
should be even more caudal and closer to the alar margin. Often
this maneuver will result in increased alar flare, which must be
addressed with alar base reductions.
Further improvement in nostril shape can be obtained with
alar rim grafts. These can help recreate and support the tip–alar
transition and correct alar concavities. Alar rim grafts are typi-
cally 2 to 3 mm wide and 12 to 15 mm long. A pocket is carefully
dissected caudal to the marginal incision, and the graft is slid
into the pocket (Fig. 62.19, Fig. 62.20). It is held in place with a
single 6–0 poliglecaprone (Monocryl, -ohnson -ohnson, 1ew
Brunswick, 1-) suture (Fig. 62.21). The medial graft edge should
be gently crushed with Adson-Brown forceps to prevent visibility.
Alar rim grafts help correct the alar concavities seen on the basal
view and create a smooth transition from tip lobule to alar lobule.
62.6.9 Closure
Closure begins by reapproximating the skin flap with a single
deep 6–0 Monocryl suture. The marginal incisions are then care-
fully approximated with 5–0 chromic gut; poor reapproximation
can lead to the development of vestibular webs and nasal valve
stenosis. The columellar skin is closed with 7–0 nylon vertical
mattress sutures placed perpendicular to the incision line apices.
Precise closure at the columellar edge is crucial to prevent visible
contour irregularities. The spaces in between are then filled with
Fig. 62.17 Artistic rendering of the creation of a new dome utilizing
lateral crural release and lateral crural strut graft.
Fig. 62.18 Artistic rendering of lateral crural replacement grafts.

62 Tip Grafting for Nasal Contouring
963
vertical mattress or simple interrupted sutures, depending on
the amount of eversion needed. The vestibular portion of the
columellar incision is closed with single interrupted 6–0 fast-
absorbing gut sutures. Meticulous technique helps to camou-
flage the scar.
Lateral wall splints fashioned from 0.25-mm bivalve septal
splints facilitate integration of lateral crural struts. The bivalve
septal splint is cut in half and the edges trimmed. One piece is
placed intranasally and the other across the sidewall and ala.
The splints are sutured in place with a single 3–0 nylon suture
placed through-and-through the sidewall, and the knot is tied
intranasally. To account for the lateral wall edema and prevent
skin ulceration or necrosis, the knot should be loose enough to
allow passage of a needle-holder tip. Vestibular splints, also
fashioned from 0.25-mm bivalve septal splints, may be placed to
stent constricted airways and to help preserve the lateral position
of lateral wall grafts.
A narrow strip of nonadherent gauze is placed over the dorsum
from the radix to the supratip. The nose is then taped with 0.25-
inch reinforced paper tape, and a thermoplastic cast is applied to
the dorsum. Bacitracin is applied to all suture lines. A gauze drip
pad is placed across the nose. 1onadherent gauze and a transpar-
ent dressing are used to cover the chest incision at the harvest site.
Fig. 62.19 Developing a pocket for alar rim graft with Converse scis-
sors. Creation of a tight pocket allows for easy placement of rim graft.
Fig. 62.21 Fixation of rim graft.
Fig. 62.20 Placement of rim graft into pocket.

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62.7 Postoperative Care
A broad-spectrum antibiotic is prescribed postoperatively for up
to 2 weeks. Patients are encouraged to take acetaminophen for
pain, although hydrocodone/acetaminophen pills are prescribed
for more severe pain. Vestibular splints are removed at the
earliest on postoperative day 1 but may be left in place for up
to 1 week. The columellar sutures, nasal cast, and lateral wall
splints are removed on postoperative day 7. Alar base reduction
sutures are removed on postoperative day 14. Patients return to
the office for two additional visits the first month, monthly for
the next two visits, and then bimonthly for two visits. Long-term
follow-up beyond this period is highly encouraged, as patients
are counseled that the nose is 30 healed at 1 year and 40
healed at 2 years.
Correction of minor asymmetries with compression maneuvers
can begin 3 weeks after surgery. Patients are directed to apply
pressure to specific areas for 1 minute 10 times daily. If costal car-
tilage is harvested, silicone sheeting is provided for chest incisions
3 weeks after surgery. Patients are instructed to tape the sheeting
over the scar nightly and clean it with alcohol in the morning;
sheets are changed monthly.
