Kỹ Thuật Nâng Mũi Hiện Đại: Góc Nhìn Từ Các Bậc Thầy Hàn Quốc (Man Koon Suh, 2021)

448
Pre-operative and Post-operative
Photographs (Fig. 16a, c, e, g, i and
b, d, f, h, j)
Fig. 16  Preoperative (a, c, e, g, i) and post-operative (b, d, f, h, j) views
a
c
d
b
e
g
h
f
i
j
M. H. Paik and L. S. Chu

449
Case 6
Pre-operative Findings
Upturned tip, retracted columella, pinched tip
(Fig. 17a, b).
a
b
Fig. 17  A patient presents with an upturned tip, retracted columella, and pinched tip
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Intra-operative Findings
Skin tightly adhered to the underlying capsule of
the implant. Alar cartilages retracted upwardly
and densely adhered to the upper lateral cartilage
and septum. Silicone implant was on the mid-­
dorsal area.
Operative Procedures
The skin flap elevated from the underlying cap-
sule of the implant for skin elongation
(Fig. 18a).
Scar flap was elevated from the cartilage
framework, and the silicone implant was removed
(Fig. 18b).
Alar cartilages were isolated from scar tissue
and released from upper lateral cartilages and
septum. Rib cartilage harvested from the 9th rib
of the right chest (Fig. 18c).
Mid-dorsal augmentation was done using rib
cartilage graft. Columellar strut graft was per-
formed with rib cartilage (Fig. 18d).
A wide derotation graft with conchal cartilage
was placed for caudal rotation of the tip and
spreading domes and lateral crura. Tip graft with
conchal cartilage (Fig. 18e–g).
Fig. 18  Surgical procedures
a
c
d
b
e
g
f
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451
Fig. 19  Preoperative (a, c, e, g, i) and post-operative (b, d, f, h, j) views
a
c
d
b
e
g
h
f
i
j
Pre-operative and 
Post-operative Photographs
(Fig. 19a, c, e, g, i and b, d, f, h, j)
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Cases 7
Pre-operative Findings
Upturned tip, pinched tip, retracted columella,
asymmetric tip, asymmetric nostrils (Fig. 20a–f).
Fig. 20  A patient shows an upturned tip, pinched tip, retracted columella, asymmetric tip, and asymmetric nostrils
a
c
d
b
e
f
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453
Fig. 21  Surgical procedures
b
a
c
d
f
e
g
h
Intra-operative Findings
Heavy scar tissue and remaining alar cartilages
were intermingled with each other, and densely
adhered to upper lateral cartilages and septal
area. The remaining alar cartilages were badly
damaged and distorted and had many defect
areas. The patient did not have enough ear carti-
lage for nose correction.
Operative Procedures
Skin flap was elevated from underlying scar tis-
sue for skin elongation (Fig. 21a, b).
Scar flap was elevated (Fig. 21c).
Remnant alar cartilages were isolated and
freed from upper lateral cartilage and septum.
Columella strut with rib cartilage graft was done.
(Fig. 21d–f).
Bilateral septal extension graft with rib carti-
lage graft was performed. Caudal ends of bilat-
eral septal extension graft and anterior end of
columellar strut were fixed with nylon suture.
Alar cartilage remnants were fixed to columellar
strut (Fig. 21g).
Dermis graft was performed on the caudal end
of rib cartilage framework (Fig. 21h).
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Pre-operative and 
Post-operative Photographs
(Fig. 22a, c, e, g, i, k and 22b, d, f, h, j, l)
Fig. 22  Preoperative (a, c, e, g, i, k) and post-operative (b, d, f, h, j, l) views
a
b
c
e
g
h
i
k
l
f
d
j
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455
a
b
Fig. 23  A patient with an underdeveloped small nose, short nose, low nasal bridge, low tip, and severely retracted
columella
Case 8
Pre-operative Findings
Underdeveloped small nose, short nose, low
nasal bridge, low tip, severely retracted columella
(Fig. 23a, b).
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456
a
b
c
Fig. 24  Previously used L-shaped silicone implant
Intra-operative Findings
L-shaped implant was found inside the nose
(Fig. 24a–c).
Low nasal bridge almost the same level of the
cheekbone, short and low underdeveloped sep-
tum, poorly developed alar cartilages were found.
M. H. Paik and L. S. Chu

457
Operative Procedures
Skin flap was elevated from the underlying capsule
of the implant for skin elongation (Fig. 25a, b).
Alar cartilages were isolated from upper lat-
eral cartilage and septal structure to move down-
wardly (Fig. 25c).
7th rib cartilage was harvested from right
Chest and carved into four pieces (Fig. 25d).
One was used for dorsal augmentation and
lengthening, another one was used for columella
strut, two thin segments were used for stabiliza-
tion of the former two grafts (Fig. 25e).
Alar cartilages were fixed to columella strut
(Fig. 25f, g).
Onlay tip grafts with ear cartilage were done
(Fig. 25h).
Dorsal rib graft and tip graft were covered
with dermis graft from the sacral area to prevent
noticeability of cartilage grafts (Fig. 25i).
Fig. 25  Surgical procedures
a
b
c
d
e
f
g
h
i
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Fig. 26  Preoperative (a, c, e) and post-operative (b, d, f) views
a
b
c
d
e
f
Pre-operative and Post-operative
Photographs (Fig. 26a, c, e and b, d, f)
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459
Fig. 27  A patient presents with an upturned tip, retracted ala, asymmetric nostrils, and columellar deviation
a
b
c
d
e
f
Case 9
Pre-operative Findings
Upturned tip, retracted ala, asymmetric nostrils,
columellar deviation (Fig. 27a–f).
Intra-operative Findings
Scar tissue and alar cartilages were intermingled
and retracted upwardly and densely adhered to a
cephalically fixed structure. Alar cartilages were
severely distorted and asymmetrically arranged.
A piece of irradiated homologous costal cartilage
was in the intercrural space.
Operative Procedures: 1st Stage
Operation
The skin flap was elevated from underlying scar
tissue for skin extension (Fig. 28a).
A scar flap was elevated from the cartilage
framework. Alar cartilages were separated from
scar tissue, upper lateral cartilages, and septal
structure to move downwardly. Previously used
irradiated homologous costal cartilage was
removed (Fig. 28b).
Symmetric arrangement of the caudal border
of lateral crura was achieved, and maintained with
columella strut and derotation graft (Fig. 28c).
A columella-septal suture was done to prevent
hanging columellar base (Fig. 28d).
Despite insufficient elongation and augmenta-
tion, the operation had to be finished for the
moment due to worsened tip skin circulation dur-
ing the surgery (Fig. 28e).
Fig. 28  Surgical procedures in the first stage operation
a
b
c
e
d
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460
Fig. 29  Before (a, c, e, g, i, k) and after (b, d, f, h, j, l) the first stage operation
a
c
e
g
i
k
b
d
f
h
j
l
Pre-operative and 
Post-operative Photographs
(Fig. 29a, c, e, g, i, k and b, d, f, h, j, l)
M. H. Paik and L. S. Chu

