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

974
X Rhinoplasty
the tip. Asian patients frequently have wide tips that resist sig-
nificant narrowing and necessitate restrained dorsal narrowing to
preserve tip–dorsum harmony.
The radix of Caucasian/European individuals commonly lies
between the superior lash line and the upper lid crease, whereas
the radix of Asian patients typically lies at the midpupillary level.
Dorsal graft placement thus depends on the degree of ethnic char-
acteristics the patient wishes to maintain, which is ascertained in
the preoperative visit and confirmed with preoperative computer
imaging.
In primary augmentation rhinoplasties, dissection of a narrow
dorsal pocket facilitates tight graft placement. For grafts extend-
ing over the bony dorsum, graft adherence can be improved by
roughly rasping the dorsum and suturing perichondrium to
the graft’s undersurface. This will create a bone–perichondrial
interface that promotes graft adhesion in the early postoperative
period. The graft can be secured caudally to the middle vault with
5–0 PDS.
In complex revisions, the L-strut may need to be reconstructed.
After the dorsal component of the L-strut is built with extended
spreader grafts and a septal extension graft, a separate dorsal graft
can be placed on top of the stable middle vault. Placing the dorsal
graft on top of extended spreader grafts permits minor movement
independent of the L-strut.
Removal of large alloplastic implants in patients undergoing
revision procedures requires wider dissection and often results
in a large pocket. Grafts can be sutured to adjacent soft tissue
or transcutaneously using 6–0 Monocryl. In the rare patient in
whom graft stability cannot be obtained with suture fixation, a
transcutaneous threaded .irschner wire can be drilled through
the dorsal graft and into the underlying nasal bone (Fig. 63.6). On
postoperative day 7, the wire can be removed in the office with
little patient discomfort.
63.5.5 Tip Contouring
The tip in Asian patients is often bulbous, underprojected, and
lacking in definition. Frequently used techniques include cephalic
trim of the lateral crura, dome binding and interdomal sutures,
and shield tip grafting with lateral crural grafts. Repositioning of
the lateral crura is seldom performed, because it can accentuate
the hanging ala and alar flare commonly found in Asian patients.
Slightly increased projection may be obtained with onlay tip
grafts in selected Asian patients with thin skin. These rectangular
or elliptical grafts are sutured horizontally over the domes with
6–0 Monocryl to simulate the natural horizontal tip highlight. Soft
cartilage, such as auricular or trimmed lower lateral cartilage, is
ideal for this purpose, and approximately 1 to 2 mm of increased
projection can be achieved.
Thick-skinned patients frequently require shield tip grafts with
lateral crural grafts to increase projection, stretch the skin, and
Fig. 63.5 Carved dorsal augmentation graft prior to implantation.
Fig. 63.3 Costal cartilage harvested from 17-year-old Asian female
patient. Note the white color and absence of calcifications.
Fig. 63.4 Costal cartilage harvested from 55-year-old Asian male patient.
Note the yellow-brown discoloration and presence of calcifications.
Fig. 63.6 Kirschner wire (0.35 mm) for fixation of dorsal augmentation
graft. This is removed on postoperative day 7.

63 Asian Rhinoplasty
975
refine the tip. The shape of the shield graft simulates the divergent
medial crura and domes. Shield grafts are sutured to the medial
crura with 6–0 Monocryl. Large grafts, creating substantial
increases in projection (greater than 2 mm), are often supported
with buttress grafts and/or lateral crural grafts. Both grafts
maintain postoperative tip projection by preventing cephalic
rotation of the shield graft once the skin–soft tissue envelope
is sutured closed. Lateral crural grafts are sutured on top of the
native lateral crura, whereas lateral crural strut grafts are sutured
to the undersurface of the lateral crura. In addition to supporting
the shield graft, lateral crural grafts smooth the transition from
the tip to the alae and preserve the natural tip–alar highlight (Fig.
63.7, Fig. 63.8). Shield tip grafts can be carved from any type of
cartilage, although stronger septal and costal cartilage is preferred
to weaker, more flexible auricular cartilage.
Tip refinement can often be obtained with dome binding and
interdomal sutures. :hen a shield tip graft is used, the tip width
is set by the leading edge of the graft. Soft tissue or perichondrium
can be placed over and around the tip graft to provide additional
camouflage.
:eak alae can be supported with alar rim grafts. Rim grafts are
thin, sliver-shaped grafts inserted into pockets dissected caudal to
the marginal incision. They are secured with a single 6–0 Monocryl
suture, and the medial edge of the graft is crushed with Adson-
Brown forceps to prevent visibility within the tip. Articular alar
rim grafts are sutured to the lateral edges of the shield tip graft and
then advanced into the marginal incision pockets. Alar rim grafts
help form a triangular base by straightening concave alae and
camouflage shield tip grafts. Correcting alar concavities eliminates
shadows that isolate the tip and interrupt the tip–alar highlight.
The transcolumellar incision is closed deeply with a single 6–0
Monocryl to align and reduce tension on the skin edges. The skin is
then closed with interrupted vertical mattress 7–0 nylon sutures
oriented perpendicular to the incision. The marginal incisions are
closed with 5–0 chromic gut, and the septal mucoperichondrial
flaps are reapproximated with a 5–0 plain gut quilting suture.
63.5.6 Reduction of the Alar Base
Alar base reduction, if necessary, is the final step during rhino-
plasty. Different intraoperative maneuvers have variable effects
on the final alar position. For example, increasing tip projection
decreases flare, whereas lateral crural repositioning increases
flare. Regardless, Asian patients may benefit from some form
of base reduction. The degree of flare, nostril size, and native
alar/sill anatomy determine incision placement. Base reduction
incisions made across the nostril sill are at a high risk for visible
scarring. These patients are better candidates for external alar
reductions unless the nostrils are very large. Patients should be
counseled preoperatively that their thick, sebaceous skin makes
them more likely to scar unfavorably.
The amount to be resected is first outlined with a marking pen.
Conservative excisions are preferable, because additional ala can
be excised postoperatively at a later time. The ala is excised with
a 1o. 11 blade. The incision is closed deeply with a single 6–0
Monocryl suture, and the skin is closed with interrupted vertical
mattress 7–0 nylon sutures and simple 6–0 fast-absorbing gut
sutures. Meticulous technique is necessary to prevent visible
scarring.
63.6 Problems and Complications
Close postoperative follow-up is important after augmentation
rhinoplasty to monitor the dorsal graft. Mild graft warping
Fig. 63.7 Anterior view of shield tip graft with lateral crural grafts.
Fig. 63.8 Basal view of shield tip graft.

976
X Rhinoplasty
or shifting can be treated with nasal compression exercises
for 1 minute 10 times daily until the graft position stabilizes.
Severe warping or migration necessitates operative revision.
Severe warping usually manifests within the first 3 months
postoperatively.
Dorsal irregularities are often camouflaged by thick skin in
Asian patients. Small visible bumps can be treated with a needle
shave in the office. The area to be treated is first marked and then
injected with a local anesthetic. A 16-gauge needle is inserted,
and the bump is rasped with the needle’s bevel. Depressions,
unfortunately, cannot be treated in this manner. Revision surgery
is often needed to fill the depression with cartilage or soft tissue
grafts.
:ide, underprojected tips are susceptible to postoperative
loss of projection if not properly stabilized. Correction requires
operative revision to stabilize the nasal base. Grafting material is
needed to place a caudal septal extension or replacement graft to
which the lower lateral cartilages can be secured.
The thick skin of many Asian patients can cause prolonged
postoperative edema. This can be especially problematic in the
supratip area, where edema can lead to scar formation and create
a polly-beak deformity. Edema that has persisted 4 weeks after
surgery can be treated with nightly nasal taping. Recalcitrant
edema can be treated with injections of 0.2 to 0.3 mL triamcino-
lone acetonide 10 mg/mL.
Pneumothorax can occur during rib graft harvest. Meticulous
technique, especially blunt dissection within the perichondrial
sleeve, is the best defense against this morbid complication. If a
pleural tear is discovered intraoperatively, a red rubber catheter
can be inserted into the defect. The wound should then be closed
with the catheter in place. After closure, a Valsalva maneuver can
be performed as the catheter is withdrawn to remove as much
air as possible. A postoperative chest radiograph can confirm the
presence of any residual pneumothorax and help to determine
whether chest tube placement is necessary.
Scarring of the columella, alar base, and chest is more common
in thick-skinned Asian patients. Asian patients in particular scar
poorly on the chest. Three weeks after surgery, patients are given
Silastic (Dow Corning, Midland, MI) sheeting to place on their
incisions each night. The compression from the Silastic is thought
to enhance the scar’s appearance. Triamcinolone acetonide injec-
tions can also be used to treat hypertrophic scarring.
63.7 Results
63.7.1 Case 1
The 28-year-old woman shown in Fig. 63.9 requested rhino-
plasty. On anterior view, she had an amorphous tip. On lateral
view, she had a low dorsum and an underprojected tip. Intranasal
examination revealed a right septal spur.
Surgical Plan
The plan for this patient was to perform an augmentation
rhinoplasty. She had a low, wide dorsum that is typical in the
Asian patient. Costal cartilage was harvested to obtain material
for dorsal augmentation. An alloplastic implant could have been
used to avoid harvesting costal cartilage, but this patient did not
want artificial material used in her nose. The dorsal graft was
used to raise her dorsum and produce a narrowing effect on
frontal view. A caudal septal extension graft stabilized the nasal
base. A shield tip graft was used to project and narrow the tip.
Surgical Steps
The patient’s rhinoplasty worksheet illustrates the steps per-
formed during the surgery (Fig. 63.10).
1. Right inframammary fold incision and sixth-rib harvest
2. Inverted-V midcolumellar incision connected to bilateral mar-
ginal incisions
3. Open septoplasty and septal cartilage harvest
4. Costal cartilage spreader grafts
5. Caudal septal extension graft placed end to end and secured
with extended spreader grafts and bilateral splinting grafts (Fig.
63.11)
6. Costal cartilage tip graft and lateral crural grafts covered in
perichondrium
7. Bilateral alar rim grafts
8. Costal cartilage dorsal graft covered with perichondrium and
crushed cartilage (Fig. 63.12)
9. Supratip graft
10. Bilateral alar batten grafts
11. Bilateral alar base reductions
Results
One year postoperatively (Fig. 63.13), the patient has a narrower
dorsum and a narrower and more refined tip. The lateral view
reveals increased dorsal height and tip projection. Her nasal
starting point is close to her midpupillary line. The basal view
shows increased projection and a more refined tip.
Fig. 63.9 Preoperative photoarray for case 1.

63 Asian Rhinoplasty
977
Fig. 63.10 Rhinoplasty worksheet for case 1.
Fig. 63.11 Intraoperative view of extended spreader grafts with caudal septal extension graft.

978
X Rhinoplasty
Fig. 63.12 Intraoperative view of dorsal augmentation graft.
Fig. 63.13 (a,c,e,g,i) Pre- and (b,d,f,h,j) postoperative photoarray for case 1.
a
e
i
b
f
j
c
g
d
h

63 Asian Rhinoplasty
979
63.7.2 Case 2
The 28-year-old woman (Fig. 63.14) requested correction of her
nasal deformity. She had no nasal obstruction. On anterior view,
she had a wide dorsum, tip, and nasal base. On lateral view, she
had a low radix, a very low dorsum, and an underprojected tip.
The basal view revealed a wide, underprojected tip.
Surgical Plan
The plan for this patient was to perform an augmentation rhino-
plasty. She did not want an alloplastic implant, so costal cartilage
was harvested. Two ribs were needed in this patient: a very large
dorsal graft to augment her flat dorsum and the other rib graft
for the septal extension graft and tip grafts. An extended colu-
mellar strut was used to stabilize the nasal base. A notch carved
in the strut’s base was integrated with the nasal spine to prevent
movement. The strut was further stabilized with thin splinting
grafts overlapping the caudal septum. To keep the dorsal graft
midline, it was notched and integrated with the columellar strut.
This maneuver is frequently unnecessary, because the dorsal
Fig. 63.14 Preoperative photoarray for case 2.
Fig. 63.15 Rhinoplasty worksheet for case 2.

980
X Rhinoplasty
graft can be sutured to the upper lateral cartilages. A shield tip
graft and lateral crural grafts were used to provide tip projection
and contour.
Surgical Steps
This patient’s rhinoplasty worksheet illustrates the surgical
steps performed (Fig. 63.15).
1. Right inframammary incision and harvesting of the sixth and
seventh ribs
2. Inverted-V midcolumellar incision connected to bilateral mar-
ginal incisions
3. Septoplasty and septal cartilage harvest
4. Caudal septal extension graft sutured to nasal spine (Fig. 63.16)
5. Hole drilled in nasal spine with a 16-gauge needle
6. Caudal septal extension graft secured to caudal septum with
bilateral splinting grafts
7. Bilateral alar batten grafts
8. Shield tip graft and lateral crural grafts (Fig. 63.17)
9. Costal cartilage dorsal graft covered in perichondrium (Fig.
63.18)
10. 1otch carved in caudal aspect of dorsal graft and integrated with
caudal septal extension graft (Fig. 63.19)
11. Crushed cartilage and perichondrium placed over tip graft
12. Supratip graft placed
Results
Six months postoperatively, the patient has a narrower dorsum
and tip. On lateral view, she has increased dorsal height and tip
projection. The basal view reveals her increased tip projection
(Fig. 63.20).
63.8 Concluding Thoughts
Asian patients requesting rhinoplasty frequently require
increasing nasal tip projection or augmenting the nasal dorsum.
They tend to have weak lower lateral cartilages and lack nasal
Fig. 63.16 Intraoperative view of extended caudal septal extension graft and fixation to the nasal spine.
Fig. 63.17 Intraoperative view of shield tip graft with lateral crural extensions.

63 Asian Rhinoplasty
981
tip support. Reductive methods may further decrease nasal
tip support and leave the patient with inadequate refinement.
Structural grafting can improve tip support and tip definition.
Increasing the dorsal height can improve nasal dorsal definition
and create a narrowing effect. Structural grafting may require
harvesting ear cartilage or costal cartilage. Most Asian patients
have inadequate septal cartilage for grafting purposes. Costal
cartilage will provide more than enough material for grafting
but does require more advanced techniques. Management of the
Asian patient requires clear communication to ensure that the
patient and physician agree on the intended aesthetic changes.
Fig. 63.18 Dorsal augmentation graft with perichondrium to allow for fixation superiorly.
Fig. 63.19 (a) Dorsal augmentation graft fixated to septal extension graft; (b) shield tip graft with lateral crural grafts.
a
b

982
X Rhinoplasty
Clinical Caveats
• Requests for cosmetic procedures are increasing in Asian
patients; rhinoplasty is the most commonly requested.
• Clear operative goals are necessary for patient satisfaction.
• Careful planning of the chest incision for costal cartilage
harvest minimizes morbidity.
• Early and sequential costal cartilage carving allows warping
tendencies to manifest intraoperatively.
• Knowledge of cartilage curvatures is essential for proper
graft selection and usage.
• Stable dorsal graft placement prevents postoperative graft
migration.
• Base reduction is frequently necessary in Asian patients.
• Close postoperative follow-up is necessary for optimal results.
Suggested Reading
[1] DeRosa -, Toriumi DM. The Asian nose. In Gunter -P, Rohrich R-, Adams :P, eds.
Dallas Rhinoplasty: Nasal Surgery by the Masters, 2nd ed. St. Louis, MO: 4uality
Medical Publishing; 2007
>2@ Lopez MA, Shah AR, :estine -G, O’Grady ., Toriumi DM. Analysis of the
physical properties of costal cartilage in a porcine model. Arch Facial Plast Surg
2007;9(1):35–39
>3@ Toriumi DM, Pero CD. Asian rhinoplasty. Clin Plast Surg 2010;37(2):335–352
>4@ Toriumi DM, Swartout B. Asian rhinoplasty. Facial Plast Surg Clin North Am
2007;15(3):293–307, v
Fig. 63.20 (a,c,e,g,h) Pre- and (b,d,f,h,j) postoperative photoarray for case 2.
a
e
i
b
f
j
c
g
d
h