:alking may begin on postoperative day 1, but patients are
asked to refrain from strenuous physical activity for 6 weeks.
Swimming is restricted for 4 weeks; afterward patients may swim
only in chlorinated pools for the next 2 months. Patients may wear
glasses while their cast is still in place. Thereafter, patients are
asked to bring glasses to the office so that their resting position on
the nasal bridge can be assessed.
62.8 Problems and Complications
The most common complication after surgery is residual
asymmetries, especially in difficult revisions or congenital or
traumatic cases. The likelihood that asymmetries may develop is
strongly correlated with the patient’s skin thickness. Thick skin
remains edematous for much longer after surgery and will tend
to hide many irregularities; even minor irregularities will show
through thin skin.
1ostril asymmetry can be one of the most difficult problems to
correct in revision patients. Preference is given to aligning nostrils
on anterior view. An appropriate alar–columellar relationship on
lateral view is the next goal in nostril reshaping. Symmetry on
the basal view is the most difficult to achieve, but fortunately the
least visible.
Additional complications include bleeding, infection, and
scarring. Epistaxis is uncommon after surgery and can often be
treated with oxymetazoline spray. Recalcitrant bleeding may
require application of hemostatic agents, packing, or operative
intervention. The risk of infection is very low but increases
substantially in patients who have had multiple procedures. Any
suspicion of nasal cellulitis should be treated quickly and aggres-
sively. A low threshold for incision and drainage in the operating
room is prudent, since chronic abscesses can smolder and destroy
nasal cartilage grafts or, in the worst cases, irreparably damage
the skin envelope.
Careful attention to closure of the transcolumellar incision
can maximize scar camouflage. Poor scars can be treated with
dermabrasion or revision. Improper closure of marginal and
intracartilaginous incisions can lead to vestibular scarring. Even
the smallest scars or webs can compromise the internal nasal
valve and drastically decrease nasal airflow. Repair often requires
placement of an auricular composite graft.
Base reduction and chest incisions can be especially trouble-
some, particularly in thick-skinned ethnic patients, such as Asians
and mestizos. Silicone sheeting, steroid injections, and dermabra-
sion can all be used to improve the appearance of hypertrophic
scars.
62.9 Results
The 28-year-old woman shown in Fig. 62.22 requested nasal
refinement. She reported nasal dyspnea at rest and during
exercise. On anterior view, she had a narrow dorsum and lateral
wall pinching, with slight bulbosity in the nasal tip (Fig. 62.22,
Fig. 62.23). On lateral view, she had a small dorsal hump, an
underprojected tip, and a deep radix (Fig. 62.24, Fig. 63.25).
Additionally, she had a slightly underprojected chin. On basal
view, she had short, flared medial crura, a wide columella, and
a trapezoidal configuration secondary to her wide tip and lateral
wall collapse (Fig. 62.26). She also exhibited moderately severe
external valve collapse on inspiration (Fig. 62.27).
62.9.1 Surgical Plan
Correction of the patient’s nasal airway obstruction required
repositioning the cephalically oriented lateral crura. A small
caudal septal extension graft was placed to support the nasal
base. Spreader grafts were placed to correct the middle vault
pinching (Fig. 62.28). The lateral crura were dissected from the
vestibular skin and supported with lateral crural strut grafts
(Fig. 62.29). The lateral crura were then positioned caudally to
correct the cephalically oriented cartilages (Fig. 62.30). A small,
soft cartilage graft was placed over the domes to provide some
additional tip projection and narrowing (Fig. 62.31). A medium
extended anatomic Silastic chin implant was also inserted
through a small submental incision.
62.9.2 Surgical Steps
The rhinoplasty worksheet demonstrates the maneuvers per-
formed during her surgery (Fig. 62.32):
1. Inverted-V midcolumellar incision connected to bilateral mar-
ginal incisions
2. Open septoplasty and septal cartilage harvest
3. Bilateral spreader grafts
4. Caudal septal extension graft end-to-end with caudal septum
5. Bilateral lateral crural strut grafts, dome sutures, and lateral
crura caudal repositioning
6. Soft cartilage placed over domes
7. Soft tissue placed where necessary to camouflage tip grafting

62 Tip Grafting for Nasal Contouring
965
Fig. 62.22 Case study, preoperative anterior view.