461
a
b
c
Fig. 30  Surgical procedures in the second stage operation
Operative Procedures: 2nd Stage
Operation
Retracted right alar cartilage was separated from
left alar cartilage and upper lateral cartilage and
moved caudally and laterally (Fig. 30a, b).
The gaps were covered with alar spreader graft
and intercartilaginous graft. A multilayered onlay
tip graft was done for tip augmentation (Fig. 30c).
Dermofat graft from the sacral area was used
for
dorsal
augmentation
and
tip
skin
reinforcement.
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462
Fig. 31  Before (a, c, e, g, i, k) and after (b, d, f, h, j, l) the first and second stage operations
a
c
e
g
i
k
b
d
f
h
j
l
Pre-operative and Post-operative
Photographs (Fig. 31a, c, e, g, i, k and
31b, d, f, h, j, l)
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463
Fig. 32  A patient shows upturned tip, tip deviation, columellar deviation, asymmetric nostrils, and low nasal bridge
a
b
c
d
e
Case 10
Pre-operative Findings
Upturned tip, tip deviation, columellar deviation,
asymmetric
nostrils,
low
nasal
bridge
(Fig. 32a–e).
Intra-operative Findings
Severely shortened nose, tightly adhered skin to
underlying scar tissue was found. Alar cartilages
were badly deformed and retracted over upper
lateral cartilages and septum. There was a bilay-
ered columella strut with septal cartilage fixed to
the base of the caudal septum.
Operative Procedures: 1st Stage
Operation (Skeletal Framework
Reconstruction)
The skin flap was elevated from underlying
inelastic scar tissue for skin extension
(Fig. 33a, b).
Alar cartilages were separated from each other
(Fig. 33c).
Bilayered columella strut was removed
(Fig. 33d).
Both alar cartilages were isolated from scar,
upper lateral cartilages, and septum to move cau-
dally without resistance (Fig. 33e).
Rib cartilage graft was harvested from the 6th
rib of right Chest (Fig. 33f).
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L-shaped cartilage framework with rib carti-
lage was made and fixed to the nasal bridge
(Fig. 33g–i).
Alar cartilages were pulled down and medial
crura were sutured to the vertical limb of
L-shaped framework (Fig. 33j).
Both domes and lateral crura were lateralized
and maintained in that position with alar spreader
graft (Fig. 33k).
Onlay graft and cap graft with septal cartilage
were done. Lateral strut grafts were done bilater-
ally with a thin rib cartilage graft (Fig. 33l).
Fig. 33  Surgical procedures in the first stage operation
a
b
c
d
e
f
g
h
i
j
k
l
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465
Fig. 34  Before (a, c, e, g, i) and after (b, d, f, h, j) the first stage operation
a
c
e
g
i
b
d
f
h
j
Pre-operative and 
Post-operative Photographs
(Fig. 34a, c, e, g, i and b, d, f, h, j)
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a
b
c
d
Fig. 35  Surgical procedures in the second stage operation
Operative Procedures: 2st Stage
Operation (For More Tip
Lengthening, Dorsal Augmentation,
Tip Refinement)
The skin flap was elevated from underlying scar
tissue. Scar flap including previous tip graft and
alar spreader graft was elevated.
Alar cartilages were separated from L-shaped
rib cartilage framework of the previous opera-
tion, and moved caudally (Fig. 35a).
Umbrella-shaped columella strut was made
with conchal cartilage. Multilayered derotation
graft using thinned rib cartilage graft with
banked rib in the patient’s abdominal wall
(Fig. 35b).
Scar flap including tip graft and alar spreader
graft was redraped. Dermis graft on dorsum and
tip over the rib graft and tip graft (Fig. 35c, d).
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467
Fig. 36  Before (a, c, e, g, i) and after (b, d, f, h, j) the first and second stage operations
a
c
e
g
i
b
d
f
h
j
Pre-operative and 
Post-operative Photographs
(Fig. 36a, c, e, g, i and b, d, f, h, j)
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Case 11
Pre-operative Findings
Collapsed nasal tip, deeply retracted scar on the
tip, short nasal length, retracted columella
(Fig. 37a–e).
Intra-operative Findings
Tip skin was very thin, deeply retracted and
tightly adhered to the septum.
Operative Procedures: 1st Stage
Operation
Through bilateral infracartilaginous incision,
skin flap was elevated carefully not to make a
perforation (Fig. 38a, b).
A piece of dermofat graft from the sacral area
was inserted in the tip (Fig. 38c, d).
Fig. 37  A patient with collapsed nasal tip, deeply retracted scar on the tip, short nasal length, and retracted columella
a
b
c
d
e
a
b
c
d
Fig. 38  Surgical procedures in the first stage operation
M. H. Paik and L. S. Chu