64 Ethnic Rhinoplasty
983
64 Ethnic Rhinoplasty
Ashkan Ghavami and Sean Y. Saadat
Abstract
This chapter discusses the important considerations a surgeon
must take into account when performing rhinoplasty on an
´ethnicµ or non-Caucasian patient. Beauty standards have long
been based off of Caucasian ideals, but with increasing levels of
globalization unlike any other time in human history, surgeons
are being faced with a more diverse patient population with a
wide range of aesthetic goals that vary based on their own ethnic
origin as well as specific preferences. This chapter discusses
important preoperative considerations that must be made when
assessing a non-Caucasian patient. The rhinoplasty surgeon
must utilize numerous surgical techniques to execute natural,
yet effective reshaping in Middle Eastern, African, and Hispanic
patients. The goal of this chapter is to delineate the variations
in morphologic preoperative presentation and the plethora of
dynamic surgical techniques available to perform a racially
congruent and aesthetically pleasing rhinoplasty.
Keywords
ethnic rhinoplasty, rhinoplasty, surgical technique, aesthetic
surgery, African nose, Middle Eastern nose, Hispanic rhinoplasty,
facial cosmetic surgery
64.1 Introduction
For hundreds of years now, beauty standards around the globe
have been described in ways that are centered around Caucasian
European aesthetic principles. Of late, the concepts surround-
ing beauty have quickly evolved in complexity as the world
increasingly respects and appreciates the differences in physical
features of differing ethnicities and cultural backgrounds. These
trends have begun to grow exponentially with the powerful,
ever-present force of social media. Much of social media is
centered on beauty: makeup, plastic surgery (surgical and non-
surgical), and fitness. Despite the falsity of images manipulated
by Facetune (Lightricks, -erusalem, Israel) or Photoshop (Adobe
Systems, San -ose, CA), prospective patients make use of these
images as a tool in communicating desired results. This places
extra challenges on plastic surgeons to communicate effectively
with their patients and, if selected, execute the surgery with
optimal technique and accuracy.
:hen it comes to the nose, specifically, these trends have
become extremely relevant, not just in the world of aesthetic sur-
gery but even in areas such as makeup, hair care, and the overall
beauty industry, as ethnic groups have begun to create a stronger
global presence and obtain more of a seat at the table of human
influence. For example, nasal makeup contouring is one of the
quintessential trends on social media, with makeup shades mar-
keted to all skin color shades and hues. There is, thus, a blending
of ethnic beauty standards in the global landscape that is being
led by a strong social media influence.
The term ´ethnic rhinoplastyµ describes a surgical approach
that is taken to construct a nose that is aligned with the standards
of beauty specific to that patient’s own ethnicity. 1ot to say that
only descendants of white Europeans have been getting cosmetic
rhinoplasties since the practice became popular, but until recently,
many surgeons have approached rhinoplasty using beauty ideals
that did not take into account the patient’s ethnicity and the
differences in facial morphology that come with it.
This is why we often see patients of nonwhite ethnicities pre-
senting with very unnatural or ´ethnically incongruentµ-appear-
ing noses and other features. A perfect example of this would be
the late Michael -ackson. The physical transformation undergone
by the ´.ing of Popµ from his childhood years to the time imme-
diately prior to his passing is one of the most dramatic examples
of racial incongruence of our time. In addition to the anatomic
incongruity, there is a subset of patients who specifically want to
move away from their ethnic origins. This places further demands
on plastic surgeons with respect to patient selection and psycho-
logical ramifications.
It is important to remember that the nose, although just one
part of the human face, is in many ways the most important piece
of the puzzle that together creates true facial beauty. The nose is
in the center of the face and establishes harmony between the
upper face and lower face. If nasal shape and proportion are not
aesthetically appropriate, it can create a complete disharmony of
the patient’s facial features. This can lead to an overly operated
look that does not coincide with any cultural standard of beauty.
Although ´ethnic rhinoplastyµ is a recently coined term, it has
been practiced by many surgeons throughout history. :hether
Sushruta in 500 BC, who operated on noses with Indian aesthetic
ideals in mind, or John Roe in 1999, who pioneered operations on
what he called the ´Irish pug nose,µ it has always been important
to keep the patient’s ethnicity in mind when planning to alter
their features for the purpose of improving their overall aesthetic.
For the purpose of this chapter, we have divided ethnic rhino-
plasty techniques into three separate subgroups based on ethnic
origin: Middle Eastern, African American, and Hispanic. Asian
rhinoplasty is covered in Chapter 63.
64.2 Middle Eastern
64.2.1 Introduction
The term ´Middle Easternµ is often unclear when relating to
ethnic origins, because the nations that constitute this specific
ethnicity are not always clear. The term, however. most often
refers to people of Arabic, Turkish, 1orth African, or Persian
descent. Further clarifications and delineations have been made,
such as that of Bizrah, who divided the Middle Eastern popu-
lation into the Middle East, 1orth African, Gulf, and non-Gulf

984
X Rhinoplasty
regions. The Gulf regions consist mainly of the nations that
surround the Persian Gulf, such as Saudi Arabia, the United Arab
Emirates, .uwait, Iran, and Oman. The non-Gulf countries are
not as clean-cut in their definition, but for the purpose of this
chapter we will consider the following nations in our discussion:
Syria, Turkey, Lebanon, Egypt, and Morocco. Lastly, anthropolo-
gists would consider countries such as Iran and adjacent states as
Near Eastern. Further detail is beyond the scope of this chapter.
The distinctions between subgroups are important not only for
geographic reasons but also because the nasal form and expecta-
tions differ accordingly. Most of those regions with large dorsal
humps seek out dorsal hump reduction and stable cephalad
rotation of their nasal tip, whereas those in the Arab nations and
in 1orth Africa may require more cartilage frame augmentation
with thick skin debulking and alar base reduction. This is very
important to consider when operating on individuals of Middle
Eastern origin, as aesthetic outcomes are certain to be judged
not just by the patients, but also by their community and family.
Interestingly, there are further subsets in countries such as Iran,
Lebanon, and other nations with younger populations who may
request a more dramatic or :esternized appearance. Those same
groups, when residing in the United States, seek out a more natu-
ral look with lesser magnitudes of dorsal reduction, curved dorsal
profile, tip rotation, and narrowing.
All Middle Eastern groups have a large percentage of their fellow
countrymen and women migrating or already migrated for two
generations to Europe, the United States, and Canada. All surgeons
interested in becoming rhinoplasty experts should become com-
fortable delivering desired results in function and aesthetics to
these groups of patients, who seek out rhinoplasty often as young
as 14 and 15 years old. In Iran, the most notorious of the Middle
Eastern countries when it comes to rhinoplasty, it is estimated that
each year there are about 200,000 rhinoplasties performed in a
population of 77 million individuals. The United States is estimated
to see about 221,000 rhinoplasties in a population of 330 million.
This means that per capita, Iranians undergo four times as many
rhinoplasties as Americans do on a yearly basis.
In many Middle Eastern nations, rhinoplasties are often seen as
a ´coming of ageµ gift, especially for young women. This is because
the classic Middle Eastern nose is often notable for its large dorsal
hump, high radix, and bulbous ptotic tip. The young patients will
present to a plastic surgeon’s office with their parents (often the
mother) with clear expectation of a specific rhinoplasty result in
mind. This activity has been even more propagated by social media
and the current global youth (Millennials and younger) culture of
´selfies,µ self-focus, low attention span, and general impatience.
64.2.2 Preoperative Evaluation and
Anatomic Assessment
As with any aesthetic procedure, a proper preoperative assess-
ment is key to both understanding the patient’s native anatomy
as well as surveying the desired and expected outcome. At the
first consult, it is important that the surgeon elicit the reasons
for the patient wanting a rhinoplasty. In the Middle Eastern
population, it is not uncommon that a younger teenage patient
presents with a parent or parents who have convinced them that
this is something that is required as a traditional rite of passage
to adulthood. This paradigm is shifting, however, and the senior
author has witnessed more autonomy in younger patients, with
many presenting after they have completed college or are at the
beginning of their chosen career paths.
The Middle Eastern nose is anatomically very distinct from
that of any other ethnic group. Bearing individual similarities to
the African, Hispanic, and Caucasian noses, the Middle Eastern
nose frequently demonstrates a combination of a high dorsum, a
dependent or ill-defined nasal tip, a deviated nasal septum, and
thick skin–soft tissue envelope. There is, however, a spectrum,
not unlike that seen in the Hispanic nose, in which features
can include a thin skin envelope with a more dominant bone–
cartilage frame, and those more mixed in origin from Arab or 1orth
African genetics demonstrating a thicker skin envelope, wide alar
base, and weak frame. By and large, Middle Eastern patients have
Fitzpatrick type III–IV skin and tend to have moderate to thick,
sebaceous skin, specifically at the nasal tip and nostrils. As in
any ethnicity, however, the more important consideration is not
the thickness of the skin but rather the elasticity. Both thick and
thin skin can be nonelastic, not responding ideally to reductive or
augmentative maneuvers.
64.2.3 Characteristics of the
Middle Eastern Nose
The following characteristics of the Middle Eastern nose are
illustrated in Fig. 64.1.
• Skin either thick or thin, and noncontractile
̑ Thick, sebaceous tip and alar skin (fibrofatty soft tissue
envelope), especially at the tip and supratip
̑ Thin skin (usually dorsally) that can reveal significant
osseous changes, especially at the rhinion; thin skin in tip/
soft triangle facets can serve as pitfalls during nasal tip
maneuvers.
• Significant dorsal hump: bony and cartilaginous
• Overprojecting radix; shallow high radix
• :ide bony and middle nasal vaults: wide ´dorsal aesthetic
linesµ (increasing or unmasked by dorsal reduction)
• 1asal deviation: septal deviation common and commonly
visible externally
• Poorly defined, bulbous and/or boxy nasal tip
• Tip projection:
̑ Underprojected nasal tip, caudally displaced (insufficient
medial crura)
̑ 1ote: tip overprojection with long lower lateral and long
medial crura
• Droopy nasal tip with very acute nasolabial (and columellar–
labial) angle
• Cephalically and vertically malpositioned lower lateral crura
• Hyperdynamic nasal tip (hyperactive depressor septi nasi
muscle)
• Dominant lower lateral crura and insufficient middle and
medial crura
• 1ostril–tip imbalance
• 1ostril asymmetries with flaring and/or excess sill

64 Ethnic Rhinoplasty
985
64.2.4 Technical Steps
After elevation of the soft tissue envelope, the first component
to address is reduction of the dorsal hump. In the Middle Eastern
population, the nasal dorsum is often wide and overprojected.
It is made up of the paired nasal bones, ascending maxillary
processes, septal excess, and upper lateral cartilages (ULCs). It
is a common pitfall for surgeons to overresect the dorsal hump,
leading to a ´ski jumpµ appearance to the nose, an increase in
perceived dorsal length, and an ethnically incongruent result.
The senior author has noted instances of this in which an
improperly shaped dorsal septal graft, polytetrafluoroethylene
(PTFE; Gore-Tex, Implantech, Ventura, CA), or even a diced carti-
lage fascia graft (DCFG) was placed by necessity when avoidance
would have been the prudent route.
An incremental component dorsal technique is preferred in
dorsal height reduction for Middle Eastern patients. It is also not
uncommon for Middle Eastern patients to have an overprojected
radix, which is why burring or rasping of the radix is often required
to establish a proper dorsal height set point, a proper nasofrontal
angle, and finally an appropriate nasolabial angle (Fig. 64.2).
A component dorsal hump reduction is often necessary in order
to correct a significant open roof deformity. Osteotomies, along
with spreader grafts or flaps, are also common maneuvers required
in most Middle Eastern noses. Dorsal width is addressed by per-
forming osteotomies, using a low-to-low percutaneous technique
in a - orientation, because the bony width commonly begins at
the ascending maxillary process (Fig. 64.3). The reason the senior
author prefers a low osteotomy technique is because it helps to
avoid creating any visible bony stepoffs or creating unbalanced
dorsal aesthetic lines. It is very common to perform unilateral or
bilateral double-level osteotomies, which we believe is best accom-
plished with a percutaneous technique, introducing the osteotome
through a single stab incision and sweeping it along the outline of
the intended curve, making intermittent breaks around the area to
Fig. 64.1 Classic Middle Eastern nasal features and preoperative nasal measurements. The classic Middle Eastern nose is depicted in this image with
the traditional characteristics that lead a high percentage of Middle Eastern people to seek out rhinoplasties.
Fig. 64.2 Measurements of Middle Eastern nasal features compared
with conventional ideals. (a) The traditional nasofrontal angle is
known to be about 150°. The Middle Eastern population is known
for a radix that is overprojected, leading to a blunted nasofrontal
angle. (b) The nasolabial angle cannot be too narrow or overrotated,
and 90–100° is most appropriately requested in this ethnic group.
Recurrent tip ptosis is a frequent concern of Middle Eastern patients.

986
X Rhinoplasty
be mobilized, similar to the perforations around a postage stamp.
This effect of the bones creates a more customized curvilinear
takeoff from the ascending process of the maxilla (Fig. 64.4).
Once the dorsal hump has been addressed, the next step is cor-
rection of any septal deviation, which is often present in Middle
Eastern patients despite a negative history of nasal trauma. A
septoplasty is indicated both in correction of the septal deviation as
well as for cartilage harvest for grafting purposes. A classic L-strut
technique is used for the septoplasty, leaving at least a 1 ð 1-cm
(preferably 1.5-cm or greater) L-strut in place for proper structural
support. The strongest component of septal cartilage should then
be used primarily for spreader grafts and lateral crural strut grafts.
Many patients with large dorsal humps also have a tilted or C- or
S-shaped septum. Commonly the caudal septum is deviated off of
the anterior nasal spine and nasomaxillary crest. The nasomaxil-
lary crest itself may also be shifted along with the deviation (often
left). All these components and septal, vomerine spurs must be
addressed thoroughly for proper correction of external asymmetry
and improvement of internal nasal airway function.
The role of true spreader grafts has recently been a topic of
debate where many are now advocating for using autospreader
flaps in place of septal cartilage. The autospreader flap technique
was developed using the dorsal segments of the redundant upper
lateral cartilages after component reduction, turning them inward
toward the septum (Fig. 64.5). The springlike effect that occurs
from turning the cartilages inward provides a strong support for
Fig. 64.3 Osteotomies are performed in low–low “J-shaped” fashion
to address the dorsal width beginning at the maxillary process and
allow for a natural curvilinear line that mimics native bony anatomy.
A double level is often needed to further improve the stepoff.
Fig. 64.5 Intraoperative photo of auto spreader flaps. This technique
allows for smooth dorsal aesthetic contour lines and functional airway
tension and will leave more septal cartilage available to use as other
grafts. The bending medially of the upper lateral cartilages (ULCs) with-
out scoring allows for a springlike effect and, when secured, provides
tensioning of the midvault cartilage and superficial musculoaponeurotic
system (SMAS). The ULCs are held in caudal tension while suturing so
that the tension is set in two axes and pulls the nasal SMAS accordingly.
Fig. 64.4 (a) Percutaneous osteotomy involves creating “postage
stamp” perforations on the bones through a single stab incision. (b)
Manipulating the mobilized bone controls the nasal bone width.

64 Ethnic Rhinoplasty
987
the internal valve angle. :e prefer at least a 4-mm segment so
that after bending medially, a 2 ð 2-mm spring is created. Scoring
is not recommended. However, multiple horizontal mattress and
simple sutures are required to avoid convexities and irregularities.
The septum–spreader flap construct should be seamless to avoid
postoperative midvault asymmetries. In many cases, however,
spreader grafts may still be indicated to provide adequate support
and even to improve external contour of the dorsal aesthetic lines.
Most importantly, if the open roof extends cephalad enough to
leave a space between the cephalically attenuated upper lateral
cartilage and nasal bones, then a spreader graft will be necessary.
:e advocate strongly for use of either spreader graft or spreader
flap unless a very minimal alteration is made to the nasal bones
and frame dorsally or laterally. In that case a simple reapproxi-
mation of the upper lateral cartilages with possible trimming and
proper tension setting of the ULC and nasal superficial muscu-
loaponeurotic system (SMAS) is established (Fig. 64.6).
It is also our contention that spreader techniques in and of
themselves do not improve nasal airway but rather the tension
and tautness created between the SMAS, ULCs, and midline struc-
tures. The midvault may also still require a lower lateral cartilage
(LLC) strut or a batten-type technique for proper dynamic airway
function.
The nasal tip in Middle Eastern patients can provide a complex
challenge with respect to the soft tissue:cartilage ratio. Middle
Eastern patients often present with an ill-defined nasal tip that
is bulbous or boxy with overlying thick skin, mandating more
aggressive tip modification using reductive and augmentative
techniques in conjunction to create a strong underlying support for
the newly sculpted nasal tip. A stepwise approach is encouraged
when reconstructing the nasal tip, beginning with placement of a
columellar strut, medial crural/graft sutures, transdomal sutures,
interdomal sutures, tip grafting, and soft tissue facet treatment.
The soft triangle facets should be supported using a soft triangle
tension graft (Fig. 64.7). Highly morselized cartilage grafts (via
syringe injection) can further support the soft tissue facets or
smooth dorsal irregularities in moderate to thick skin noses. The
soft tissue facet has more recently been a focal point for experts
globally, as attention must be paid to a smooth alar rim–to-tip
transition. A notch, irregularity, or exaggeration of the soft tissue
facets postoperatively can detract from the natural appearance of
the final contours. Alar contour grafts are utilized as well in more
than 75 of primary and secondary cases and are a staple in all
rhinoplasties regardless of the ethnic background.
After tip modification is done, it is important to assess the result
by redraping the soft tissue and then appropriately thinning the
fibrofatty layer in patients with thicker skin. Thick skin will often
thwart attempts at final tip refinement outcomes, which is why
selective defatting is indicated in a majority of Middle Eastern
patients who present with thick, sebaceous, inelastic skin. The
fibrofatty layer is conservatively and electively reduced and can
include fibrous fat, nasal SMAS, and sometimes scar from fillers.
As a counterpoint, highly visible tip onlay grafts must be
selected very carefully or not at all. Cephalic remnants or morse-
lized thin grafts are preferred, if indicated, as long-term visibility
can be an unsightly issue. Tip suturing techniques are always the
first choice in the algorithmic approach.
The lower lateral crus is often long and dominates the weaker,
thinner medial crus, creating a nasal tripod imbalance. This can
lead to postoperative polly-beak formation and tip ptosis recur-
rence, which are the more common reasons for revisions in Middle
Eastern patients. The positioning of the tripod and rebalancing,
which involves positioning the domes and central tripod axis
biomechanically anterior to the anterior septal angle. Improper
tip complex position and/or inadequate septal angle and caudal
reduction will make these sequelae more likely.
The convexity and width of the LLC in these patients allows use
of the LLC turnover flap technique. This will correct concavities,
irregularities, and convexities of the LLC along with creating a
stronger bilaminate support to the alar rim. This can be combined
Fig. 64.6 Sutures are used in a horizontal mattress fashion spanning across the upper lateral cartilages in order to narrow and refine the contour of
the nasal midvault.

