The Unfavorable Result in Plastic Surgery_ Avoidance and Treatment (2018, Thieme)

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Fig. 23.44, cont’d (g) Coronal computed tomography revealed left septal spur and related greater turbinate hypertrophy on the right. His
preoperative appearance (h,j) can be compared with the 1-year postoperative results (i,k).
Continued
g
h
i
j
k

317
Chapter 23 Rhinoplasty
Case 4: Secondary
A 52-year-old man had undergone three previous rhino­
plasties, including septoplasty followed by septal perfora­
tion and conchal graft attempts for dorsal reconstruction
(Fig. 23.45). He was concerned about a narrow and asym­
metrical middle vault, tip deformity and saddling, and ob­
vious breathing impairment.
Clinical analysis revealed asymmetrical osteotomies, tip
pinching, alar retraction caused by alar overresection, and
dorsal collapse.
An open rhinoplasty was performed with reconstitution
of the dorsal plateau using rib grafting and tip and sidewall
after a modified extracorporeal septoplasty. A precisely mea­
sured DCF construct finalized the dorsum height and width.
Alar wedges were used. All cartilage was harvested from the
septum.
The 1-year postoperative images demonstrate appropri­
ate dorsal lines on the frontal view, satisfactory tip shape,
and improved dorsal height. There is still a small amount
of supratip edema, which usually takes more than a year to
fully subside.
Fig. 23.44, cont’d His preoperative appearance (l,n) can be compared with the 1-year postoperative results (m,o).
n
o
l
m

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318
Fig. 23.45 Secondary rhinoplasty. His preoperative appearance (a,c,e) can be compared with the 1-year postoperative results (b,d,f). The
cephalic view is useful in assessing middle vault changes after surgery.
a
b
c
d
e
f
Continued

319
Chapter 23 Rhinoplasty
Fig. 23.45, cont’d His preoperative appearance (g,i,k) can be compared with the 1-year postoperative results (h,j,l).
g
h
i
j
k
l
Continued

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320
reconstruction with rib grafts. No attempt was made to close
the wide existing fistula, although residual septal deviation
could be addressed working around the fistula edges. This is
a classic example of an obvious indication for rib reconstruc­
tion of the tip and dorsum.
Box 23.3
1. Temporalis fascia and rib harvest and preparation if planned (otherwise will be done when decided during
the procedure).
2. Transcolumellar access.
3. Tip and dorsum full dissection; removal of permanent fillers and inappropriate grafts.
4. Intraoperative diagnosis and assessment; possibly plan change.
5. Septum dissection and exploration from the septal angle.
6. Septoplasty (if needed, when septum present); correction of possible residual deviation; graft harvest, if
available.
7. Inferior and middle submucosal turbinectomy, if needed.
8. Further harvest of temporalis fascia, rib, or concha, if necessary (done initially if preplanned).
9. Dorsum work: creating the dorsal plateau (osteotomies, bone reshaping by power tools, centralizing and
fixating the septum or neoseptum in midline, spreaders or autospreaders, or a combination) Note: Available
septum is centralized and fixated as an L-strut to the upper laterals and spine, or neoseptum is built by total
or subtotal extracorporeal septoplasty.
10. Tip rebuilding: structure, projection and shape (domal and lateral crural reconstruction or alternative op­
tions; multiple sutures and grafts).
11. Augmenting or rounding off the dorsum (fascia or diced cartilage and fascia).
12. Smoothly linking the dorsum to the tip complex (final tip finesse grafting to achieve correct supratip break
and columellar–lobular angle).
13. Final inspection after temporary transcolumellar suture: three-point check.
14. Possible alar and footplate work.
15. Final closure and splints.
Robotti’s Steps for Structural Revision Rhinoseptoplasty
Fig. 23.45, cont’d His preoperative appearance (m) can be compared with the 1-year postoperative results (n).
m
n

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17. Davis RE, Raval J. Powered instrumentation for nasal bone
reduction: advantages and indications. Arch Facial Plast
Surg 2003;5(5):384–391
18. Gerbault O, Daniel RK, Kosins AM. The role of piezoelec­
tric instrumentation in rhinoplasty surgery. Aesthet Surg
J 2016;36(1):21–34
19. Gruber RP, Perkins SW. Humpectomy and spreader flaps.
Clin Plast Surg 2010;37(2):285–291
20. Cerkes N. The crooked nose: principles of treatment. Aes­
thet Surg J 2011;31(2):241–257
21. Jang YJ, Kwon M. Modified extracorporeal septoplasty
technique in rhinoplasty for severely deviated noses. Ann
Otol Rhinol Laryngol 2010;119(5):331–335
22. Gubisch W. Twenty-five years experience with extracor­
poreal septoplasty. Facial Plast Surg 2006;22(4):230–239
23. Daniel RK. Rhinoplasty: dorsal grafts and the designer
dorsum. Clin Plast Surg 2010;37(2):293–300
24. Daniel RK. Tip techniques. In: Daniel RK, ed. Mastering
Rhinoplasty. 2nd ed. Heidelberg: Springer; 2010:101–154
25. Rohrich RJ, Janis JE, Ghavami A, Ahmad J. A predictable
and algorythmic approach to tip refinement and projec­
tion. In: Rohrich RJ, Adams WP Jr, Ahmad J, eds. Dallas
Rhinoplasty: Nasal Surgery by the Masters. 3rd ed. St.
Louis, MO: Quality Medical Publishing; 2014:441–473
26. Toriumi DM. Structure approach in rhinoplasty. Facial
Plast Surg Clin North Am 2005;13(1):93–113
27. Sands NB, Adamson PA. Nasal tip deprojection with crural
cartilage overlap: the M-arch model. Facial Plast Surg Clin
North Am 2015;23(1):93–104
28. Foda HM, Kridel RW. Lateral crural steal and lateral crural
overlay: an objective evaluation. Arch Otolaryngol Head
Neck Surg 1999;125(12):1365–1370
29. Behmand RA, Ghavami A, Guyuron B. Nasal tip sutures
part I: the evolution. Plast Reconstr Surg 2003;112(4):
1125–1129, discussion 1146–1149
30. Gruber RP, Chang E, Buchanan E. Suture techniques in rhi­
noplasty. Clin Plast Surg 2010;37(2):231–243
31. Toriumi DM, Checcone MA. New concepts in nasal tip con­
touring. Facial Plast Surg Clin North Am 2009;17(1):55–
90, vi
32. Gubisch W, Eichhorn-Sens J. Overresection of the lower
lateral cartilages: a common conceptual mistake with
functional and aesthetic consequences. Aesthetic Plast
Surg 2009;33(1):6–13
33. Davis RE. Revision of the overresected nasal tip complex.
Facial Plast Surg 2012;28(4):427–439
34. Cerkes N. Nasal Tip Deficiency. Clin Plast Surg 2016;43(1):
135–150
35. Unger JG, Roostaeian J, Small KH, et al. Alar contour grafts
in rhinoplasty: a safe and reproducible way to refine alar
contour aesthetics. Plast Reconstr Surg 2016;137(1):52–61
36. Lee M, Zwiebel S, Guyuron B. Frequency of the preopera­
tive flaws and commonly required maneuvers to correct
them: a guide to reducing the revision rhinoplasty rate.
Plast Reconstr Surg 2013;132(4):769–776
37. Fischer H, Gubisch W. Nasal valves—importance and sur­
gical procedures. Facial Plast Surg 2006;22(4):266–280
38. Rohrich RJ, Krueger JK, Adams WP Jr, Marple BF. Rationale
for submucous resection of hypertrophied inferior tur­
binates in rhinoplasty: an evolution. Plast Reconstr Surg
2001;108(2):536–544, discussion 545–546
39. Chu E, Davis RE. SMAS Debulking for Management
of the Thick-Skinned Nose. JAMA Facial Plast Surg
2015;17(4):305–306
40. Constantian MB. What motivates secondary rhinoplasty?
A study of 150 consecutive patients. Plast Reconstr Surg
2012;130(3):667–678
The 1-year postoperative photos and Video 23.17 dem­
onstrate an appropriate result with the reestablishment of
dorsal lines, dorsal height, and tip structure. A mild asym­
metry of the DCF construct is visible on the left side of the
radix.
Conclusion
My usual operative steps in structural revision rhinosepto­
plasty are listed in Box 23.3.
References
1. Guyuron B. Dynamics of rhinoplasty. Aesthetic Plast Surg
2002;26(Suppl 1):S10
2. Rohrich RJ, Ahmad J. A practical approach to rhinoplasty.
Plast Reconstr Surg 2016;137(4):725e–746e
3. Rohrich RJ, Lee MR. External approach for secondary rhi­
noplasty: advances over the past 25 years. Plast Reconstr
Surg 2013;131(2):404–416
4. Ponsky D, Eshraghi Y, Guyuron B. The frequency of sur­
gical maneuvers during open rhinoplasty. Plast Reconstr
Surg 2010;126(1):240–244
5. Lee M, Unger JG, Gryskiewicz J, Rohrich RJ. Current clini­
cal practices of the Rhinoplasty Society members. Ann
Plast Surg 2013;71(5):453–455
6. Constantian MB. Four common anatomic variants that
predispose to unfavorable rhinoplasty results: a study
based on 150 consecutive secondary rhinoplasties. Plast
Reconstr Surg 2000;105(1):316–331, discussion 332–333
7. Chait LA, Widgerow AD. In search of the ideal nose. Plast
Reconstr Surg 2000;105(7):2561–2567, discussion 2568–
2572
8. Daniel RK, Palhazi P, Gerbault O, Kosins AM. Rhinoplasty:
the lateral crura-alar ring. Aesthet Surg J 2014;34(4):526–
537
9. Stewart MG, Witsell DL, Smith TL, Weaver EM, Yueh B,
Hannley MT. Development and validation of the Nasal Ob­
struction Symptom Evaluation (NOSE) scale. Otolaryngol
Head Neck Surg 2004;130(2):157–163
10. Gorney M. Recognition and management of the patient
unsuitable for aesthetic surgery. Plast Reconstr Surg
2010;126(6):2268–2271
11. Tasman AJ. The psychological aspects of rhinoplasty. Curr
Opin Otolaryngol Head Neck Surg 2010;18(4):290–294
12. Cakir B, Oreroğlu AR, Doğan T, Akan M. A complete sub­
perichondrial dissection technique for rhinoplasty with
management of the nasal ligaments. Aesthet Surg J 2012;
32(5):564–574
13. Cerkes N. Concurrent elevation of the upper lateral carti­
lage perichondrium and nasal bone periosteum for man­
agement of dorsum: the perichondro-periosteal flap. Aes­
thet Surg J 2013;33(6):899–914
14. Rohrich RJ, Muzaffar AR, Janis JE. Component dorsal
hump reduction: the importance of maintaining dor­
sal aesthetic lines in rhinoplasty. Plast Reconstr Surg
2004;114(5):1298–1308, discussion 1309–1312
15. Palhazi P, Daniel RK, Kosins AM. The osseocartilaginous
vault of the nose: anatomy and surgical observations.
Aesthet Surg J 2015;35(3):242–251
16. Ghanaatpisheh M, Sajjadian A, Daniel RK. Superior rhino­
plasty outcomes with precise nasal osteotomy: an indi­
vidualized approach for maintaining function and achiev­
ing aesthetic goals. Aesthet Surg J 2015;35(1):28–39

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41. Davis RE, Bublik M. Psychological considerations in the
revision rhinoplasty patient. Facial Plast Surg 2012;28(4):
374–379
42. Alavi M, Kalafi Y, Dehbozorgi GR, Javadpour A. Body dys­
morphic disorder and other psychiatric morbidity in aes­
thetic rhinoplasty candidates. J Plast Reconstr Aesthet
Surg 2011;64(6):738–741
43. Daniel RK. Rhinoplasty: septal saddle nose deformi­
ty and composite reconstruction. Plast Reconstr Surg
2007;119(3):1029–1043
44. Rohrich RJ, Lee MR. Ahmad J. Achieving Consistent Re­
sults in Secondary Rhinoplasty. In: Rohrich RJ, Adams WP
Jr, Ahmad J, eds. Dallas Rhinoplasty: Nasal Surgery by the
Masters. 3rd ed. St Louis, MO: QMP; 2014:951–971
45. Daniel RK. Diced cartilage grafts in rhinoplasty surgery:
current techniques and applications. Plast Reconstr Surg
2008;122(6):1883–1891
46. Codazzi D, Ortelli L, Robotti E. Diced cartilage combined
with warm blood glue for nasal dorsum enhancement.
Aesthetic Plast Surg 2014;38(4):822–823
47. Davis RE, Bublik M. Common technical causes of the
failed rhinoplasty. Facial Plast Surg 2012;28(4):380–389
48. Kim DW, Toriumi DM. Nasal analysis for secondary rhino­
plasty. Facial Plast Surg Clin North Am 2003;11(3):399–
419
49. Ha RY, Byrd HS. Septal extension grafts revisited: 6-year
experience in controlling nasal tip projection and shape.
Plast Reconstr Surg 2003;112(7):1929–1935
50. Kridel RW, Scott BA, Foda HM. The tongue-in-groove
technique in septorhinoplasty. A 10-year experience. Arch
Facial Plast Surg 1999;1(4):246–256, discussion 257–258
51. Gruber RP, Peled A, Talley J. Mattress sutures to remove
unwanted convexity and concavity of the nasal tip: 12-
year follow-up. Aesthet Surg J 2015;35(1):20–27
52. Guyuron B, Poggi JT, Michelow BJ. The subdomal graft.
Plast Reconstr Surg 2004;113(3):1037–1040, discussion
1041–1043
53. Davis RE. Lateral crural tensioning for refinement of
the wide and underprojected nasal tip: rethinking
the lateral crural steal. Facial Plast Surg Clin North Am
2015;23(1):23–53
54. Fedok FG. Costal cartilage grafts in rhinoplasty. Clin Plast
Surg 2016;43(1):201–212
Discussion by Mark B. Constantian
Although Dr. Robotti performs open rhinoplasty, and
I use the endonasal approach exclusively, we agree on
many things. In fact, if a surgeon’s technical results are
good—the dorsum straight, tip projection adequate, the
profile in perfect balance, and the airway optimized—it
does not really matter how he or she got there, how tip
projection or normal radix height were defined, or how
the surgeon treated the valves. Nature only has one set
of rules. Surgeons who follow them produce good re­
sults; those who don’t produce deformities.
Dr. Robotti and I also agree on the analysis of the
critical anatomic variants, whose treatment must be
encompassed in the surgical plan. The two surgical ap­
proaches, however, tend to lead surgeons using them
in different analytical directions. The open approach
becomes more “micro” as the surgeon focuses on the
intricacies of suture and graft placement. In contrast,
the closed approach becomes more “macro,” simply
because the surgeon must make his or her judgments
from observing surface changes. As a consequence,
some of the feedback that can guide the surgeon’s de­
cisions appears more readily through the closed ap­
proach. Overall nasal balance, accurate assessment of
tip shape (i.e., blunt or angular), the details of dorsal
contour, and soft tissue movement in response to skel­
etal manipulation (e.g., nasal shortening or lengthening
after dorsal resection) are simply not visible through
the open approach. For the endonasal rhinoplasty sur­
geon, skeletal manipulation becomes only a means to
an end. It is that aspect of rhinoplasty upon which this
discussion will focus.
I have several essential rhinoplasty principles:
•• All secondary nasal deformities fall into one of three
patterns: deformities from soft tissue contraction;
deformities from skeletal contraction; or deformities
of imbalance.
•• Nasal deformities are therefore not limitless or
idiosyncratic but follow patterns—so their solutions
can also follow patterns. The only difference
between primary and secondary rhinoplasty,
therefore, is the availability of donor sites.
•• The most common motivation for secondary surgery
is an iatrogenic deformity created by the prior
surgeon(s).1
•• All key planning decisions can be made
preoperatively from the nasal surface. Each anatomic
point translates directly to a diagnosis and then to a
surgical step; the entire rhinoplasty strategy can be
set before surgery.
•• Only four common anatomic variants determine
rhinoplasty success: (1) low radix or low dorsum, (2)
inadequate tip projection, (3) narrow middle vault,
and (4) alar cartilage malposition.2
•• Reconstruction of both internal and external
valvular incompetence triples or quadruples airflow
in most patients without concomitant septoplasty or
turbinectomy; this airflow effect has been confirmed
by a level 2, 600-patient outcome study.3,4
•• Most primary nasal deformities can be corrected
with only one of two operative strategies: (1) radix,
spreader, and tip grafts or (2) dorsal and tip grafts.