469
a
b
Fig. 39  Before (a) and after (b) the first stage operation
Pre-operative and Post-operative
Photographs (Fig. 39a, b)
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470
Operative Procedures: 2st Stage
Operation
Skin flap including some portion of previous der-
mofat graft was elevated through transcolumellar
and infracartilagenous incision. Soft tissue flap
including the remaining dermofat graft of the
previous operation was elevated (Fig. 40a).
Alar cartilage was released from scar tissue
and isolated from upper lateral cartilage and sep-
tum. A defect area on left lateral crus was cov-
ered with ear cartilage (Fig. 40b).
Umbrella-shaped columella strut was used for
tip projection (Fig. 40c).
The tip complex was caudally rotated and
fixed with a derotation graft (Fig. 40d).
Onlay tip graft was done with ear cartilage,
and soft tissue flap was redraped over derotation
graft (Fig. 40e).
Operative Procedures: 3rd Stage
Operation
Onlay tip grafts with three layers of conchal car-
tilage were done (Fig. 41a–c).
A layer of dermis graft was done over the tip
grafts (Fig. 41d).
Fig. 40  Surgical procedures in the second stage operation
a
b
c
d
e
a
b
c
d
Fig. 41  Surgical procedures in the third stage operation
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471
Pre-operative and Post-operative
Photographs (Fig. 42a, c, e, g, i and
b, d, f, h, j)
Fig. 42  Before (a, c, e, g, i) and after (b, d, f, h, j) the first, second and third stage operations
a
c
e
g
i
b
d
f
h
j
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472
a
b
Fig. 43  A patient presents with right nostril stricture
Case 12
Pre-operative Findings
Right nostril was small by nostril stricture
(Fig. 43a, b).
Intra-operative Findings
Shortage of inner lining of right nostril caused by
the previous operation.
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473
Fig. 44  Surgical procedures
a
b
c
d
e
f
g
h
i
Operative Procedures
The skin flap was elevated (Fig. 44a).
Alar cartilages were released and freely iso-
lated from scar tissue, upper lateral cartilages,
and septum (Fig. 44b).
Umbrella-shaped columella strut with conchal
cartilage was used for tip augmentation and dome
symmetry (Fig. 44c).
Onlay graft and shield graft were used for
more tip projection. A derotation graft was used
for length control (Fig. 44d).
Right lateral crus and underlying mucosa were
cut from the pyriform aperture area, and the inci-
sion was extended following intercartilaginous
junction, and this chondromucosal flap was
moved anteromedially (Fig. 44e).
The defect area of this flap donor area was
covered with a full-thickness skin graft (Fig. 44f).
Dorsal augmentation with dermofat graft from
the sacral area was done (Fig. 44g).
Dermis graft on the tip graft was done (Fig. 44h).
Right nostril was supported with a Silastic
nostril retainer for 3 months (Fig. 44i).
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474
a
c
b
d
Fig. 45  Preoperative (a, c) and post-operative (b, d) views
Pre-operative and Post-operative
Photographs (Fig. 45a, c and b, d)
M. H. Paik and L. S. Chu

475
a
b
c
d
Fig. 46  A patient with complete obliteration of both nostrils
Case 13
Past Surgical History
She had six times of nose operation for nostril
widening by using simple scar excision and stent
insertion, and every operation worsened the
results.
Pre-operative Findings
Both nostrils were completely obliterated by scar
tissue, and there was no lining (Fig. 46a–d).
The severely contracted scar was around nos-
trils, alar rims, and columella. Retracted colu-
mella, left Retracted ala were found.
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476
Fig. 47  Surgical procedures in the first stage operation
a
b
d
c
e
f
h
g
Operative Procedures: 1st Stage
Operation
Left perialar transcolumella incision was made
(Fig. 47a, b).
A Gore-Tex implant was removed from the
nasal bridge (Fig. 47c).
A piece of Medpore implant for septal exten-
sion graft was removed from the septum
(Fig. 47d).
Left lower lateral cartilage with underlying
mucosa was separated from the pyriform aper-
ture area and upper lateral cartilage, and this
chondromucosal flap was moved anteromedially.
Right lower lateral cartilage with underlying
mucosa was also moved anteromedially in the
same manner (Fig. 47e, f, g, h).
Retracted left alar base was pulled down
(Fig. 47i, j).
The defect area of the chondromucosal flap
on a lateral wall of both nasal cavities was cov-
ered with a full-thickness skin graft (Fig. 47k, l,
q, r).
The defect on columella was covered with
chondrocutaneous composite graft from left heli-
cal rim (Fig. 47m–o).
Nasal bridge augmentation was done with a
dermofat graft (Fig. 47p).
M. H. Paik and L. S. Chu

477
n
m
p
o
r
q
i
j
k
l
Fig. 47  (continued)
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478
Pre-operative and Post-operative
Photographs (Fig. 48a, c, e and b–f)
Fig. 48  Before (a, c, e) and after (b, d, f) the first stage operation
a
c
e
b
d
f
M. H. Paik and L. S. Chu

479
Operative Procedures: 2st Stage
Operation
Columella was lengthened with a chondrocutane-
ous composite graft from right helical rim
(Fig. 49a–f).
Fig. 49  Surgical procedures in the second stage operation
a
c
e
b
d
f
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480
Operative Procedures: 3rd Stage
Operation
Depressed scar on intralobular and columella was
corrected by dermis graft through right rim inci-
sion (Fig. 50a–d).
a
b
d
c
Fig. 50  Surgical procedures in the third stage operation
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481
Fig. 51  Before (a, c, e, g) and after (b, d, f, h) the first, second, and third stage operations
a
c
e
g
b
d
f
h
Pre-operative and Post-operative
Photographs (Fig. 51a, c, e, g and
b, d, f, h)
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483
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
M. K. SUH (ed.), State of the Art Rhinoplasty Techniques,