988
X Rhinoplasty
with a caudal repositioning and further posterolateral support
(via batten or short strut; Fig. 64.8).
The tension that is created in the LLC through tip suturing medi-
ally and the strength created by bilamination or strut support, as
well as nonanatomic soft tissue facet and alar rim grafting, all
serve to establish a natural and strong transition from alar rim to
the reshaped tip. Any deviation away from this in appearance will
set back the result to a classic 1980s ´nose jobµ look, which many
modern Middle Eastern patients want to avoid at all costs.
True transection of the middle lateral cartilage (MLC) and/
or the LLC with strut support may be necessary (Fig. 64.9). The
lower lateral crura can be vertically oriented in these patients,
and repositioning with strut support will address many factors
such as alar strength (external valve sufficiency). Lower lateral
crural transection also provides a powerful method for increasing
rotation in a very ptotic tip. It is important, however, to pay close
attention so as not to make a sharp supratip break or overrated
nasal tip, because the result can quickly become ethnically incon-
gruent. Although some Middle Eastern patients may request this,
the surgeon should consider carefully the reputation that will be
linked to overoperated nasal contours in the community.
Fig. 64.7 (a) The nose is composed of several aesthetic subunits that
are all individually addressed in cosmetic rhinoplasty. The nasal soft
triangle, located at the medial portion of the ala, is very prone to
notching when the marginal incision is made too close to the exterior.
Such issues are easily addressed using morselized cartilage grafts
placed directly into the space. (b) The soft triangle (ST) tension graft
(first presented by the senior author in 2013) is usually derived from
the cephalic remnant and is malleable to provide tension and control
of the domes and fill the soft tissue facets. (c) The ST tension graft
provides a stenting of the facets and maintains an open angle of the
domes as well as fills dead space in the facets.
Fig. 64.8 Transection of the lower lateral cartilage with placement
of a strut graft extension and caudal repositioning of the accessory
piece can be helpful when addressing nasal tripod imbalance and a
malpositioned tip.
Fig. 64.9 True transection of the lower lateral cartilage (LLC) with a long strut graft attached. (a) Location of transection. (b) Transection corrects
convexities and concavities, and a strut provides further support and strength. This allows for repositioning of the lateral crus of the LLC in patients
with vertical displacement of the cartilage.

64 Ethnic Rhinoplasty
989
There is also often hypertrophy of the depressor septi nasi
muscle, which leads to a ptotic and hyperdynamic nasal tip, which
is also exaggerated in appearance by already present tip ptosis
and a short upper lip length. Transection and/or excision of this
muscle can help to improve upper lip length as well as decrease
dynamic deformity of the nasal tip postoperatively. However, the
open approach with inter–medial crural dissection, by its nature,
will disassociate the depressor muscle adequately in most cases.
Placement of a columellar strut graft will further ensure contin-
ued depressor inactivity.
Lastly, alar flare and excess nostril sill should be differentiated.
The first requires lateral alar bulk/flare excision through :eir
excision, whereas the latter necessitates sill excision. Often a
combination of the two techniques is required. It is critical not
to perform these maneuvers if in doubt and to be very judicious,
as this is one of the few irreversible moves in rhinoplasty. Alar
base modification will be addressed in more detail in the African
rhinoplasty section.
Tip Shaping Highlight
• Define the nasal tip through controlled, cartilage-preserv-
ing techniques (use flaps instead of large grafts whenever
possible).
• Avoid overcorrection of the nasolabial angle and excessive
nasal tip rotation.
• Address tip underprojection and definition by establishing
ideal rotation and insufficient middle/medial crura.
• Recognize length/strength discrepancies between the lower
lateral and medial crura.
• Address the soft tissue facets for proper alar rim–to-tip
contour transition.
• Address the hyperdynamic tip.
• Avoid tip ptosis recurrence and/or polly-beak formation
through proper nasal tripod position.
• Address alar base through sill and/or alar flare reduction.
• Correct nostril asymmetries.
64.2.5 Case 1 Example
The 17-year-old Lebanese-Armenian patient shown in Fig.
64.10a–d desired an overall smaller nose with particular empha-
sis on lifting her tip and reducing her hump so as not to exaggerate
when smiling. She stressed the importance of a ´naturalµ nasal
appearance and a minimal dorsal curve that is near-straight.
Evaluation
Her nasal skin was overall thin. She had a significant dorsal
hump and droopy tip which was worst when smiling. The nasal
tip was bulbous and asymmetric. Alar base asymmetry but lack
of excess sill or flare was noted. Her septum was of a C configu-
ration and deviated to the left with right turbinate compensated
hypertrophy.
Surgical Technique
• Dorsal hump reduction with spreader grafts placement
• -- or hockey stick–configured percutaneous osteotomies
• Bulbous tip reshaping and narrowing
• Droopy tip correction with overall nasal length reduction and
subtle cephalad tip rotation
Tip shaping was accomplished with suturing techniques, soft
triangle tension graft, and small alar contour grafts. A minimal
cephalic trim was performed.
Result
One year postoperatively (Fig. 64.10e–h), she was happy with
her outcome and had improved nasal breathing.
64.3 African
64.3.1 Introduction
The African nose, much like the Middle Eastern, is both complex
and unique in its structural composition and therefore requires
extensive understanding from the point of the surgeon who
hopes to accurately sculpt a result that is congruent with the
patient’s ethnic features. Rhinoplasty has been gaining popular-
ity among the African American population, likely correlating
with the surgical world’s improved understanding of surgical
approaches to create results that are more in line with a more
natural appearance post rhinoplasty. It should be stressed, how-
ever, that this is still one of the most complex of morphologies
to modify effectively without creating a need for a future, more
complex revision.
To achieve aesthetically appropriate outcomes in patients
of African ancestry, the rhinoplasty surgeon must have a clear
understanding of the desired standards of beauty and the unique
anatomic characteristics of the African nose. Even more than that
of Middle Eastern populations, the African nose presents with a
wide range of anatomic variations and a very specific relationship
of the nose to the greater context of the African facial aesthetic.
However, unlike Middle Eastern and Hispanic noses, the tenets
are a bit more focused and a high percentage of this population
requires a few classic techniques to be performed. Those are
principally the following:
• Osteotomies
• Dorsal augmentation (rib graft, DCFG)
• Septal angle and caudal septal augmentation (septal extension
graft, extended spreader grafts, vs. large columellar strut graft)
• Tip projection and judicious narrowing
• LLC strengthening (lateral tripod strength with support)
• Alar base narrowing (interalar distance and/or alar flare
reduction)
• Soft tissue envelope thinning
:hen evaluating a patient of African descent for a rhinoplasty,
the surgeon must inquire about the motivation for seeking oper-
ative correction. Historically, beauty standards have often been
tailored to Caucasian standards of beauty, which may have caused
a misunderstanding of the ideals required when referring to
beauty among any other ethnic population, most notably in those
of African descent. A surgeon must understand the patient’s goals
prior to surgery and make it known that ethnically incongruent

990
X Rhinoplasty
results will lead to a distortion of the nasofacial aesthetic harmony
rather than improvement. There is a subset of patients who will
request an exaggerated change in their nasal appearance that may
be difficult to obtain without risking an overoperated appearance,
even regardless of racial incongruity. For example, alar notching
can be significant, as can excessive alar base resection leading to
a triangulation of the overall nasal shape with effacement of the
natural curvilinear transition at the alar–cheek junction.
Regardless of the patient’s ethnicity, nasofacial harmony should
always be the goal outcome with any rhinoplasty patient, and
understanding the patient’s ethnic standard of beauty and indi-
vidual anatomic variations is key to a desired surgical outcome
(Fig. 64.11).
64.3.2 Preoperative Evaluation and
Anatomic Assessment
The African American nose, although showing a great deal of
variation between individual patients, is often characterized by a
wide, low dorsum, broad and underprojected tip, a thick bulbous
tip, a short columellar complex, excessive alar flaring, and nasal
bones that are often wider than the interalar distance. The wide
range of variation in the African patient population is attributed
to the varying regional differences and historic influences of
multiple cultural backgrounds within the African continent. For
example, the northeast African countries are often characterized
with noses that closely resemble the Middle Eastern nose, with a
higher dorsal hump and more ptotic and hyperdynamic tip com-
plex. In contrast, the nasal complexes of northwestern African
descendants often more closely resemble that of the Hispanic
ethnic nasal morphologies.
A very crucial difference in the African face that sets them
apart from other ethnic groups is the presence of bimaxillary pro-
trusion, leading to a perceived decrease in nasal projection. It is
important, however, as stated by Byrd, that the ideal nasal length
must be measured from the radix to the tip-defining points and
should approximate the distance from the stomion to the menton.
The nasal length measurement should be derived from a clinical
examination and a profile view of the patient rather than a frontal
view.
1asal projection is defined as the distance from the alar–cheek
junction to the nasal tip. In the Caucasian patient this is approx-
imately 0.67 times the ideal nasal length, whereas in the African
American patient this distance is shorter and is approximately 0.5
times the nasal length.
:hen further compared with the Caucasian ideal in a study
by Porter and Olson, the African study population demonstrated
a decreased columella–lobule ratio, greater variability in the
nasal base shape, an alar base width wider than the intercanthal
distance, a smaller nasolabial angle, and an increased nasofacial
angle. Consideration of these differences is key to producing an
ethnically congruent result in any rhinoplasty patient of African
descent.
Fig. 64.10 (a,b,c,d) This 17-year-old Lebanese-Armenian patient desired an overall smaller nose with particular emphasis on lifting her tip and
reducing her hump so as not to exaggerate when smiling. She stressed the importance of a “natural” nasal appearance and minimal dorsal curve that
is near-straight. (e,f,g,h) She is seen 1 year postoperatively and is happy with her outcome and has improved nasal breathing.

64 Ethnic Rhinoplasty
991
Another important concept is proper nasal alignment in the
African rhinoplasty patient. The ideal nasal alignment is a lateral
attachment of the ala to the cheek that lies within a vertical line
drawn through the medial canthus. 1asal features can be improved
without altering ethnic appearance by bringing the elements of
the nose closer to this boundary. Given the differences relative to
the Caucasian standard and the variability of the features of the
African American nose, an appreciation of and sensitivity toward
African American nasofacial aesthetics is essential for obtaining
consistent aesthetic results in this patient population. As in any
rhinoplasty, it is important to perform preoperative anatomic
analysis in a stepwise fashion to determine the best method of
approach (Fig. 64.12).
Skin
The skin, especially in the tip area, is notably thicker, sebaceous,
and relatively inelastic in the African American patient com-
pared to the Caucasian, leading to a poorly defined, flattened,
and bulbous tip. The skin memory is significant in these patients.
The fibrofatty layer underlying the skin of the nasal tip often
measures 2 to 4 mm in thickness and is relatively inelastic in
nature, which leads to obscuring of any underlying cartilage
framework. The fibrofatty tissue should be selectively defatted,
particularly over the domal highlights. In the rare occasion,
however, when thin skin is present, less extensive maneuvers
are warranted, particularly at the tip complex. In addition, the
soft tissue facets must be supported. An articulating alar contour
graft, in which the graft is sutured to the lateral domes instead
of free-floating in a soft tissue pocket, is a powerful maneuver.
A larger than normal alar contour graft or a tripod-secured
one will help avoid an unnatural notching or retraction in the
soft tissue facet. Retraction in this region is due to the need for
significant tip projection as well as caudal augmentation. There
is a demand on the skin to stretch in every dimension, and its
weakest transition point is the facet. Therefore, rigidity and
framework need to be added in this region to prevent buckling,
notching, and retraction. A soft triangle tension graft may also
serve useful in addition to the maneuvers just described.
Alar Cartilages
Initially, alar cartilages in the African population were thought
to be weak and thin; hence their inability to support the thick
Fig. 64.11 Classic African nasal traits and postoperative goals.

992
X Rhinoplasty
fibrofatty overlying skin, as represented by the classically
underprojected and bulbous tip. It was not until recently that
studies have shown the size of the alar cartilages of the African
population to actually bear great similarity to those of the
Caucasian population, with the difference being in the obtuse
angle between the lateral and medial crura and a space filled
with a great deal of fibrofatty tissue. The nasal spine has also
been found to be often underdeveloped along with insufficient
medial crura, all leading to the lack of tip projection in this pop-
ulation of individuals. Septal extension grafts with or without
extended spreader grafts are often required to add both septal
angle projection and caudal framework.
The alar cartilages are commonly weak, and turnover tech-
niques and flaps are not sufficient to counteract the heavy soft
tissue. Formal LLC strut grafts are necessary in most cases. These
can be accompanied with transection and caudal transposition,
usually with posterolateral alar margin pocket insertion. This
reinforces the tripod and aids in overall tip and nasal projection
as well.
Alar Base
Alar base abnormalities in the African American patient can be
defined as one of three entities:
1. Increased interalar distance (excess sill), with the alar bases be-
ing lateral to the medial canthal lines
2. Excessive alar flaring, which is characterized by a portion of the
ala extending lateral to the alar attachment of the cheek (more
than 2 mm)
3. A combination of alar flaring and increased interalar distance,
making the correction more challenging
The columella is short and rounded and often hidden on the
profile view by heavy overlying alar rims. Strong alar contour
grafts (typically secured and fixated to the domal elements)
establish an elongation of the nostril apices and can help modify
horizontal large nostrils into narrower taller ones that are directed
more vertically and have a teardrop shape. This is one of the most
rewarding maneuvers for which this patient population will be
very grateful.
Nasal Pyramid
The average African patient will present with a nasal bony
pyramid that is widened with a dorsum that is low and broad
and nasal bones that are often similar in their height and width.
The classically deepened nasofrontal angle also exaggerates
the already present ´flattenedµ look of the overall nose. This is
where the bimaxillary protrusion seen in the African population
also contributes to flattening the appearance of the nose, as it
causes a further decrease in nasal tip projection. Augmentation
of the maxilla and/or periapical area near the piriform aperture
with fat grafts and/or morselized cartilage will go a long way in
Fig. 64.12 Characteristics of the African nose and underlying fibrofatty tissue and ligaments. Selective defatting of the nasal tip is key to achieving a
more refined result in these patients.

64 Ethnic Rhinoplasty
993
establishing overall nasal projection. Proper preoperative assess-
ment is crucial in order to determine the length of the nasal
bones, whether osteotomies are indicated, and whether dorsal
augmentation alone would be better to improve the appearance
of projection.
A very important concept in performing rhinoplasty on this
population is that the bony base in Africans is often wider than
that in Caucasians. This is important when considering narrowing
of the nasal base in these patients because aggressive narrowing
can lead to an appearance of increased interpupillary distance and
disruption of the patient’s nasofacial harmony. A classic stigma
of an overoperated black nose is a narrow, pencil-like dorsum.
By performing a judicious osteotomy and combining with either
radix or full dorsal augmentation, nasal narrowing and height will
synergistically be improved. See the following section for dorsal
augmentation nuances.
64.3.3 Technical Steps
As in any other rhinoplasty, the operation should begin with
meticulous dissection and elevation of the soft tissue envelope
using a transcolumellar incision extended into bilateral infra-
cartilaginous incisions along the caudal edge of the lower lateral
cartilages. The soft tissue should be left on the skin envelope and
the dissection carried subchondrially whenever possible. The
open approach is optimal for the African population because
the soft tissue envelope in this population can often skew pre-
operative anatomic assessments and hide the true underlying
framework of the patient’s nasal complex. Furthermore, frame-
work augmentation requires careful and precise suture fixation
in multiple anatomical regions.
The soft tissue dissection is best done in a subperichondrial
plane by dissecting from inferior to superior and medial to lat-
eral, to expose the most lateral aspect of the alar cartilages last.
Once elevated, the soft tissue is retracted and nasal framework
is assessed. The entire nasal complex must be assessed together,
since any adjustment to tip will affect the dorsal appearance and
vice versa. Dorsal augmentation and osteotomies are typically
performed first, but the surgeon may need to revisit the dorsum
to perform further alterations after tip alterations are complete.
Commonly this comes in the form of more radix augmentation
and/or supratip augmentation to reestablish an appropriate dorsal
profile and dorsum-to-tip transition.
Most patients of African descent will require some form of
dorsal augmentation, but rasping is often necessary to remove
irregularities and create a smooth bed on which to place any
dorsal augmentative grafts. If there is a dorsal hump that is not too
cephalad, then it can be kept and augmented with separate radix
and dorsal septal angle DCFG or a single DCFG graft that is left
bulkier at the radix. Regardless of the method, any form of dorsal
augmentation should be suture-secured at three points to skin or
bone (with bony drill hole using an awl or drill) cephalad and two
points to the ULCs caudally. In cases of significant augmentation
(more than 10 mm, a formal rib (fresh or fresh-frozen cadaveric)
should be carved and secured with a DCFG or fascial sleeve overlay
or wrap. The augmentation, when indicated, is performed after all
septal cartilage is harvested and can be performed either before
or after tip position is optimized. The senior author prefers to aug-
ment the dorsum and do all cephalic and bony manipulation first,
then determine tip projection. Tip projection using tripod struts
and onlay grafts can be more easily adjusted, while osseous width
and dorsal height cannot without obtaining more significant graft
sources.
Septal cartilage is harvested from the anterior septal angle by
separating the septum from the ULCs and then dissecting apart
the medial crura. Once the cartilage is harvested, this is when
the osteotomies may often be performed when indicated prior to
moving onto the nasal tip restructuring.
In the African patient, tip work should focus mainly on
increasing tip projection, as the nasal tip in this population is
often heavily underprojected with minimal baseline support.
Initially, a columellar strut is placed between the medial crura,
which are often weak and short. The strut graft provides an initial
structural support to make up for the weak medial crus. African
patients typically present with a retracted columella in addition
to decreased projection, which is why a columellar strut is key to
creating an ideal end result.
Suture techniques are essential in increasing tip projection in
the African rhinoplasty. Excessive ´stealµ effect and warping or
weakening of the LLC or MC are avoided by LLC strut reinforce-
ment with or without repositioning of the native LLC. Suture
techniques are often combined with an infratip lobular and/or
onlay-type graft and, at times, even multiple layers of onlay grafts
when indicated. The heavier soft tissue sleeve necessitates thicker
and more rigid tip grafts than in most Middle Eastern or Hispanic
patients. Traditionally larger-sized shield grafts still do well in this
ethnic nasal type, but facet support is still imperative.
Once the ideal tip projection is achieved, the soft tissue enve-
lope is then defatted in order to decrease the weight of the skin
on the new nasal framework and improve resulting tip projection
and definition. The surgeon must take close care when defatting
the soft tissue envelope to preserve the subdermal plexus and
prevent postoperative tip necrosis due to vascular compromise,
although this complication is rare.
Temporal mastoid or (if harvesting rib) rectus fascia is often used
in conjunction with diced cartilage (conchal preferred), which has
been shown to have a more permanent and augmentative effect
than just using either of them by itself. The senior author has had
considerable success with minimally morselized and shaped one-
piece conchal dorsal grafting (with perichondrium attached) with
fascial overlay in black patients. The soft tissue characteristics
lend themselves to not always having to wrap fully, as in classic
DCFG techniques, and not always having to extend from radix to
supratip (Fig. 64.13).
Once the ideal nasal framework is achieved, the skin is redraped
and incisions are closely reapproximated using a series of external
sutures. It is at this time that the alar complex is assessed and
alar base or sill resections are performed for further refinement.
An excess of alar flaring is defined by the alar rims falling more
than 2 mm outside of the medial canthal lines. In order to correct
flaring, alar base resections are performed using extreme care to
maintain the lower incision precisely within the alar–cheek junc-
tion. The incision must also be carried medially into the nostril to
prevent any alar notching.
Alar nostril sill excisions are often indicated in this population
when there is an increased interalar distance. The technique
used is the alar nostril sill resection, which helps to decrease the
interalar distance and give a more refined appearance to the final