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Chapter 23 Rhinoplasty
Alar wall grafts are additionally needed when the
external valves are unstable. Thus the surgeon need
only learn four techniques (because radix and dorsal
grafts are the same thing in different lengths) to
perform most rhinoplasties.
•• Reconstruction must be anatomic, keeping nasal
function paramount and obliging the patient’s
aesthetic.
•• Most intraoperative and postoperative problems are
under the surgeon’s control and therefore avoidable
or easily correctable.
•• Effective patient selection is mandatory.
Rhinoplasty is uniquely difficult and uniquely reward­
ing surgery, but some excellent surgeons stop perform­
ing rhinoplasty after unsuccessful attempts at produc­
ing the results that they and their patients desire. This
need not be the case.
Why Rhinoplasty Is Difficult
The advocates of open rhinoplasty argue that open rhi­
noplasty is easier than the endonasal approach because
the surgeon has good binocular vision and can see and
modify the nasal anatomy under direct vision. If that is
true, why are so many open rhinoplasties ­unsuccessful?
Endonasal rhinoplasty is not open rhinoplasty
­performed through a keyhole. The mindset is different,
just like it is between liposuction and abdominoplasty.
In fact, endonasal rhinoplasty has several distinct and
unique advantages that make it more simple:
1. Dissection is restricted to those areas that will be
changed, limiting patient morbidity and the pos­
sibility of introducing new deformities, especially
paramount for young surgeons.
2. Fewer techniques need to be mastered—I only use
four. Internal sutures and struts are not required.
3. Most importantly (and counterintuitively), the
surgeon actually sees better through the endonasal
approach.
The nasal skin is not a passive tablecloth that will as­
sume any skeletal shape that the surgeon creates. In­
stead, half of nasal shape is imparted by the skin, which
adds its own variability to the outcome. If the skin were
always passive, there would be no such entity as supra­
tip deformity, and augmentation would never correct
it. A surgeon who chooses the open approach therefore
unwittingly forfeits all surface feedback—50% of the
intraoperative information that the nose can provide,
and 50% of the determinant of the final result. An open
rhinoplasty surgeon sees the skeleton very well, but the
skin not at all. The observant closed rhinoplasty sur­
geon sees and can benefit from both.
It is therefore more accurate to say that the follow­
ing make rhinoplasty difficult:
•• The nasal soft tissues have limited contractility.
•• The nasal regions are structurally and functionally
interrelated, not independent.
•• The operation is dynamic and interactive.
•• Rhinoplasty is a right brain operation.
Rhinoplasty is not difficult because of limited visibility.
Modern rhinoplasty therefore becomes an operation
of reduction, augmentation, and equilibration—still dif­
ficult, but easier when viewed in the context of a model
that considers both function and aesthetics and pre­
scribes techniques that modify them together.4
Healing Forces and Postoperative
Distortion
The fact that many postrhinoplasty nasal configura­
tions, and all “end-stage” noses, look the same is not
a coincidence. Healing forces collapse the upper nose
caudally and medially over the pyramidal bony and
upper cartilaginous vaults, cephalad at the columella,
posteriorly over the maxillary arch, and posteriorly
and concentrically around the tip lobule. Unsupported
soft tissues collapse according to their own vectors,
­ultimately producing supratip deformity. Whether the
nasal skeleton has been reduced by surgery, trauma,
congenital anomalies, or Wegener’s granulomato­
sis, the essential external appearance is the same.
­Variations occur because of disequilibrium between
skeletal and soft tissue volumes or differences in soft
tissue thickness and elasticity, not because biologic
forces differ from patient to patient.
Preoperative nasal shape is not static but rather rep­
resents a dynamic equilibrium, the sum of balanced, op­
posing forces between the nasal soft tissues and their
underlying support. Skeletal reduction during rhino­
plasty disrupts this preoperative equilibrium, and so soft
tissue and skeletal contraction occurs until the nose re­
establishes its internal equilibrium or until contraction
can no longer occur. The degree of disequilibrium at the
end of the procedure thus determines the amount of re­
draping and contraction that will occur postoperatively:
The bigger the disequilibrium, the bigger the postop­
erative change. The surgeon therefore ideally controls
the postoperative equilibrium by permitting soft tissue
contraction only where it is most predictable (e.g., over
the bony and cartilaginous dorsa) and by minimizing
contraction where it is less predictable (e.g., the lower

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324
nasal third). In doing so, the surgeon immediately gains
greater control over postoperative contour.
The Structural Nasal Layers
The nose behaves structurally as a system of two in­
terrelated layers. The outer layer slides over the inner
semirigid layer and contains the entire investing nasal
soft tissues—with their own contributions to nasal con­
tour and their own independent vectors—plus the alar
cartilages and their associated lining. The inner layer
contains everything else (the bony and upper carti­
laginous vaults, the nasal septum, and their associated
linings). This two-layer concept associates those struc­
tures that behave together anatomically and function­
ally and provides an explanation for the “global” mani­
festations of some surgical changes (e.g., the effect of
dorsal reduction or augmentation on nasal length).
Three Patterns of Secondary Nasal
Deformity
All secondary rhinoplasty deformities fall into one of
three patterns (Box 23D.1). Although they overlap to a
certain degree, one always dominates and usually can
key the surgeon to the original nasal shape and inad­
equately treated deformity.
Anatomic Variants Predisposing to
Unfavorable Results
Four common anatomic variants that predispose to
unfavorable results are shown in Table 23D.1 and
Fig. 23D.1a.
Box 23.D1
Pattern One: Soft Tissue Collapse
The dominant surface characteristic in each of
these noses is shrinkage, collapse, and distor­
tion of the soft tissues around a reduced skel­
eton that is too small for them, manifested by
a low dorsum; narrow middle third; blunt,
convex supratip; thickened soft tissues with­
out their preoperative delicacy; and a round,
shapeless tip.
Pattern Two: Skeletal Collapse
Here the dominant characteristic is distortion
of the destabilized underlying skeleton, pulling
with it the soft tissues and collapsing the air­
way, and manifested by a narrow middle vault,
inverted-V deformity, and alar wall collapse,
hollowing, or retraction.
Pattern Three: Nasal Imbalance
In this pattern the most striking surface char­
acteristic is incongruence between the nasal
parts; either the dorsum is too low for a large
nasal base, or the base is too short for a high
dorsum and vertical nasofacial angle. These
three patterns link directly to the four ana­
tomic variants that cause them and to the four
graft types that correct them.
Patterns of Secondary
Rhinoplasty
Table 23D.1 Core anatomic variants, consequences, and treatments
Anatomy
Threats
Treatment
Associated
secondary pattern
Inadequate tip
projection
Supratip deformity
Tip grafts
Deformities from soft
tissue collapse
Narrow middle vault
Internal valvular obstruction
or cartilaginous roof resection
Spreader grafts
Deformities from skeletal
collapse
Malposition
External valvular obstruction
Reposition lateral crus
or alar wall grafts
Deformities from skeletal
collapse
Low radix or low
dorsum
Nasal imbalance
Radix or dorsal grafts
Deformities from
imbalance

325
Chapter 23 Rhinoplasty
Fig. 23D.1 (a) This tertiary rhinoplasty patient had all four anatomical variants: low radix, inadequate tip projection, narrow middle
vault, and alar cartilage malposition. (b) At the beginning of the nasal reconstruction. (c) After dorsal and tip reductions. The radix
is low and the tip is still inadequately projecting; reduction alone will not correct this nasal deformity. (d) Large left spreader graft.
(e) Radix graft. (f) After placement of the radix graft. The dorsum immediately became straight and nasal proportion improved.
(g) Alar wall graft. (h) Final intraoperative view after tip graft placement.
a
b
c
f
g
h
e
d

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326
A great deal can be learned about primary rhino­
plasty by observing the deformities of secondary rhi­
noplasty patients and by examining one’s own unsatis­
factory results. A retrospective study of 150 consecutive
secondary rhinoplasty and 50 primary rhinoplasty pa­
tients suggests that only four anatomic variants in the
primary nose particularly predispose to unfavorable
rhinoplasty results: low radix or low dorsum, narrow
middle vault, inadequate tip projection, and alar carti­
lage malposition.2 Each contributes to one of the three
deformity patterns seen in secondary rhinoplasty pa­
tients and described in Box 23D.1.
Low Radix or Low Dorsum
A low radix or low dorsum begins caudal to the level
of the upper lash margin with the patient’s eyes in pri­
mary gaze; this variant was present in 93% of the sec­
ondary patients and 32% of the primary patients in the
series.2 First described by Sheen and Sheen,5 the low
radix is one of several primary causes of nasal imbal­
ance: an upper nose that seems too small for its lower
nasal component.
When the radix begins lower than the upper lash
margin, dorsal length is therefore shorter and so the
nasal base appears larger. The classic imbalance may
take the form of a depression or notch in the upper na­
sal third or a low, straight dorsum that accompanies a
large nasal base. The presenting patient complaint is of­
ten, “The tip of my nose sticks out too far.” The surgical
dilemma is as follows: If the surgeon reduces the na­
sal dorsum, the patient’s preoperative skeletal and skin
sleeve maldistribution will worsen; the lower nose will
appear even larger. The surgeon fortunately has two
other choices: either limit tip reduction or raise the dor­
sum segmentally (radix graft) or entirely (dorsal graft)
to balance the nasal base. Variations of the latter option
are generally safer, because they require less contraction
of the thicker nasal base tissues. Failure to recognize the
low radix or low dorsum leads to the third pattern, de­
formity from imbalance (Table 23D.2).
Narrow Middle Vault
A narrow middle vault is arbitrarily defined as any up­
per cartilaginous vault that is at least 25% narrower
than the upper or lower nasal third (present in 87% of
the secondary patients and 38% of the primary patients
in one series).2 This variant places the patient at special
risk for internal valvular obstruction, which can exist
preoperatively or may be produced by dorsal resection.
Resection of even 2 mm of the cartilaginous roof dur­
ing hump removal ablates the stabilizing confluence
that braces the middle vault, which can now collapse
toward the anterior septal edge, restricting airflow at
Table 23D.2 Reasoning for two
strategies for primary nasal
deformities
Strategy 1: Radix, spreader, and tip
Strategy 2: Dorsal and tip grafts*
For primary or secondary dorsal humps
Reduction opens the middle
vault.
Spreader or
dorsal grafts
Most tips are inadequately
projecting, or are rendered so
by reduction.
Tip grafts
Most hump noses are
unbalanced and bottom-heavy.
Radix grafts
For primary low dorsum
and most secondary issues
Dorsum is low, internal valves
incompetent.
Dorsal grafts
Tip shape is poor or
nonprojecting.
Tip grafts
*Alar wall grafts are added to either strategy if the external valves
are incompetent.
the internal valves, producing a characteristic inverted-V
deformity and often reducing the airway by 50%. Rhino­
manometric studies indicate that valvular obstruction is
4 times more common than pure septal obstruction in
primary rhinoplasty patients and 12 times more com­
mon in secondary patients; reconstruction of incompe­
tent, internal valves by dorsal or spreader graft doubles
nasal airflow in most patients.3
Some surgeons use “spreader flaps” instead, redun­
dant or unresected upper lateral cartilages that are turned
medially and fixed to the septal edge by sutures. Although
spreader flaps have become a popular technique, a re­
cent study has indicated that they do not increase nasal
airflow.6
Other technical variations have been described, such
as tension sutures with or without spreader grafts,7–9 but
these studies have either suffered from short follow-up,7
cadaveric model only,8 or no accompanying functional
measurements.9 There is also a theoretical problem with
spanning sutures: Normal nasal sidewalls create vary­
ing resistance during inhalation (so the alveoli can open)
and during exhalation (so that carbon dioxide and oxygen
exchange can occur). Tension sutures create a barrel ef­
fect and do not permit sidewall movement. Furthermore,

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Chapter 23 Rhinoplasty
sutures cannot hold biologic structures under tension
indefinitely. Much more proof is needed before any of
these techniques can replace a method with so much
clinical and research support.
Cartilaginous roof resection and failure to recognize
malposition contribute to the secondary pattern defor­
mity from skeletal contraction (see Table 23D.1).
Inadequate Tip Projection
Tip projection is the intrinsic ability of the alar carti­
lages to support the tip lobule independent of dorsal
height and depends on alar cartilage middle crural size,
shape, and substance. No patient can have a straight
profile line without adequate tip projection; that is its
importance. Tip projection is not a reflection of nasal
base size but rather alar cartilage strength, a distinction
that is often misunderstood. Many noses have large
lower nasal thirds; skin volume is not tip projection.
The tip, the lower nasal skin, and in many patients
nearly the lower half of the profile line depend on sus­
pension of the skin sleeve by the alar cartilages, which,
like a “cap” anterior to the remaining skeleton, main­
tains lower nasal tension. The alar cartilages carry a
larger responsibility for caudal nasal support than may
at first be evident.
A tip with inadequate projection does not project
to the level of the anterior septal angle. Inadequate tip
projection was present in 80% of the secondary patients
and 31% of the primary patients in one reported series.2
Despite its importance, the term tip projection has been
used to connote different things by different authors.
Some surgeons have assessed tip projection by measur­
ing the distance of the most projecting point of the tip
from a facial parameter, and others by the relative pro­
portion of the nasal base segments anterior and poste­
rior to the upper lip, or the relative lengths of the nasal
base and upper lip.10–12 Although these definitions apply
in some cases, there are patients whose nasal bases are
large but whose tip cartilages are nevertheless poorly
projecting. In these individuals, tip projection may be
inaccurately assessed as “adequate” or even “excessive,”
even though the alar cartilages lack the substance re­
quired to support the tip independently of bridge height.
A better functional definition of tip projection is the
relationship of the tip lobule to the anterior septal angle.
Alar cartilages sufficiently strong to support the tip to
the level of the septal angle are “adequately projecting”;
alar cartilages too weak to do so are “inadequately pro­
jecting.” The practical value of this definition lies in its
ability to define treatment. Failure to recognize inade­
quate tip projection causes dorsal overresection, supra­
tip deformity, and deformity from soft tissue contraction
(see Table 23D.1).
Alar Cartilage Malposition
Alar cartilage malposition describes cephalically ro­
tated lateral crura whose long axes run toward the me­
dial canthi instead of toward the lateral canthi, the po­
sition most commonly depicted in texts. This anatomic
variation was first recognized by Sheen and Sheen5 as
an aesthetic deformity that produced a round or boxy
tip lobule with characteristic “parentheses” on frontal
view. Initially believed to be a rare variant, malposition
is present in approximately 50% of primary patients
and 80% of secondary patients.2 Malposition also has
two additional ramifications that are not aesthetic.
First, the abnormal cephalic position of the lateral
crura places them at special risk if an intercartilaginous
incision is made at its normal intranasal location, a ma­
neuver that will transect the entire rotated lateral crus
instead of only splitting the intended cephalic portion.
Most malpositioned lateral crura do not provide ad­
equate external valvular support, and so malposition is
not only associated with boxy or ball tips but is also the
leading cause of external valvular incompetence.13 The
secondary deformity is characteristic.
Adequate treatment of cephalic rotation of the lat­
eral crura requires resection and replacement of these
structures, relocation of the lateral crura to support the
external valves, or supporting the areas of external val­
vular collapse with autogenous grafts. Approximately
50% of patients who present with external valvular ob­
struction have alar cartilage malposition. Correction of
external valvular incompetence doubles mean nasal air­
flow in most patients (2.5 times for primary patients;
4.0 times for secondary patients).3 Cartilaginous roof re­
section and failure to recognize malposition contribute
to the secondary pattern deformity from skeletal contrac­
tion (see Table 23D.1).
None of the following four anatomic variants always
requires treatment:
1. Low radix or low dorsum
2. Narrow middle vault
3. Inadequate tip projection
4. Alar cartilage malposition
For example, the low radix must always be assessed
relative to nasal base size: If the base is short, a low
radix may create the best balance. However, at least
one of these four anatomic traits was present in each
of the 150 secondary patients in the reported series.2
Some 78% of the secondary patients and 58% of the pri­
mary patients had three or all four of the traits. None of
these anatomic variants is adequately treated by classic
reduction rhinoplasty, emphasizing the importance of
careful preoperative diagnosis.

SECTION IV AESTHETIC SURGERY
328
Rhinoplasty and the Airway
Although many patients with obstructed nasal airways
improve after septoplasty with or without inferior turbi­
nectomy, not all do. Adding to the frustration for the pa­
tient and surgeon are three other common observations:
1. There is often a poor correlation between a pa­
tient’s symptoms and the apparent site of clinical
septal or turbinate obstruction.
2. Patients commonly breathe better (preoperatively
and even postoperatively) on the “narrower” side
(ipsilateral to the septal deviation).
3. Many patients who have undergone prior suc­
cessful septoplasty and turbinectomy or who have
straight, unoperated nasal septa still complain of
airway obstruction.
These apparently inconsistent observations are more
understandable if the reader considers airway size to
be the product of at least four factors3,4:
1. Mucosal sensitivity to the environment or heredi­
tary factors
2. Inferior turbinate hypertrophy from many causes
3. Septal deviation
4. Position and stability of the lateral nasal wall dur­
ing the dynamic process of ventilation
Thus any congenital or acquired weakness or instability
of the upper or lower lateral cartilages or their invest­
ing soft tissues (which compose the internal and ex­
ternal nasal valves, respectively), along with septal and
inferior turbinate size and position, becomes a factor
that may profoundly influence the ability to draw ad­
equate volumes of air through the nose.
The internal nasal valve is formed by the articula­
tion of the caudal and anterior (or dorsal) edges of the
upper lateral cartilages with the anterior septal edge;
the external nasal valve is composed of the cutaneous
and skeletal support of the mobile alar wall (the alar
cartilage lateral crura with their associated external and
vestibular skin coverings). The watershed area between
the valves occurs at the transverse portion of the alar
crease and at the articulation of the caudal edge of the
upper lateral cartilages with the lateral crura.
Results of an Airway Outcome Study
To help resolve some of these conflicting clinical obser­
vations and to provide quantitative measurements of
the relative increases in nasal airflow after functional
septal or valvular surgery, an ongoing study of 600 con­
secutive patients undergoing surgery for airway ob­
struction was undertaken between 1991 and 2007.3,4
Patients with septal perforation, atopic patients, and
patients requiring turbinectomy were excluded. The
diagnosis of septal obstruction or valvular incompe­
tence was made by observation of the nasal airway
and nasal sidewall movement with and without a nasal
speculum during quiet and forced inspiration. When a
flaccid or collapsible valve was supported during inspi­
ration by a cotton-tipped applicator, the patient could
usually appreciate an immediate improvement in nasal
airflow, thus directing the surgeon toward appropriate
operative treatment. Septoplasty and valvular recon­
struction by cartilage or bone grafts were performed as
indicated. Anterior, active, mask rhinomanometry was
performed according to the method of Mertz et al.14
That study comprised 600 patients: 78% women and
22% men; 36% primary rhinoplasties and 64% secondary
rhinoplasties (median follow-up 14.3 months, mean 27
months). The longer-term data of 362 patients observed
for a minimum of 12 months (median 29 months) sup­
ported the numbers in the entire group. See Box 25.2
for the summary data.3,4
Rhinomanometric data thus support the concept that
lateral nasal wall movement caudal to the bony arch (con­
taining both the internal and external valves) constitutes
a cause of airway obstruction equal to or greater than
septal deviation in most rhinoplasty patients. By visual­
izing the airway as a structure in which the septal par­
tition forms one side and the mobile lateral nasal wall
forms the other, and in which the turbinates and mucosa
function as additional dynamic structures, the inconsis­
tencies in prior clinical observations become easier to ex­
plain. The observation that patients often breathe worse
on the side contralateral to the septal obstruction (45% of
our patients with lateralized obstructions) can therefore
be explained through valvular incompetence. In patients
with septal deviation and valvular incompetence, the side
with the greater airflow and greater transmural pressure
(i.e., the side contralateral to the septal deviation) will
collapse first and therefore become more symptomatic.
Resection of nasal lining, alar cartilage malposition,
excessive alar wedge resection, and inadequate or ex­
cessive nasal shortening may also obstruct the airway.
Surgical Planning
Almost every rhinoplasty I perform follows one of only
three stages7:
1. Remove the deformity (dorsal reduction, nasal
shortening, lateral crural reduction or relocation,
osteotomies).
2. Harvest graft materials (septal, conchal, or rib
cartilage).
3. Add balance and support to create the desired nasal
shape in one of two schemas: (1) radix, spreader,
and tip grafts or (2) dorsal and tip grafts.