Secondary Cleft Lip Rhinoplasty
Hojin Park and Kyung S. Koh
Introduction
Patients with cleft lip with or without cleft palate
have complex forms of nasal deformities. The
deformity involves all tissue layers around the lip
and nose, including the external skin, cartilagi-
nous structures, and inner mucosal lining. The
degree of the associated deformity varies with the
severity of lip abnormality. Secondary deformi-
ties are also affected by previous surgeries and
patient growth. This usually results in significant
esthetic and functional problems. The nasal shape
is usually asymmetric, and nasal obstruction is a
common functional problem. These problems
affect patients throughout development.
Rhinoplasty is classified into primary and sec-
ondary according to the time of correction.
Primary rhinoplasty is performed with cleft lip
repair at 3 months of age. Secondary rhinoplasty
includes intermediate and definitive rhinoplas-
ties. Intermediate rhinoplasty is usually per-
formed before nasal growth completion between
4 and 6  years to reduce psychosocial distress
from peers. Some surgeons advocate performing
intermediate rhinoplasty at 8 and 12 years of age
until the completion of orthodontic alignment
and alveolar bone grafting for a better skeletal
base. Definitive rhinoplasty is performed after
skeletal growth is completed. It is usually per-
formed at the ages of 16–18 for males and
15–17 years for females.
Traditionally, surgeons have focused on bal-
ancing nasal deformity in an anteroposterior
view. However, due to recent advances in smart-
phones and social network services (SNS), facial
photographs can be taken from various angles,
including selfies. It has been raising patient
expectations regarding correction of the defor-
mity on basal views as well as on the anteropos-
terior view.
The goal of definitive rhinoplasty in unilateral
cleft lip nasal deformity is to gain nasal symme-
try in terms of the esthetic aspect, as well as
improve the nasal airway in terms of the func-
tional aspect. This requires an understanding of
the pathophysiology and nature of the deformity.
In this chapter, the anatomy and pathophysiology
of cleft lip nasal deformity is discussed, and the
currently used procedure of definitive rhinoplasty
is described.
H. Park · K. S. Koh (*)
Department of Plastic and Reconstructive Surgery,
University of Ulsan College of Medicine,
Asan Medical Center, Seoul, South Korea
e-mail: kskoh@amc.seoul.kr

484
Secondary Nasal Deformity
Patients with unilateral cleft lip have a wide pyri-
form aperture and hypoplastic maxillary bone.
These features displace the cleft side ala base lat-
erally, inferiorly, and posteriorly. The caudal sep-
tum and non-cleft side maxilla are deviated to the
non-cleft side, and the dorsal side of the septum
is tilted toward the cleft side. Moreover, the
abnormal insertion of the orbicularis oris muscle
pulls the caudal septum asymmetrically to the
non-cleft side and aggravates septal deflection.
The lower lateral cartilage is slumped and disso-
ciated from the ipsilateral upper lateral cartilage.
Moreover, there is pathologic tethering of the
accessory chain of the lower lateral cartilage to
the pyriform aperture. Due to caudal septal dislo-
cation and pathologic tethering, the lateral crus of
the lower lateral cartilage on the cleft side is
stretched, and the medial crura are shortened.
There is still controversy as to whether lower
lateral cartilage asymmetry is caused by tissue
malposition or tissue hypoplasia with malposi-
tion. An anatomical study of stillborn fetuses
with cleft lip by McComb and Li et al. confirmed
that the lower lateral cartilage is normal in length,
width, and thickness compared with the non-cleft
side. However, Byrd et al. argued that hypoplasia
of the lower lateral cartilage was also associated
with malposition from a stillborn cleft study and
rhinoplasty experience. The malposition of the
lower lateral cartilage, septal deviation, and
abnormal bony structures manifests as a splayed
alar rim, flattened nasal dome, alar rim caudal
hood, alar base displacement, and an alar–colu-
mellar web.
In patients with a bilateral cleft, the maxilla is
hypoplastic, and alar bases are displaced in the
posterior, lateral, and inferior directions. The
deficient skeletal base leads to a bilaterally wid-
ened lateral crura and a short medial crura. This
manifests as an under-projected, bulbous, and flat
nasal tip. Moreover, the short columella makes
the bulbous nasal tip even more pronounced.
Unlike unilateral cleft lips, bilateral cleft lips
often have symmetrical nasal shapes. The ante-
rior nasal spine and caudal nasal septum are not
usually displaced.
Secondary cleft lip nasal deformity is a distor-
tion that persists after primary operative proce-
dures. Secondary deformity manifests as a
combined result of residual deformities after pri-
mary correction, growth-related changes, and iat-
rogenic effects. The appearance of secondary
cleft nasal deformities varies according to growth
effects, residual deformities, and iatrogenic
effects. Residual deformities after primary cor-
rection develop as a result of correction failure,
under-correction, over-correction, or relapse of
the primary deformity. Iatrogenic effects include
expected or unexpected changes after primary
deformity correction surgery. Scar contracture
and vestibular webs that occur after alar base
medial movement are representative examples of
iatrogenic effects. Growth-related nasal changes
mainly occur during adolescence, and the nasal
shape becomes more asymmetric, especially in
patients with a unilateral cleft lip.
In unilateral cleft lip nasal deformity, the nasal
bone is frequently widened at the dorsum, and a
c-shaped mid-vault curvature may be present. In
addition, the maxilla is often underdeveloped.
Since the nasal structures rest on the underdevel-
oped maxilla, the alar base and alar rim become
more asymmetric during puberty. A foreshort-
ened columella further compromises the tip pro-
jection, and the caudal septum is displaced away
from the cleft side. External valve collapse may
occur due to alar base malposition, leading to
imbalanced muscular pull and abnormal attach-
ment of the cheek muscles. The internal valve
often collapses and nasal airway obstruction is
present in over 60% of patients with cleft lip
nasal deformities. In a bilateral cleft lip nasal
deformity, the alar bases widen progressively, but
the columella does not grow. This makes the
nasal tip appear bulbous in patients with bilateral
cleft lips.
The deformity is corrected on an individual-
ized basis depending on the shape of the defor-
mity, patient expectations, and the surgeon’s
preference. Secondary cleft nasal deformities are
corrected after completion of facial growth, gen-
erally around 16–18 years of age for males and
15–17 years of age for females. If the patient is to
undergo orthognathic surgery to correct a
H. Park and K. S. Koh