994
X Rhinoplasty
result. The medial aspect is always incised first and an incremen-
tal lateral incision/excision is carried second to avoid excess skin
removal. More skin can always be trimmed and refined, but it
cannot be put back if excess is removed. It is important to use a
curvilinear angle, which will avoid excess pulling of the alar soft
tissue and a triangular/unnatural alar cheek junction (Fig. 64.14).
This patient population is often subject to prolonged postoper-
ative edema because of the thick and sebaceous nature of the soft
tissue envelope. This is why prolonged postoperative taping can
help to decrease this swelling and lead more quickly to a refined
final result. Silicone sheeting can also be used for up to 3 months
for thick-skinned patients in order to accelerate the resolution of
postoperative edema. Postoperative protocols are listed nearer to
the end of each chapter.
64.3.4 Case 2 Example
The 28-year-old African American woman shown in Fig. 64.15a–c
did not like her wide, flat nose and lack of tip projection. She
emphasized the lack of tip refinement as well as her nose being
too close to her face. She also disliked her nostril flaring but did
not want an awkward or overly narrowed nostril appearance.
She was wary of looking ´unnatural or overdone.µ
Evaluation
• Thick skin and soft tissue
• :ide asymmetric dorsum and tip
• Underprojected tip with mild alar retraction and excess nos-
tril show
• Excess alar flare and interalar (sill) distance
• Bilateral turbinate hypertrophy and mild left septal tilt/
deviation
• Large left vomerine spicule
Surgical Technique
• Lateral low-to-low percutaneous osteotomies
• Internal medial osteotomies
• 1o dorsal reduction except to roughen the dorsal surface for
receiving the DCFG
• Minimal cephalic trim
• Lower lateral crural strut grafts after transection and caudal
transposition of the lower lateral crura
• Pocket placement of the LLC/strut constructs
• Large columellar strut graft and tip shaping sutures
• Ear cartilage conchal graft harvest for diced cartilage grafting
• Onlay tip graft, shield graft, soft triangle tension graft as well
as articulating alar contour grafts
• Alar base :eir and sill reduction performed incrementally
with a tailored cut-as-you-go approach.
Results
The patient appears postoperatively in Fig. 64.15d–f.
64.4 Hispanic
64.4.1 Introduction
Much like the African American population, the Hispanic patient
population has become an increasingly large group seeking
rhinoplasty. By 2050 it is projected that the Hispanic population
will actually surpass Caucasians as the largest ethnic group in
the United States. This steady increase in Hispanic patients has
led to a greater understanding of the anatomic differences and
approaches required for a rhinoplasty surgeon when operating
on a Hispanic nose.
Fig. 64.13 Diced cartilage fascia graft (DCFG) types. (a) DCFG full wrap extending from radix to midvault and supratip. Note: This can also consist of
a perichondrially preserved single unit of conchal cartilage with only edges beveled and/or morselized. Both techniques are fixated at three points.
(b) DCFG only in radix, which can be with fascial overlay or free diced or fully morselized cartilage. (c) Combination of both techniques as indicated by
the anatomical end points.

64 Ethnic Rhinoplasty
995
:hat makes the Hispanic nose so unique compared to
other ethnicities is that there is often a misconception among
American plastic surgeons about what the classic Hispanic nasal
appearance actually is. The term “Hispanic” is often misinter-
preted specifically from Latin America, but that would actually
constitute individuals of Latino origin. Hispanic ethnicity
implies that that the individual is of Spanish origin (from either
Spain or Latin America) with varying degrees of 1ative Central/
South American descent; such a combination is referred to as
mestizo. This is where many surgeons who have not had much
exposure to Hispanic patients often mistakenly assume that the
patient’s anatomy mustclosely resemble that of the 1ative South
American.
This distinction is an important one, because depending on
degree of ethnic influence between Spanish, or ´Castilian,µ and
1ative Central/South American, the anatomic differences and
postoperative beauty ideals can be dramatically different. This
chapter will define the differences between the two Hispanic
subgroups and the unique surgical considerations that must be
taken into account, both for operative approach as well as for
outcome, in order to achieve an appropriately racially congruent
result.
64.4.2 Preoperative Evaluation and
Anatomic Assessment
For the purpose of classification, there are four different
types of noses among the Hispanic ethnicity that should be
considered to properly guide a surgeon’s approach to a rhi-
noplasty. Conceptually, the spectrum (not unlike the Middle
Eastern nose) ranges from a dominant cartilage/bone frame
Fig. 64.14 (a) Nasal sill and (b) alar base resection techniques.

996
X Rhinoplasty
with thinner soft tissue to one with weak soft cartilaginous
framework. Daniel has described and delineated this range as
follows:
• Type I consists of a profi le with normal radix height, high
bridge, and normal tip projection and is often referred to as a
Castilian nose.
• Type II consists of low radix height, near-normal bridge, and
dependent tip. It is a new designation and one extremely
important to the diagnosis, because minimal dorsal reduction
can lead to major secondary problems.
• Type III consists of a broad base, thick skin, and wide tip, with
its strongest expression in the mestizo nose.
• Type IV is similar to the Chata nose, with predominant African
features, not represented in this classifi cation. This type pres-
ents more often on the East Coast of the United States because
of a large number of Hispanics from the Caribbean who reside
there and have some African ethnic roots in their background.
Thus, there is a great deal of diversity within the Hispanic
ethnicity when it comes to nasal structure and anatomic classifi -
cation. :e will simplify these the subgroups as follows:
• Type I: Castilian
• Type II: Mexican-American
• Type III: Mestizo
• Type IV: Creole
:hat is important to note about the Hispanic nose is that each
of these subgroups requires a diff erent surgical approach and
technique, which is why it is imperative to understand specifi c
morphological nuances. For example, in the mestizo-type nose
there is often need for a greater level of tip augmentation, since
one of the unique factors of this nasal complex is a consistent lack
of tip projection at baseline.
The Castilian nose, as previously discussed, requires a com-
pletely diff erent operative approach, because the European
Fig. 64.15 (a,b,c) This 28-year-old African American woman did not like her wide, fl at nose and lack of tip projection. She emphasized the lack of tip
refi nement as well as her nose being too close to her face. She also disliked her nostril fl aring but did not want an awkward or overly narrowed nostril
appearance. She was wary of looking “unnatural or overdone.” (d,e,f) Postoperative views.

64 Ethnic Rhinoplasty
997
influence in this subgroup has led to noses that often have a dorsal
hump, which patients desire to have reduced with normal or even
overprojection of the nasal tip. This would require a more reduc-
tive technique to refine the appearance of the nasal complex, as
opposed to augmentation. The nasal skin envelope is often thin.
See Fig. 64.16 for a depiction of the differences in cartilage-to–
soft tissue ratio.
The Mexican-American and Creole subtypes are unique
themselves because they are more a mix of multiple ethnicities
with a predominance of Hispanic features. These patients require
meticulous preoperative assessment because they arguably have
the least standardized nasal anatomy thanks to the multiethnic
influence in their anatomic development.
64.4.3 Technical Steps
Type I (Castilian)
The common triad of concern in these patients is large dorsal
hump; long, ptotic nasal tip; and lack of tip refinement. In order
to address these specific issues, a straightforward component
dorsal hump reduction is performed with preservation of
the upper lateral crura. If the open roof is very cephalad, then
ULC length may be insufficient, and true spreader grafts will
be required. The radix can be high and shallow, and, as in the
Middle Eastern nose, deepening of the radix will enhance the
orbital appearance, allowing for a more feminine nasofacial
contour. Osteotomy is indicated in a low-to-low with a “J” exten-
sion to close the open roof and optimize and medialize the dorsal
aesthetic contour lines. Medial osteotomies are necessary when
the cephalad nasal bones are very thick.
For the nasal tip, a combination of appropriate tip-shaping
sutures as well as tensioning of the alar rim and LLC are neces-
sary. Creating tautness, strength, and convexity correction in the
LLC requires bilamination with a turnover or strut when thin or
persistently convex. If the LLCs are inherently stout, then minimal
cephalic trim with alar rim graft support and a soft triangle ten-
sion graft may be all that is necessary. Avoiding LLC ´tensioningµ
and treatment can create contour issues along with weakness of
the external valve/alar arch due to the anteromedially directed
´stealµ that tip suturing can produce.
Overall, the Castilian nose can be addressed very similarly to
the classical Middle Eastern nose, which makes geographic sense
since the Spaniards were under Moorish rule for over 500 years.
The primary goal in these patients should be to achieve a smaller
nose by performing a functional reductive operation without
overresection, which would lead to an overly operated, ethnically
incongruent result with dynamic collapse problems.
Type II (Mexican-American)
Among this specific subtype, the challenge exists mostly in
the rhinion/radix region because of the extremely delicate
balance between reduction of the dorsal hump, coupled with
a low radix that can often require augmentation using grafting
techniques. The skin at the rhinion region is often very thin, so
grafts must be placed with care as not to become visible with
surface irregularities. Any partial-length graft is also likely
to be visible through the skin where the junction between
the graft and dorsum occurs, which is why full-length grafts
are much more effective and aesthetically acceptable in this
patient population. In addition, camouflage with flattened fas-
cial (blanket) or highly morselized cartilage covered with soft
tissue onlay can be done.
For augmentation of the radix, the author prefers to use diced
cartilage grafting from the concha, rather than use of an intact
onlay graft. The diced graft allows the scraps of cartilage that go
unused after septal or conchal harvest to be used for a productive
purpose. The cartilage is preferably wrapped in temporal fascia
or topped with a fascial onlay (from mastoid or temple) to pre-
vent reabsorption and migration of the graft material. In a few
instances where the overlying skin envelope is thicker, the diced
cartilage graft may be placed without any facial wrap, although
resorption of the graft may be more likely with eventual loss of
any augmentation. The author prefers cartilage-only augmenta-
tion to be reserved for the radix.
For the nasal tip, overly exaggerated modification is to be
avoided; hence the author prefers to use mainly tip suture
techniques to reposition and contour the shape of the domes
and tension the LLC without soft support using soft triangle
grafting and alar contour grafts. A strong columellar strut graft
is mandatory if projection is to be increased and maintained in
the long term. In addition to tip suturing, the thickness of the
tip skin will determine the dimensions and thickness of any
tip grafts.
Fig. 64.16 Variations of the classic Hispanic nasal anatomy displaying
a spectrum of soft tissue–to-cartilage ratio. The Castilian represents
a strong osseocartilaginous frame and thinner skin sleeve, while the
Chata is the furthest on the spectrum, with a reverse osseocartilagi-
nous-to–soft tissue relationship.

998
X Rhinoplasty
Type III (Mestizo)
-ust as the Castilian nose can be related to the Middle Eastern
nose when discussing operative approaches, the Type III or mes-
tizo subgroup rhinoplasty is very closely related to that of the
African subgroup. Thus, the mestizo nose requires the addition
of sturdy cartilage grafts with LLC thickening and repositioning
more caudally. This often necessitates transection, LLC strut
underlay, and repositioning caudally to lateral fibrofatty tissue
or in a formal alar rim soft tissue pocket. The senior author pre-
fers creation of a lateral pocket in most cases, as this maneuver
allows for more rigidity and support to the alar rim along its full
length. This provides more support to reduce the alar base via a
:eir/sill combination technique, without an unnatural buckling
or contour in the lateral third of the alar arch. It is critical to
establish adequate tip projection and overall nasal lengthening.
Commonly a large columellar strut graft is sufficient. However,
if the overall nasal length is short, then a septal extension graft,
either end to end or with extended spreader grafts, is required
to lengthen the septum proper. :e do not prefer a tongue-and-
groove-type technique in which the medial crura are secured to
the septum or septal extension graft. This rigidity is unnatural
and can be uncomfortable for many patients. It is extremely
important, when performing the myriad of lower third and tip
complex maneuvers, to keep in mind the patient’s overall facial
aesthetic, as overrotation of the tip or overresection of the base
can lead to an overly operated appearance.
Volume reduction of the nasal tip soft tissue can be done by
direct excision of subcutaneous tissue from the lobule, wide skin
undermining to allow for a lateral shift of the lobular skin, and
incremental stepwise alar base/sill wedge excisions with precise
reapproximation. A poorly performed alar base excision with
overresection or improper incision placement will result in an
awkward redraping of the alar base soft tissues and alar–cheek
region. This can be a devastating complication for these patients,
as these scars are both incredibly obvious even to the untrained
eye and also very difficult to correct.
Type IV
The final Hispanic subtype, or ´chataµ-type nose, is extremely
similar to the thickest African type of nose, with a very amorphous
overall nasal contour with flat and wide frame and overlaying
inelastic, sebaceous, thick nasal skin sleeve. The most funda-
mental concept to remember when performing rhinoplasty on
the classic chata patient is the global nasal rebalancing between
heavy dominant soft tissue forces and weak frame: dorsal aug-
mentation, increase in tip projection and columellar lengthening,
tip definition, alar rim rigidity, and alar base narrowing may all
be necessary. Techniques will center around maneuvers that
those of African origins often require. The thick, noncontractile
soft tissue needs selective debulking, while the frame from radix
to caudal and anterior septum needs lengthening and support.
Since the skin and soft tissue will not retract predictably and
shrink, more rigid and extensive frame and tip augmentation is
required to imprint against the skin from beneath it.
The inherent position of the LLC is often not conducive to
proper nasal reshaping, and transection with large strut grafts is
often needed. As with the wider-spectrum, flat Mexican variation
of the Hispanic nasal type, a lateral soft tissue pocket with LLC
strut insertion will provide lateral two-thirds alar arch support.
This will lead to a more natural alar base and nostril soft tissue
reduction. The anterior third of the tip/alae and soft tissue facets is
supported by soft triangle grafting with modified shield (infratip
lobule) onlay grafting and, almost always, alar contour grafts. The
plethora of cartilage relocation, strut and support grafts, along
with dorsal augmentation and narrowing, will provide an unop-
erated but appropriate change in the amorphous nasal contour to
that of a refined one.
64.4.4 Case 3 Example
The 22-year-old Mexican-American woman shown in Fig.
64.17a–d had thin skin and desired a refined, smaller nose and
reduction of her dorsal hump as well as tip refinement.
Evaluation
• Thin skin with underlying cartilage frame highly visible
• High dorsal hump, mostly bony
• :eak medial crura and wide flat tip complex
• Soft triangle facets pronounced
• Asymmetric nasal bones and mild left septal deviation with
left nasomaxillary crest spiculization
Surgical Technique
• Component (incremental) dorsal hump reduction with auto-
spreader flaps
• Low to low with medial extended osteotomies
• Minimal cephalic trim
• Columellar strut graft to stretch and strengthen medial crura
anteriorly
• Lateral crural tensioning with asymmetric transdomal and
interdomal suture placement
• Soft tissue facet graft
• Finely placed cartilage paste via syringe injection at rhinion
and soft tissue facets prior to final skin and lining suture
closure
Results
As shown in Fig. 64.17e–h, 13 months postop she was very
pleased with the natural result.
64.5 Postoperative Care
In any ethnicity, the postoperative care for a rhinoplasty patient
should remain fairly consistent while providing tasks for patients
to be involved proactively in their healing. Immediately postop-
eratively, icing can alleviate and prevent a great deal of swelling
from forming and leading to increased discomfort for the patient.
Patients should always be counseled prior to undergoing rhino-
plasty that postoperative swelling will continue to subside over