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Chapter 23 Rhinoplasty
As mentioned previously, alar wall grafts are added as
needed for external valvular insufficiency.
Because radix and dorsal grafts are the same graft
in different lengths, the surgeon need only master four
graft types to solve almost all rhinoplasty problems.
Though not easy, these three strategies make the op­
eration comprehensible and manageable even for occa­
sional nasal surgeons.
These strategies make better sense when the sur­
geon considers the three patterns of secondary defor­
mity and the four anatomic variants (see Tables 23D.1
and 23D.2). Tip grafts correct inadequate projection and
supratip deformity, which comprise the soft tissue col­
lapse pattern (Pattern 1). Spreader and alar wall grafts
support the internal and external valves, respectively,
the components of the skeletal collapse pattern (Pattern
2). Radix and dorsal grafts correct the imbalance pattern
(Pattern 3)4 (Fig. 23D.2).
Conclusion
Surgeons who use endonasal rhinoplasty simplify their
technical challenge and greatly decrease the chance of
an iatrogenic deformity. Only areas that will be modi­
fied are exposed. Incisions and dissection can be lim­
ited, making graft placement easier and suture fixation
unnecessary and preserving maximal circulation. Nasal
shortening or lengthening, the nuances of nasal shape
and nasal proportion, are plainly visible because the
surgeon observes both skeletal support and soft tissue
behavior. The need for compensatory adjustments (for
example, caudal septum reduction after dorsal hump
resection) becomes obvious. High septal deviations
creating new external deformities and precise realign­
ment with spreader grafts can be seen and adjusted.
Tip shape can be contoured to the patient’s aesthetic by
placing multiple grafts for a rounder contour, or fewer
grafts for a more angular contour (see Figs. 23D.1 and
23D.2).
Perhaps most importantly, complications are rare
because very little can go wrong. Dorsal grafts that move
out of position can be easily repositioned secondarily.
Tip augmentation that has been inadequate, excessive,
or asymmetrical can be seen and adjusted through a
limited incision. Technically well-performed spreader
and alar wall grafts rarely require revision. The under­
lying anatomy has not been dissected, split open, su­
tured, or distorted, greatly minimizing the chance of un­
expected consequences or iatrogenic deformities (see
Fig. 23D.2).
I interviewed 150 consecutive secondary patients to
determine their reasons for having another operation.1
The stunning conclusion was that 89% sought another
operation because of an iatrogenic deformity—either
uncorrected or new—caused by the first procedure. For
any other operation, that statistic would be unaccept­
able. Similarly, it should not be tolerated in rhinoplasty.
To many surgeons, modern rhinoplasty techniques have
become overwhelmingly complicated. But that is not the
major drawback. A surgeon who cannot assess the intra­
operative nose with its soft tissues under normal ten­
sion and position loses the opportunity to judge nuances
of contour, nasal balance, tip aesthetics and projection,
and, most of all, the “fit” of the soft tissues to the nasal
skeleton, which ultimately determines the patient’s aes­
thetic and functional result.15

SECTION IV AESTHETIC SURGERY
330
Fig. 23D.2 (a,c,e) Skeletal reduction did not correct this low radix or inadequate tip projection in this patient from Fig. 23D.1a; the
reduction further narrowed her internal and external valves, increasing her preoperative airway obstruction. (b,d,f) At 12 months
postoperatively, her result was not flawless. The patient’s dorsum is straight, her tip is adequately projecting, her valves are stable,
airflow is four times what it was preoperatively, and the nasal proportion has improved. However, her left middle vault is still flatter
than her right, accentuating an asymmetry in lateral crural convexity. Because her nasal anatomy is otherwise undisturbed, a left
lateral crural revision and an additional left middle vault onlay graft through a short vestibular incision would be easy, minimally
traumatic corrections if the patient someday desires them. (g) Schematic of the surgical correction. (g, Reproduced from Con­
stantian MB. Rhinoplasty: Craft and Magic. St Louis: Quality Medical Publishing; 2009:1252.)
a
b
c
d
e
f
g

331
Chapter 23 Rhinoplasty
References
1. Constantian MB. What motivates secondary rhino­
plasty? A study of 150 consecutive patients. Plast Re­
constr Surg 2012;130(3):667–678
2. Constantian MB. Four common anatomic variants
that predispose to unfavorable rhinoplasty results:
a study based on 150 consecutive secondary rhino­
plasties. Plast Reconstr Surg 2000;105(1):316–331,
discussion 332–333
3. Constantian MB, Clardy RB. The relative importance
of septal and nasal valvular surgery in correcting air­
way obstruction in primary and secondary rhinoplas­
ty. Plast Reconstr Surg 1996;98(1):38–54, discussion
55–58
4. Constantian MB. Rhinoplasty: Craft and Magic. St Lou­
is, MO: Quality Medical Publishing; 2009:133–186
5. Sheen JH, Sheen AP. Aesthetic Rhinoplasty. 2nd ed.
St Louis, MO: Mosby; 1989:828–853
6. Saedi B, Amali A, Gharavis V, Yekta BG, Most SP.
Spreader flaps do not change early functional out­
comes in reduction rhinoplasty: a randomized con­
trol trial. Am J Rhinol Allergy 2014;28(1):70–74
7. Jalali MM. Comparison of effects of spreader grafts
and flaring sutures on nasal airway resistance in rhi­
noplasty. Eur Arch Otorhinolaryngol 2015;272(9):
2299–2303
8. Gwanmesia I, Couto R, Papay F. A cadaveric study
comparing the efficacy of the Sheen spreader graft
and the fulcrum spreader graft: part 1. Plast Reconstr
Surg 2015;136(4):669–676
9. Geissler PJ, Roostaeian J, Lee MR, Unger JJ, Rohrich RJ.
Role of upper lateral cartilage tension spanning su­
ture in restoring the dorsal aesthetic lines in rhino­
plasty. Plast Reconstr Surg 2014;133(1):7e–11e
10. Ricketts RM. Divine proportion in facial esthetics.
Clin Plast Surg 1982;9(4):401–422
11. Gunter JP. Facial analysis for the rhinoplasty patient.
In: Gunter JP, Rohrich RJ, eds. Dallas Rhinoplasty
Symposium Syllabus; 1997:195–208
12. Papel ID, Mabrie DC. Deprojecting the nasal profile.
Otolaryngol Clin North Am 1999;32(1):65–87
13. Constantian MB. The incompetent external nasal valve:
pathophysiology and treatment in primary and sec­
ondary rhinoplasty. Plast Reconstr Surg 1994;93(5):
919–931, discussion 932–933
14. Mertz JS, McCaffrey TV, Kern EB. Objective evaluation
of anterior septal surgical reconstruction. Otolaryn­
gol Head Neck Surg 1984;92(3):308–311
15. Constantian MB. Closed technique rhinoplasty. In
Rubin JP, ed. Plastic Surgery. 4th ed. Vol 2: Aesthetic
Surgery. London:Elsevier, in press.

332
CHAPTER
24

Secondary Rhinoplasty
Ali Totonchi and Bahman Guyuron
Secondary surgery may be performed for minor imperfec­
tions (revision rhinoplasty) or correction of major flaws,
largely using primary rhinoplasty maneuvers. Some of the
common flaws encountered in secondary rhinoplasty are
listed in this chapter.
Managing a patient who requires secondary rhinoplasty
is vastly different from the management of a primary rhino­
plasty patient in many aspects, presenting a technical chal­
lenge and requiring even greater precision in the planning
and execution of surgical techniques. A surgeon’s interper­
sonal skills are also important in providing the patient with
requisite emotional support throughout the process.1–5 The
surgeon must have a clear understanding of the patient’s
concerns, define the imperfections precisely, and identify
corresponding solutions while setting realistic goals and ex­
pectations. Comprehensive knowledge of potential problems
and pitfalls and finesse during surgery is crucial to achieving
these goals. In this chapter, the main differences between
primary and secondary rhinoplasty in terms of patient eval­
uation, surgical planning, technical details, and postopera­
tive care are discussed.
Avoiding Unfavorable Results
and Complications in Secondary
Rhinoplasty
Patient Evaluation
Secondary rhinoplasty patients have spent significant
time analyzing the form and function of their nose. Many
patients spend time researching revision rhinoplasty on
the internet, often exploring medical literature in addi­
tion to navigating through the nonscientific sources of
information before consultation. Often, they have also
sought the opinions of other plastic surgeons, and as a
Summary Box
Common Deformities Encountered in
Secondary Rhinoplasty
•• Skin thickness issues
•• Radix depth imperfections
•• Nasal bone flaws
•• Tip disharmonies
•• Nostril imbalance
•• Nasolabial angle abnormalities
•• Alar rim retraction
•• Airway issues
result, patients pre­sent with clear ideas and define the
deformity using plastic surgery terminology. Some even
have opinions regarding the techniques they wish used to
fix the abnormalities.
Listening to patients while they explain their dissat­
isfaction and noting the manner in which these concerns
are expressed may provide valuable insight regarding their
level of perfectionism and nature of their expectations. This
will help the surgeon better determine whether the patient
would be likely to be pleased with the surgical outcome.
For example, if a patient avers that his or her previous sur­
geon “butchered the nose,” but the examination reveals
only some minor flaws, it is very unlikely that the patient
will be pleased with the results of any secondary surgery.
Conversely, a patient whose nose has major flaws but who
makes mitigating remarks about the previous surgery has
the highest probability of being satisfied with the outcomes
of a subsequent procedure.

333
Chapter 24 Secondary Rhinoplasty
Therefore if the patient is reluctant to return to her previous
surgeon and if the previous surgeon’s skills are unknown
or questionable, a more experienced or seasoned surgeon
should undertake the patient care. In doing so, operative
notes from the previous surgery should be obtained and
confirmed by physical examination. The magnitude of pre­
vious septal cartilage resection and turbinectomy must be
assessed before surgery.
A secondary rhinoplasty consult should also include an
entire facial analysis, like the primary rhinoplasty, because
other facial disharmonies like forehead prominence or re­
trusion, chin deformities, malar bone hypoplasia, or a dys­
morphic maxilla or mandible may be contributing factors
to the patient’s dissatisfaction.9,10 Any disharmony in these
features, if detrimental to rhinoplasty outcomes, should be
brought to the patient’s attention and documented. How­
ever, insistence on correcting these deformities before or at
the time of rhinoplasty should be discouraged.
It is crucial to ensure that the patient has realistic ex­
pectations and is not suffering from any underlying psycho­
logical conditions that would contribute to patient dissat­
isfaction regardless of the surgical outcome. A significantly
disproportionate concern about the deformity is prodi­
giously alarming, and these patients require careful evalu­
ation to rule out body dysmorphic disorder. Asking the pa­
tient to rate the nasal deformity on a scale of 1 to 10 (with
10 being a perfect nose) and comparing this to the number
assigned by the surgeon can be enormously helpful in rec­
ognizing those patients who may not be pleased after the
surgery, regardless of triumphant surgical results. Proceed­
ing with another rhinoplasty when there is more than a 3- to
4- point disparity between the patient’s and the surgeon’s
scores may not be advisable without further analysis.
Physical Examinations and Common Flaws
Observation of the skin thickness is the first important step
in evaluating a patient for a rhinoplasty, because thick and
sebaceous skin could be a reason for a failed primary rhi­
noplasty procedure, and these patients may not be optimal
candidates for any external skin incision. For patients with
sebaceous and thick skin, referral to a dermatologist may
be appropriate to reduce sebaceous overactivity before sec­
ondary rhinoplasty. Tretinoin or isotretinoin are often used
to treat this condition. However, surgery should be delayed
for 6 months or more after this treatment has been com­
pleted to reduce treatment-induced hypertrophic scarring
or increased bleeding.
Achieving pleasing tip definition is often difficult in pa­
tients with thick skin. Appropriate measures should be in­
corporated into the surgery to attain better tip delineation
in these patients. Any dead space, in particular, should be
avoided, because it can be replaced with blood, followed by
scar or fibrofatty tissue, all of which can adversely affect tip
definition and result in a polly beak or supratip deformity.
Patients presenting for a secondary rhinoplasty may
have thin skin over the dorsum of the nose because of a
subcutaneous dissection instead of subperiosteal dissection
Many patients seeking primary rhinoplasty are not
aware of their breathing problems, and thus they do not
volunteer any information regarding breathing concerns or
may even deny having airway concerns. Careful observation
may reveal that many of these patients are mouth breath­
ers, and internal examination may reveal airway obstruc­
tion. The main reason for this unawareness or denial is that
they have grown up with this problem and lack a base for
comparison. Conversely, secondary rhinoplasty patients are
aware of their breathing difficulties and commonly associate
it with previous surgery. These patients have a clear base for
comparison, and if their airway is adversely affected for dif­
ferent reasons, they can sense it. Common conditions lead­
ing to airway problems are alteration in internal or external
valves, scar tissue formation, medialization of inferior tur­
binates and upper lateral cartilages or, often, a combination
of these adverse changes.6–8
Secondary rhinoplasty patients have a great deal of ap­
prehension before the upcoming surgery compared with pri­
mary surgery patients. They also exhibit more frustration
and impatience. They may have a more negative attitude
toward the surgical team because of their perceived undesir­
able experience with primary surgery. Thus restoring their
trust may pose a challenge. To overcome these adversities,
the surgeon must demonstrate more compassion and restore
confidence by identifying and describing the disharmonies
and providing a thorough explanation regarding how to cor­
rect the flaws.
A longer consultation time is needed for secondary rhi­
noplasty patients compared with primary surgery patients,
because some of them spend a significant portion of their
visit trying to explore what went wrong during the initial
surgery. It is crucial to redirect the patient’s focus to the cur­
rent problems and avoid any negative statements about the
previous surgery and the surgeon. Any unfounded adverse
statements made by the second surgeon may evoke or inten­
sify the patient’s rage toward the primary team. When ap­
propriate, potential legal actions can be averted by explain­
ing how complicated rhinoplasties can be and how rare it is
to attain perfect outcomes under most circumstances. Voic­
ing a negative opinion or making any disapproving state­
ments about the primary surgery and the surgeon solely
based on the patient’s emotional statements is utterly unfair
and inappropriate. It is important to be especially cognizant
of the potential effects of nonverbal cues while listening to
the patient. Any intentional or unintentional facial expres­
sions, eye rolling, grimacing, or gesture of disdain should
be prevented. This unethical, unprofessional conduct may
further escalate a patient’s negative emotions toward his
or her primary surgeon and place additional strain on the
already disturbed relationship. Any professional judgments
should either be deferred until all of the facts pertaining to
the previous surgery have been scrutinized or be avoided
altogether.
Every attempt should be made to persuade the patient
to return to the previous surgeon. This is a professional
courtesy and often offers an economic advantage to the pa­
tient. However, the patient’s interest is the main priority.