485
­hypoplastic
maxilla,
secondary
rhinoplasty
should be delayed after orthognathic surgery.
Preoperative Evaluation
A history and operative record review are the first
steps in the preoperative evaluation. For instance,
alveolar bone grafting and Lefort I maxillary
advancement can change the patient’s nasal
shape. Alveolar bone grafts augment the skeletal
support of the alar base and correct its posterior
displacement. Lefort I maxillary advancement
elevates the nasal tip, widens the columella-labial
angle, and increases inter-alar width.
Traditionally, nasal shape is evaluated by
dividing the nose into thirds. The upper third is
composed of the nasal bone, and the deviation
and wideset should be noted. The nasal dorsum
and sidewall comprise the middle third. Nasal
deviations, dorsal humps, and irregular dorsal
esthetic lines are common in unilateral cleft lip
nasal deformities. The lower third is composed of
the nasal tip, columella, soft triangles, alar lob-
ules, alar bases, and nasal sill. The lower third is
the most deformed area in patients with unilateral
cleft lip, with this area being the focus of defini-
tive rhinoplasty. Poor tip projection, asymmetric
tip-defining points, a boxy tip, flattening of the
alar rim, angulation of the columella, deviation of
the caudal septum, and alar base displacement
(lateral, inferior, and posterior displacement) are
common problems.
Sixty percent of patients with cleft lip nasal
deformities have nasal airway obstruction. Septal
deviation, maxillary bony spurs, turbinate hyper-
trophy, vestibular webbing, and external or inter-
nal valve collapse are common problems.
However, many patients do not recognize their
nasal obstruction because they have been habitu-
ally mouth breathing and have not experienced
normal breathing. A history of recurrent sinusitis,
sinus headache, and mouth breathing may be
essential signs of nasal obstruction. Nasal airway
problems can be diagnosed by nasometry.
However, nasometry is not always necessary to
confirm an impeded nasal airway. The Cottle
maneuver and adhesive breathing strip test may
help diagnose internal valve collapse.
Secondary Unilateral Cleft
Rhinoplasty
Patients with unilateral cleft lip nasal deformities
also have an asymmetric skeletal structure. The
maxilla on the cleft side is hypoplastic and
retruded. Many patients have class III malocclu-
sions and wider pyriform apertures. Due to the
lack of skeletal support on the cleft side alar base,
the alar base is posterior, inferior, and laterally
displaced. Lefort I maxillary advancement is a
commonly performed procedure. The skeletal
structure must be corrected before rhinoplasty
because Lefort I maxillary advancement changes
the nasal shape.
The nasal soft tissue of unilateral cleft nasal
deformity is deficient, and Asian patients tend to
have thick skin. Therefore, columella strut graft
and cartilage graft placement are significant com-
ponents of definitive rhinoplasty. Placement of a
columella strut graft supports the nasal structure,
allows for improved tip definition, and prevents
nasal collapse from tissue deficiency and scar
contractures. However, there is a tendency for the
nose to relapse back to its preoperative shape.
Therefore, a nostril retainer should be placed
after definitive rhinoplasty to maintain nasal
shape. Yeow et al. demonstrated that postopera-
tive nasal splint patients showed better nasal
symmetry and esthetics than patients without a
nasal splint. The nasal retainer also allows for air-
way patency by supporting the external and inter-
nal nasal valves.
Definitive rhinoplasty aims for nasal symme-
try, creation of nasal tip definition, nasal obstruc-
tion relief, and nasal webbing management. The
definitive rhinoplasty procedure of unilateral
cleft nasal deformity involves septal reposition-
ing with a columella strut, lateral crura reposi-
tioning with chondromucosal advancement,
mid-vault correction, and alar base repositioning.
Definitive rhinoplasty also uses traditional rhino-
plasty with standard esthetic techniques to
Secondary Cleft Lip Rhinoplasty