Fig. 62.24 Preoperative lateral view.
Fig. 62.23 Preoperative close-up anterior view.
Fig. 62.25 Preoperative close-up lateral view.

966
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62.9.3 Result
Five years postoperatively, the patient has smooth brow-tip
aesthetic lines, improved dorsal width, and a narrower tip (Fig.
62.33, Fig. 62.34). She no longer has a parentheses shape to her
nasal tip, and the shadowing of her tip is more favorable. On
lateral view, she has a smooth dorsum, increased projection, and
an improved nasolabial angle (Fig. 62.35, Fig. 62.36). The basal
view reveals a triangular configuration, lateral wall support, and
increased nostril size (Fig. 63.37).
Fig. 62.26 Preoperative basal view.
Fig. 62.27 Preoperative basal view during inspiration.
Fig. 62.28 Intraoperative view of spreader grafts and caudal septal
extension graft.
Fig. 62.29 Intraoperative view of lateral crural strut grafts prior to
repositioning.

62 Tip Grafting for Nasal Contouring
967
Fig. 62.30 Intraoperative view of lateral crural strut graft after
repositioning.
Fig. 62.32 Rhinoplasty worksheet.
Fig. 62.31 Intraoperative view of tip after soft tissue grafting placed
for camouflage.

968
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62.10 Concluding Thoughts
Grafting for nasal tip contouring is a difficult endeavor but can
provide dramatic improvements in both aesthetics and func-
tional outcomes. Patients must be carefully selected and coun-
seled regarding expected outcomes and postoperative course.
Although it is difficult to master the proper techniques for tip
grafting, the results can be very rewarding.
Clinical Caveats
• Understanding ideal aesthetic tip contour is essential in
primary and revision rhinoplasty to maximize aesthetic and
functional outcomes.
• Patients with strong, caudally oriented lateral crura can be
managed with less aggressive techniques utilizing dome
sutures and less cartilage grafting due to the inherent
strength of the LLCs.
• Patients with weak, cephalically oriented lateral crura must
be managed more aggressively and often require reposition-
ing of the lateral crura into a more caudal pocket with strong
lateral crural strut grafts.
• Shield tip grafting is another powerful means of improving
tip projection and definition. Care must be taken to prevent
long-term visibility, and some patients with very thin skin are
not candidates for this type of grafting.
Fig. 62.33 Postoperative anterior view.
Fig. 62.34 Postoperative close-up anterior view.
Fig. 62.35 Postoperative lateral view.

62 Tip Grafting for Nasal Contouring
969
Suggested Reading
[1] Daniel R.. The nasal tip: anatomy and aesthetics. Plast Reconstr Surg
1992;89(2):216–224
>2@ Guyuron B, DeLuca L, Lash R. Supratip deformity: a closer look. Plast Reconstr
Surg 2000;105(3):1140–1151, discussion 1152–1153
>3@ DeRosa -, Toriumi DM. Toriumi’s approach. In: Gunter -R Rohrich R-, Adams :R,
eds. Dallas Rhinoplasty: Nasal Surgery by the Masters, 2nd ed. St. Louis, MO:
4uality Medical Publishing; 2007
>4@ DeRosa -, :atson D, Toriumi DM. Structural grafting in secondary rhinoplasty.
In: Gunter -R Rohrich R-, Adams :R, eds. Dallas Rhinoplasty: Nasal Surgery by
the Masters, 2nd ed. St. Louis: 4uality Medical Publishing; 2007
>5@ Sheen -H. Rhinoplasty: personal evolution and milestones. Plast Reconstr Surg
2000;105(5):1820–1852, discussion 1853
>6@ Tardy ME. Rhinoplasty: The Art and the Science. Philadelphia, PA: :B Saunders;
1996
[7] Toriumi DM. Structure approach in rhinoplasty. Facial Plast Surg Clin North Am
2005;13(1):93–113
[8] Toriumi DM, Checcone MA. 1ew concepts in nasal tip contouring. Facial Plast
Surg Clin North Am 2009;17(1):55–90, vi
[9] Toriumi DM. 1ew concepts in nasal tip contouring. Arch Facial Plast Surg
2006;8(3):156–185
Fig. 62.36 Postoperative close-up lateral view.
Fig. 62.37 Postoperative basal view.