SECTION IV AESTHETIC SURGERY
334
mity because of medial shift or collapse of the upper lateral
cartilages (Fig. 24.5). Increased awareness of this problem
and the use of spreader grafts has reduced the incidence of
inverted-V deformities. This collapse is usually not seen in­
traoperatively or in the early postoperative period. Depend­
ing on skin thickness, the problem may reveal itself several
months to several years after the surgery.
during the primary surgery. In these patients, some of the
valuable soft tissue is eliminated while removing the dorsal
hump. On patients with thin skin even the smallest dorsal ir­
regularities are easily discernable. A layer of perichondrium,
fascia, or dermis graft may be required to augment the soft
tissue and overcome this deficiency. Dorsal augmentation
with alloplastic material is another reason for thinning of
the skin. These patients may have purplish discoloration of
the skin directly over the implanted material, which is often
more noticeable in cold weather. This discoloration can be
improved by replacement of the implant with the autoge­
nous materials and addition of soft tissue in the subcutane­
ous plane of the dorsum.
Some secondary rhinoplasty patients have telangiectasia
on the nasal skin, which may become more intense after sur­
gery. These patients need to be informed of this matter and
the fact that it might be necessary to treat this undesirable skin
appearance with laser. Suboptimal scars from primary surgery
might be a predictor of poor healing after secondary surgery.
A systemic examination of the external nose from the
radix to the subnasale is necessary to detect all of the im­
perfections. A shallow radix is a fairly common finding that
results in an undesirable transition from the forehead to the
dorsum of the nose (Fig. 24.1). The radix may be too shal­
low because of undercorrection or not correcting the abnor­
mality during primary surgery. Overresection of the radix is
uncommon, because inexperienced surgeons have difficulty
deepening the radix.
Nasal bone asymmetry or irregularity is one of the most
common reasons for patient dissatisfaction (Fig. 24.2). In an
optimal rhinoplasty outcome, there is a graceful transition of
the shadows from the eyebrows to the tip of the nose. Dorsal
aesthetic lines may be distorted or another line posterior to
the excising line may be seen in patients with suboptimal
rhinoplasty results. This extra dorsal line is usually a result
of the lateral osteotomy being too anterior (Fig. 24.3). Upper
lateral cartilages may also appear asymmetrical as a result
of unilateral overresection or, more commonly, be caused
by anterior deviation of the septum (Fig. 24.4). Overresec­
tion of the middle vault might cause an inverted-V defor­
Fig. 24.1 A patient with an underresected radix. (Reproduced from
Totonchi A and Guyron B. Common secondary nose flaws and their
logical correction. In: Rohrich RJ, Ahmad J, eds. Secondary Rhino­
plasty by the Global Masters. St. Louis: CRC Press; 2016.)
Fig. 24.2 A patient with an asymmetrical nasal bone after primary
rhinoplasty. (Reproduced from Totonchi A and Guyron B. Common
secondary nose flaws and their logical correction. In: Rohrich RJ,
Ahmad J, eds. Secondary Rhinoplasty by the Global Masters. St.
Louis: CRC Press; 2016.)
Fig. 24.3 An anterior lateral osteotomy during initial surgery caused
this step deformity. (Reproduced from Totonchi A and Guyron B.
Common secondary nose flaws and their logical correction. In:
Rohrich RJ, Ahmad J, eds. Secondary Rhinoplasty by the Global Mas­
ters. St. Louis: CRC Press; 2016.)
Fig. 24.4 Deviation of the anterior septum resulting in the appear­
ance of asymmetrical upper lateral cartilages. (Reproduced from
Totonchi A and Guyron B. Common secondary nose flaws and their
logical correction. In: Rohrich RJ, Ahmad J, eds. Secondary Rhino­
plasty by the Global Masters. St. Louis: CRC Press; 2016.)

335
Chapter 24 Secondary Rhinoplasty
tion. In contrast, a retracted columella can result from over-
resection of the caudal septum or a short caudal septum.
Rarely, this disharmony is the cause of a hanging ala, creat­
ing an ostensible retracted columella.
On the basilar view, asymmetry of the domes, nostril
shape, and infratip lobule volume and length would be eval­
uated. Excessive soft triangle lining and overall nasal tip and
columella deviation can be assessed in this view as well.
Nasal valves should be evaluated during deep breathing.
Collapse of the internal nasal valves was very common in
rhinoplasties done in 1980s because of aggressive resection
of the middle vault. Although this is less common today, it
is still seen occasionally.
Intranasal examination to identify nasal septal devia­
tion, septal perforation, enlarged turbinates, synechiae, and
polyps is crucial in every rhinoplasty patient evaluation.
Because of the level of precision required to correct
the deformities seen in secondary rhinoplasty, patient
assessment using digital life-sized photographs is even
more important than in primary rhinoplasty.13 This tool
also ensures synchronicity between the surgeon’s and the
patient’s goals.
Preoperative Planning
Generally, secondary rhinoplasty should not be performed
until at least 1 year has passed after the original surgery.
However, in rare cases, the amount of deformity and anxi­
ety of the patient may mandate earlier intervention. In
these cases, scar tissue and swelling may sacrifice the fi­
nal results; even with a perfect initial surgical outcome,
subsidence of swelling that is hiding flaws may reveal the
necessity for further revisions in the future. Multiple vis­
its and discussions are advisable to ensure a clear mutual
understanding between the surgeon and patient before the
secondary surgery. This will also provide more time for
healing before a revision surgery.
Routine steps for informed consent should be taken
by going over procedure-specific, general anesthetic, and
Tip deformities may range from minor imperfections,
such as asymmetry of the domes, to gross disharmony and
complete distortion.11 An underprojected tip is a common
problem requiring secondary rhinoplasty. Disproportionate
nasal tip width is also a common issue. A hanging or retracted
tip is a common component of the imbalances necessitating
secondary rhinoplasty. Disproportionate width of the alar
base is also common and may be the reason for dissatisfac­
tion. A supratip deformity (Fig. 24.6) may be caused by an un­
derresected or overresected caudal dorsum, underprojected
tip (pseudodeformity), or a combination of these factors.12 As
stated previously, overresection of the caudal septum may
result in a dead space, facilitating accumulation of blood and
fluid and promoting scar formation and fibrosis, which ulti­
mately create fullness in the supratip area.
An obtuse nasolabial angle (overshortened nose) was
the hallmark of rhinoplasties performed in 1970s and early
1980s, whereas suboptimal tip rotation is more common
today. The latter is the consequence of an effort to be con­
servative and prevent an obtuse nasolabial angle. A hang­
ing columella (Fig. 24.7) may result from the placement of
the columella strut or protrusion of the caudal septum. Ide­
ally, about 4 mm of columella is visible on the profile view.
Excessive columellar show is displeasing and needs correc­
Fig. 24.5 An inverted-V deformity. (Reproduced from Totonchi A
and Guyron B. Common secondary nose flaws and their logical cor­
rection. In: Rohrich RJ, Ahmad J, eds. Secondary Rhinoplasty by the
Global Masters. St. Louis: CRC Press; 2016.)
Fig. 24.6 A supratip deformity. (Reproduced from Totonchi A and
Guyron B. Common secondary nose flaws and their logical correc­
tion. In: Rohrich RJ, Ahmad J, eds. Secondary Rhinoplasty by the
Global Masters. St. Louis: CRC Press; 2016.)
Fig. 24.7 A hanging columella. (Reproduced from Totonchi A and
Guyron B. Common secondary nose flaws and their logical correc­
tion. In: Rohrich RJ, Ahmad J, eds. Secondary Rhinoplasty by the
Global Masters. St. Louis: CRC Press; 2016.)

SECTION IV AESTHETIC SURGERY
336
After induction of anesthesia, the nose is packed with
gauze saturated in 4% cocaine or phenylephrine. Lidocaine
containing 1:200,000 epinephrine is infiltrated in an or­
ganized manner circumferentially, and if a turbinectomy
is planned as part of the procedure, the turbinates are in­
jected before nasal injection. After allowing a few minutes
for the initial vasoconstriction, a second injection is admin­
istered with a mixture of lidocaine and ropivacaine includ­
ing 1:100,000 epinephrine for additional vasoconstriction.
Vasoconstriction after the first injection will minimize the
systemic effects of the secondary injection and produce
more protracted anesthesia and more comfortable recovery.
A step or inverted-V incision is made in the columella,
and meticulous dissection is carried to the nasal tip and dor­
sum, separating soft tissue from the nasal frame.
Alteration of the Radix
A guarded burr can be used to remove additional bone from
an undercorrected or shallow radix.16 This tool is safe and
very effective if used properly.
After adequate dissection of the soft tissue in the dor­
sum and radix, the guarded burr is introduced into the ra­
dix area (Fig. 24.8). After activation of the device, the ra­
dix is lowered using a side-to-side motion of the device for
short duration to avoid thermal damage. If the dorsal hump
is large, it can be removed first to facilitate the insertion
of the device between the skin pocket and radix bone. Oc­
casional soft tissue interference with the movement of the
burr should not discourage its use. Repeated, judicious use of
this tool will achieve its intended results. However, caution
­surgical complications. Unpredictability and possible fail­
ure to reach the goal should be discussed with the patient
and documented. Limitations resulting from the presence of
scar tissue, finite supply of available and suitable cartilage
grafts, shrinkage of the skin, and telangiectasis must be ex­
plained to the patient. The potential need for cartilage graft
from costal or conchal sources should also be reviewed and
the potential cartilage graft source and backup source deter­
mined before surgery based on the surgeon’s and patient’s
preference. Other complications like airway problems and
scarring should be reviewed.
The ideal candidate for surgery is a patient with a clear
understanding of the surgery and its limitations. A patient
with unrealistic expectations or one who demands perfec­
tion, makes disparaging remarks about the previous sur­
geon, or makes the surgeon uncomfortable is not a good
candidate for secondary rhinoplasty.
Surgical Technique
Correction of nasal deformities resulting from a primary
surgery might require minor, intermediate, or major rhino­
plasty. Minor revision, such as placement of a tip or dorsal
graft, can be done under local anesthesia with or without
sedation. It is preferable that major surgeries are performed
with general anesthesia for three reasons:
1. Scar tissue might make the diffusion of the local anes­
thetic more difficult and unpredictable.
2. Dissection of the nose and septum often is very difficult
because scar tissue requires more intense surgeon
concentration and patient relaxation.
3. Airway protection and blood aspiration are better
controlled with endotracheal anesthesia than with
deep sedation.
Incision
A minor revision can be achieved with an endonasal inci­
sion for the placement of tip or dorsal grafts. However, for a
major revision, a columellar stair-step incision or a V inci­
sion is preferred.14,15 An open approach provides a better
view of the deformity and offers an opportunity for analyz­
ing the reasons for the failed previous surgery and more
successful correction. If the original surgery was performed
with an open technique, another open incision is safer be­
cause of the “delayed” phenomenon. Regardless, an open
technique can be used even if the original surgery was per­
formed with a closed technique.
The key to a successful surgery is the ability to iden­
tify the imperfections and facilitate adequate exposure,
regardless of the surgical technique used. Most deformi­
ties can be readily detected during external examination.
However, it is not always possible to fully delineate struc­
tural flaws, especially in the tip area, during physical ex­
amination; thus the surgeon might experience some un­
expected findings during surgery and must be prepared
to manage them.
Fig. 24.8 Guarded burr for reduction of a bony radix. (Reproduced
from Totonchi A and Guyron B. Common secondary nose flaws and
their logical correction. In: Rohrich RJ, Ahmad J, eds. Secondary Rhi­
noplasty by the Global Masters. St. Louis: CRC Press; 2016.)

337
Chapter 24 Secondary Rhinoplasty
bones and placing spreader grafts, which will reposition the
upper lateral cartilages and improve the airway.
Correcting the Dorsal Deficiency
A cartilage graft can be used to correct the deficiencies on
the dorsum of the nose caused by overresection or asym­
metrical resection of the hump. The septal cartilage is an
optimal source of cartilage for dorsal augmentation. A his­
tory of septoplasty should not necessarily change the plan
by either precluding the exploration or use of the septum.
If available, the septal cartilage is prepared and gently
crushed and the margins are beveled to prevent harsh dor­
sal lines or step-off (Fig. 24.9). Adequate soft tissue dissec­
tion is necessary to avoid forcing and subsequently fractur­
ing or malpositioning the graft. After proper positioning,
the cartilage is secured to the dorsum to prevent shifting
using 5–0 PDS sutures. The conchal cartilage is a second
choice only for minor deformities. For major deficiencies, a
costochondral graft is a better choice.
Harvesting a Conchal Cartilage Graft
To harvest a conchal cartilage graft, the ear is infiltrated on
its medial and lateral surfaces with lidocaine containing
1:100,000 epinephrine, using a 27-gauge needle. The site of
the cartilage incision is marked from the anterior surface us­
ing a 25-gauge needle dipped in methylene blue. An incision
is made on the posterior surface of the ear. The dissection is
carried toward the cartilage, leaving the perichondrium on
the medial surface of the cartilage graft. The lateral surface
is dissected in the subperichondrial plane and the cartilage
is incised, guided by the methylene blue marks.
The wound is irrigated and a 5–0 plain catgut suture is
passed through the upper portion of the conchal fossa on the
lateral side, taken through the mastoid fascia and brought
out through the lower part of the fossa and clamped, leav­
ing a sufficient loop. Then the posterior skin is closed using
a 5–0 running locking catgut. At the end, a cotton ball is
moistened and placed in the conchal fossa and the 5–0 cat­
gut loop is closed over it to secure the cotton ball in place
and to eliminate the dead space.
should be exercised because this tool is very powerful and
may cause excessive bone removal if used too aggressively.
Removing the Residual Dorsal Hump
A rasp can be used to remove the residual dorsal hump. It
is crucial to dissect the soft tissue completely off the bone
before using the rasp to prevent thinning of soft tissue, as
mentioned previously. Rasping of the bone might create a
wide appearance to the dorsum, or even an open roof de­
formity, which would require a corrective osteotomy. If
septoplasty is indicated, it should be done at this time us­
ing a dorsal open technique. If the area is devoid of a dor­
sal hump to be removed or the dorsal hump removal does
not create an open roof, septoplasty can be done using an
L-shaped mucoperichondrial incision. Although some au­
thors recommend the removal of dorsal humps using an
osteotome, this is not usually advisable on secondary rhi­
noplasty patients, because the remaining dorsal hump is
irregular.
Nasal Bone Osteotomy
Lateral low-to-low osteotomies can be performed percu­
taneously or through a small incision in the vestibular
lining. If the latter is selected, subperiosteal dissection
may not be as easy as in the primary rhinoplasty because
of the extent of the adhesions. On the other hand, sec­
ondary osteotomy is often easier if it is performed at the
same site as primary osteotomy, because bone deposi­
tion at the osteotomy site is never as strong as the origi­
nal bone.
The secondary osteotomy is sometimes done further
posteriorly, because the osteotomies leading to the second­
ary procedures are performed too anterior and require cor­
rection by another more posteriorly placed osteotomy. This
is done mainly to make the lateral wall smoother. In patients
who have a wide bony dorsum or who have very thick bone
in this area, which may prevent the medialization of the na­
sal bone, a double medial osteotomy will be necessary to
remove a bony wedge. The first osteotomy is on the me­
dial aspect of the nasal bone, slightly lateral to the midline,
aiming superiorly and medial. The second is immediately
lateral to the septum, aiming laterally and superiorly. These
two osteotomies are joined at the nasion, and then the bony
wedge is removed.
After completing the low-to-low and medial osteoto­
mies, a percutaneous anteroposterior osteotomy at the na­
sion area (at the location of nasal divergence) is performed
to reposition the nasal bone as a unit.
A small lateral depression over the nasal bone can be
camouflaged using a cartilage graft, or even a fat graft, as
long as the airway has not been significantly narrowed by
the medial displacement of the nasal bone and the upper
lateral cartilage and the internal valve remains competent.
If the patient experiences difficulty breathing, it may be nec­
essary to correct the nasal valve by outfracturing the nasal
Fig. 24.9 Septal cartilage prepared for dorsal augmentation. (Repro­
duced from Totonchi A and Guyron B. Common secondary nose flaws
and their logical correction. In: Rohrich RJ, Ahmad J, eds. Secondary
Rhinoplasty by the Global Masters. St. Louis: CRC Press; 2016.)

SECTION IV AESTHETIC SURGERY
338
Splay grafts are used when the upper lateral cartilages
are too attenuated or too short to allow a spreader graft to
provide sufficient improvement in the valve function and
achieve the intended aesthetic goals. The graft is tailored to
extend from the posterior extent of the upper lateral car­
tilage on one side to the opposite side, spanning the ante­
rior septum. A spring effect of the graft provides durable
competency to the internal valves. An open approach is the
preferred method for splay graft placement. The mucoperi­
chondrium is separated from the medial surface of the up­
per lateral cartilage bilaterally to create a pocket for graft
placement. Conchal cartilage is preferable. Hydrodissection
can facilitate this process. This graft is sutured to the an­
terior septum with a 5–0 PDS suture. If dorsal projection
is considered to be optimal before application of the splay
graft, it is necessary to lower the dorsum in the amount of
the cartilage thickness. The upper lateral cartilages are then
sutured to the graft tightly.
Adjustment of Caudal Dorsum
Supratip deformity can be a result of inadequate resection
or overresection of the caudal septum. Inadequate resec­
tion is easy to manage by removing more of the anterior
caudal septum after exposing the dorsum. To do this, the
upper lateral cartilages are dissected and separated from
the anterocaudal septum. It is essential to keep the muco­
perichondrium over the caudal nasal valve intact to pre­
vent upper lateral cartilage collapse. The anterocaudal sep­
tum, which is usually rigid after the primary rhinoplasty, is
lowered. This rigidity can prevent the skin from redraping
over the dorsum after removal of the caudal septum. The
resistant supratip tissues will tent over the caudal sep­
tum, causing dead space, and this might set the stage for
recurrent supratip deformity. Use of a supratip suture will
approximate the supratip soft tissues to the septum and
eliminate the dead space (Fig. 24.11).
Harvesting Costal Cartilage Graft
To harvest a costal cartilage graft, a submammary inci­
sion is used for female patients and an anterior chest wall
incision is designed for male patients. After injecting the
incision site with local anesthetic including 1:100,000
epinephrine, an incision is made. The dissection is carried
deeper and the pectoralis muscle fibers are separated with­
out cutting to reach the fifth or sixth rib. At this point, the
costochondral junction is identified, the perichondrium is
elevated off the cartilage circumferentially and medially,
and 5 to 6 cm of the cartilage is harvested.
For patients with thin nose skin, the lateral portion of
the perichondrium is harvested as a graft. After filling the
cavity with normal saline, the Valsalva maneuver is per­
formed to ensure the integrity of the pleural layer. A drain
is placed only if deemed necessary, and the wound is closed
in layers using 3–0 Monocryl, 5–0 Monocryl, and 5–0 plain
catgut. An occlusive waterproof dressing is applied.
If the costal cartilage is used for grafting, the graft is
first placed in a saline-soaked sponge for 10 to 15 minutes.
Should there be any tendency for warping, a 5–0 or 4–0 PDS
suture is started on the convex side and passed through the
full thickness of the graft two to three times along the long
axis and tied over the convex side tight enough to straighten
the warped graft and resist any additional warping. Diced
cartilage is used only for camouflage of minor irregularities
in our practice.
Correction of an Inverted-V Deformity
and Nasal Collapse
It is commonly necessary to restore the function of the in­
ternal valve by repositioning the upper lateral cartilages.
Collapse of the upper lateral cartilages disturbs nasal
function and creates an undesirable shape known as an
inverted-V deformity. Less severe forms of the deformity
can be corrected using a spreader graft, whereas more se­
vere deformities may require the use of a splay graft for
correction.17
To insert the spreader graft, the mucoperichondrium
and upper lateral cartilages are separated from the septum.
The spreader graft is placed on each side of the septum ex­
tending from the junction of the nasal bones and upper lat­
eral cartilages superiorly to the lower end of the upper lat­
eral cartilages inferiorly. The graft is approximately 3 mm
wide and 12 to 15 mm long, with the thickness of the graft
determined based on the magnitude of the deformity and
internal valve collapse (Fig. 24.10). If the graft is too thin to
serve the purpose, two layers of it can be used.
The graft is secured in place using at least two through-
and-through 5–0 Vicryl mattress sutures. This step is crucial
in preventing cartilage displacement during stent placement
or the healing process. After fixation of the cartilage, the up­
per lateral cartilages are approximated and sutured to the
spreader graft and the septum. Placement of the spreader
grafts may have a more positive effect on the creation of
optimal dorsal lines than on valve function.
Fig. 24.10 A bilateral spreader graft. (Reproduced from Totonchi A
and Guyron B. Common secondary nose flaws and their logical cor­
rection. In: Rohrich RJ, Ahmad J, eds. Secondary Rhinoplasty by the
Global Masters. St. Louis: CRC Press; 2016.)