486
achieve nasal symmetry and relieve nasal
­obstruction. In general, an open approach is rec-
ommended to address cleft nasal deformities.
The open approach allows better visualization of
the nasal structures and enables exact placement
of suturing and grafts.
Surgical Techniques
Repositioning the Alar Cartilage
The lower lateral cartilage is often displaced infe-
riorly compared with the non-cleft side. The dis-
placement of the cartilage manifests as flattened
nostrils and recurvatum on the cleft side. If the
medial crura are not correctly positioned and the
alar base is laterally displaced, simultaneous cor-
rection of the alar base and lower lateral cartilage
will be necessary. If the medial crura are in a nor-
mal position, elevation of the medial crus is not
necessary. Instead, a procedure to relocate the
lower lateral cartilage is used. The lateral-to-­
medial movement of the lower lateral cartilage is
mandatory, and the V-Y advancement of the lat-
eral crural composite chondrocutaneous flap, as
introduced by Potter, can be used.
In the definitive rhinoplasty procedure, V-Y
advancement is combined with the Tajima
inverted-U technique to manage the alar–colu-
mellar web. The marginal incision, which is
designed along the lower cartilage margin, is
extended along the junction of the columella
and membranous septum. In patients with
slumped lower lateral cartilage, the incision
for lower lateral cartilage V-Y advancement is
added to the reverse-U incision. The lateral cru-
ral composite flap is advanced laterally to the
medial direction, and the resultant lateral defect
is repaired directly. The lower lateral cartilages
are widely undermined from the skin envelope
and anatomically repositioned. The compos-
ite flap advancement relocates the position of
the nostril apex and creates a soft triangle by
converting the external skin of the alar web to
the nasal lining. It corrects the deficiency of the
vestibular skin as well as the alar–columellar
web. The lower lateral cartilage is suspended
superiorly and anteriorly to the ipsilateral
upper lateral cartilage through intercartilagi-
nous sutures.
The nasal tip of patients with unilateral cleft
lip is poorly defined and asymmetric due to a lack
of support. Nasal tip correction in unilateral cleft
lip nasal deformity should improve tip symmetry,
definition, and projection. The nasal tip can be
corrected with a columellar strut graft, lower lat-
eral cartilage V-Y advancement, transdomal and
interdomal sutures, and tip grafts.
A columellar strut graft is placed between the
medial crura. This supports the existing medial
crura and maintains final tip projection. The
lower lateral cartilage V-Y advancement, also
called as the lateral crural steal, improves tip pro-
jection. The lateral crura are advanced medially,
which increases the medial crural length at the
expense of the lateral crura. Interdomal and trans-
domal suture techniques can be used to narrow
the widened nasal tip. Transdomal sutures are
placed to recreate the intermediate crus and
adjust the tip-defining point. Interdomal sutures
approximate both sides of the intermediate crura
and narrow the overall nasal tip. The tip onlay
graft from cartilage (costal cartilage, auricular
cartilage, septal cartilage) or soft tissue (dermo-
fat, artificial dermis) can augment tip projection
and camouflage irregularities. Tip correction
techniques are usually combined in unilateral
cleft nasal deformities, and no single technique
can achieve satisfactory results. Columellar struts
and interdomal sutures with lateral crural steals
are typically sufficient to improve tip symmetry
and definition in most unilateral cleft nasal defor-
mities (Figs. 1 and 2).
In bilateral cleft nasal deformities, rim inci-
sions are made on both sides. Fibrofatty tissues
between the medial crura are excised to correct
the bulbous nasal tip. Thereafter, the lower lateral
cartilages are repositioned anteriorly and superi-
orly. Interdomal sutures and intercartilaginous
suspension sutures are placed between the lower
lateral cartilage and ipsilateral upper lateral carti-
lage. A columella strut graft is often necessary to
fix the lower lateral cartilage in the anterior and
superior positions and support nasal tip
projection.
H. Park and K. S. Koh

487
a
b
c
d
Fig. 1  Bulbous nasal tip in a unilateral cleft lip nasal
deformity. (a, b) Preoperative photograph of a unilateral
cleft lip nasal deformity with a bulbous nasal tip and wide
nasal dorsum. (c, d) Postoperative photographs after nasal
tip onlay graft, septal extension graft, and columella strut
graft. Nasal dorsum is narrowed with medial and lateral
nasal osteotomy, and diced costal cartilage is grafted onto
the nasal dorsum
Secondary Cleft Lip Rhinoplasty

488
Septal Repositioning
with a Columella Strut
In a unilateral cleft nasal deformity, the anterior
nasal spine and caudal septum are deviated to the
non-cleft side. The caudal septum is relocated to
the cleft side using the swinging door technique.
Through a hemi-transfixion incision on the non-­
cleft side, ligamentous attachments between the
anterior nasal spine and septum are released. The
septum was swung to the midline and fixed on the
premaxilla periosteum with a polydioxanone
suture. In cases of severely deviated ANS from
the midline, the ANS is usually overswung to the
cleft side. The nasal septum can also be
approached and relocated through the dorsal
approach, which splits the medial crura of the
lower lateral cartilage without additional hemi-­
transfixion incisions. In complete clefts, there is
often a bony septal spur that requires removal to
achieve a patent nasal airway. The columellar
strut graft is placed between the medial crura for
stable central segment support and nasal tip pro-
jection. This supports the existing medial crura
and maintains final tip projection. The columella
strut is a major component of definitive rhino-
plasty in Asian patients with thick nasal skin. In
cases of an insufficient amount of septal carti-
lage, a caudal pattern graft or caudal septal exten-
sion graft from the auricular or costal cartilage is
sometimes required.
Alar Base Repositioning
The alar base in a unilateral cleft lip nasal defor-
mity is typically displaced in the inferior, lateral,
and posterior directions. Posterior displacement
results from maxillary absence and can be
improved by skeletal augmentation. A simple
V-Y plasty can be used to reposition a laterally
and inferiorly displaced alar base, as described
by Mulliken (Fig. 3). The design of the y-stem
angle is adjusted according to the required
amount of vertical movement. If a large amount
of vertical movement is required, the redundant
skin should be trimmed. An alar cinching suture
is placed between the maxillary periosteum and
nasalis of the alar base. The alar base position
should be slightly overcorrected due to the lateral
muscle pulling around the alar base.
Midvault Asymmetry
Patients with unilateral cleft lip nasal deformi-
ties often experience dorsal deviation and inter-
nal valve collapse. The cleft side of the upper
Medial osteotomy
Lateral osteotomy
Diced costal
cartilage graft
Columella strut
Nasal tip onlay
graft
Septal extension
graft
Diced costal
cartilage graft
Septal extension graft
Nasal tip onlay
graft
Columella strut
Fig. 2  Rhinoplasty techniques used in Fig. 1. Patient
H. Park and K. S. Koh