64 Ethnic Rhinoplasty
999
the course of one year and, in some cases, up to 18 months or
longer. The radix and tip complex regions are the last for edema
to resolve, particularly if multiple maneuvers are employed.
Especially in multicultural nasal types, where soft tissue is
often very dense and inelastic, there may be a predisposition to
more edema as the soft tissue sticks to the restructured frame.
Sometimes intralesional dilute triamcinolone injections into the
tip or other areas of persistent edema can be very helpful in these
cases. It is imperative that these patients and their families know
what to expect. It is not uncommon for patients to return early
and be impatient with the somewhat slow process, complaining
that those around them are criticizing their results. Constant
reassurance from the surgeon and properly trained staff is key. It
is helpful to have one designated staff member assigned to that
patient, including the patient coordinator.
Patients will often mistakenly believe that they will be com-
pletely in love with their results within days or weeks. Social media
has confused patients, as many immediate postoperative results
are shown without long-term ones or a depiction of the process
through time. This has improved somewhat as of late, as more
surgeons are showing long-term and intermediate-time-frame
results along with education. As an interesting aside, patients
who have their surgery filmed or photographed will see how the
general shape is intraop, before edema and ecchymosis really set
in (when the surgery is not prolonged and surgery is performed
meticulously and cleanly). This, however, must be mitigated with
the proper counseling, as patients are often concerned and disap-
pointed with the result after splints are removed at the 1-week
mark, given the level of edema that makes their nose look, at
times, even larger than what it was preoperatively.
The senior author prefers an Aquaplast (Patterson Medical,
Mendota Heights, M1) splint, which molds easily over the side-
walls. It is removed along with internal Doyle splints and sutures
at 6–7 days postoperative. Turbinoplasty with outfracture and/or
minimal conchal bone excision can result in slight postoperative
bleeding and oozing. Formal partial turbinectomies of the inferior
turbinate can result in more epistaxis. Intraoperative judicious
cauterization (fulguration of the submucosa) can aid in limiting
this. In addition, surgical and antibiotic ointment placed against
the raw turbinate mucosa and in the dead space of the soft tissue
facets are also helpful.
The nose should be thoroughly irrigated with saline irrigation
for up to 3 months postoperatively. This will help to ensure the
patient is able to breathe well through the healing process and
will continue to eliminate any exuded nasal lining, or crusting.
The incisions should also be kept moist, especially while sutures
remain in place for 1 week postoperatively, using antibiotic oint-
ment applied with a cotton tip applicator.
Fig. 64.17 (a,b,c,d) This 22-year-old Mexican-American woman had thin skin and desired a refined, smaller nose and reduction of her dorsal hump as
well as tip refinement. (e,f,g,h) She is 13 months postop and very pleased with the natural result

1000
X Rhinoplasty
Pain is often more of an issue when patients have undergone
osteotomies with their rhinoplasty, so proper medication should
be provided to prevent undue discomfort. It is best to counsel
patients to stay away from narcotic medications as much as pos-
sible, given the negative side effect profile, but at times the pain is
too great and narcotics must be taken. It is wise to have patients
take acetaminophen around the clock starting from the day of
surgery in order to give a base line level of pain control. Ibuprofen
should be avoided for the first 2 to 3 days postoperatively, given
the potential increased bleeding risk and continued risk of devel-
oping septal hematoma, but many authors are now describing
allowing patients to begin ibuprofen therapy on postoperative
day 2 or 3, given that true increased risk of bleeding has yet to be
concretely proven in any studies. Ibuprofen or other nonsteroidal
anti-inflammatory drugs (1SAIDs) can also help to mitigate a
great deal of the discomfort from the peak of inflammation on
postoperative day 3, but ultimately this decision must remain in
the hands of the surgeon.
At 1 week, splints and sutures are removed and the external
nasal splint is removed as well. Patients must continue to take
great care of the nose to prevent any trauma, given that the bones
will continue to be unstable for 6 to 8 weeks and any cartilage
grafting has yet to set and heal in this time frame as well. Patients
will often describe that their nose feels firmer than before, which
is to be expected. This is a result of both postoperative inflam-
mation and any augmentative grafting that has increased the
nasal tip support framework. The nose will likely remain firmer
permanently, although some degree of softening does definitely
occur with time.
64.6 Concluding Thoughts
The concepts and techniques that are necessary to perform an
aesthetic rhinoplasty properly on a patient of any ethnic origin
must culminate in nasofacial harmony, regardless of the specific
ethnic origin. :hile some ethnicities demonstrate thick skin,
weak broad cartilage frame, and a low/wide dorsum, it is incorrect
to assume that this is the sin qua non of an ´ethnic rhinoplasty.µ
Multicultural rhinoplasty is, perhaps, a better term. This would
delineate that a spectrum of morphology is present ranging
from a bone/cartilage heavy nose with thin skin and pronounced
large dorsal hump (classic Middle Eastern, Castilian, Ethiopian,
1ortheast African) to a nose that has weak, wide cartilage frame,
low dorsum, and wide alar base (e.g., Caribbean Hispanic, Chata,
Classic African, Arab/1orth African). :ithin all these regions and
the people that originate in them, there is a mixing of the ances-
tral features. The key to performing a rhinoplasty effectively is
to recognize which presenting traits require what treatments
and what combinations of technical maneuvers would produce a
final, racially congruent aesthetic result. The rhinoplasty surgeon
should be comfortable utilizing cartilage from sources outside of
the nose when necessary, not hesitate to transect/translocate the
LLC, maximize special grafting (septal extension grafts, DCFG,
auto and true spreader grafts), as well as optimally handle the
nostril soft tissues and overall skin envelope.
As with all rhinoplasty, repetitive practice and some judicious
trial and error are necessary to master this most unpredictable of
all aesthetic plastic surgery operations. Therefore, patient selection
and communication are, as always, a cornerstone of this journey.
Clinical Caveats
• It is critical preoperatively to evaluate and understand the
dynamic interactions and limitations of the skin and soft
tissue envelope as well as the internal nasal lining. Controlling
the unpredictability of the frame-soft tissue ratio is a key
factor in successful outcomes.
• Proper evaluation of the skin and soft tissue variations and
the planned preoperative preparation (if applicable), intra-
operative techniques, and postoperative regimen should be
discussed with the patient.
• The specific aesthetic goals should be discussed in detail with
the patient. Preferences with regard to desired curvature
or straightness to the dorsal profile line, nostril shaping,
animated nasal features patient dislikes, and degree of tip
modification are some examples of common specificities that
patients give their preferences on. The degree of judicious
dorsal reduction or augmentation should be incremental and
include continual assessment and reassessment of dorsum to
tip relationship.
• Nasal airway analysis must be comprehensive, and changes to
nasal width, external and internal valves should be addressed.
It is not uncommon that narrowing excessive nasal width can
compromise the airway, as can nasal tip narrowing. Spreader
grafts and flaps should be considered in every case, particu-
larly when larger degrees of modification are to be employed.
• Thick-skinned amorphous nasal types invariably have a weak
cartilage frame and require addition of cartilage from septum
and often distant sources such as ear or rib cartilage. The rhi-
noplasty surgeon should feel comfortable in acquiring these
donor sites.
• Septal extension grafts that lengthen the central L-frame of
the nose are often required in wide, short, less projected
ethnic nasal types. Increasing nasal length as well as height
with dorsal augmentation are cornerstones of proper surgical
treatment and are the foundation of a positive aesthetic
outcome.
• Once the dorsal height and nasal length are established, the
tip complex shape and its relationship to the alar rim and
dorsum can be modified. This will commonly require lower
lateral crural struts, alar contour grafts (articulating or nonan-
atomic), as well as soft tissue facet treatment. Alar-to-tip
transition can be strong and seamless when using the above
techniques properly.
• Dorsal augmentation may require a combination of techniques
such as onlay rib or rigid grafts as well as diced cartilage or
fascia-only grafts as camouflage and “blending” grafts.
• Alar base and nostril alterations should be incremental. A
less-is-more approach is wise. If both Weir and sill reduction is
necessary, the surgeon can begin with the medial sill incision
and release of the lateral nostril base with medialization and
visualizing the amount of reduction required before the final
excision. A tailored approach will avoid overresection of skin
and lining which is for the most part, irreversible.
• Postoperative treatments are important and can include
massage, stretching, intermittent taping, as well as visits for
triamcinolone or 5-fluorouracil injection sessions. The senior
author begins these injections as early as 6 weeks postop
when feasible.

64 Ethnic Rhinoplasty
1001
• Tretinoic acid and, in some cases, low-dose isotretinoin
(Accutane, Roche Pharmaceuticals, Basel, Switzerland) may
be necessary to optimize outcomes. A thorough discussion
should be had with the patient pre- and postop regarding
ongoing skin regimen(s), and if Accutane is to be prescribed,
a dermatologist should be utilized for comanagement.
Resurfacing lasers as well as regular facials can also be useful.
Suggested Reading
[1] Behmand RA, Ghavami A, Guyuron B. 1asal tip sutures part I: the evolution. Plast
Reconstr Surg 2003;112(4):1125–1129, discussion 1146–1149
>2@ Bizrah MB. Rhinoplasty for Middle Eastern patients. Facial Plast Surg Clin North
Am 2002;10(4):381–396
>3@ Byrd HS, Meade RA, Gonyon DL -r. Using the autospreader flap in primary rhino-
plasty. Plast Reconstr Surg 2007;119(6):1897–1902
>4@ Byrd HS, Hobar PC. Rhinoplasty: a practical guide for surgical planning. Plast
Reconstr Surg 1993;91(4):642–654, discussion 655–656
>5@ Byrd HS, Burt -D. Dimensional approach to rhinoplasty: perfecting the aesthetic
balance between the nose and chin. In: Gunter -P, Rohrich R-, Adams :P, eds.
Dallas Rhinoplasty: Nasal Surgery by the Masters, Vol. 1, 1st ed. St. Louis, MO:
4uality Medical Publishers; 2002:117–131
>6@ Constantian MB. Functional effects of alar cartilage malposition. Ann Plast Surg
1993;30(6):487–499
[7] Converse -M. Corrective rhinoplasty. In: Converse -M, ed. Reconstructive Surgery,
2nd ed. Philadelphia, PA: :B Saunders; 1977:1040
[8] Daniel R.. Diced cartilage grafts in rhinoplasty surgery: current techniques and
applications. Plast Reconstr Surg 2008;122(6):1883–1891
[9] Daniel R.. Middle Eastern rhinoplasty in the United States: Part I. Primary rhino-
plasty. Plast Reconstr Surg 2009;124(5):1630–1639
>10@ Daniel R.. Diced cartilage grafts³delight or delusion" Presented at the Annual
Meeting of the Rhinoplasty Society, Las Vegas, 1V, April 2002
[11] Daniel R.. Hispanic rhinoplasty in the United States, with emphasis on the Mexi-
can American nose. Plast Reconstr Surg 2003;112(1):244–256, discussion 257–258
>12@ Daniel R.. Open tip suture techniques. Part I: primary rhinoplasty. Plast Reconstr
Surg 1999;103:1491
>13@ Daniel R.. Rhinoplasty and rib grafts: evolving a flexible operative technique.
Plast Reconstr Surg 1994;94(5):597–609, discussion 610–611
>14@ Daniel R.. Middle Eastern rhinoplasty in the United States: Part II. Secondary
rhinoplasty. Plast Reconstr Surg 2009;124(5):1640–1648
>15@ Erol OO. The Turkish delight: a pliable graft for rhinoplasty. Plast Reconstr Surg
2000;105(6):2229–2241, discussion 2242–2243
>16@ Foda HM. External rhinoplasty for the Arabian nose: a columellar scar analysis.
Aesthetic Plast Surg 2004;28(5):312–316
[17] Ghavami A. Indication and technique for diced cartilage and fascia grafting in
rhinoplasty. In: Chung .C, Disa --, Gosain A, et al, eds. Operative Techniques in
Plastic Surgery. Philadelphia, PA: Lippincott :illiams and :ilkins; 2019
[18] Ghavami A, -anis -E, Acikel C, Rohrich R-. Tip shaping in primary rhinoplasty: an
algorithmic approach. Plast Reconstr Surg 2008;122(4):1229–1241
[19] Ghavami A, Rohrich R-. Discussion of Daniel R.. Middle Eastern Rhinoplasty in
the United States: Parts 1 and 2. Plast Reconstr Surg 2009;124(5):1649
>20@ Ghavami A, Rohrich R-. The ethnic rhinoplasty. In: Aston S-, Steinbrech DS,
:alden -L, eds. Aesthetic Plastic Surgery. London, U.: :B Saunders; 2009 May
>21@ Ghavami A. Tip shaping in primary rhinoplasty. In: Shiffman MA and Di
Giuseppe A, eds. Advanced Aesthetic Rhinoplasty: Art, Science, and New Clinical
Techniques. 1ew >22@ Ghavami A. Secondary rhinoplasty in the Middle Eastern patient. In: Shiffman
MA and Di Giuseppe A, eds. Advanced Aesthetic Rhinoplasty: Art, Science, and
New Clinical Techniques. 1ew >23@ Gunter -P, Rohrich R-, Friedman RM. Classification and correction of alar-colu-
mellar discrepancies in rhinoplasty. Plast Reconstr Surg 1996;97(3):643–648
>24@ Gunter -P, Friedman RM. Lateral crural strut graft: technique and clinical
applications in rhinoplasty. Plast Reconstr Surg 1997;99(4):943–952, discussion
953–955
>25@ Gunter -P, Rohrich R-. Augmentation rhinoplasty: dorsal onlay grafting using
shaped autogenous septal cartilage. Plast Reconstr Surg 1990;86(1):39–45
>26@ Gunter JP. Facial analysis for the rhinoplasty patient. Dallas Rhinoplasty Symp
1997;14:45
>27@ Guyuron B, Ghavami A, :ishnek SM. Components of the short nostril. Plast
Reconstr Surg 2005;116(5):1517–1524
>28@ Guyuron B. Guarded burr for deepening of nasofrontal junction. Plast Reconstr
Surg 1989;84(3):513–516
>29@ Guyuron B. Alar rim deformities. Plast Reconstr Surg 2001;107(3):856–863
>30@ Guyuron B. Rhinoplasty. Philadelphia, PA: Elsevier Saunders; 2012
>31@ Heir -S, Sandhu BS, Barber HD. Considerations for esthetic facial surgery
in the African-American patient. Atlas Oral Maxillofac Surg Clin North Am
2000;8(2):113–125
>32@ -anis -E, Trussler A, Ghavami A, Marin V, Rohrich R-, Gunter -P. Lower lateral cru-
ral turnover flap in open rhinoplasty. Plast Reconstr Surg 2009;123(6):1830–1841
>33@ McCollough EG, English -L. A new twist in nasal tip surgery. An alternative to the
Goldman tip for the wide or bulbous lobule. Arch Otolaryngol 1985;111(8):524–529
>34@ Ofodile FA, Bokhari F. The African-American nose: Part II. Ann Plast Surg
1995;34(2):123–129
>35@ Planas -, Planas -. 1ostril and alar reshaping. Aesthetic Plast Surg 1993;17(2):139–150
>36@ Porter -P, Olson .L. Analysis of the African American female nose. Plast Reconstr
Surg 2003;111(2):620–626, discussion 627–628
>37@ Roe -O. The deformity of the pug nose and its correction by a simple operation.
Med Rec 1887;31:621
>38@ Rohrich R-, Muzaffar AR. Rhinoplasty in the African-American patient. Plast
Reconstr Surg 2003;111(3):1322–1339, discussion 1340–1341
>39@ Rohrich R-, Ghavami A. Rhinoplasty for Middle Eastern noses. Plast Reconstr Surg
2009;123(4):1343–1354
>40@ Rohrich R-, Raniere - -r, Ha R<. The alar contour graft: correction and prevention
of alar rim deformities in rhinoplasty. Plast Reconstr Surg 2002;109(7):2495–
2505, discussion 2506–2508
>41@ Rohrich R-, Ghavami A. The Middle Eastern nose. In: Rohrich R-, Adams :PA -r.,
Ahmad -, Gunter -P, eds. Dallas Rhinoplasty: Nasal Surgery by the Masters, 3rd ed.
Boca Raton, FL: CRC Press; 2014:1195–1224
>42@ Rohrich R-, Muzaffar AR, Ghavami A. The black nose. In: Rohrich R-, Adams :PA
-r., Ahmad -, Gunter -P, eds. Dallas Rhinoplasty: Nasal Surgery by the Masters, 3rd
ed. Boca Raton, FL: CRC Press; 2014:1139–1170
>43@ Rohrich R-, Adams 😛 -r. The boxy nasal tip: classification and manage-
ment based on alar cartilage suturing techniques. Plast Reconstr Surg
2001;107(7):1849–1863, discussion 1864–1868
>44@ Rohrich R-, Muzaffar AR, -anis -E. Component dorsal hump reduction: the im-
portance of maintaining dorsal aesthetic lines in rhinoplasty. Plast Reconstr Surg
2004;114(5):1298–1308, discussion 1309–1312
>45@ Ofodile FA, Bokhari F-, Ellis C. The black American nose. Ann Plast Surg
1993;31(3):209–218, discussion 218–219
>46@ Sanchez AE. Rhinoplasty in the ´Chataµ nose of the Caribbean. Aesthetic Plast
Surg 1980;4(1):169–177
>47@ Sheen -H, Sheen AP. Aesthetic Rhinoplasty, 2nd ed. St Louis, MO: 4uality Medical
Publishing; 1998
>48@ Tebbetts -B. Shaping and positioning the nasal tip without structural disruption:
a new, systematic approach. Plast Reconstr Surg 1994;94(1):61–77
>49@ Toriumi DM. 1ew concepts in nasal tip contouring. Arch Facial Plast Surg
2006;8(3):156–185
>50@ Toriumi DM, Asher SA. Lateral crural repositioning for treatment of cephalic
malposition. Facial Plast Surg Clin North Am 2015;23(1):55–71
>51@ Toriumi DM. Caudal septal extension graft for correction of the retracted colu-
mella. Oper Tech Otolaryngol--Head Neck Surg 1995;6(4):311–318