339
Chapter 24 Secondary Rhinoplasty
Inadequate tip projection can be improved with su­
ture techniques, a columellar strut, tip graft placement, or
a combination of these tools. If the projection deficiency
is minimal and domal arches are too wide, placement of
a transdomal suture will achieve both goals. It will nar­
row the domes and increase the projection. If the tip un­
derprojection is a result of a short columella, a columellar
strut is the appropriate choice. On the other hand, if the
underprojected tip is caused by a short lobule, a tip graft
would correct the flaw more suitably (Fig. 24.12). These
techniques cannot be used interchangeably. The excess pro­
jection can be lessened either by resecting the footplates
or overlapping the lateral crura using Anderson’s tripod
concept, depending on the nose length and projection, or
by removing the domes if they are too wide or distorted
to be saved by using less-aggressive options. Any time the
domes are transected a tip graft should be used to restore
an optimal definition.
Lateral Crural Strut
A Gunter lower lateral strut can correct collapse of the
lower lateral cartilage.19 The lower lateral strut is a piece
of cartilage placed under the surface of the existing lower
lateral cartilage, extending from the maxilla to the ipsilat­
eral dome. This graft is also used when the lower lateral
cartilages are transected or transposed.
Correction of a Protruding Columella
A protruding columella can be corrected by the excision
of a rectangular piece of cartilage from the caudal sep­
tum and a proportional amount of membranous septum.
If anteriorly based, triangular cartilage is resected, it will
induce cephalic rotation of the nasal tip. If the nose is
underprojected and the patient exhibits excessive cau­
dal projection of the columella, the footplates and me­
dial crura can be overlapped and fixed over the caudal
septum, which resolves both imprecations (Fred tech­
nique).20
Placement of a Columellar Strut
A columellar strut is used to increase the tip projection when
the deficient part is on the columella and not on the lobule.
An approximately 20-mm long and 3-mm wide cartilage
graft is placed between the medial crura and rested on the
nasal spine and fixed symmetrically. Often fixing the graft
to the anterior nasal spine is preferable to prevent clicking
and to make the graft more effective. This graft will increase
the tip projection and cause cephalic rotation of the tip and
caudal projection of the columella and subnasale.
Tip Graft
For patients with a deficient lobule and inadequate tip pro­
jection, an onlay or shield tip graft is the preferred approach.
Nasal elongation for the correction of an ­overshortened
As discussed previously, overresection of the caudal sep­
tum can also cause a supratip deformity. In this case, dead
space created by overresection is filled with clotted blood,
which over time organizes to fibrofatty tissues. To correct
this deformity, the scar tissue is removed, a cartilage graft is
applied to the caudal septum, and a supratip suture is placed.
It should be noted that reduction of the caudal dorsum re­
duces the tip projection and should be considered in aes­
thetic planning. A tip graft may become necessary to attain
a more pleasing tip projection and proper supratip break.
To place a supratip suture, the columella incision is closed
temporarily with a single stitch and the supratip break site
is marked and tattooed using brilliant green with a 25-gauge
needle passing through the skin and marking the underlying
septal angle. A 6–0 Vicryl suture is used to gently approxi­
mate the deep portion of the supratip subcutaneous tissues
to the anterocaudal septum guided by the tattoo marks.
Tip Refinement
Tip deformities in secondary rhinoplasties are very common
for a variety of reasons, including overprojection, underpro­
jection, excessive or narrow width, or asymmetry. Excess
width can be controlled with suture techniques. If the domal
arches are too wide, a transdomal suture is recommended. If
the domes have a desirable shape but are positioned apart,
an interdomal suture is a better choice. Commonly, the con­
tinuity of the domes and upper lateral cartilages has been
interrupted, rendering the suture techniques more difficult,
if not impossible. A tip graft is used to control the tip width
and the position of the lower lateral cartilages. Often the ex­
isting domal cartilages are rigid and encased in scar tissues.
These factors set the stage for an unpredictable response and
asymmetry. Therefore more intraoperative trials are neces­
sary to achieve an optimal result compared with primary
rhinoplasty. For correction of a pinched or asymmetrical
tip, a subdomal graft is used, which would control the in­
terdomal distance, and if necessary an additional tip graft
would restore a better tip shape.18
Fig. 24.11 Technique for placement of a supratip suture. (Reproduced
from Totonchi A and Guyron B. Common secondary nose flaws and
their logical correction. In: Rohrich RJ, Ahmad J, eds. Secondary Rhi­
noplasty by the Global Masters. St. Louis: CRC Press; 2016.)

SECTION IV AESTHETIC SURGERY
340
causes asymmetry of the footplates, columella, and tip. It
is crucial to reposition the caudal septum after removing
the redundant overlapping portion of the cartilage, fix the
causal septum to the ANS (as long as the ANS is in the mid­
line), and adjust and approximate the footplates to create a
symmetrical nasal base.
Correction of a Retracted Alar Rim
Minor alar rim retraction can be corrected by placement
of alar rim grafts. This graft is 3 mm wide, 1 mm or less
thick, and 15 to 17 mm long. It could be septal, conchal, or
even costal graft. The graft is placed in the pocket created
as close to the rim as possible.23 It is important not to let
the graft extend anterior to the domes, or it could widen
the tip. Beveling the anterior end of the graft reduces the
potential for its visibility.
If alar rim retraction is severe, a V-Y advancement flap
is designed based on the alar rim internally, advancing the
vestibular lining caudally. The V flap is dissected as far cau­
dally as possible and an alar rim graft is placed in position.
The V incision is now converted to a Y. After advancement
of the triangular flap caudally, the incision is closed with
5–0 chromic sutures and stented with two plain silicone
sheet stents, one on the skin surface and the second on the
vestibular surface. The stents are secured using a 5–0 ny­
lon through-and-through suture, tied lightly to reduce the
potential for necrosis of the skin. A Gunter’s lower lateral
cartilage strut will also advance the alar rim caudally if the
patient exhibits alar collapse or rim retraction. A composite
conchal graft could be used for this purpose as well. How­
ever, we prefer the V-Y advancement.
nose can be accomplished by adding an extension cartilage
graft to the caudal septum or by placing a strut that ex­
tends from the medial crura to the septum, thus advancing
the columella caudally. This strut may also advance the alar
rim, as long as the medial and lateral crura are in conti­
nuity with each other through the dome and scar tissue is
released cephalically. If the alar rims are in an optimal posi­
tion, an onlay lobule and columella graft may advance the
columella without altering the rims. These techniques are
small alterations only.
In the case of severe nasal shortening, a tongue-and-
groove technique is used to elongate the nose.21,22 Two long
spreader grafts are placed on either side of the septum to
extend beyond the caudal septum proportional to the nose
elongation necessary. A columella strut is placed in position,
anteriorly wide enough to extend from the caudal septum
to the ideally positioned caudal border of the medial crura.
There is an extension of the columellar strut anteriorly be­
yond the dorsum to accommodate the medial crura and cre­
ate more support for the tip.
Footplates
Asymmetry or excess width of the footplates can be cor­
rected with a hemitransfixion incision. In the case of nasal
underprojection and footplate widening, approximation of
the footplates will help both problems. When the nose is
short and overprojected the footplates are resected and the
medial crura approximated, resulting in caudal rotation of
the tip.
Long-standing deviation of a caudal septum that is dis­
lodged to one side of the anterior nasal spine (ANS) often
Fig. 24.12 A tip graft. (a) An onlay tip and shield punch. (b) The punch is used to prepare the graft. (c) A skin hook is used to retrieve the
graft. (d,e) Fixation of the tip and shield grafts with 6–0 Monocryl. (Reproduced from Totonchi A and Guyron B. Common secondary nose
flaws and their logical correction. In: Rohrich RJ, Ahmad J, eds. Secondary Rhinoplasty by the Global Masters. St. Louis: CRC Press; 2016.)
a
b
c
d
e

341
Chapter 24 Secondary Rhinoplasty
Short Nostril
The nostril length can be increased by placement of an alar
rim graft or a columellar strut, narrowing the footplate, and
excision of the lining in the soft tissue triangle.
Figs. 24.13 and 24.14 demonstrate combinations of the
techniques mentioned in this chapter.
Alar Base Abnormalities
Alar base asymmetry and excess width is common in sec­
ondary rhinoplasty cases. The alar base can be reduced by
removing tissue from the nostril sill, lateral alar base, or a
combination based on the individual patient’s needs. The
graceful transition from the alar base to the nostril sill should
not be compromised because of the fear of scar visibility.
Fig. 24.13 Through an open technique,
this patient underwent secondary rhi­
noplasty osteotomies; application of a
dorsal graft, a columellar strut, and a
tip graft; and approximation of the me­
dial crura. (Reproduced from Totonchi
A and Guyron B. Common secondary
nose flaws and their logical correction.
In: Rohrich RJ, Ahmad J, eds. Second­
ary Rhinoplasty by the Global Masters.
St. Louis: CRC Press; 2016.)

SECTION IV AESTHETIC SURGERY
342
Conclusion
Evaluating a patient for secondary rhinoplasty is a challeng­
ing task that demands a thorough interview that includes
obtaining a complete history and physical examination.
Comprehensive analysis of the photographs and reviewing
them with the patient will help with some of the postopera­
tive satisfaction issues. In general, planning and performing
secondary rhinoplasty is technically a demanding procedure
best performed by an experienced rhinoplasty surgeon.
Postoperative Considerations
Splinting and Packing
If a septoplasty is performed, Doyle stents are used and
secured to the septum using 5–0 Prolene sutures. If oste­
otomies are not performed, Steri-Strips (3M) are adequate
for dressing. In the case of an osteotomy, Steri-Strips and
Aquaplast (Qfix) and metal splints are used in combination
and removed in 7 to 8 days.
Fig. 24.14 Through an open technique,
this patient underwent removal of the
dorsal caudally, placement of cephalic
septal cartilage graft cephalically, mini­
mal trimming of the cephalic margin of
the lower lateral cartilage, a shield graft
and narrowing of the alar base, alar rim
grafts, and correction of columella. (Re­
produced from Totonchi A and Guyron
B. Common secondary nose flaws and
their logical correction. In: Rohrich RJ,
Ahmad J, eds. Secondary Rhinoplasty by
the Global Masters. St. Louis: CRC Press;
2016.)

343
Chapter 24 Secondary Rhinoplasty
13. Guyuron B. Precision rhinoplasty. Part I: The role of life-
size photographs and soft-tissue cephalometric analysis.
Plast Reconstr Surg 1988;81(4):489–499
14. Daniel RK. Secondary rhinoplasty following open rhino­
plasty. Plast Reconstr Surg 1995;96(7):1539–1546
15. Gunter JP, Rohrich RJ. External approach for secondary
rhinoplasty. Plast Reconstr Surg 1987;80(2):161–174
16. Guyuron B. Guarded burr for deepening of nasofrontal
junction. Plast Reconstr Surg 1989;84:513–516
17. Guyuron B, Englebardt CL. The alar splay graft. Presented
at the anuual Meeting of the American Society of Aesthet­
ic Plastic Surgeons. New York; 1997
18. Guyuron B, Poggi JT, Michelow BJ. The subdomal graft.
Plast Reconstr Surg 2004;113(3):1037–1040, discussion
1041–1043
19. Gunter JP, Friedman RM. Lateral crural strut graft: tech­
nique and clinical applications in rhinoplasty. Plast Re­
constr Surg 1997;99(4):943–952, discussion 953–955
20. Fred GB. The nasal tip in rhinoplasty: use of invaginating
technique to prevent secondary drooping. Ann Otolaryn­
gol 1950;59:215–223
21. Ponsky DC, Harvey DJ, Khan SW, Guyuron B. Nose elon­
gation: a review and description of the septal extension
tongue-and-groove technique. Aesthet Surg J 2010;30(3):
335–346
22. Guyuron B, Varghai A. Lengthening the nose with a tongue-
and-groove technique. Plast Reconstr Surg 2003;111(4):
1533–1539, discussion 1540–1541
23. Guyuron B. Alar rim deformities. Plast Reconstr Surg 2001;
107(3):856–863
References
1. Juri J, Juri C. Secondary rhinoplasty. Ann Plast Surg 1987;
18(5):366–376
2. Millard DR. Secondary corrective rhinoplasty. Plast Re­
constr Surg 1969;44(6):545–557
3. Peck GC. Secondary rhinoplasty. Clin Plast Surg 1988;
15(1):29–41
4. Sheen JH. Secondary rhinoplasty. Plast Reconstr Surg
1975;56(2):137–145
5. Szalay L. Early secondary corrections after septorhino­
plasty. Aesthetic Plast Surg 1996;20(5):429–432
6. Constantian MB. The incompetent external nasal valve:
pathophysiology and treatment in primary and second­
ary rhinoplasty. Plast Reconstr Surg 1994;93(5):919–931,
discussion 932–933
7. Constantian MB, Clardy RB. The relative importance of
septal and nasal valvular surgery in correcting airway
obstruction in primary and secondary rhinoplasty. Plast
Reconstr Surg 1996;98(1):38–54, discussion 55–58
8. Guyuron B. Nasal osteotomy and narrowing of the airway.
presented at the annual meeting of the American soci­
ety of plastic and reconstructive surgeons, San Francisco,
1997
9. Guyuron B. Genioplasty. Boston: Brown & Co; 1992
10. Guyuron B, Michelow BJ, Willis L. Practical classification
of chin deformities. Aesthetic Plast Surg 1995;19(3):257–
264
11. Nicolle FV. Secondary rhinoplasty of the nasal tip and
columella. The choice of cartilage grafts. Scan J Plast Re­
constr Surg 1986;20(1):67–73
12. Guyuron B, DeLuca L, Lash R. Supratip deformity: a closer
look. Plast Reconstr Surg 2000;105(3):1140–1151, dis­
cussion 1152–1153
Discussion by Dean M. Toriumi
I believe secondary rhinoplasty can be divided into sev­
eral different categories:
1. Completion rhinoplasty
2. Intermediate level of complexity
3. Severe deformity
Completion Rhinoplasty
A completion rhinoplasty is necessary when the previ­
ous surgeon did not complete the rhinoplasty proce­
dure and the correction requires completion of some
of the maneuvers. This may involve completion oste­
otomies, dorsal hump reduction, or modification of the
nasal tip.
Intermediate Level of Complexity
An intermediate level of complexity involves a secondary
rhinoplasty patient who requires some lesser degrees of
reconstruction that may involve placing spreader grafts,
lateral crural strut grafts, alar rim grafts, or a septal ex­
tension graft.
The subdomal graft is a very useful cartilage graft
for correcting asymmetries and pinching of the domes
of the lateral crura and has numerous advantages to its
use.1–3 It involves the use of columellar struts and sutur­
ing maneuvers to repair the deformities in these patients.
Severe Deformity
The third category involves more severe deformities
with significant structural deficiencies. These patients
have major structural problems that have resulted in
worsening of their deformity and nasal function over
time (such as middle vault collapse, alar retraction, or
overrotation of the nasal tip).
Approach to Secondary Rhinoplasty
Most secondary rhinoplasty patients that I see have
a major structural deficiency and their deformity is

SECTION IV AESTHETIC SURGERY
344
evolving. Most secondary rhinoplasty patients have
undergone some degree of reduction and subsequent
weakening of the cartilaginous structures of their nose.
I believe the nose will continue to contract and poten­
tially deform as the nasal tissues “shrink-wrap” over
the weakened structures.
I have witnessed these changes in secondary rhi­
noplasty patients for whom I performed secondary re­
pair using cartilage grafts that were placed to change the
contour by building on top of the existing weakened na­
sal structures. I would place shield tip grafts, columellar
struts, and alar batten grafts with some improvement
that would not hold up over time. In addition, the lay­
ering of cartilage grafts on top of the weakened struc­
tures resulted in thickening of the nasal sidewalls and
occasionally pushing the tissues medially to obstruct the
nasal airway.
For this reason I have transitioned to a different ap­
proach to secondary rhinoplasty that assumes that the
nose needing treatment is at a single point along a con­
tinuum of healing that will tend to progress with time.
If there are five deformities noted at that point in time,
it is likely that other problems are developing and will
soon become apparent if not addressed.
My present approach to secondary rhinoplasty is to
“deconstruct and reconstruct” by taking down the most
vulnerable structures and then reconstructing these
structures using strong cartilage grafts typically com­
posed of costal cartilage. For many years I used auricular
cartilage for the cartilage grafting and found that this
cartilage can work well but is suboptimal for correcting
certain deformities:
•• Short nose
•• Overrotated nasal tip
•• Severely collapsed middle nasal vault
•• Underprojected nasal tip
•• Asymmetrical nasal tip
•• Severe alar collapse
•• Severe alar retraction
In such cases I use costal cartilage for the cartilage
grafting. I use costal cartilage for grafting the nose if
the patient’s septal cartilage was harvested in a previ­
ous operation or there is inadequate cartilage for all
of the structural grafts. I typically harvest the sixth or
seventh rib for grafting. I harvest the cartilage from
a 1- to 1.1-cm incision in the right side of the chest4
(Fig. 24D.1). I moved to this smaller incision to better
camouflage the scar and allow me to take whatever rib
I choose based on need. When I made larger incisions,
I would always make my incision in the inframam­
mary crease to hide the scar. The smaller 1-cm incision
is quite inconspicuous when it heals and thus can be
made anywhere on the chest so the rib that best suits
the needs for the particular patient can be harvested.
This has been very helpful in providing the best carti­
lage stock for reconstructions.
The technique of “deconstruct and reconstruct” re­
quires much more cartilage than is needed for onlay
grafts over the existing weakened nasal structures. I
use this approach to correct any deformities of the os­
seous nasal vault. This commonly requires infracturing
or outfracturing the nasal bones. If the bones are out­
fractured because of excessive narrowing I typically run
long costal cartilage spreader grafts up under the nasal
bones to hold them in the proper position (Fig. 24D.2).
In some patients with thin dorsal nasal skin, I cam­
ouflage the nasal bones by placing a layer of costal peri­
chondrium over the nasal bones to thicken the overlying
dorsal nasal skin (Fig. 24D.3) The costal perichondrium
is more substantial than temporalis fascia and provides
increased thickening. If the nasal dorsum has been
overresected, I augment the dorsum using a technique
that incorporates suturing perichondrium on the un­
dersurface of the dorsal graft, then placing the dorsal
graft with costal perichondrium interface over the nasal
bones that have been perforated with a 2-mm straight
osteotome. This perichondrium interface acts to ossify
and rigidly fix the dorsal graft to the bony dorsum, mini­
mizing the risk of cartilage warping.5–7 This maneuver
is critical to decreasing the likelihood of postoperative
graft displacement or warping. The act of fixation makes
the graft less capable of bending and creates a more nor­
mal “feel” to the nasal bridge.
Fig. 24D.1 A 3.5-cm costal cartilage segment can be harvested
through a small, 10-mm chest incision on the seventh rib.