489
lateral cartilage collapses compared with the
non-cleft side, which causes midvault deviation.
The spreader graft is a useful technique for
patients with a narrow and collapsed middle
vault. The upper lateral cartilage is separated
from the septum, and a spreader graft, which is
a thin and long cartilage piece, is placed between
the dorsal septum and the upper lateral carti-
lage. The spreader graft widens the cross-sec-
tion of the internal nasal valve, thereby resolving
internal valve collapse. The unilateral spreader
graft or asymmetric graft can also resolve mid-
dle vault deviation and asymmetry, with a
thicker graft placed on the cleft side. If the mid-
vault deviation remains after the spreader graft,
an onlay graft can be placed on the cleft side of
the upper lateral cartilage for camouflage
(Figs. 4 and 5).
a
b
c
d
Fig. 3  V-Y advancement of the alar base. (a) The left alar
base is displaced into the inferior, lateral, and posterior
directions. (b) The V-Y advancement of the alar base is
designed. The angle and distance of Y-stem is adjusted
according to the required vector and movement. (c, d)
Postoperatively, the alar base is repositioned in a more
symmetrical position
Secondary Cleft Lip Rhinoplasty

490
Nostril Rim Correction: Cleft and Non-­
cleft Sides
The cleft side of the lower lateral cartilage is usu-
ally concave. This concavity causes collapse of
the external nasal valve and functional airway
problems. The cleft side lateral curs can be sup-
ported with an alar rim graft, alar strut graft, and
interposition graft between the upper and lower
lateral cartilages. The alar rim graft is placed in a
subcutaneous pocket at the alar rim margin. It is
located inferior to the lower lateral cartilage and
supports the alar rim. The alar strut graft is also
known as a lateral crural strut graft. It is affixed to
the deep surface of the lower lateral crura, and
the lateral edge is placed in a pocket at the pyri-
form aperture. Both grafts help support the alar
rim and reposition the rim symmetrically. In
cases of wide lower cartilage, cephalic trimming
is required following lower lateral cartilage sus-
a
b
c
d
Fig. 4  Midvault asymmetry. (a, b) Preoperative photo-
graph of a patient with a right side unilateral cleft lip nasal
deformity. The midvault is collapsed and deviated. (c) The
upper lateral cartilage and lower lateral cartilage are
exposed. The displacement of the upper and lower lateral
cartilage on the right side is noticed. (d) The unilateral
spreader graft, upper lateral onlay graft, and lower lateral
cartilage onlay graft are placed on the cleft side
H. Park and K. S. Koh

491
pension. This simple procedure can be used in
conjunction with the method described above, or
as a single procedure in mild cases.
In patients with a unilateral cleft lip, alar
retraction of the non-cleft side can be observed.
Simply correcting the cleft side to be symmet-
ric to the non-cleft side might result in bilateral
alar retraction and unfavorable outcomes just
trying to fit the cleft side to the non-cleft side
should be avoided. Instead, making a pleasing
esthetic appearance should be pursued regard-
less of the cleft or non-cleft side. In these
cases, internal V-Y advancement, introduced
by Guyuron, can be performed for non-cleft
side alar retraction correction. An alar rim graft
is placed for structural support after V-Y
advancement of the alar rim. Alar rim retrac-
tion can also be corrected by separating the
lower lateral cartilage from the upper lateral
cartilage. Then, the lower lateral cartilage
draws downward, and an interposition graft is
placed between the upper and lower lateral car-
tilages (Figs. 6 and 7).
Nasal Dorsum
The nasal bones are typically wide and deviated.
Therefore, nasal osteotomy can be performed to
refine the nasal midline and narrow the nasal
width. Low-to-night lateral ostomies are com-
monly used. Paramedian osteotomy is performed
if a single lateral osteotomy is not sufficient to
narrow the nasal base. A spreader graft is neces-
sary after in-fracture of the nasal bone to recon-
struct the internal nasal valve.
If the nasal dorsum is deficient or short, a dorsal
onlay graft with a silicone implant or rib cartilage
is preferred. Silicone is widely used for dorsal aug-
mentation because it has a low degree of tissue
reaction and is easy to handle. However, it may
result in alloplastic-associated complications, such
as infection or extrusion. Rib cartilage is an autol-
ogous tissue that provides an abundant amount of
cartilage. Diced cartilage with or without fascia
wrapping is placed between the nasal bone and
periosteum. The cartilage is then molded into the
desired shape for dorsal augmentation (Fig. 8).
Unilateral
spreader graft
Alar rim graft
Upper lateral
cartilage onlay graft
Lower lateral
cartilage onlay graft
Columella strut
Columella strut
Alar rim graft
Fig. 5  Grafts used in Fig. 4 patients for midvalut and nostril asymmetry correction
Secondary Cleft Lip Rhinoplasty

492
a
b
Fig. 6  Alar base widening and non-cleft side alar retrac-
tion. (a) Preoperative photograph of a patient with a left
side unilateral cleft lip nasal deformity. Non-cleft side alar
retraction and cleft side alar base widening are noticed.
(b) Postoperative photographs after V-Y advancement of
alar base on cleft side and internal V-Y advancement of
nostril rim on non-cleft side. A non-cleft side alar rim
graft, nasal tip only graft, and columella strut graft are
placed. The nasal dorsum is augmented with a silicone
implant
H. Park and K. S. Koh