970
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63 Asian Rhinoplasty
Jeffrey T. Steitz, Sheena Samra, and Dean M. Toriumi
Abstract
:ith the substantial increase in Asian rhinoplasty over the past
decade, surgical approach has evolved and a wide variety of
techniques are utilized. Dorsal augmentation with alloplasts has
exploded in the :estern Hemisphere, which has also increased
the amount of revision procedures required, given the popularity
of Silastic implants and their associated extrusion rates. Herein
we discuss the intricacies of Asian rhinoplasty, specifically in
regard to dorsal augmentation and tip reconstruction.
Keywords
Asian rhinoplasty, reconstructive rhinoplasty, costal cartilage
graft, structural rhinoplasty, dorsal augmentation
63.1 Indications and
Contraindications
Rhinoplasty in the Asian population has dramatically increased
over the past two decades and is one of the most common facial
plastic procedures in that population. The impressive increase
in popularity is largely due to improvement in social acceptance
of aesthetic plastic surgery and an explosion in pop culture and
social media platforms. Rhinoplasty in the Asian population is
largely a procedure of augmentation rather than reduction.
Asia contains a wide variety of ethnicities and cultures. It is
important for the surgeon who performs rhinoplasty in the Asian
population to understand these regional differences and tailor the
surgery towards the patient’s specific desires. The term ´Asian
rhinoplastyµ typically refers to East Asian patients, originating
primarily from China, Hong .ong, -apan, and the .oreas. These
patients typically present for augmentation rhinoplasty due to an
underprojected nasal bridge and tip, wide nasal base, and thick,
sebaceous skin. In contrast to the Eastern region, the southern and
western parts of Asia have a stark contrast in nasal anatomy. These
regions comprise primarily Iran, Iraq, 4atar, Saudi Arabia, Turkey,
and United Arab Emirates as well as India, Pakistan, Afghanistan,
and many others. In general, patients of these regions tend to
have larger, overprojected noses with dorsal humps and medi-
um-thickness skin. These operations tend to be more reductive
in nature. Finally, in northern parts of Asia it is more common to
see noses similar to those of Eastern European descent in Russia.
Overall, there are a wide variety of ´Asianµ noses. The terminol-
ogy used frequently refers to patients of Eastern Asian descent,
and that will be the focus of this chapter.
63.2 Pertinent Anatomy
Anatomic descriptions in the plastic surgical literature, such as
´high dorsumµ and ´low radix,µ traditionally refer to the ideal
Caucasian (European) nose. However, this custom does not mean
that characteristics described for a Caucasian individual’s nose
are the universal aesthetic ideal. Cultural norms and preferences
dictate aesthetics: the model Asian nose differs from the model
Caucasian nose. Most Asian patients would like a higher nasal
dorsum and more projected nasal tip, keeping a ´naturalµ look.
The Asian nose typically has a low radix, low dorsum, and
broad, underprojected tip. Thick, sebaceous skin contributes to a
round tip with poor definition and blunted soft tissue triangles.
The columella is commonly retracted. Asian patients frequently
exhibit an acute nasolabial angle and retrusive premaxilla.
Cartilages within the Asian nose tend to be weak, especially
the caudal septum, which is typically cranially positioned. The
cartilaginous septum is frequently very small, necessitating the
harvest of cartilage from a secondary location. The nasal bones
trend toward being shorter than in other ethnic groups, which
contribute to the small cartilaginous septum, as short nasal bones
are usually accompanied by a prominent perpendicular plate. This
does, however leave a larger amount of ethmoid bone, which may
be used as grafting material. Skin elasticity should be assessed,
and patients may be instructed to perform stretching exercises in
an attempt to accommodate larger augmentation grafts.
63.3 Preoperative Assessment
The surgeon elicits specific reasons for seeking rhinoplasty at
the initial consultation and reviews the patient’s cosmetic and
functional concerns. It is vitally important to understand an
Asian patient’s aesthetic goals. The majority of Asian patients
request cosmetic enhancements that preserve their unique
ethnic characteristics; occasionally patients will seek a more
´:esternµ or northern European standard. Fastidious patients
may voice their concerns using accurate terminology, whereas
others will have difficulty identifying features they like and
dislike. For the latter, photographs of desirable noses will help to
focus the conversation.