345
Chapter 24 Secondary Rhinoplasty
Management of the middle nasal vault typically
involves placement of spreader grafts to create appro­
priate middle vault width and to reestablish the nasal
airway.8,9 I typically use costal cartilage spreader grafts
that extend from the caudal margin of the nasal bones,
extending caudally beyond the anterior septal angle.
These extended spreader grafts are used to stabilize a
caudal septal extension graft.10 The upper lateral car­
tilages are then resutured to the middle nasal vault to
complete the reconstruction. Patients who have shorter
nasal bones are at much higher risk for middle vault col­
lapse and an inverted-V deformity and usually require
thicker spreader grafts to adequately stabilize the mid­
dle nasal vault.4
Stabilizing the nasal base is critical to success in
secondary rhinoplasty. I usually use a caudal septal ex­
tension graft placed end to end and stabilized with ex­
tended spreader grafts to enhance nasal tip support.11 I
believe the key to successful nasal tip surgery involves
creating good nasal tip support to prevent postopera­
tive loss of nasal tip projection. If the nasal tip is not ad­
equately stabilized, the tip can drop postoperatively, cre­
ating inadequate tip projection and potentially a polly
beak deformity. The drawback to septal extension grafts
is the increased stiffness in the nasal tip postoperatively.
I explain this to all patients preoperatively. It is this in­
creased nasal tip stiffness that represents the increased
nasal tip support. In most patients the caudal septal ex­
tension grafts are triangular, with the wider margin of
the triangle facing superiorly to prevent excessive rota­
tion of the nasal tip12 (Fig. 24D.4). In some patients the
caudal septal extension graft is extended down to the
nasal spine to provide maximal stability at the risk of
creating stiffness in the patient’s upper lip when smiling.
Once the nasal tip is stabilized, the caudal septal ex­
tension graft is the new foundation for the tip structure.
At this point I suture the medial crura to the caudal sep­
tal extension graft, setting the nasal tip position. This al­
lows the surgeon to set the projection, length, and alar–
columellar relationship and to control the contour of the
nasolabial angle. When the medial crura is advanced
anteriorly, the tip projection can be increased and the
Fig. 24D.2 A patient who underwent previous rhinoplasty that
resulted in a collapsed left nasal bone. (a) A Boise elevator was
used to outfracture the left nasal bone. (b) The outfractured
nasal bone. (c) The costal cartilage spreader graft over the site
of implantation. (d) The spreader graft positioned under the
outfractured left nasal bone.
a
b
c
d
Fig. 24D.3 Costal perichondrium to be placed under thin atro­
phic skin over the nasal dorsum to thicken the skin and camou­
flage irregularities.
a
b
Fig. 24D.4 A caudal septal extension graft oriented to prevent
tip rotation. (a) A triangular caudal septal extension graft ori­
ented with the longer margin superior to counter the tendency
toward the tip rotating upward. (b) The caudal septal extension
graft sutured to the extended spreader grafts.

SECTION IV AESTHETIC SURGERY
346
In some cases the nasal tip cartilages are severely
damaged or deformed and require major restructuring.
In these cases I perform lateral crural release, stabili­
zation with lateral crural strut grafts, and reposition­
ing13–15 (Fig. 24D.6). This technique requires dissect­
ing the lateral crura off of the underlying vestibular
skin after hydrodissecting with local anesthetic. Care is
taken to avoid damaging the vestibular skin, which is
very important for internal lining. Once released, the
lateral crural strut grafts act to stabilize the weakened
or reduced lateral crura.16 Then appropriate pockets are
created along the sidewall of the nose. The placement
of the pockets is determined by the position of the ala
or alar insertions. If the alar insertion is higher on one
side of the nose, the pocket is designed to move inferi­
orly toward the upper lip. This pocket placement will
force the alar insertion inferiorly and create improved
symmetry of the alar insertions. If the alar insertions
are symmetrical, then symmetrical pockets are created.
Once in the pockets the repositioned lateral crura pro­
vide increased lateral wall support and improved stabil­
ity to the alar margins. One drawback to this technique
is the increased stiffness in the lateral wall of the nose
and an increased need for alar base reduction because
of flared ala.
When the lateral crura have been resected or are
severely deformed I prefer to completely transect any
remnant lateral crura at the level of the medial crura
and then suture new lateral crura or domes to the cau­
nasolabial angle can be blunted. By moving the medial
crura posteriorly, nasal tip projection can be decreased
and the nasolabial angle can be made more acute. Nasal
tip rotation can be controlled by contouring the caudal
septal extension graft and positioning the graft with a
longer superior segment or by making a narrower su­
perior segment4 (Fig. 24D.5).
Fig. 24D.5 A caudal septal extension graft oriented with the
longer margin inferior to push out the nasolabial angle and aid
in rotating the nasal tip.
a
b
c
Fig. 24D.6 (a) Deformed lower lateral cartilages from a previous surgery. (b) The lateral
crura released from the underlying vestibular skin. (c) Lateral crural strut grafts sutured to
the undersurface of the lateral crura. (d) The lateral crura with lateral crural strut grafts
repositioned into caudally positioned pockets.
d

347
Chapter 24 Secondary Rhinoplasty
dal septal extension graft.4 With this technique I have
complete control over the nasal tip contour and lobular
contour (Fig. 24D.7). If there is no identifiable cartilage
I use scar tissue or costal perichondrium to create new
domes (Fig. 24D.8). These tissues allow the reformation
of new domes that are stabilized laterally with lateral
crural strut grafts.
Two of the keys to this technique are to have a prop­
erly positioned caudal septal extension graft and to cre­
ate proper orientation of the new lateral crura off of the
midline caudal septal extension graft. With this addi­
tional control comes the potential for creating deformity.
If additional tip projection is needed, a soft cartilage on­
lay tip graft can be sutured over the domes. This graft
Fig. 24D.7 (a) A patient with a severely deformed right lateral crus. (b) The lateral crural remnants amputated from the medial
crura. (c) The lateral crural remnants sutured to the caudal septal extension graft in symmetrical orientation with proper tilt.
(d) Lateral crural strut grafts sutured to the undersurface of the lateral crural replacement grafts. (e) Lateral crural replacement
grafts with lateral crural strut grafts placed into the pockets.
d
e
a
b
c
Fig. 24D.8 A patient who underwent previous rhinoplasty with no identifiable lateral crura. (a) Costal perichondrium used to
make new dome structures. (b) Lateral crural strut grafts sutured to the perichondrium. (c) Lateral crural strut grafts placed into
the lateral pockets.
a
b
c

SECTION IV AESTHETIC SURGERY
348
will act to create some separation from the new domes
and the tip-defining point.
In some cases in which significant increases in tip
projection are needed, I use a shield tip graft sutured
over the domes (Fig. 24D.9). If the shield tip graft is su­
tured more than 3 mm above the existing domes, I place
lateral crural grafts that extend from the posterior sur­
face of the shield graft at a 45-degree angle off of mid­
line to support the tip graft and prevent it from rotating
cephalically (Fig. 24D.10). Soft tissue grafts are typically
placed over the leading edge of the shield tip graft for
camouflage. I prefer to limit the use of shield tip grafts
to patients who have thicker skin, because these grafts
can become visible over time.
Many patients who have undergone previous rhino­
plasty have nostril asymmetry, alar retraction or inter­
nal nasal vestibular deficiencies, and scar contracture.
In these patients internal lining may be needed. I typi­
cally use composite skin and cartilage grafts harvested
from the auricle to reline the internal nasal vestibule.4
Composite skin cartilage grafts are typically harvested
from the cymba concha of the ear and should be handled
carefully to avoid damaging the graft before placement.
With larger composite grafts survivability of the grafts
can be increased by making the skin island portion of
the graft slightly smaller than the cartilage component.
In this scenario perichondrium is left on the cartilage
portion of the graft to allow the tissue at the recipient
site to overlap the perichondrium on the cartilage and
allow more rapid revascularization and improved sur­
vivability of the grafts.4 The most common use of the
composite skin cartilage graft is in a patient with alar
retraction whose retraction was corrected using lateral
crural strut grafts with repositioning, leaving a large gap
at the marginal incision closure. In these cases I do not
close the incision under tension but rather place a com­
posite skin cartilage graft into the marginal incision to
correct the deficiency (Fig. 24D.11).
Fig. 24D.9 A shield tip graft used in patients with thicker skin. (a) A shield tip graft with a buttress graft sutured to the dome
structure. (b) The buttress graft supports the posterior margin of the shield tip graft.
a
b
Fig. 24D.10 If the shield tip graft is projected more than 3 mm above the existing domes, lateral crural grafts can be placed off
of the posterior surface of the lateral crura that extend to the existing lateral crura to support the graft. (a) A shield tip graft with
lateral crural grafts. (b) Lateral crural grafts extending off of the shield tip graft at a 45-degree angle off of the midline. (c) Soft
tissue placed over the leading edge of the tip graft to provide camouflage.
c
b
a

349
Chapter 24 Secondary Rhinoplasty
Fig. 24D.11 A patient who underwent previous rhinoplasty that resulted in alar retraction. (a) A composite skin cartilage graft was
harvested from right cymba concha. (b) A defect at the closure of the marginal incision that is too tight to close. (c) A composite
graft over the site of the vestibular skin deficiency. The composite graft sutured into the defect. (d,f) Bilateral alar notching pre­
operatively. (e,g) One year postoperatively she has improved nostril symmetry, including an improved profile and nostril position.
(a–c Reproduced from Toriumi DM. Open structural approach to secondary rhinoplasty. In: Rohrich RJ, Ahmad J, eds. Secondary
Rhinoplasty by the Global Masters. St. Louis: CRC Press; 2016.)
a
b
c
d
e
f
g
Continued

SECTION IV AESTHETIC SURGERY
350
h
i
Fig. 24D.11, cont’d (h) Bilateral alar notching preoperatively. (i) One year postoperatively she has improved nostril symmetry,
including an improved profile and nostril position.
Fig. 24D.12 A patient who underwent a previous rhinoplasty that resulted in severe nasal vestibular stenosis. (a) Near-complete
stenosis of the right nasal vestibule. (b) A large raw area created with no mucosal coverage after releasing the stenotic area. (c) A
bivalved composite graft splitting the cartilage but not the skin to fit up into the nasal valve angle. (d) A composite graft sutured
into position. (e) Postoperative view of the right nostril showing the open vestibule and airway. (f) The well-healed donor site at
the cymba concha.
b
a
c
e
d
f
Composite skin cartilage grafts are also used for ves­
tibular skin deficiencies when correcting a short nose or
overrotated nasal tip or for patients with severe internal
nasal vestibular stenosis (Fig. 24D.12).
Postoperative follow-up is critical for all patients who
have undergone rhinoplasty. However, follow-up is most
important for secondary rhinoplasty patients because of
the potential scar contracture and prolonged edema that
can plague these patients. If necessary I treat patients
with steroid injections (triamcinolone, 10 mg/mL), tap­
ing, or nasal compression to manage prolonged edema
and subtle asymmetries. I also believe it is important to
follow these patients to ensure they have maximal nasal
function.
Conclusion
Secondary rhinoplasty is very complex and is changing
dramatically with the increased use of the open rhi­
noplasty approach and filler injections into the nose.
Secondary deformities are more severe, and the recon­
structions are more complex. With the structure ap­
proach and readily available costal cartilage for graft­
ing, the long-term outcomes have improved, including
improved functional outcomes.

351
Chapter 24 Secondary Rhinoplasty
References
1. Guyuron B, Poggi JT, Michelow BJ. The subdomal graft.
Plast Reconstr Surg 2004;113(3):1037–1040, discus­
sion 1041–1043
2. Lee M, Guyuron B. Dynamics of the subdomal graft.
Plast Reconstr Surg 2016;137(6):940e–945e
3. Toriumi DM. Discussion: dynamics of the subdomal
graft. Plast Reconstr Surg 2016;137(6):946e–949e
4. Toriumi DM. Secondary rhinoplasty. In: Rohrich RJ,
Ahmad J, eds. Secondary Rhinoplasty by the Global
Masters. New York: Thieme; 2016
5. Toriumi DM, Swartout B. Asian rhinoplasty. Facial
Plast Surg Clin North Am 2007;15(3):293–307, v
6. Toriumi DM. Discussion: Use of autologous costal
cartilage in Asian rhinoplasty. Plast Reconstr Surg
2012;130(6):1349–1350
7. Toriumi DM, Asher SA. Primary rhinoplasty tech­
niques: use of costal cartilage. In: Cobo R, ed. Ethnic
Considerations in Facial Plastic Surgery. Philadelphia,
PA: Thieme; 2015:196-217
8. Sheen JH. Spreader graft: a method of reconstructing
the roof of the middle nasal vault following rhino­
plasty. Plast Reconstr Surg 1984;73(2):230–239
9. Toriumi DM. Management of the middle nasal vault
in rhinoplasty. Op Tech Plast Reconst Surg 1995;2:
16–30
10. Guyuron B, Uzzo CD, Scull H. A practical classification
of septonasal deviation and an effective guide to sep­
tal surgery. Plast Reconstr Surg 1999;104(7):2202–
2209, discussion 2210–2212
11. Toriumi DM. Caudal septal extension graft for cor­
rection of the retracted columella. Op Tech Otol Head
Neck Surg. 1995;6(4):311–318
12. Toriumi DM, DeRosa J. Toriumi’s approach. In:
Rohrich RJ, Adams WP Jr, Ahmad J, Gunter JP, eds.
Dallas Rhinoplasty: Nasal Surgery by the Masters. 3rd
ed. Hoboken, NJ: CRC Press; 2014:1461-1494
13. Toriumi DM. New concepts in nasal tip contouring.
Arch Facial Plast Surg 2006;8(3):156–185
14. Constantian MB. The boxy nasal tip, the ball tip, and
alar cartilage malposition: variations on a theme—a
study in 200 consecutive primary and secondary rhi­
noplasty patients. Plast Reconstr Surg 2005;116(1):
268–281
15. Toriumi DM, Asher SA. Lateral crural repositioning
for treatment of cephalic malposition. Facial Plast
Surg Clin North Am 2015;23(1):55–71
16. Gunter JP, Friedman RM. Lateral crural strut graft:
technique and clinical applications in rhinoplasty.
Plast Reconstr Surg 1997;99(4):943–952, discussion
953–955

352
CHAPTER
25

Postoperative Nasal Airway Obstruction
Mark B. Constantian and Mark Albert
Secondary rhinoplasty is the surgery of unintended con­
sequences. Uncorrected or, even worse, iatrogenic, airway
obstruction is one of the most common complaints of sec­
ondary rhinoplasty patients. This surgical problem is par­
ticularly ironic, because it is virtually always avoidable if
the primary surgeon makes the correct anatomic diagnosis,
locates the critical anatomic variants that control or im­
pair the airway, and uses techniques that are effective and
proven.
Unfortunately for the surgeon trying to learn rhinoplasty
today, too many surgical techniques have uncertain value,
and many opportunities to deliver care with proven value
are missed. This chapter outline a system of understanding
and treating nasal airway obstruction that is based on sur­
gical methods that are logical, anatomic, expeditious, effec­
tive, and proven and that have the least chance of creating
new deformities.
Nasal Anatomy Relevant to the Airway
The internal nasal valve is formed by the articulation of the
caudal and anterior (or dorsal) edges of the upper lateral
cartilages with the anterior septal edge; the external nasal
valve is composed of the cutaneous and skeletal support of
the mobile alar wall (the alar cartilage lateral crura with
their associated external and vestibular skin coverings)1
(Fig. 25.1).
Internal Valves
The width and stability of the upper cartilaginous vault
(formed by the upper lateral cartilages and the anterior
septal edge), the critical area of the internal nasal valves,
depends on the width of the bony vault and the height and
width of the middle vault roof. Any resection of the middle
vault roof greater than 2 mm during hump reduction re­
moves this most critical anterior stabilizing force on the
upper lateral cartilages, which fall medially and produce a
characteristic inverted-V deformity and obstruction at the
internal valves.2,3 Middle vault collapse virtually always
occurs when the cartilaginous roof has been resected and
whether osteotomy has been performed but may not be vis­
ible if the overlying soft tissues are sufficiently thick; when
the nasal skin is thin, the deformity can be impressive (Fig.
25.2). Uncorrected, the patient’s airway will decrease by
50%. To prevent middle vault collapse and internal valvular
incompetence, the surgeon should plan to reconstruct the
normal forces by a substantial dorsal graft or by spreader
grafts,3 which provide the same degree of functional mean
nasal airflow improvement as documented by a level 2 out­
come study (discussed later).1,4
Internal
valve
External
valve
Fig. 25.1 The internal and external nasal valves, which constitute
lateral nasal wall support to the middle and lower thirds of the mo­
bile sidewall, respectively. (Reproduced from Constantian M. Rhi­
noplasty: Craft and Magic. St Louis: Quality Medical Publishing;
2009:138.)