1002
X Rhinoplasty
65 Revision Rhinoplasty
Jeffrey T. Steitz, Robert T. Cristel, and Dean M. Toriumi
Abstract
Revision rhinoplasty is a challenging and meaningful endeavor.
It is considered to be one of the most difficult operations due
to both the immense technical difficulty and the complexity of
the reconstructions. Critical to excellent results is a thorough
understanding of nasal anatomy and rhinoplasty techniques.
The more severe the nasal deformity, often the more aggressive
the approach is needed, utilizing adjunctive grafting material to
maximize the outcome. Adequate underlying structure is the
foundation for excellent results; in the revision setting, septal
cartilage is usually absent, weakened, or insufficient to support
the nose. In these settings, costal cartilage is utilized and, in our
experience, is often required to correct most major deformities.
Complicating revision surgery is the increased popularity of
alloplastic implants and nonsurgical ´fillerµ rhinoplasty, which
can create additional scarring and deformities that may not be
evident on physical examination of the nose. Additionally, these
materials can cause chronic inflammation and infection, which
can predispose the patient to complications in the postoperative
period. Our goal will be to highlight a deformity-based approach
toward revision rhinoplasty and the powerful techniques neces-
sary to correct them.
Keywords
revision rhinoplasty, structural rhinoplasty, nasal deformity
65.1 Indications and
Contraindications
The primary indication of revision rhinoplasty is deformity from
previous surgery. An incidence rate is often reported between
5 and 15 of rhinoplasty patients; in reality, a higher number
warrant revision but do not seek it out. The difficulty in rhino-
plasty lies in the understanding that the structural integrity of
the underlying osseocartilaginous framework directly contrib-
utes to external appearance and contour. Even seemingly minor
techniques and maneuvers, if not performed carefully and in
the right patient, can cause significant deformity, such as over-
resection of the cephalic margin of the lateral crus leading to alar
retraction, or overreduction of the structure in a patient with
thick skin leading to a soft tissue polly-beak deformity (Fig. 65.1,
Fig. 65.2, Fig. 65.3).
General indications for revision rhinoplasty can be seen as
complications from primary rhinoplasty, including these common
findings: tip asymmetry; deviated middle or upper third of the
Fig. 65.1 Common iatrogenic deformity highlighting pinching in the
tip with lateral wall collapse due to overreduction of inherently weak
lower lateral crura.
Fig. 65.2 (a) Anterior view of a revision patient showing residual tip
bulbosity and inverted-V deformity with inferomedial collapse of the
upper lateral cartilage in relation to the nasal bones. Brow–tip aes-
thetic lines are severely disrupted. (b) Basal view of the same patient,
highlighting internal recurvature of the lower lateral crura, causing
severe nasal valve obstruction. Also note the lack of support from tip
lobule to alar lobule.
a
b

65 Revision Rhinoplasty
1003
nose; nasal airway obstruction from nasal valve collapse; overre-
duction of the cartilaginous framework; alar retraction; excessive
scarring, especially at the alar base and in the supratip; and graft
failure or extrusion. Specific nasal deformities and their respective
treatments will be expanded upon in succeeding sections.
As with any surgical procedure, a patient’s candidacy for
revision needs to be assessed. Several relative contraindications
of surgery are active tobacco or alcohol use, diabetes mellitus,
connective tissue disease, autoimmune conditions, bleeding or
coagulopathy disorders, and history of keloid formation. These
conditions may be ameliorated before surgery proceeds, but
they may compromise the postoperative result if not addressed
appropriately. Other considerations for surgical candidacy include
assessment of patient goals. Primary and revision rhinoplasty
patients often suffer anxiety about the appearance of their nose.
Body dysmorphic disorder remains a concern with a widely
debated level of prevalence. The nose is the most common pre-
occupation of these patients, and if high levels of suspicion are
present, a psychiatric evaluation would be of benefit to both the
patient and the surgeon before proceeding with surgery.
65.2 Pertinent Anatomy
A comprehensive understanding of nasal anatomy is paramount
to success in revision rhinoplasty. The surgeon must have a
mastery of normal nasal anatomy and vasculature, as revision
rhinoplasty is a surgery of iatrogenic deformities that vary sub-
stantially from patient to patient. The majority of the operation
aims toward correcting deformities and trying to restore normal
form and function to a damaged osseocartilaginous framework.
A deformity-based approach is often the most effective when
performing revision rhinoplasty. Additional considerations are
obviously necessary outside of the deformity, including skin
thickness, scarring, and presence of complicating factors such as
septal perforation or vestibular stenosis. Nasal deformities can
be divided into deformities of the upper third, middle third, and
lower third. Deformities of the alar base and nasal septum can
further complicate reconstruction.
65.2.1 Upper Third
Upper-third deformities most frequently are caused by either
inadequate osteotomies or minor contour irregularities as a
result of primary surgery. Additionally they can be related to
unrecognized deformities at the initial surgery, such as a deep
radix. Diagnosis is primarily based on external inspection and
palpation of the bony vault. The surgeon should pay careful
attention to palpation of the edges of the nasal bones and the
transition from the upper third to the lower third. The radix
should approximate one-third of the nasal length as measured
from the junction between the nasal bones and the orbit.
Important to consider in the height of the radix is the contour
of the forehead, as an improperly placed radix graft in a patient
with a flat forehead can cause significant blunting of the naso-
frontal angle.
65.2.2 Middle Third
The transition between the upper third and middle third of the
nose is a common site for deformity in revision rhinoplasty. The
most common abnormalities of the middle third are internal
nasal valve collapse, inverted-V deformity, open roof deformity,
saddle nose, and polly-beak deformities. Careful inspection of
this area is critical to success both aesthetically and functionally.
Functional assessment should include intranasal examination
of the dorsal septum as it meets the internal nasal valve and
modified Cottle maneuver checking for dynamic collapse.
Inverted-V deformity results from inadequate support in the
middle nasal vault, leading to inferomedial collapse of the upper
lateral cartilage (ULC) and resultant internal nasal valve collapse.
This combines with an obvious external deformity with a notice-
able transition from nasal bones to midvault (Fig. 65.4). Patients
with short nasal bones and long ULCs are particularly prone to
this deformity.
The open roof deformity is created when a dorsal hump removal
has been performed and measures are not taken to close the open
roof that results, leaving a gap between the dorsal septum and
medial edge of the nasal bones. This creates flattening of the
bridge and an obviously palpable irregularity over the transition
between the upper and middle third of the nose.
Fig. 65.3 Another common iatrogenic deformity showing residual tip
bulbosity, loss of lateral wall support, and alar retraction of the right
nostril margin.

1004
X Rhinoplasty
Saddle nose deformity is an unmistakable deformity with
collapse in the middle nasal vault, creating a saddled appearance.
This can be multifactorial but most often results from over-
resection of the cartilaginous dorsum, failure to leave an adequate
dorsal strut, or unrecognized disarticulation of the dorsal septum
from the perpendicular plate of the ethmoid bone.
Finally, polly-beak deformity is another easily recognized
deformity of the middle nasal vault (Fig. 65.5). A polly beak can
be either a true cartilaginous polly beak due to an unrecognized
cartilaginous prominence at the anterior septal angle (particularly
if the tip is being deprojected); a soft tissue polly beak, which is
seen in thick-skinned patients where there is a structural void in
the supratip due to overresection at the anterior septal angle; or a
perceived supratip fullness due to inadequate tip support leading
to deprojection and relative supratip fullness.
65.2.3 Lower Third
Deformities of the lower third, like deformities elsewhere,
are usually either iatrogenic or unrecognized deformities not
treated in the primary setting. The lower third can be exception-
ally difficult to manage and often requires relatively extensive
grafting techniques in revision surgery. Asymmetry is the most
common abnormality seen, which usually manifests as asym-
metry of the nostril margin or alar retraction. Additionally seen
are external valve collapse, tip irregularities/bossae, supra-alar
pinching, overrotation, and tip ptosis. Examination of the lower
third should focus on evaluation of symmetry, external valve
collapse, tip rotation/position, and presence of alar retraction.
Irregularities of the nasal septum and alar base can significantly
complicate management of the tip, including caudal septal
deflections and alar base scarring from previous alar base reduc-
tions or premaxillary deficiency.
65.3 Preoperative Assessment
and Planning
Accurate preoperative assessment is critical to appropriate
surgical planning and patient counseling in revision rhinoplasty.
Often revision rhinoplasty patients have educated themselves
on aesthetics, have a grasp on different techniques utilized in
surgery, and have very high expectations regarding the result.
Many enter the consultation with caution and will seek multiple
opinions, with much higher scrutiny toward the surgeon than
when they proceeded with their first operation. Many times
patients will state that they ´want their old nose backµ or have
photographs of friends, family, or celebrities showing what they
hope to attain. A comprehensive medical and surgical history
should be ascertained, a detailed physical exam performed, and
preoperative photographic documentation done. Discussion of
functional disabilities should focus on fixed and dynamic nasal
obstruction. Adequate assessment of allergy and environmental
etiologies for intermittent nasal obstruction can help provide
realistic expectations for improvement postoperatively and lead
to appropriate counseling. Many revision rhinoplasty patients
have had previous inferior turbinate reduction, and questions
geared toward atrophic rhinitis, including nasal suffocation,
burning, and dryness, can help predict the patient who may have
obstructive issues postoperatively.
It is paramount to discuss previous operations. Some patients
will come prepared and have copies of previous imaging and
rhinoplasty worksheets. Others will have minimal recollection
of previous surgeons and sometimes even timing of previous
surgeries. Some obvious external deformities, such as saddle
nose, inverted-V, or polly-beak deformity, usually predict the
underlying structural problem. Most important to discuss would
be any previous grafting material used or whether or not alloplas-
tic implants or fillers were used. Previous implants or fillers can
significantly increase the rate of infection postoperatively, and
adequate counseling needs to be performed.
The physical examination focuses in on the external nose and
internal structures. The upper third, middle third, and lower third
Fig. 65.5 Lateral view of a patient with polly-beak deformity. This
patient has very thick, sebaceous skin that will require reprojection
of the cartilaginous framework into the thick skin–soft tissue envelope.
Fig. 65.4 (a) Frontal view showing inferomedial collapse of the left
upper lateral cartilage (ULC). (b) Surgical markings of the same patient
highlighting the inferomedial displacement of the ULC and widened
appearance of the left nasal bone.
a
b

65 Revision Rhinoplasty
1005
are systematically analyzed for deviations, asymmetries, contour
irregularities, and obvious deformities. Endonasal examination is
performed with anterior rhinoscopy and rigid nasal endoscopy
to assess for septal deviations, inferior turbinate hypertrophy or
scarring, and presence/absence of vestibular stenosis. Additionally
for functional purposes, a modified Cottle maneuver should be
performed to assess nasal valve patency and lateral wall support.
Thickness of the skin–soft tissue envelope (SSTE) should be
analyzed prior to surgery and prior to preoperative imaging ser-
vices. It is important to consider skin thickness when performing
computer imaging alterations to provide realistic expectations to
patients. For instance, a thick-skinned patient will not be able to
attain a petite nose without developing a polly-beak deformity.
Thin skinned patients should be counseled on developing minor
asymmetries and contour irregularities if certain precautions
are not taken. Particularly in revision surgery, patients may have
developed thinning of the SSTE, scarring, and vascular compro-
mise. Thin-skinned patients typically require additional grafting,
especially in revision surgery, to camouflage contour irregularities
and minor depressions, particularly in transition zones. Patients
should be counseled that postoperatively they will have a wider
appearance to the nose, but that most of this resolves within 9 to 12
months as the SSTE contracts. In contrast to thin skin, a thick SSTE
will conceal minor irregularities, but these patients will typically
have prolonged edema that may last well beyond the first year.
This usually fluctuates dramatically with temperature, salt intake,
alcohol intake, and sun exposure. In the surgical management of
thick-skinned patients, it is paramount to project the cartilaginous
framework into the SSTE to provide adequate structural support,
thus preventing long-term deformities due to increased amounts
of dead space between the SSTE and structural framework.
In addition to visual inspection, the surgeon should target
questions to ask about intermittent blue or white discoloration,
which could indicate vascular compromise. Even the presence
of vascular compromise and a damaged SSTE is not an absolute
contraindication to surgery; however, precautions must be taken
to minimize risk of complication, including minimizing electro-
cautery and keeping the dissection limited as much as possible so
as not to disrupt the remaining vasculature.
Inspection of the external nose should focus on the upper,
middle, and lower thirds. Particular attention towards width,
deviation, asymmetries, and contour irregularities should be
noted and documented. The external nose and caudal septum
should be palpated to assess for strength and resiliency. The upper
and middle thirds most commonly present with contour irregu-
larities, asymmetries, and deviation, which should be corrected
in the revision surgery. The lower third is more complicated and
should be assessed for pinching, tip support and resiliency, and
alar retraction. The alar–columellar relationship should be ana-
lyzed, with 2 to 4 mm of columellar show being ideal. A hidden or
hanging columella should be corrected at surgery.
Following adequate history and physical examination, pre-
operative photography and interactive computer imaging are
performed. Standard anterior, lateral, oblique, and basal views
are obtained for all patients, both full-face and close-up views. In
addition, smiling views and three-dimensional photographs are
useful adjuncts. After appropriate photographs are taken and a
discussion of the patient’s surgical goals is completed, computer
imaging is performed on the anterior and lateral views to portray
a realistic surgical goal. It is important to consider skin thickness
and elasticity when performing computer imaging to provide
the most accurate portrayal and realistic expectations. Patients
should understand that computer imaging modalities are an esti-
mation, not a guarantee, of a result. The surgeon should make best
efforts to give an accurate portrayal of the expected postoperative
appearance. Once the surgeon and patient have agreed upon
an estimated result, counseling may begin regarding the risks
and benefits of revision surgery as well as discussion regarding
adjunctive grafting materials needed. Risks discussed should at
minimum include bleeding, infection, septal perforation or hema-
toma, scarring, asymmetries, numbness, donor site morbidity,
skin loss, and the generalities of the postoperative recovery period
specific to that surgeon’s practice. Once the informed consent has
been discussed, the patient may proceed with scheduling surgery.
65.4 Preoperative Placement
and Markings
Once the patient enters the operating room, the patient should
be positioned supine on the operating room table. It is our pref-
erence to use general anesthesia with endotracheal intubation
using an oral RAE tube. The tube should be taped in such a way
that minimizes compression of the lower lip. Throughout the
operation the lower lip should be mobilized to minimize the risk
of a superficial necrosis.
It is our practice to perform a series of preoperative and intraop-
erative measurements including nasolabial angle, tip projection,
length from the radix to the subnasale, length from the radix to
the infratip, base width/flare, and lip length. These are measured
preoperatively, after injection of local anesthetic, intermittently
throughout the operation, and immediately following closure of
incisions.
Prior to injection, the external nose is palpated and marked for
deviations, contour deformities, tip bulbosity, and asymmetries
(Fig. 65.6). Photographs are then taken of the markings prior to
injection of local anesthetic. After appropriate photography, 1
lidocaine with 1:100,000 epinephrine is injected to the external
nose and septum. Care is taken to inject the marginal incisions,
the columella, the tip, the dorsum, and over the nasal bones. The
septum is infiltrated and palpated with a 25-gauge needle to note
the degree of previous septal cartilage resection. Oxymetazoline
(Afrin; Bayer, Leverkusen, Germany)–soaked pledgets are then
inserted into each nasal passage. At least 15 minutes are allowed
to elapse for maximal vasoconstriction prior to incisions.
The nose and face are prepped with a diluted povidone-iodine
solution, taking care not to let the prep soak in or around the eyes.
Refresh Lacri-Lube (Allergan, Irvine, CA) ointment is placed in each
eye, and the eyes are taped shut with a 0.5-inch Steri-Strip (3M, St.
Paul, M1). The endotracheal tube is prepped into the field so that
the mouth and lips can be visualized during surgery. Both ears are
always prepped into the field, and the right chest if costal cartilage
is to be harvested. If any adjunctive procedures are planned, then
the patient should be prepped for those as well.