Computer imaging is particularly helpful in these situations.
A consensus can quickly be reached based on the visuals, and
imaging facilitates discussion of realistically achievable results.
Imaging can demonstrate realistic, balanced results that will help
the patient and surgeon develop an appropriate surgical plan.
Some patients express the desire to maintain their ethnicity, yet
present photographs of a Caucasian person’s nose. In the senior
author’s practice, Asian patients frequently provide photographs
of Asian actresses, many of whom who have undergone prior
augmentation rhinoplasties, rendering their nose more :estern.
Patients who request revision procedures must be screened
for prior implants. Alloplastic implants are frequently used in
Asia for augmentation rhinoplasty, particularly silicone L-strut
implants. Implants can damage skin, particularly of the dorsum,
leaving it thin, irregular, and telangiectatic. Silicone L-strut
implants may also thin the tip skin, because the implant genu

63 Asian Rhinoplasty
971
is the point of greatest tension. Implant removal frequently
requires replacement with an autologous costal cartilage graft.
This greatly increases the complexity of surgery and must be
fully discussed with the patient. Porous polyethylene, polytetra-
fluoroethylene (PTFE), and extended PTFE are also seen, though
less commonly than silicone in the Asian population. These
grafts tend to integrate more with the surrounding skin and
soft tissue envelope, leaving a significant amount of fibrosis and
contracture. In addition to implants, nonsurgical rhinoplasty is
gaining in popularity, and many patients are having filler placed
into the soft tissues of the nose. In Asian patients, this is most
frequently performed to the radix, bridge, and nasal tip. This
can lead to vascular compromise, infections, and scarring and
must be managed very carefully. Hyaluronic acid fillers may be
reversed preoperatively or removed intraoperatively. Calcium
hydroxyapatite fillers tend to integrate more with the surround-
ing tissues and are usually more difficult to remove, especially
if injected into a subdermal plane. Intraoperative removal of
filler close to the dermis may compromise the vascularity of the
nasal tip, and this should frequently be assessed during and after
removal. Patients with previous implants or filler injections are
at much higher risk of infection and must be counseled properly
regarding their risk.
The potential use of autologous grafting materials such as
auricular or costal cartilage must be discussed with the patient
preoperatively. If harvesting of costal cartilage is anticipated,
knowledge of prior breast augmentation is important for both
operative counseling and intraoperative technique. The scar from
inframammary implant placement or breast reduction may be
useful for costal cartilage harvest if it is still located within the
inframammary fold.
The risks of costal cartilage harvesting and implantation should
be carefully explained to the patient. In addition to the standard
risks of pneumothorax, scarring, and graft warping, the patient
should understand that he or she will have increased nasal stiff-
ness postoperatively. This will soften over time, but the nose will
always remain more rigid than it was preoperatively. Chest pain
may range from nonexistent to moderate for 3 or 4 days postoper-
atively. Discomfort when lifting heavy objects may persist for 1 to
2 months before it subsides completely. Dorsal augmentation with
costal cartilage in Asian patients stretches skin near the medial
canthus, and changes to the epicanthal fold may occur.
63.4 Preoperative Planning
The septum is unlikely to provide sufficient grafting material for
Asian patients undergoing augmentation rhinoplasty; invariably,
auricular or costal cartilage harvest is necessary.
Multiple factors must be considered when designing the inci-
sion for costal cartilage harvest. The senior author preferentially
harvests the seventh rib, as it allows for the straightest segment
of rib. The incision must be placed below the inframammary fold
at the superior border of the seventh rib, but incisions can be kept
shorter than 12 mm, which often heals with minimal scarring. If
the incision is larger and made at the inframmary fold, the fifth,
sixth, and seventh ribs may all be harvested through the same
incision when additional grafting material is needed. Fifth-rib
harvest can be more difficult, because it requires dissecting under
the breast tissue in women and through the pectoralis muscle in
men, either of which also makes harvest more painful. The fifth
rib has a more continuous curve than the sixth rib, making it
difficult to harvest a long, straight segment. Seventh-rib harvest
is generally safer, especially laterally, as this segment of rib does
not typically overly the pleura. There can be some destabilization
of the rib cage depending on the eighth rib’s attachment to the
sternum. If destabilization occurs, this can often increase postop-
erative pain. Removal may cause a slight but noticeable depression
and can potentially produce a less stable rib cage.