493
Outcome and Limitation
In unilateral cleft nasal deformities, asymmetry
mainly occurs at the alar base and nostril. The
imbalance of muscle pulling around the alar base
and lower lateral cartilage malposition aggra-
vates its shape as patients grow. Therefore, alar
cinching with orbicularis oculi rearrangement
during primary cheiloplasty decreases the extent
of nasal deformity at the time of definitive rhino-
plasty, which leads to better outcomes.
After definitive rhinoplasty, nasal asymmetry
can persist to various degrees. This can occur at
the nasal bones, nasal vault, tip of the nose, and,
most commonly, at the alar base and nostril.
Inherent asymmetric muscle contraction and
skeletal asymmetry make definitive diagnosis
difficult. In addition, reconstructing a sufficient
nasal tip projection is also challenging in cleft lip
patients due to weak structural support and
scarring.
When evaluating patients, consideration
should be given to whether deformity can be
improved through surgery. Even if surgery is
performed, improving nasal deformities is some-
times challenging. Surgical treatment may not be
effective. Since cleft patients have undergone
several surgeries since childhood, surgeons
should be cautious when deciding on surgical
correction, and secondary correction should be
minimized. It is essential to know the gap
between ideal versus realistic outcomes when
patients are unlikely to be helped by any further
intervention. The patient can present with a more
complex deformity and may desire improve-
ments in esthetic appearance. However, physi-
cians should be able to explain the limitations of
surgical treatment.
Silicone implant
Nasal tip onlay graft
Alar rim graft
Columella struct
Nostril rim
V-Y advancement
Chondromucosal
V-Y advancement
Alar base
V-Y advancenment
Fig. 7  Rhinoplasty procedures of the patients in Fig. 6
Secondary Cleft Lip Rhinoplasty

494
a
b
Fig. 8  Nasal dorsal augmentation. (a) Preoperative pho-
tograph of a patient with a left side unilateral cleft lip
nasal deformity. A wide nasal dorsum and deviation are
noticed. (b) Postoperative photographs after dorsal nasal
augmentation. A silicone implant is inserted on the nasal
dorsum, and a nasal tip onlay graft from the conchal carti-
lage is placed
H. Park and K. S. Koh

495
Further Reading
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© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
M. K. SUH (ed.), State of the Art Rhinoplasty Techniques,

Injection Rhinoplasty
Ik-Soo Koh and Won Lee
Surgical rhinoplasty has several disadvantages.
Patients are apprehensive of prolonged healing
time and surgical results. Therefore, many of
them prefer injection rhinoplasty owing to the
relatively less invasive procedure. However,
injection rhinoplasty is associated with some
serious complications, which are best avoided. To
prevent complications, surgeons must be well
acquainted with the basic anatomy and surgical
techniques. Here, we discuss the topic of injec-
tion rhinoplasty.
Anatomy for Injection Rhinoplasty
Layers of the Nose
Injection rhinoplasty induces lesser changes
compared to surgical rhinoplasty. Usually, it is
focused on increasing the height of the dorsum of
the nose. The anatomical layers of the radix, rhin-
ion, supratip, and tip area (Fig. 1) are involved
and, therefore, the surgeon should be well
acquainted with these layers.
Periosteum overlies the nasal bone and carti-
lages. The supraperiosteal layer, overlying the
periosteum, is a deep fat layer. The nasalis and
procerus muscles are located in the fibromuscular
layer. Further, there is a superficial fatty layer.
Finally, the dermis and epidermis are present
(Fig. 2).
Vessels are usually located in the superficial
fatty layer and, therefore, fillers should be
I.-S. Koh (*)
Koh Ik Soo Aesthetic Plastic Surgery Clinic,
Seoul, South Korea
W. Lee
Yonsei E1 Aesthetic Plastic Surgery Clinic,
Anyang, South Korea
Fig. 1  Basic anatomy of the nose, including the radix,
rhinion, supratip, and tip

498
injected in the deep fatty layer (Fig.  2). Filler
injection in the vascular layer causes serious
complications, necessitating the understanding of
the vascular anatomy.
Vascular Anatomy of the Nose
The major vessels of the nose are the intercan-
thal vein and dorsal nasal artery. Dorsal nasal
artery embolism is a serious complication of
filler injection, and it further causes ocular
complications. The the dorsal nasal artery
should be identified accurately. Its location var-
ies but is mostly present in the the superficial
fatty layer.
Choi et al. reported that the dorsal nasal artery
could cross the midline, rendering the midline
injection technique unsafe (Fig. 3). Similarly, the
dorsal nasal artery has tributaries in the supra-
periosteal layer, detected by ultrasound, render-
ing the supraperiosteal layer, which is the deep
fatty layer, unsafe.
Surgeons should be aware of the basic loca-
tion of the dorsal nasal artery and consider varia-
tions.
Further,
the
injection
should
be
administered gently to avoid reaching the super-
ficial fatty layer.
Considerations for Filler Injection
Needle/Cannula
Fillers can be injected with a needle or cannula.
The diameter of the needle or cannula is associ-
ated with the vessel diameter. Table  1 lists the
outer diameters of needles and cannulas of vari-
ous gages.
As seen in Table  1, the outer diameter of a
27-G needle is 0.41 mm. This needle could easily
penetrate the dorsal nasal artery. Figure 4 shows
the relationship between the dorsal nasal artery
and the cannula diameter. Since the mean diam-
eter of the dorsal nasal artery is 1.0 ~ 1.2 mm,
smaller than that of a 20-G cannula, it could enter
the dorsal nasal artery.
Forces required for penetrating arteries are
similar between a 27-G cannula and a 27-G nee-
dle. This implies that a blunt cannula functions
similarly as a needle. Therefore, a larger-­diameter
cannula is preferred for safe injections.
Fig. 2  The five basic layers of the nose: (1) cartilage/bone, (2) deep fatty layer, (3) fibromuscular layer, (4) superficial
fatty layer, (5) dermis and epidermis
I.-S. Koh and W. Lee