353
Chapter 25 Postoperative Nasal Airway Obstruction
leave an external deformity, typified by deepening and
lengthening of the alar creases. The surgeon should resect
the upper lateral cartilages submucosally only when failure
to do so would allow them to prolapse into the airway or
when necessary to shorten the nose.
External Valves
The stability of the lower third of the nasal sidewall de­
pends on the thickness of its external and vestibular skin
and the position of the alar cartilage lateral crura. In the
primary rhinoplasty population, 50% of lateral crura are
cephalically rotated (“malpositioned”) and run along axes
that angle toward the medial canthus. In this circumstance,
even the unoperated cartilaginous support to the alar side­
wall is poorly positioned to support the alar rim against in­
spired airflow speeds of up to 60 km/hr. In two rhinomano­
metric studies of external valvular function, most patients
The middle vault and therefore the internal valves are
particularly threatened in three circumstances:
1. When the preoperative middle vault is congenitally
narrow
2. When the nasal bones are short, therefore creating a
larger percentage of sidewall that is only supported by
cartilage (Fig. 25.3)
3. When the surgeon reduces the nasal dorsum by more
than 2 mm1
Intersection of the Middle and Lower
Cartilaginous Vaults
The upper lateral cartilages are supported caudally by their
relationship to the cephalic margins of the lateral crura in
the region of the so-called “scroll”; radical alar cartilage
resection can compromise middle vault support and may
Fig. 25.2 Preoperative (a) and postoperative (b) views of
a patient whose dorsal resection caused internal valvular
incompetence and an inverted-V deformity and decreased
her preoperative airway by 50%. Alar cartilage resection pre­
cipitated alar rim contraction and external valvular incom­
petence. Thus this patient’s airflow after one surgery would
be approximately 25% of its original value.
a
b
Fig. 25.3 This tertiary rhinoplasty patient had internal and external valvular obstruction. (a) In her presurgical photograph her short nasal
bones are evident, which only extend 25% down the nasal sidewall. (b) After reduction, the sidewalls have collapsed and the alar rims have
deformed. (c) Spreader grafts, a rib cartilage dorsal graft (for an overresected dorsum), and composite skin and cartilage alar wall grafts
were used for her reconstruction. Replacing the normal anatomy re-created the appropriate surface landmarks.
a
b
c

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354
as septal deviation, one would expect to find more unanim­
ity in clinical series. These observations were clouded fur­
ther by the fact that approximately 80% of nasal septa in
the population at large are “deviated” and by imprecision in
distinguishing internal from external valvular incompetence.
Nevertheless, mounting clinical evidence indicates that ob­
struction at either set of valves may profoundly obstruct the
airway, even in the absence of septal deviation.7–15
Airway Outcome Study in 600 Patients
To help resolve some of these conflicting clinical observa­
tions and to provide quantitative measurements of the
relative increases in nasal airflow after functional septal or
valvular surgery, a level 2 study of 600 consecutive patients
undergoing surgery for airway obstruction was undertaken
between 1991 and 2008.1,4 Patients with septal perforation,
atopic patients, and patients requiring turbinectomy were
excluded. The diagnosis of septal obstruction or valvular in­
competence was made by observation of the nasal airway
and nasal sidewall movement with and without a nasal
speculum during quiet and forced inspiration. Septoplasty
and valvular reconstruction by cartilage or bone grafts were
performed as indicated and as described in this chapter.
Anterior, active, mask rhinomanometry was performed ac­
cording to the method of Mertz, McCaffrey, and Kern.16
That study comprised 600 patients: 78% women and 22%
men; 36% primary rhinoplasties and 64% secondary rhino­
plasties (median follow-up 14.3 months, mean 27 months).
The longer-term data of 362 patients observed for a min­
imum of 12 months (median 29 months) supported the
numbers in the entire group. A summary of the results are
presented in Box 25.1.1,4
This study did not answer the question of where turbi­
nates fit into the hierarchy of nasal obstructions. In atopic
individuals with gross turbinate hypertrophy or polyps, tur­
binectomy is unquestionably valuable.17 However, the mean
nasal airflow improvements listed previously were achieved
without turbinectomy, even in a population of patients with
with alar cartilage malposition had incompetent external
valves that collapsed upon inspiration.5,6 Significant resec­
tion of orthotopic lateral crura (those that more closely
parallel the alar rims and whose long axes run toward the
lateral canthi) or even modest resections of malpositioned
lateral crura cause varying degrees of external valvular in­
competence, alar hollowing, alar wall notches, or retraction
of the rims. Most of these secondary cases require alar wall
cartilage grafts, and in cases of severe retraction composite
skin and cartilage grafts from the conchal floor. Malposi­
tion occurs in 80% of the secondary rhinoplasty population
(Fig. 25.4).
What Matters in Functional Nasal
Anatomy
Although many patients with obstructed nasal airways im­
prove after septoplasty with or without inferior turbinec­
tomy, not all do. Adding to the frustration of patient and
surgeon are three other common observations:
1. There is often a poor correlation between a patient’s
symptoms and the apparent site of clinical septal or
turbinate obstruction.1,3
2. Patients typically breathe better (preoperatively and
even postoperatively) on the “narrower” side (ipsilat­
eral to the septal deviation).
3. Many patients who have undergone prior successful sep­
toplasty and turbinectomy or who have straight, unoper­
ated nasal septa still complain of airway obstruction.
These observations cannot be explained by indicting only
septal deviation and contralateral inferior turbinate hyper­
trophy.
Until recently, efforts to correlate nasal airflow with clin­
ical symptoms had yielded equivocal conclusions. There was
argument on both clinical and rhinomanometric grounds
that septoplasty either did or did not improve nasal airflow.
For such a commonly and easily diagnosed clinical problem
Fig. 25.4 Secondary rhinoplasty patient with internal and
external valvular incompetence. (a) Preoperatively she had
an obvious alar cartilage malposition. (b) Lateral crural re­
section has deformed the alar walls and allowed the rims to
retract. Nevertheless, the “footprints” of the malpositioned
cartilages remain. This patient’s airflow can be presumed to
have diminished at least 75% from its preoperative value.
a
b

355
Chapter 25 Postoperative Nasal Airway Obstruction
plasty, regardless of whether obstructing septal and turbi­
nate factors have been satisfactorily corrected (Fig. 25.5).
Avoiding Unfavorable
Results and Complications in
Postoperative Nasal Airway
Obstruction
Three distinct differences separate primary and second­
ary rhinoplasty: (1) tissue tolerance, (2) donor site deple­
tion, and (3) patient depletion (i.e., limited physical and
emotional tolerance for uncorrected or new problems).
The difficulty in any rhinoplasty is therefore not primarily
technical or anatomic; it is recognizing the phenomenol­
ogy present in nasal structure and function and learning to
work within it.
secondary deformities, valvular incompetence, prior intra­
nasal scars, webs, or vestibular atresia, confirming that tur­
binate obstruction in many patients may be largely reactive
or secondary.
Based on this study and the doubling of airflow from
reconstructing incompetent internal valves, we speculated
that the rhinoplasty surgeon who reduces a nasal dorsum,
opening the middle vault and creating internal valvular in­
competence where it did not exist preoperatively, will de­
crease the postoperative airway by 50%. That speculation has
been confirmed by a recent study.15 Furthermore, the results
of external valvular reconstruction suggested that lateral
crural resection significant enough to cause external valvu­
lar incompetence will decrease the postoperative airway by
another 50%. The inescapable implication of these observa­
tions is that a patient whose internal and external valves
have been destabilized by dorsal and tip reduction can lose
75% of his or her preoperative airway in only one rhino­
Box 25.1
1. Septal and valvular surgery corrected the airway obstruction in more than 95% of patients in a single opera­
tion. These results were possible even though two thirds of the population were secondary rhinoplasties
with more severe deformities.
2. Although septoplasty improved airflow ipsilateral to the obstruction, there was no significant improvement
in total (geometric mean) nasal airflow after septoplasty alone.
3. Internal valvular reconstruction by dorsal or spreader grafts doubled nasal airflow.
4. Spreader grafts and dorsal grafts were equally effective in supporting the internal nasal valves.
5. External valvular reconstruction doubled mean nasal airflow.
6. The largest postoperative improvement was seen in patients after correction of both internal and external
valvular incompetence (more than four times preoperative values).
7. Septoplasty in addition to valvular reconstruction did not significantly improve nasal airflow over the results
obtained by valvular reconstruction alone, even in patients observed more than 100 months postoperatively.
8. These results were produced without performing inferior turbinectomy in any of the patients.
9. In those patients with lateralized symptoms, the septum was contralateral to the more obstructed side in
45% of cases.
10. Of the 384 secondary rhinoplasty patients, 94% had previously undergone adequate septoplasties but were
still symptomatically obstructed. Within this group, valvular reconstruction alone corrected the airway in
97% after one operative procedure.
11. When primary and secondary rhinoplasty patients were stratified, the improvement in primary patients
equaled or exceeded the improvement achieved in secondary rhinoplasty patients in six of the eight ob­
structed sites examined.
12. Valvular obstruction was 4 times more common than pure septal obstruction in primary rhinoplasty pa­
tients and 12 times more common than pure septal obstruction in secondary rhinoplasty patients.
13. When the entire 600-patient group was stratified, the greatest improvement was observed in those patients
observed more than 12 months, supporting the view that the airway continues to enlarge as edema resolves.
14. By measuring airflow during quiet and forced inspiration, sidewall stiffness could be quantified and shown
to increase following valvular reconstruction by dorsal, spreader, or alar wall grafts.
15. A decrease in nasal airflow was not obligatory, even in patients with preoperative airway obstruction.
Summary Data: Airway Outcome Study
Source: Data from Constantian MB, Clardy RB. The relative importance of septal and nasal valvular surgery in correcting airway obstruction in primary
and secondary rhinoplasty. Plast Reconstr Surg 1996;98:38 and Constantian MB. Rhinoplasty: Craft and Magic. St Louis: Quality Medical Publishers;
2009:133–186.

SECTION IV AESTHETIC SURGERY
356
Fig. 25.5 (a) Preoperatively this patient had a straight nasal dorsum and sidewall and good tip aesthetics with alar cartilage malposition.
(b) Postoperatively, dorsal and tip reductions in a single rhinoplasty have deformed the nose and crippled the internal and external valves.
The patient’s original surgical goal was a minor tip refinement. The patient’s septum was straight, but valvular incompetence rendered her
subtotally obstructed.
a
b
Summary Box
Key Points Relevant to Postoperative Airway Obstruction
•• The most common patient motivation for secondary rhinoplasty is an iatrogenic deformity from the previous
surgery.18 The primary surgeon must therefore use techniques that minimize the chance of creating secondary
deformities.
•• There is no strategic difference between primary and secondary rhinoplasty except the donor sites. The surgical
approach to all noses must respect the skeletal and soft tissue interdependencies and the contributions of
both skin and skeleton to the final outcome. These contributions are often more easily assessed through the
endonasal approach than through open rhinoplasty because the soft tissues, which determine 50% of the
final result, are largely undisturbed. All key planning decisions can be made from the external and airway
examinations.
•• Secondary rhinoplasty deformities are not limitless. They form one of three patterns:
Pattern 1: Deformities from soft tissue contraction.
Pattern 2: Deformities from skeletal contraction. Airway deformities typically create this pattern.
Pattern 3: Deformities from imbalance.
•• Only four common anatomic variants determine the success of any rhinoplasty2 (Table 25.1):
○
○Low radix or low dorsum.
○
○Inadequate tip projection, which determines the lateral view and whether the patient has a straight profile.
○
○Narrow middle vault.
○
○Alar cartilage malposition, which determines the frontal view and controls the airway. The latter two must be
recognized to aid creating new postoperative airway complications.
•• These four critical anatomic variants directly explain all three secondary deformity patterns:
○
○Inadequate tip projection creates supratip deformity and therefore pattern 1.
○
○Narrow middle vault and alar cartilage malposition allow skeletal collapse and create pattern 2.
○
○Low radix and low dorsum affect nasal proportion and create pattern 3.
○
○The interdependencies of anatomy and postoperative deformity emphasize the importance of correct
diagnosis and of recognizing anatomic variations.
•• Reconstruction of both internal and external valvular incompetence triples or quadruples airflow in most
patients, with or without concomitant septoplasty.
•• Most functional primary, secondary, and tertiary deformities can be corrected with only one of two operative
strategies: spreader or dorsal grafts to reconstruct or stabilize the middle vault or alar wall or
composite grafts to stabilize the external valves.

357
Chapter 25 Postoperative Nasal Airway Obstruction
collapsing area with a cotton-tipped applicator soaked in
1% pontocaine hydrochloride for the patient’s comfort. Pa­
tients with valvular incompetence will notice an obvious
and gratifying increase in airway size. The surgeon may ob­
serve valvular collapse and substantial airway obstruction
even in a patient with a straight, unoperated septum and
without turbinate hypertrophy. Here, septoplasty may be
indicated to harvest grafts but by itself will not open the
airway; the surgeon must also place appropriate valvular
grafts (Video 25.1). Some surgeons prefer spreader flaps
or autospreader grafts,19 redundant or unresected upper
lateral cartilages that are turned medially and fixed to the
septal edge by sutures. If redundant upper lateral cartilages
are long enough and strong enough to support the middle
vault, spreader grafts may be effective. At the time of this
writing, however, no study has shown that they prevent or
correct internal valvular incompetence. One paper has in
fact indicated the contrary.20
External Valves
Once the alar wall has been palpated and the patient has
been observed during quiet and forced inspiration, the po­
sition of the lateral crus and the strength of the alar wall
can be estimated. In primary patients, adequate treatment
of cephalic rotation of the lateral crura requires resection
and replacement of these structures, relocation of the lat­
eral crura to support the external valves, or supporting the
areas of external valvular collapse with autogenous grafts.
Correction of external valvular incompetence doubles
mean nasal airflow in most patients (2.5 times for primary
patients; 4.0 times for secondary patients).1,4
However, most secondary rhinoplasty patients have in­
sufficient remaining lateral crura and require cartilaginous
support with septal, conchal, or rib cartilage grafts. When
alar rim retraction is severe, the lining must also be replaced
in the form of composite skin and cartilage grafts from the
conchal floor.21
Septum
The septum should be palpated for remaining obstructing
cartilage and bone and the mucosal cover examined (indi­
cating the sequelae of allergy, injury, perforation, or chronic
cocaine use). It is also important to assess whether a “high”
(i.e., toward the anterior edge) septal deviation exists; be­
cause hump removal can unmask a high septal curvature,
the surgeon should be prepared to camouflage or correct
the septal deflection with unilateral or asymmetrically
thick spreader grafts.1,3,4
The surgeon should inquire about the airway first to
avoid becoming distracted by the patient’s aesthetic con­
siderations. Patients become accustomed to a poor airway.
Many have never breathed normally; others have lost their
basis for comparison after trauma or previous surgery and
have forgotten how much better their airways used to be.
Ask about periodic or cyclic airway obstruction; which air­
way is worse; any nasal trauma history; seasonal allergies
that obstruct the airway; clear rhinitis and suppurative si­
nusitis; snoring, epistaxis, and sinus headache or frequent
nose blowing; and what nonsurgical remedies the patient
has previously tried. Secondary rhinoplasty patients with
poor airways commonly will chronically self-medicate with
steroid or vasoconstrictive sprays that must be eliminated
before surgery. Also important are the patient’s work envi­
ronment and a history of tobacco or alcohol consumption
(either of which may cause nasal congestion) and, more
common now than in previous years, cocaine use.
Valves
Internal Valves
Sidewall collapse with inspiration at one or both of the
nasal valves is surprisingly common.1 It is important to
determine why valvular incompetence exists (e.g., prior
surgery, intrinsic weakness, or alar cartilage malposition).
If sidewall collapse occurs, the surgeon should occlude
one nostril and ask the patient to compare flow through
the unobstructed airway with and without supporting the
Table 25.1 Three patterns of
secondary deformity that can
be avoided by proper primary
rhinoplasty technique
Pattern
Dominant physical findings
1. Deformities from soft
tissue contraction
Low dorsum, blunt tip,
supratip deformity, re­tracted
columella or alar rims
2. Deformities from
skeletal collapse
Inverted-V deformity,
knuckled domes, collapsed
alar rims
3. Deformities from
nasal imbalance
Low dorsum, large base;
high dorsum, small base