In women the incision is ideally placed in the inframammary
fold. The right side of the chest is preferred for a right-handed
surgeon; thus the patient’s rib pain will not be confused with
cardiac pain. In larger-breasted women, an incision can easily be
hidden in the inframammary fold. If future breast augmentation
is a consideration, the incision should be made lower to anticipate
the new inframammary fold. In some women the incision should
be placed slightly more laterally so that it is not visible when the
woman is wearing a dress with a low neckline. In patients with
breast implants, the inferior extent of the breast pocket must be
determined before the incision is made to prevent implant injury
or violation of the implant capsule.
The size of the incision depends on a number of factors.
Asian patients scar poorly on the chest, so incision length and
placement are critical to a favorable outcome. Muscular or obese
patients and those with pectus excavatum require larger incisions
to accommodate the greater depth of dissection needed; in thin
patients with superficial ribs, smaller incisions are required.
Longer incisions are necessary for harvesting longer pieces of rib.
Incisions as small as 1.2 cm can be used to harvest 4 or 5 cm of rib
in patients with the appropriate chest characteristics. Harvesting
rib through a small incision is more difficult and time consuming
but is a cosmetically superior approach. Surgeons with less expe-
rience harvesting costal cartilage should use a larger incision to
avoid damaging the pleura.
63.5 Operative Technique
The procedure is typically performed with the patient under
general anesthesia in the supine position; the patient’s head is
placed on a small soft support. :e prefer to use general anes-
thesia with endotracheal intubation to protect the airway from
blood that may drip down to the larynx during the septoplasty
portion of the operation. :e typically prepare the ear in case
additional cartilage is needed. :ith secondary rhinoplasty or
augmentation rhinoplasty, we also prepare the chest to allow
costal cartilage harvesting if needed.
Typically the operation is longer than a standard septorhino-
plasty, so care must be taken to mobilize the extremities at least
once every hour, place sequential compression devices on the
extremities, and make sure there is no compression of the lower
lip underneath the endotracheal tube to prevent pressure necrosis.
63.5.1 Harvest of Costal Cartilage
Graft warping is a potential complication when using costal
cartilage, but the risk can be mitigated with meticulous tech-
nique. Early graft harvest and sequential carving allow time for

972
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bending and warping tendencies to present and be managed
intraoperatively.
Costal cartilage can often be harvested before opening the nose
in Asian patients because of the insufficient septal cartilage and
the obvious need for grafting material to augment the nose. Before
the skin incision is made, the costal cartilage is palpated with a
27-gauge needle to assess for calcification. If the palpated rib
contains excessive calcification, then surgical planning is directed
toward the next most appropriate rib. This is especially helpful
when making small incisions ( 2–3 cm), as selection of the
proper rib is critical prior to making the incision. Some surgeons
use preoperative imaging to assess for calcifications, but in our
experience this has largely become unnecessary thanks to the
accuracy of needle palpation. The skin is then incised with a 1o.
15 blade, and the subcutaneous fat is sharply dissected. Ragnell or
Senn retractors are used to expose the muscular fascia. Frequent
palpation with a 27-gauge needle ensures a proper trajectory of
dissection and identifies the bony–cartilaginous junction. The
rectus sheath and pectoral fascia fuse to form the fascial sheath
above the sixth rib. A cruciate incision is made through the fascia,
and any muscle is bluntly dissected to expose the rib. Blunt dis-
section minimizes bleeding and postoperative pain.
The thick, fibrous rib perichondrium is excellent material for
camouflaging grafts, especially when performing tip grafting and
dorsal augmentation. The outer layer of rib perichondrium may
be excised initially or removed once the rib is harvested. Larger
sheets can often be harvested by excising the perichondrium first.
The perichondrium is incised with a 1o. 15C scalpel; the smaller
profile of the 1o. 15C blade permits greater visualization through
a small incision. The perichondrium is then elevated from lateral
to medial with a Freer elevator, and the pedicle is divided with
scissors after sufficient material has been raised.