1006
X Rhinoplasty
65.5 Operative Technique
A generalized plan for operative technique should be in mind
prior to making incisions. If possible, the incision should be
designed in such a way that the previous scar can be excised.
If not enough skin is available, then the incision can be made
through the previous scar. If deprojection is anticipated, the
incision should be made immediately anterior to the scar. If addi-
tional cartilage is needed for grafting, it is preferable to harvest
it early in the operation, particularly when utilizing costal carti-
lage. It is desirable to harvest costal cartilage prior to opening the
nose so that sequential carving can be performed to observe for
warping throughout the operation. (See Ancillary Procedures,
subsequently, for further details on cartilage harvest.)
The approach depends largely on the deformity present, but in
general the open approach is most frequently utilized for major
deformities in revision rhinoplasty. Endonasal approaches can be
used in the appropriate setting with minor contour deformities,
slight asymmetries, and more easily correctible deformities.
After the incisions are made, the skin is elevated in a sub–
superficial musculoaponeurotic system (SMAS) plane over the
lower lateral cartilages (LLCs) and toward the middle nasal vault.
Tissue planes in revision surgery can sometimes be distorted or
significantly scarred. Hydrodissection is critical in maintaining
adequate thickness of the SSTE throughout the dissection. Once
the bony vault is encountered, a Joseph periosteal elevator can be
used to dissect the appropriate pocket. A narrow pocket should
be created, especially if dorsal or radix augmentation is planned.
Once the nose has been opened, the surgeon should assess the
underlying framework and the thickness of the SSTE. Particular
attention should be given toward nasal bone deviation, middle
nasal vault collapse or depression, stability of the cartilaginous
L-strut, tip support, and strength of the LLCs. Frequently in
revisions, surgeons will encounter evidence of previous cephalic
resection of the lower lateral crus, indicating weakened lateral wall
support and supra-alar pinching. Intranasal examination should
be performed again at this time to assess the presence of resid-
ual septal deviations and need for revision septoplasty. Various
approaches to the nasal septum exist, depending on the surgeon’s
preferred approach. If the caudal septum is in the midline and the
tip is not deviated, a .illian incision can be performed. However,
in many revision operations, residual caudal septal deflections are
common, in which case we prefer to dissect between the medial
crura and identify the anterior septal angle. The septum is then dis-
sected in a submucoperichondrial plane with a Freer elevator. This
plane is often distorted due to scarring. If the previous surgeon did
not dissect in the appropriate plane, this becomes markedly more
difficult. Visualization is improved by dividing the attachment of
the ULC to the dorsal septum. This is not always necessary unless
significant deviation or middle vault collapse is present. A staged
approach to reconstruction is then taken depending on the specific
deformity present. Usually in revision operations there is a combi-
nation of issues present that lead to many of the aforementioned
deformities of the upper, middle, and lower thirds.
Attention is first paid toward the upper third and bony vault.
The nasal bones are again assessed for deviations, contour defor-
mities, stepoffs, and dorsal height. It is preferable to begin with
the bony vault prior to addressing the middle and lower thirds
to create a stable, midline construct that creates the foundation
for the reconstruction. This is undertaken prior to further septal
manipulation, as it is easy to dislocate the dorsal septum at
the keystone area, creating a very difficult problem to correct.
Deviated nasal bones are the most common deformity in revision
rhinoplasty. Usually one or both bones will be more vertically
oriented due to aggressive osteotomies in the primary setting.
Many surgeons will routinely perform bilateral medial and lateral
osteotomies, which can be refractured using a Boise elevator or
digital manipulation. Surgeons should be conservative when per-
forming revision osteotomies, as this can significantly destabilize
the bony vault. Minor refinements of slight asymmetries can be
performed with rasping.
Aside from residual deviations or asymmetries of the nasal
bones, open roof deformity is frequently seen following dorsal
hump reduction with inadequate or incomplete osteotomies in
the primary setting. This is corrected in a similar fashion with
revision osteotomies or fracture of the nasal bones. Alternatively,
camouflage grafting can be performed for minor open roof
deformities.
The height of the radix should be assessed early and addressed
late in the operation. In patients with appropriate dorsal height but
Fig. 65.6 Anterior view of presurgical markings highlighting significant
tip bulbosity with asymmetry in the nasal bones and broken brow–tip
aesthetic lines.

65 Revision Rhinoplasty
1007
the appearance of a slight hump, a low radix may be the culprit.
It is important not to overreduce the dorsum in these patients, as
they will end up with a wide appearance on anterior view. The
radix height should approximate one-third of the nasal length as
measured from the corneal surface of the globe on lateral view.
Radix grafting can be difficult, especially in patients with thin
skin. Soft, pliable cartilage with beveled edges is best and ideally
covered with soft tissue if available (Fig. 65.7). It is preferable to
place these grafts near the end of the operation, and they can be
fixated with a transcutaneous 5–0 poliglecaprone (Monocryl,
-ohnson -ohnson, Somerville, 1-) suture. Forehead contour
should be noted, as patients with a flat forehead may not tolerate
radix grafting due to significant blunting of the nasofrontal angle.
Once deformities of the upper third have been addressed, atten-
tion can be turned initially to the middle third and subsequently
the lower third. Middle nasal vault deformities are primarily com-
prised of dorsal septal deviations, inverted-V, saddle nose, and
polly-beak deformities. The surgical correction revolves around
creation of a strong structural bridge that connects the upper third
to the lower third. This is most frequently accomplished with the
use of spreader grafts and/or dorsal augmentation. Spreader grafts
that extend beyond the anterior septal angle can be used to secure
caudal septal extension grafts that can help control tip projection
and help straighten a slightly deviated caudal septum (Fig. 65.8).
Dorsal septal deviations can be corrected by utilizing spreader
grafts and suturing techniques. Spreader grafts create a splinting
effect of the dorsal strut, which can straighten minor deviations
(Fig. 65.9). Usually a slightly thicker graft is placed on the con-
cave side of the deviation, whereas a thinner graft is placed on
the convex surface. A slight tilt to the septum requires clocking
sutures. In some cases of significant facial asymmetry where
the midline of the upper lip does not match up with the midline
between the medial canthi, a slight tilt is desirable to counteract
the discrepancy.
Inverted-V deformities result from inferomedial collapse of the
ULC with resultant nasal valve obstruction. Treatment revolves
around restoring support in the middle nasal vault, which is
accomplished with strong spreader grafts. The thickness varies
based on the deformity, and the ULC must often be divided from
the dorsal septum to optimize the result. Submucosal spreader
grafts create a cantilever effect that may improve mild deformities
(Fig. 65.10).
A low dorsum, or saddle nose deformity, is encountered with a
loss of dorsal support in the middle nasal vault. As such, treatment
Fig. 65.7 Soft cartilage radix graft with sutured soft tissue.
Fig. 65.8 Extended spreader grafts (costal cartilage) to a small caudal
septal extension graft.

1008
X Rhinoplasty
aims at restoring middle vault support versus camouflage with
dorsal augmentation. Again, spreader grafts can be utilized to
restore support in the mid-vault. Typically saddling is a result
of significant structural weakness and needs strong cartilage to
recreate the dorsal L-strut. Costal cartilage is usually required
for repair of this type of deformity. :ith severe saddling, occa-
sionally spreader grafts do not allow for enough augmentation
of the dorsum for adequate improvement. In these cases dorsal
augmentation grafts carved from costal cartilage can be placed
over the bridge. Grafts should be carved into a canoe shape with a
slight curvature face down toward the dorsum. Edges are beveled
for camouflage, and the graft is inserted up to the nasal starting
point and terminates at the supratip (Fig. 65.11). Fixation is
accomplished by various means, including within a tight subperi-
osteal pocket, suturing techniques or transcutaneous 0.35-mm
.irschner wires, which are then removed on postoperative day
7. Regardless of fixation technique, perichondrium is sutured to
the undersurface of the cephalic margin of the graft (Fig. 65.12).
Small osteotomies are made in the dorsal nasal bone with a 2-mm
osteotome prior to placement of the graft. These steps are taken to
secure the graft to the underlying osseocartilaginous framework.
Polly-beak deformities, as discussed earlier, are multifactorial,
and treatment is targeted towards the specific etiology. Soft tissue
supratip fullness is managed with resection of any excess scar,
tip reprojection, and stabilization. Cartilaginous supratip fullness
secondary to an overprojected anterior septal angle and dorsal
septum can be managed with appropriate resection. Supratip
fullness, secondary to tip deprojection and a relative fullness in
the supratip, is managed with tip reprojection and stabilization.
A strong L-strut and adequate tip support transition the middle
third to the lower third. Maintenance of that structure helps
avoid polly-beak deformities, and recreation of it resolves them.
Understanding skin thickness is paramount to correction of pol-
ly-beak deformities as patients with thick skin need tip projection
into the thick SSTE for correction of supratip fullness.
The lower third or nasal tip is frequently addressed following
structural stabilization of the L-strut and management of the
upper and middle thirds. Abnormalities of the lower third are
frequently present in revision rhinoplasty, requiring extensive
grafting techniques. Achieving symmetry in the tip is challenging
and the most time-consuming aspect of the operation. External
valve collapse due to weak lower lateral crura and residual bul-
bosity due to cephalically oriented lower lateral crura are often
seen in revision surgery due to neglect in the primary operation.
For a detailed discussion on tip grafting and tip contouring, refer
to Chapter 62. Secondary deformities such as tip ptosis, alar
retraction and short-nose deformity will be discussed in further
detail.
Fig. 65.10 Submucosal placement of spreader grafts in a patient
undergoing dorsal augmentation.
Fig. 65.9 Intraoperative placement of a spreader graft, which will
correct a mild septal deviation using the strength of costal cartilage.

65 Revision Rhinoplasty
1009
Major tip support mechanisms include the strength and
resiliency of the LLCs, medial crural attachment to the caudal
septum, and the attachment of the ULC to the LLCs, or scroll area.
Disruption of major tip support mechanisms, which is intention-
ally done in the primary setting, without adequate resuspension
or restructuring can lead to tip ptosis over time. Repair is done
with restructuring and resupporting the nasal tip. This can be
accomplished with caudal septal extension grafts or extended
columellar strut grafts (Fig. 65.13). If the caudal septum has been
severely dislocated or deviated, caudal septal replacement grafts
anchored to the anterior nasal spine are used (Fig. 65.14). The
medial crura are then set back onto the caudal septum, extension
graft, or extended strut. It is important to consider the alar–col-
umellar relationship, as patients with tip ptosis will often have
the appearance of a hidden columella. Achieving alar–columellar
harmony creates a more natural, youthful appearance.
Resection of the cephalic margin of the lower lateral crus, or
“cephalic trim,” is commonly performed in primary rhinoplasty
Fig. 65.11 (a) Dorsal augmentation graft prior to placement. (b) Lateral view of dorsal augmentation graft highlighting a slight downward-facing
curvature, which is well tolerated in dorsal grafts. (c) Lateral view of graft prior to placement.
a
b
c

1010
X Rhinoplasty
to improve tip definition and reduce tip bulbosity. At least 6 mm
of the lower lateral crus is necessary (with 8–10 mm being pref-
erable) for structural support of the lateral wall and maintenance
of nostril position; however, the strength of the lower lateral crus
is highly variable between patients. If overresection is performed
in a patient with a thin, weak lower lateral crura, alar retraction
can result, which causes significant disharmony on the anterior
view and can be highly distressing to patients. It is one of the
most common reasons patients seek revision operations. Repair
is performed with caudal repositioning of the lower lateral crura
into a pocket below the supra-alar groove, utilizing strong lateral
crural strut grafts. The grafts are sutured to the undersurface of
the lower lateral crura abutting the new dome (Fig. 65.15). :hen
combined with dome sutures and avoidance of dissection of the
remainder of the alar lobule, placement creates a cantilever effect,
lowering the nostril margin. The nostril margin can be further
supported by the placement of alar rim grafts, which create a
more triangular base view (Fig. 65.16).
A short, overrotated nose is one of the most difficult deformities
in revision rhinoplasty. On external examination there is a char-
acteristic obtuse nasolabial angle with excess nostril show and
underprojection of the nasal tip and a low dorsum (Fig. 65.17).
There is generally significant contracture of the SSTE, which can
be very adherent to the underlying osseocartilaginous framework.
Patient should be counseled that correction may require multiple
operations. The repair requires advanced and powerful grafting
techniques with dorsal augmentation, caudal septal replacement/
Fig. 65.12 Costal perichondrium sutured to the undersurface of dorsal
augmentation graft.
Fig. 65.13 Large caudal septal extension graft.
Fig. 65.14 Caudal septal replacement graft insertion.

65 Revision Rhinoplasty
1011
extension grafts, and frequently large composite grafts. Patients
are instructed preoperatively to perform stretching exercises
of the nasal skin to optimize the elasticity of the SSTE prior to
surgery. Dorsal augmentation grafts and septal replacement/
extension grafts are similar to those used in treatment of other
deformities. Septal and auricular cartilage grafts are not strong
enough for correction of this particular problem, and costal carti-
lage must be utilized. Once the tip has been reprojected and dorsal
augmentation graft has been secured, there is often a large deficit
of the internal vestibular lining. In these cases, composite grafts
are needed to create a tension-free closure so as not to distort the
nostril margin. Composite grafts are harvested from the cavum
conchae (Fig. 65.18). A subunit resection of the cavum conchae
creates a donor site easily closed with a postauricular full-thick-
ness skin graft, which camouflages well (Fig. 65.19). :hen manip-
ulating the composite graft, the surgeon must remain gentle so as
not to avulse the skin from the underlying perichondrium. The
shape of the graft should be elliptical to maximize surface area for
vascular ingrowth to improve survivability (Fig. 65.20, Fig. 65.21).
Patients may have some residual narrowing of the internal nasal
valve and nasal vestibule following repair due to the thickness of
the caudal septal replacement graft and composite grafts. These
can be thinned in a secondary operation to improve functional
outcomes if necessary.
Finally, attention turns toward closure of the incisions. The
marginal incisions are closed with 5–0 chromic suture in an
interrupted fashion. The transcolumellar incision is closed with
a combination of 7–0 nylon and 6–0 fast-absorbing gut suture.
If lateral crural repositioning was performed, then lateral wall
splints made from 0.25-mm septal splints are secured to the nasal
sidewall with 3–0 nylon suture. Prior to cast placement, drains
may be placed. In patients at high risk for infection, a 22-gauge
angiocath is inserted through the marginal incision and directed
toward the tip. It is secured with a 5–0 nylon suture to the lateral
wall splint and connected to IV tubing for irrigation in the post-
operative period (Fig. 65.22). A piece of Telfa (Medtronic, Dublin,
Ireland) is then cut and placed over the dorsum, and Steri-Strips
are applied. An Aquaplast (Patterson Medical, Mendota Heights,
M1) cast is then placed. All ancillary sites are closed, and the
operation is concluded.
65.6 Ancillary Procedures
Revision rhinoplasty generally requires extensive reconstruction
of the osseocartilaginous framework. Various grafting materials
are utilized to perform the operation, including septal cartilage,
auricular cartilage, costal cartilage, bone grafts, alloplasts, and
soft tissue augmentation. Each of these will be described in detail
with their uses and limitations. The ideal grafting material will
be easily harvestable with minimal morbidity and predictable
long-term results.
65.6.1 Septal and Auricular Cartilage
Grafting
Septal cartilage is an ideal grafting material utilized in rhino-
plasty and revision rhinoplasty. Septal cartilage can be strong,
resilient, easily carved, easily harvested, and resistant to warping
and changing. The resorption rate is minimal, and the long-term
results are predictable. Unfortunately, in revision surgery the
septum has often been harvested, scored, or weakened in the
Fig. 65.15 Placement of lateral crural strut graft to remnant lower
lateral crura.
Fig. 65.16 Anticipated location of a left-sided rim graft.

1012
X Rhinoplasty
Fig. 65.18 Intraoperative markings for composite graft harvest from
cavum conchae.
Fig. 65.19 Donor site closed with postauricular full-thickness skin
graft.
Fig. 65.17 (a) Anterior view of a patient with a short nose, obtuse nasolabial angle, and severe tip and nostril asymmetry. (b) Lateral view showing an
obtuse nasolabial angle, low radix, low dorsum, underprojected tip, and overrotated tip lobule. (c) Basal view highlights a deviated tip, unfavorable
transcolumellar scar, and severe nostril asymmetry with the left nostril apex being much higher than the right. Additionally seen is internal recurva-
ture, more prominent on the patient’s left side.
a
c
b

65 Revision Rhinoplasty
1013
Fig. 65.20 Intraoperative placement of composite graft to right mar-
ginal incision. Note the lack of internal lining, which allows visualization
of the lateral crural strut graft through the right marginal incision.
Fig. 65.22 Intraoperative placement of 22-gauge angiocath drains,
which will be used for irrigation of antibiotic solution until approxi-
mately postoperative day 3.
Fig. 65.21 Marginal incision after closure with composite graft.
Fig. 65.23 Ethmoid bone graft with holes being drilled with 1.1-mm
drill bit to enable suture fixation of graft.