SECTION IV AESTHETIC SURGERY
358
Surgeons must recognize consistent published and pre­
sented data that indicates that secondary patients who have
undergone open rhinoplasty have significantly more defor­
mities than those treated endonasally, especially deformities
of the columella, external valves, alar rims, and nasal tip—
areas invaded or manipulated though the open approach.23
Confusing matters further, no published outcome study has
yet demonstrated that either surgical technique creates bet­
ter results and fewer complications for most patients, which
deepens the weeds for novices. Surgeons new to rhinoplasty
are advised to question what they read and hear and to ex­
pect proof that published functional or aesthetic techniques
work consistently before adopting them. Because all patients
invest money, time, discomfort, and emotion in their rhi­
noplasties, what the patients fear most, and need least, are
additional disappointments.24
Most functional nasal deformities can be corrected
with only one of two operative strategies: spreader or dor­
sal grafts for internal valvular obstruction or alar wall grafts
for external valvular obstruction. In primary cases in which
the lateral crura are malpositioned or secondary cases in
which the patient’s lateral crura are still present, the sur­
geon can dissect out the lateral crura, cut them free at the
lateral genu, trim the cartilages to a size appropriate to sup­
port the alar walls, and replace them along the alar rims to
support the collapsing areas25 (Fig. 25.6).
Turbinates
Clinical and rhinomanometric data indicate that obstruct­
ing turbinates are relatively low in the hierarchy of com­
mon airway obstruction causes in primary and secondary
patients. Because turbinates warm and humidify inspired
air, the surgeon should plan conservative resections even in
atopic patients. Furthermore, histologic studies have shown
that turbinate hypertrophy secondary to septal deviation is
characterized by bony, not mucosal, overgrowth.22 There­
fore most patients who have had good septal and valvular
reconstruction can be adequately treated by only turbinate
crushing and outfracture (or no treatment at all). Hyper­
trophy will not return postoperatively in most patients if
septal and valvular causes have been corrected.1
Technical Details of Surgical Correction
It is important to identify which of the four critical pre­
disposing anatomic variants are present: low radix or low
dorsum, narrow middle vault, inadequate tip projection, or
alar cartilage malposition. Everything else is a relative de­
tail. If the surgeon recognizes the four anatomic variants in
the primary nose and makes their management part of the
surgical plan, the most common secondary deformities can
be eliminated.
Fig. 25.6 Original presurgical profile (a) and preoperative frontal view (b) demonstrate valvular incompetence after dorsal and tip reductions.
a
b
Continued

359
Chapter 25 Postoperative Nasal Airway Obstruction
Fig. 25.6, cont’d The preoperative nose (c,e,g) has a low radix, narrow middle vault, and malposition, three of the four critical anatomic
variants. Tip projection was adequate. Although the lateral crura were malpositioned, the tip cartilages were small and the alar rims poorly
supported even in the unoperated state. (d,f,h) Two-year postoperative result.
c
d
e
f
g
h
Continued

SECTION IV AESTHETIC SURGERY
360
metrically can be repositioned. Alar wall grafts that heal
asymmetrically or thicken can be revised through short
access incisions. Our most common corrections are dorsal
or tip graft revisions for displacement, undercorrection, or
overcorrection. Spreader grafts virtually never need revi­
sion and are, therefore, the first grafts novices should mas­
ter26 (Fig. 25.7).
I (M.C.) provide a written preoperative surgical plan to
each of my patients that includes the percentage chance that
revision may be indicated for the best possible result. This
is not risk management; it is patient education. No revision
should be performed until the end of the first postopera­
tive year. Resolution of swelling and stabilization of the final
appearance take at least that long in the primary nose and
often longer in patients undergoing secondary rhinoplasty.
Nothing should be done until healing is complete. The sur­
geon should control every possible variable.
The decision of who should perform the revision de­
pends, to some degree, on the same factors involved in the
prior rhinoplasty. The surgeon’s model and proposed solu­
tion should be clear and the patient’s goals reasonable; the
Managing Unfavorable Results
in Postoperative Nasal Airway
Obstruction
Discussion of Potential Complications
and Revisions
Both patients and surgeons must remember that revisions
may be necessary, and are almost predictable, in some dif­
ficult configurations if the best possible result is desired.
Revisions are typically minor. However, once the surgeon
becomes facile with the techniques, the need to revise alar
wall, spreader, or even dorsal grafts is uncommon, particu­
larly if surgery has been performed endonasally. One sig­
nificant advantage of that approach is that the underlying
anatomy and support structures are largely undisturbed.
Only the areas that require modification have been ac­
cessed or dissected. Therefore less can go wrong and cor­
rections are easier. Spreader grafts that are too wide or too
narrow can be adjusted. Dorsal grafts that do not heal sym­
i
j
k
Fig. 25.6, cont’d Spreader (i, dorsal (j), and alar wall (k) grafts were used
for her reconstruction. Intradermal fat grafts were injected as a secondary
procedure for camouflage under the patient’s excessively thin and scarred
nasal skin. (l) Schematic of the surgical correction. (l, Reproduced from Con­
stantian M. Rhinoplasty: Craft and Magic. St Louis: Quality Medical Publish­
ing; 2009:1241.)
l

361
Chapter 25 Postoperative Nasal Airway Obstruction
widening and nostril stenosis are also common, as is late
infection after tip sutures24 (Fig. 25.8). All composite grafts
oriented axially, coronally, or sagittally21 and alar base
flaps27 (see Fig. 25.6c,d) can improve some of these defor­
mities and enlarge the airways.
Skeletal Problems
Irregularities or asymmetries may occur in any modified
skeletal structure; their visibility varies with the thickness
of the soft tissue cover. Irregularities at the caudal edges
of the bony vault are often attributed to inadequate reduc­
tion but more often represent middle vault collapse, which
causes the caudal end of the bony arch to stand out in relief;
treatment is spreader or dorsal grafts,1,4 not further bony
resection (see Fig. 26.3).
A new frontal asymmetry can occur when the dorsal
resection uncovers a high septal deviation and can be seen
intraoperatively. Any hidden preoperative asymmetry is ex­
aggerated by collapse of the middle vault after dorsal resec­
tion because the upper lateral cartilage on the concave sep­
tal side has more room to fall medially than the upper lateral
cartilage on the convex side. A high septal deviation can be
hidden by splinting the anterior septal edge with asymmet­
rically thick spreader grafts or by a symmetrical dorsal graft.
Graft Problems
Skeletal problems caused by grafts rank third only because
fewer surgeons augment than reduce. For those surgeons
who augment often, graft imperfections are the most com­
mon reason for secondary revision. Dorsal grafts must be
patient and surgeon must understand each other explicitly.
Each operation is progressively more difficult than the last.
Specific Complications
Complex techniques introduce opportunities for more prob­
lems than simple techniques. Suboptimal results have be­
come increasingly more common and worse. This is not the
fault of the surgeon, but rather the fault of the techniques
themselves, some of which are too intricate for most rhino­
plasty surgeons to carry out successfully most of the time,
particularly in an open rhinoplasty.22–24
Unlike other plastic surgical operations that are techni­
cally or conceptually difficult, rhinoplasty has fewer of the
complications that traditionally plague surgeons. Most rhi­
noplasty surgeons never see lacrimal duct or extraocular
muscle injury after rhinoplasty; even septal perforation is
relatively uncommon. The following complications pertain
to the airway and are listed in decreasing frequency as they
are recognized in patients seen in consultation.
Iatrogenic Airway Obstruction
More common than any complication, and entirely prevent­
able, is a decrease in postoperative airway size, particularly
unfortunate if it is new and iatrogenic. Although attributed
by some authors to the use of an intercartilaginous access
incision or the narrowing effects of osteotomy, more com­
mon causes are increased internal valvular incompetence
or an incomplete septoplasty in which there are residual
obstructions posteriorly or along the floor. Inadequate tur­
binate resection is uncommon but does occur. Columellar
Fig. 25.7 Spreader grafts are placed through an intercartilaginous incision into submucoperichondrial tunnels developed with a Cottle el­
evator between the dorsal border of the septum and the dorsal borders of the upper lateral cartilages (photographed in another patient).
If the tunnels are snug and the right width, spreader grafts do not require fixation. If there is a high septal deviation, a thicker graft can be
placed on the side contralateral to the septal deviation, which is often corrective. (a) The grafts are cut from the strip of septal cartilage. (b)
Both spreader grafts are held alongside the created tunnels. Access is through an intercartilaginous incision. The septal angle and caudal
septum are evident. (c) The right spreader graft is placed. (d) A single transfixing suture closes the caudal end of the tunnel. (Reproduced
from Constantian MB. Rhinoplasty: Craft and Magic. St Louis: Quality Medical Publishing; 2009:549.)
a
b
c
d

SECTION IV AESTHETIC SURGERY
362
airflow spins through the perforated mucosa. Epistaxis com­
monly reflects an area of exposed septal cartilage or bone.
Repairing septal perforations is difficult; the recurrence rate
after local or even distant flaps is still high. In symptomatic
perforations, it is often preferable to identify and eliminate
areas of exposed septal skeleton and repair the mucoperi­
chondrial flaps to obtain a perforation with a healed, stable
surface. If symptoms can be alleviated in this manner, clos­
ing the perforation itself is not usually necessary. Surgeons
operating on patients with chronic large perforations (e.g.,
from cocaine use) should culture the nasal cavity preop­
eratively. Some of these airways are badly contaminated
with multiple gram-positive or gram-negative organisms,
and preoperative irrigation with appropriate antibiotic and
steroid solutions for several weeks will better prepare the
airway for surgical access.
carefully contoured and placed in pockets that limit their
movement. Spreader grafts may be too wide or too narrow,
and alar wall grafts may heal asymmetrically or occasion­
ally deform.
Septal Perforation
Perforations occasionally occur after difficult septoplasties
but can be minimized by cautious dissection over the vo­
mer, by repairing tears in the mucoperichondrial flaps, and
by placing 1-mm silicone splints on each side of the septal
partition before the nose is packed.
Even with these precautions, the occasional septal per­
foration may be unavoidable and is usually asymptomatic.
Small perforations may cause a curious whistling; larger
ones cause crusting, epistaxis, and rhinitis as the turbulent
Fig. 25.8 (a) Open rhinoplasty performed simply for septal access has crippled this patient’s airway. (b) Late infection after tip sutures is not
uncommon but is virtually never reported. This patient also has iatrogenic columellar and nostril distortion. (c) Left nostril stenosis corrected
by an axially oriented skin and cartilage composite graft from the ear. (d) Postoperative view of the same patient shown in c at 6 years.
a
b
c
d

363
Chapter 25 Postoperative Nasal Airway Obstruction
ten creates new alar wall notching or asymmetries, wide
columellae, or tip distortions that are technique-depen­
dent, not surgeon-dependent; they occur in the best of
hands.23 Some iatrogenic open rhinoplasty complications
are impossible with what we know today. Dissection im­
mediately beneath damaged skin through the open or
closed approaches can injure dermis or produce a tip that
remains telangiectatic, with skin adherent to the under­
lying grafts. Correction is difficult, but I (M.C.) have used
fat grafts (prepared by Coleman’s technique28 and placed
through a fine cannula or 22-gauge needle, intradermally
and subdermally) successfully in patients for whom ad­
equate skeletal correction has not been sufficient (done
secondarily for the patient in Fig. 25.6). In rare cases, direct
midline dorsal excision may be necessary.29
There is no reason to complicate a purely functional
operation by using an open rhinoplasty incision, which in­
troduces a significant risk of creating new deformities. The
patients pictured in Fig. 25.8a and Fig. 25.9 are not isolated
cases. Instead, intercartilaginous incisions should be used for
the spreader grafts, Killian incisions for the septoplasty, and
short vestibular incisions for alar wall grafts.
Circulatory Problems
Circulatory complications occur more commonly after
open than after functional rhinoplasty, especially when
cautery has been used for hemostasis of columellar vessels,
when rigid skeletal reconstruction or struts create exces­
sive wound closure tension, or when strong retraction has
been used. Early reoperation or dissection under scarred
tissues may perforate or split the dorsal skin.
Common current teaching prescribes that the worse
the secondary deformity and the more operations that have
been performed, the greater the skin and skeletal damage
and the wider the dissection should be. That logic flies in the
face of all established surgical principles and would not be
defensible in any other body area. The surgeon should treat
Rhinitis and Empty Nose Syndrome
Temporary rhinitis may occur for several weeks postop­
eratively, particularly when an obstructed airway has been
improved. Persistent rhinitis, however, is uncommon un­
less excessive turbinectomy has been performed. The pro­
ponents of turbinectomy minimize this sequela, but it is a
troublesome entity for which there is no consistently effec­
tive treatment. Empty nose syndrome is likely more preva­
lent on the Internet than in actual practice; in 37 years, I
(M.C) have seen only three cases. The usual cause is exces­
sive turbinate surgery.
Septal Collapse
Loss of cartilaginous support has protean effects, because
the intact septal partition is necessary for normal bridge
contour, nasal length, base support, internal valvular com­
petence, and upper lip carriage. The required reconstruc­
tion is therefore predictably complex. The surgeon may
minimize the possibility of septal collapse by identifying
those patients with unhealed or unstable septal fractures
before surgery and by leaving a minimum 15-mm width
of undissected septal cartilage and mucoperichondrium
along the dorsum to avoid jeopardizing septal support
if unexpected, unhealed fracture lines are encountered.
Even surgeons who intend to correct an external defor­
mity through the open approach will find it safer to access
the septum through a Killian incision and not through the
dorsal edge. Leaving the mucoperichondrium undissected
over the dorsal strut protects against septal collapse, does
not destabilize old fracture lines, and makes positioning of
spreader grafts significantly easier.
Soft Tissue Problems
Soft tissue problems can result from damaged dermis or
difficult building materials or grafts. Open rhinoplasty of­
Fig. 25.9 Preoperative (a) and postoperative (b) appear­
ance of a patient who had septoplasty performed through
an open rhinoplasty approach. This technique is unneces­
sarily complex and invites problems for the patient and
surgeon. Purely functional surgery can be easily performed
through vestibular and Killian incisions.
a
b

SECTION IV AESTHETIC SURGERY
364
and configuration of the septum and turbinates but also on
the stability and competence of the nasal valves under sig­
nificant transmural pressures. The observation that patients
often breathe worse on the side contralateral to the septal
obstruction (45% of our patients with lateralized obstruc­
tions) can therefore be explained only through valvular in­
competence. In patients with septal deviation and valvular
incompetence, the side with the greater airflow and greater
transmural pressure (i.e., the side contralateral to the sep­
tal deviation) will collapse first and therefore become more
symptomatic.
A recent review of 150 consecutive secondary rhino­
plasty patients indicated that the primary reason for an­
other operation in 81% of patients was an iatrogenic compli­
cation.18 There is no other aesthetic operation for which the
same can be said. Surgeons must therefore rely upon tech­
niques that are anatomic, proven to be effective, and unlikely
to create new deformities. In the primary circumstance this
means recognizing normal anatomic variants, particularly
short nasal bones, narrow middle vault, and alar cartilage
malposition. Intraoperatively the surgeon who resects the
cartilaginous dorsum and reduces malpositioned lateral
crura must reestablish middle vault and alar wall support
to prevent a new postoperative airway obstruction. Like­
wise, the surgeon seeing his or her own secondary patient
or that of another surgeon who complains of airway obstruc­
tion should suspect valvular, septal, and turbinate causes,
in that order. Much information can be gained by looking at
the patient’s original preoperative photographs, which will
indicate nasal bone length, middle vault width, and lateral
crural size, substance, and position. Most secondary valvular
incompetence can be corrected in one operation with a high
likelihood of success.1
As is true of all aesthetic procedures, the relationship
between patient and surgeon is paramount, because perfec­
tion is difficult and elusive and because rhinoplasty changes
facial appearance and the airway. Every patient expects and
deserves to have an improved postoperative airway, and, in
particular, no iatrogenic obstruction.
secondary soft tissue as if it had been irradiated. Dissection
should be limited, with incisions made frugally and pur­
posefully, and wounds should never be closed under tension.
Infection
Bacterial infections are rare after rhinoplasty and septal
surgery. We administer antibiotics while postoperative
packing is in place to minimize the chance of maxillary
sinusitis. Toxic shock syndrome, cavernous sinus, nasal
frontal abscess, and even endocarditis are extremely rare
but have been reported. Methicillin-resistant Staphylococ­
cus aureus (MRSA) has become increasingly common in the
United States. Approximately 3 to 4% of the U.S. population
now carries MRSA in its nasopharynx. I (M.C.) personally
saw two cases of MRSA before routine screening was insti­
tuted. We treat carriers with 5 days of intranasal mupirocin
calcium ointment 2%. When ear cartilage is harvested, the
technique must be scrupulous and new gloves and instru­
ments changed before returning to the nose. We prescribe
ciprofloxacin to all ear graft patients to cover Pseudomonas
aeruginosa, which can be present in the external auditory
canal.
Conclusion
Current rhinomanometric data support the concept that
lateral nasal wall movement caudal to the bony arch (con­
taining both the internal and external valves) constitutes a
cause of airway obstruction equal to or greater than septal
deviation in most rhinoplasty patients. By visualizing the
airway as a structure in which the septal partition forms
one side and the mobile lateral nasal wall forms the other,
and in which the turbinates and mucosa function as ad­
ditional dynamic structures, the inconsistencies in prior
clinical observations become easier to explain.
Inspired airflow passes through the nose at 15 to 65
km/hr, the latter equivalent to gale force winds. The size
of any nasal airway thus depends not only on the position
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