Shallow transverse incisions are made with a 1o. 15C scalpel
near the bony–cartilaginous junction and as far medial as the
patient’s needs dictate. Leaving a thin rim of cartilage at the
bony junction allows sharp edges to be rounded after the rib is
removed. The incisions should be superficial to avoid violating
the inner perichondrium and pleura. Costal dissection is easily
performed with the sharp end of the Freer elevator. patients have soft, white costal cartilage, whereas older patients
have yellow-brown cartilage with varying amounts of calcifica-
tion. Often there are islands of calcification at the rib periphery,
and dissection must proceed around them. Rarely is the entire
segment calcified and unusable.
:hen freeing the perichondrium from the superior and inferior
edges of the rib, it is best to err slightly into the rib itself. Leaving
a thin cuff of cartilage helps prevent inadvertent transection of
the often-attenuated deep perichondrium. There is frequently
an interchondral joint between the sixth and seventh ribs near
the rib genu. The attachment may be fibrous, a synovial joint,
or a solid cartilaginous connection that requires division with
a Freer elevator. After the rib has been dissected circumferen-
tially, the Freer elevator is used to elevate the rib bluntly off the
deep perichondrium. The undersurface of the rib and the deep
perichondrial sleeve can be viewed directly to ensure that the
pleura is not violated. Significant resistance in trying to elevate
the rib bluntly often indicates incomplete dissection at one of the
corners, especially medially, where the rib is thicker. Care must
be taken when elevating an older, more brittle rib to ensure that
it does not fracture. After the rib is freed, a double-pronged skin
hook facilitates removal from the pocket. The medial and lateral
rib edges are trimmed and smoothed with Takahashi forceps. The
inner perichondrial sleeve is inspected and irrigated with saline
solution; a Valsalva maneuver performed by the anesthesiologist
confirms pleural integrity. The rib is placed in an antibiotic-
infused saline solution.
Carving often begins after opening of the nose. Carving is best
performed on a flat carving block with a 1o. 10 blade. Toothed
forceps provide a secure grasp of the rib; nontoothed forceps may
eject grafts off the carving block. Carving the rib into three seg-
ments maximizes the number of useable grafts. The thickness of
each segment varies according to the patient’s needs. The central
portion of rib often warps least. Outer segments have a fibrous
component that causes greater warping in younger patients but
helps maintain graft integrity in older, more brittle ribs. The
segments are thinned initially and placed back into the antibiot-
ic-infused saline solution.
Final cuts are made just before the grafts are placed. Carving
the grafts in this manner allows warping tendencies to manifest
intraoperatively and to be used for curved grafts. For example,
dorsal grafts placed concave side down will lie flat after skin–soft
tissue envelope compression, whereas lateral crural strut grafts
can be placed convex side up to support the airway better. Older
calcified rib is more difficult to harvest, carve, and suture but
maintains the distinct advantage of warping very little. cartilage is easy to carve and suture but can warp dramatically
and is less predictable.
Incision Closure
Careful closure of the chest incision minimizes scarring and
visibility of the scar. Unused pieces of costal cartilage can be
placed back within the perichondrial sleeve for potential use if a
minor revision is needed at a later time. Alternatively, we prefer
to bank the leftover, usable cartilage in an incision behind the
postauricular hairline. This is generally well tolerated, requiring
a less than 1-cm incision, and offers the additional benefit of ease
of harvest at a later date. The muscular fascia over the costal car-
tilage harvest is closed with 3–0 polydioxanone sutures (PDS),
and breast tissue or subcutaneous fat is closed with 4–0 PDS. The
breast is pushed medially and inferiorly in women to assess for
puckering, which represents improper dermal tethering to the
deep closure. The epidermal edges in small incisions are often
damaged by retraction. A 1o. 15 blade can be used to trim the
wound edge up to, but not around, the incision apex; trimming
circumferentially elongates the incision. The skin is then closed
deeply with 5–0 poliglecaprone (Monocryl, -ohnson -ohnson,
1ew Brunswick, 1-) and a subcuticular 6–0 Monocryl. Any area
where the skin is not adequately reapproximated and everted
can be closed with a 5–0 fast-absorbing gut suture. Skin adhesive
is then placed over the closure. Local anesthetic is injected after
closure is completed. This can be done with 0.25 bupivacaine
mixed with liposomal bupivacaine for most effective pain relief.
63.5.2 Harvest of Auricular Cartilage
Auricular cartilage is easily harvested through a postauricular
incision placed on the pinna above the postauricular crease. This