1014
X Rhinoplasty
previous operation. Because of the lack of available septal carti-
lage, attention must frequently be turned toward other grafting
materials. For further details on septal cartilage grafting and
harvest, refer to Chapter 61 on primary rhinoplasty.
Auricular cartilage can be utilized in revision rhinoplasty. It
generally has some significant limitations in rebuilding the osseo-
cartilaginous framework, but in the right setting can be a useful
weapon in the surgeon’s armamentarium. Auricular cartilage is
generally harvested through a postauricular approach. An anterior
approach can be performed but generally has less acceptable scar-
ring. The postauricular approach is safe, with minimal morbidity.
The entire conchal cartilage can be harvested from both ears with
minimal alteration to the external shape of the ear. Auricular
cartilage should be used for nonstructural grafting. Over time the
edges of the grafts can curve slightly, which makes them a poor
choice for dorsal augmentation. In general, auricular cartilage
should be used for the least important grafts in reconstructive
rhinoplasty. Additionally, composite grafts can be harvested
from the cavum conchae for reconstruction of vestibular stenosis
or unfavorable alar base scarring. These are harvested through
an anterior approach, resecting the entire cavum conchae with
overlying skin. The donor site is closed with a full-thickness skin
graft harvested from the postauricular skin. A bolster is placed
either for composite graft harvest or for concha harvest to prevent
hematoma or seroma and is left in place for 1 week for conchal
bowl harvest and up to 2 weeks for composite grafting. Small
Penrose drains or angiocaths can be placed at the inferior aspect
of the postauricular incision if desired, or a small opening can be
left inferiorly to allow passive drainage. All are effective means
of controlling postoperative fluid collections. Auricular cartilage
grafting is a powerful adjunct in revision surgery but should
rarely be used in isolation.
65.6.2 Costal Cartilage Grafting
Most revision surgeries require structural grafting utilizing
costal cartilage. Costal cartilage is a very strong grafting material
for structural rhinoplasty. It provides strong structural support
and has minimal rates of resorption with low rates of infection.
It generally has been untouched in previous surgeries and is
abundantly available. The sixth or seventh ribs can usually be
harvested in segments up to 4 to 5 cm. Multiple grafts can be
harvested through the same small incision. For further details on
our method of costal cartilage harvest, please refer to Chapter 63
on Asian rhinoplasty. Donor site morbidity is slightly higher than
with other grafting materials, with a low risk of pneumothorax,
increased postoperative pain, and increased surgical time.
However, these risks are minimized with excellent technique,
and 4- to 5-cm grafts can be harvested in as little as 30 minutes
in thin patients. Most surgeons’ concern over costal cartilage
grafting is related to unpredictability due to warping tendencies.
In general this risk can be minimized with appropriate splinting
and sequential carving early in the operation. It is important
to harvest rib as soon as it is known to be necessary, so that
warping tendencies can be observed intraoperatively and grafts
can be appropriately selected and splinted. For instance, a slight
curvature is ideal for lateral crural strut grafts and single-piece
dorsal grafts. Caudal septal replacement or extension grafts, on
the other hand, do not tolerate warping, as it will lead to external
deviation of the nose. Once the graft is harvested, it is cut into
at least three longitudinal segments and placed in an antibiotic
solution to observe while the operation continues. The cartilage
is then assessed and carved sequentially until final alterations
are made immediately prior to graft implantation. Splinting is
performed with thin slivers of costal cartilage (or septal cartilage
if available).
Another important consideration for costal cartilage grafting is
the age of the patient. The ideal age range for harvest is 30 to 50
years old, where calcification is present but variable. In general,
the higher the degree of calcification, the less likely the rib is
to warp. There is, however, a spectrum, and ribs can be overly
calcified but are rarely unusable. excessive warping, which makes the cartilage difficult to work
with but, again, rarely unusable.
Cadaveric costal cartilage should be mentioned, as it is used
in revision rhinoplasty. Obviously, patient morbidity is removed
from the equation, but cadaveric rib does have its limitations. It
has variable rates of resorption, and vascular ingrowth has not
been demonstrated. The surgeon should approach the use of this
material with caution, as initially the reconstruction will hold up
but, due to, the variability in resorption, the long-term results can
be variable. This material should generally be reserved for patients
who are not candidates for costal cartilage harvest because of
other morbidities or severe calcification in the elderly population.
65.6.3 Bone Grafting
Various bone grafting materials can be used for revision rhi-
noplasty. First, the perpendicular plate of the ethmoid and the
vomer can be used for splinting of costal cartilage grafts or the
caudal septum. This can be more difficult to work with and
have variable rates of resorption, but overall this can be a very
powerful maneuver, especially with residual septal deviation or
fractures through the L-strut. Care must be taken with harvest,
but generally the ethmoid and vomer are frequently available
in the revision setting. Double-action scissors are used to cut
through the bone superiorly so as not to fracture the cribriform
plate, which would cause a cerebrospinal fluid (CSF) leak. The
bone is then prepared by using either a 16-gauge needle or
1.1-mm drill bit to perforate the bone for suturing (Fig. 65.23).
Holes should be spaced at least 2 to 3 mm apart depending on
the thickness. They can then be used either in small segments to
splint costal cartilage grafts or as larger segments to splint the
L-strut or straighten the caudal septum.
Also worth mentioning are split calvarial bone grafts.
Historically these are used primarily for use in dorsal reconstruc-
tion, but use is limited by variable rates of resorption and difficult
fixation of the grafts, typically requiring titanium plates. These are
easily harvested from the parietal skull at least 2 cm off midline so
as not to damage the sagittal sinus. A drill is used to cut through
the outer table of the calvarium into the medullary bone, and the
outer cortex is removed. Large quantities are available, and the
graft is decently well tolerated with the exception of moderate
pain and a slight depression at the donor site. :ith better materi-
als usually available for dorsal augmentation, calvarial bone grafts
are infrequently utilized.

65 Revision Rhinoplasty
1015
65.6.4 Alloplastic Graft Materials
Finally, alloplastic implants have gained widespread popularity,
primarily in Asian countries. There are a wide variety of implant
materials available, including porous polyethylene, polytet-
rafluoroethylene (PTFE), expanded PTFE, and silicone. Each
material has its own distinct advantages and disadvantages.
Porous polyethylene and PTFE both contain small pores that
allow vascular ingrowth and biointegration. From an implant
standpoint, ingrowth allows less mobility due to improved fix-
ation. However, this can lead to extreme difficulty with removal,
which is required in 3 to 10 of implants due to infection or
extrusion. Additionally scar contracture occurs, which can lead
to SSTE damage and decreased skin elasticity, making primary
reconstruction after implant removal more difficult. Silicone, in
contrast to the aforementioned implants, does not allow biointe-
gration but rather leads to capsule formation surrounding the
implant. This does make for easy removal, which is frequently
required because of the long-term complications associated with
silicone implants. Frequently seen will be thinning of the skin,
which can lead to delayed extrusion with a rate reported ! 8
and increasing over the lifetime of the graft.
Regardless of the implant material selected, the surgeon should
be aware of the uses and limitations of the grafting material used
and counsel the patient appropriately regarding these risks.
65.7 Postoperative Care
Discussion of postoperative care begins at the preoperative visit. It
is imperative for patients to understand their role in the recovery,
expectations regarding healing, and the importance of appropri-
ate follow-up to optimize the result. Patients will feel empowered
if they play a vital role in their recovery process. :e have all rhi-
noplasty patients perform intranasal soaks with a ciprofloxacin
irrigation solution (1 mg/mL) beginning the first night of surgery
and continuing for at least 6 weeks postoperatively. This clears
intranasal/vestibular crusting, keeps the incisions clean and free
of debris, and minimizes infection risk. It additionally averts the
need of postoperative dpbridement if performed properly. The
same irrigation solution is used if irrigation drains are inserted
at the conclusion of the operation. The drains will be removed on
postoperative day 3. Columellar sutures, lateral wall splints, and
the Aquaplast cast are removed on postoperative day 7. Careful
removal of the cast is critical so as not to put excessive tension on
the underlying skin, which may pull upward, disrupting healing
or creating a new pocket in the subcutaneous area, leading to
unwarranted scarring or additional edema. Patients should be
reminded to avoid tobacco and alcohol use, as this may compro-
mise the postoperative result. Trauma to the nose is clearly an
important problem to avoid. Follow-up visits should be expected
within the first week after surgery and several times over the
next month and year, with yearly visits thereafter. Photographs in
all views should be taken at these visits and are beneficial to both
the patient and surgeon. The patient can be educated on the pro-
gression of healing and outcomes, while the surgeon may review
favorable and unfavorable results, predict future procedures, and
refine their surgical skills.
Patient discomfort from cartilage harvest sites is often present
from the auricular or costal regions, with costal harvesting being
more notable. This typically subsides within the first 7 to 10 days.
Proper pain control is necessary to facilitate lung expansion,
decreasing the risk of atelectasis or postoperative pneumonia.
Postoperative nasal infection is a potential devastating compli-
cation that is controlled with sterile technique and perioperative
antibiotic usage. There continues to be debate about whether use
of postoperative antibiotics reduces the incidence of infection.
Currently, there is no clear consensus or proven efficacy for anti-
biotics in the reduction of postoperative infections.
65.8 Outcomes
Postoperative outcomes are relatively predictable based on
intraoperative techniques used. In general, patients can expect
a longer period of recovery than in the primary setting due to
increased extent of dissection and more powerful grafting tech-
niques. Edema can persist for months, and we routinely express
to patients that they are only 30 healed at the 1-year mark.
Changes persist over years. Most of the appreciable edema is
gone by about 9 months postoperatively; however, some patients
with thicker skin can see longer fluctuations over extended peri-
ods of time.
:ith severe deformities, multiple operations are sometimes
necessary and should be discussed prior to the initial operation. In
particular, when composite grafts and caudal septal replacement
grafts are required, as in the case with short, overrotated noses,
additional operations are sometimes needed to thin the grafts to
maximize functional improvement.
General pitfalls are similar to those of primary rhinoplasty with
some exceptions. Due to the frequent need for costal cartilage
grafts, warping may occur that can distort the nostril margin, cause
subtle deviations in the tip/dorsum, or cause functional obstruc-
tion. This risk is minimized by sequential carving intraoperatively
and splinting of costal cartilage grafts prior to implantation.
65.9 Results
The 28-year-old patient shown in Fig. 65.24 requested revision
rhinoplasty due to nasal obstruction and primarily supra-alar
pinching. She reported nasal dyspnea at rest and during exercise.
She was concerned about the overrotated, short appearance of
the nasal tip. On anterior view, she had vertically oriented nasal
bones, pinching in the left middle vault, and deviation of the
tip toward the right with broken brow–tip aesthetic lines and
notching of the ala. On lateral view, she had a very obtuse nasola-
bial angle with underprojection of the nasal tip, a low radix, and
weak chin. On basal view, she lacked support in the transition
from tip lobule to alar lobule, most pronounced on the left and
mild nostril asymmetry. She also exhibited mild external valve
collapse on inspiration.
65.9.1 Surgical Plan
Costal cartilage was harvested early in the operation due to lack
of septal cartilage and need for strong material to lower the
alar margin (Fig. 65.25). Correction of the patient’s bony vault
deformities required revision medial osteotomies with place-
ment of extended spreader grafts underneath the nasal bones,

1016
X Rhinoplasty
reestablishing and supporting the transition to the middle nasal
vault (Fig. 65.26). A caudal septal extension graft was placed to
rotate the tip lobule and slightly increase projection (Fig. 65.27).
The LLCs were released from the underlying vestibular skin, as
they were significantly weak. They were then removed due to
unfavorable curvature and resutured as lateral crural replace-
ment grafts (Fig. 65.28, Fig. 65.29, Fig. 65.30). Lateral crural strut
grafts were then sutured to the undersurface of the replacement
grafts (Fig. 65.31). These were then placed into caudally oriented
pockets to lower the alar margin (Fig. 65.32). Perichondrium was
sutured over the transition from the nasal bones to the supratip
for camouflage and a small piece placed over the tip (Fig. 65.33).
Deficiency of internal lining was managed with composite grafts
of the cavum conchae (Fig. 65.34, Fig. 65.35), with donor site
closed with a full-thickness skin graft.
65.9.2 Surgical Steps
• Harvest of seventh-rib costal cartilage (32-mm graft) through
a 1.1-mm incision at the superior border of the rib
• Inverted-V transcolumellar incision through previous scar
• Bilateral marginal incisions to complete access
• Revision septoplasty and exposure of the L-strut
• Revision osteotomies (medial only in this case)
• Extended spreader graft placement
• Caudal septal extension graft
• Lateral crural release and removal
• Lateral crural replacement grafts
Fig. 65.25 Costal cartilage harvest from right chest.
Fig. 65.24 (a) Preoperative anterior view. (b) Preoperative close-up
anterior view. (c) Preoperative lateral view. (d) Preoperative close-up
lateral view. (e) Preoperative basal view. (f) Preoperative basal view
during inspiration.
a
d
b
e
c
f
Fig. 65.26 Spreader graft placement.

65 Revision Rhinoplasty
1017
Fig. 65.27 Caudal septal extension graft placement.
Fig. 65.30 Lateral crural replacement grafts created with remnant
lateral crura.
Fig. 65.28 Lateral crural release.
Fig. 65.31 Lateral crural strut grafts prior to repositioning.
Fig. 65.29 Removal of lateral crura due to unfavorable orientation and
curvature.

1018
X Rhinoplasty
• Lateral crural strut grafts with repositioning
• Soft tissue camouflage with costal perichondrium in the
bridge and tip
• Composite graft harvest with closure of donor site by postau-
ricular full-thickness skin graft
• Transcolumellar incision and marginal incision closure with
the assistance of composite grafts
• Lateral wall splint placement
• 22-gauge angiocath sutured to right lateral wall splint and
inserted through lateral marginal incision, taking care not to
disrupt composite graft, to be used as an irrigation drain
• Telfa placed over bridge and Steri-Strips placed prior to
Aquaplast cast placement
65.9.3 Result
At 1.5 years postoperatively, the patient (Fig. 65.36) has smooth
brow–tip aesthetic lines, significant improvement in position
of the nostril margin, and a narrower tip. On lateral view, she
has a smooth dorsum, increased projection, and an improved
nasolabial angle. The basal view shows better nostril symmetry
and a more triangular configuration.
65.10 Concluding Thoughts
Revision rhinoplasty is a highly complex operation based
on repair of the osseocartilaginous framework. It requires
extensive knowledge and understanding of the consequences
of maneuvers in primary rhinoplasty and the ability to correct
the resultant deformities sometimes created. The more severe
the deformity, the more powerful the technique necessary for
correction. Though revision surgery is quite challenging, it is also
a very rewarding, but often humbling, endeavor.
Clinical Caveats
• Powerful grafting material is generally required in revision cases,
which often means harvesting and utilizing residual septum,
ethmoid bone or vomer, costal cartilage, and composite grafts.
• A restorative structural approach to revision cases enabled
correction of severe deformities with good long-term func-
tional and aesthetic results.
• Sequential carving of costal cartilage enables visualization of
warping tendencies early in the operation, which allows the
surgeon to select the appropriate grafts for the right situa-
tion and splint where necessary.
Fig. 65.32 Lateral crural strut grafts after repositioning into a caudally
oriented pocket.
Fig. 65.33 Soft tissue camouflage grafting to the tip.

65 Revision Rhinoplasty
1019
Suggested Reading
[1] Ansari ., Asaria -, Hilger P, Adamson PA. Grafts and implants in rhinoplasty–
Techniques and long-term results. Oper Techn Otolaryngol Head Neck Surg
2008;19(1):42–58 doi:10.1016/j.otot.2008.04.007
>2@ Dresner HS, Hilger PA. An overview of nasal dorsal augmentation. Semin Plast
Surg 2008;22(2):65–73
>3@ .im D:, Toriumi DM. 1asal analysis for secondary rhinoplasty. Facial Plast Surg
Clin North Am 2003;11(3):399–419. doi:10.1016/S1064-7406(03)00026-9
>4@ .im D:, Toriumi DM. 1asal analysis for secondary rhinoplasty. Facial Plast Surg
Clin North Am 2003;11(3):399–419
>5@ 1assif PS. Revision rhinoplasty: pearls and surgical techniques. In: Thomas -R,
ed. Advanced Therapy in Facial Plastic and Reconstructive Surgery. Shelton, CT:
People’s Medical Publishing House³USA; 2010:377–401
>6@ Rosenberger ES, Toriumi DM. Controversies in revision rhinoplasty. Facial Plast
Surg Clin North Am 2016;24(3):337–345. doi:10.1016/j.fsc.2016.03.010
[7] Tardy ME. Rhinoplasty: The Art and the Science. Philadelphia, PA: :B Saunders;
1996
[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, Asher SA. Lateral crural repositioning for treatment of cephalic
malposition. Facial Plast Surg Clin North Am 2015;23(1):55–71
>10@ Veale D, De Haro L, Lambrou C. Cosmetic rhinoplasty in body dysmorphic disor-
der. Br J Plast Surg 2003;56(6):546–551
[11] Vuyk HD, :atts S-, Vindayak B. Revision rhinoplasty: review of deformities, aeti-
ology and treatment strategies. Clin Otolaryngol Allied Sci 2000;25(6):476–481
>12@ revision rhinoplasty. Arch Facial Plast Surg 2010;12(5):291–297 10.1001/archfa-
cial.2010.62
Fig. 65.34 Markings for composite graft harvest from right cavum
conchae.
Fig. 65.35 Composite graft placement to right marginal incision.
Fig. 65.36 (a) Postoperative anterior view. (b) Postoperative close-up anterior view. (c) Postoperative lateral view. (d) Postoperative basal view.
a
b
c
d