194
e
f
g
h
Fig. 23 (continued)
M. H. Paik and L. S. Chu
195
i
j
k
l
Fig. 23 (continued)
Surgery of Columella, Alar Rim and Alar Base
196
Hanging Ala
Anatomic Causes of Hanging Ala
Hanging ala is the least common alar columellar
discrepancy with insufficient nostril show on the
frontal view, and dissatisfaction with it is not
common in most patients. The deficient nostril
exposure is often a consequence of droopy tip,
bulbous tip, and long nose.
Correction of Hanging Ala
The most well-known correction method of
hanging ala is the elliptical excision of vestibular
skin around the alar rim. In most of the hanging
ala, the excision method is rarely indicated, and
correction of the accompanying deformity is suf-
ficient for increasing the nostril show such as tip
narrowing sutures, cephalic trimming of lateral
crura, lateral crural steal, and cephalic rotation of
the nasal tip (Fig. 34). Since many tip plasty tech-
niques in East Asians promote a retracted ala, the
hanging ala is consequently improved. Even if
the vestibular lining excision is needed, this irre-
versible
procedure
should
be
done
in
moderation.
Wide Alar Base
Anatomic Causes of Wide Alar Base
In preoperative consultation for patients who
need rhinoplasty, a broad nasal base is one of the
common complaints, especially in East Asians. It
is often impossible to simply perform the resec-
tion of excessive ala base due to several other
complex problems to be corrected. Whether and
how much to surgically excise the alar base must
be predicted and planned considering other rele-
vant procedures and subsequent changes after the
surgery in preoperative evaluation.
In general, the ideal interalar distance is based
on the intercanthal distance as a reference. The
width of the alar base is determined by compo-
nents, including the height and length of the nasal
tip, pinched, or bulbous tip, and position of the
columella. An alar base excision should be per-
formed after all other procedures are completed,
and all incisions are closed during rhinoplasty to
reduce the margin of error because of the irre-
versibility of the procedure. If it is hard for sur-
geons to reach a decision on the adequacy of alar
base resection after all other procedures are com-
pleted, it is advisable to hold it off and consider it
again later during the follow-up period.
The nasal tip height is in inverse proportion to
the width of the alar base, which becomes nar-
rower as the tip is projected, and the chance and
amount of ala base reduction are decreased
(Fig. 35). In terms of tip position, the upturned tip
reduces the interalar distance, and the longer the
tip of the nose, the wider the width of the alar
base (Fig. 36). When the tip is pinched, the alar
base width tends to be narrowed, and if the colu-
mella is retracted, the alar base appears to be
broader than that in hanging columella.
m
Fig. 23 (continued)
M. H. Paik and L. S. Chu
197
Fig. 24 A case of retracted ala caused by the weak support
of the lateral crura corrected by derotation graft. A typical
case of retracted ala with excessive narrowing and lateral
crural steal. Before (a, c, e, g) and after (b, d, f, h) the sur-
gery. (i) Inadequate support of lateral crura. (j) Release of
lateral crura. (k) Derotation graft for supporting lateral crura
a
b
c
d
Surgery of Columella, Alar Rim and Alar Base
198
e
f
g
h
Fig. 24 (continued)
M. H. Paik and L. S. Chu
199
i
j
k
Fig. 24 (continued)
Surgery of Columella, Alar Rim and Alar Base
200
Fig. 25 A secondary case with right retracted ala due to
scar contracture caused by silicone implant. Before (a, c,
e, g, i) and after (b, d, f, h, j) the surgery. (k) Silicone
implant removal. (l) Damaged right lateral crus. (m)
Derotation graft for caudal reposition of lateral crura and
reconstruction of right lateral crus using ear cartilage. (n)
Dorsal augmentation and tip skin reinforcement using
dermofat graft
a
b
c
d
M. H. Paik and L. S. Chu
201
e
f
g
h
Fig. 25 (continued)
Surgery of Columella, Alar Rim and Alar Base
202
i
j
k
l
Fig. 25 (continued)
M. H. Paik and L. S. Chu
203
Correction of Wide Alar Base
Since the first alar base excision by Robert Weir
in 1892, it has been applied to deal with the wide
nasal base so far with various modifications. The
elliptical excision of the alar base narrows the
horizontal interalar width, and when the excision
extends to the nostril sill, the base width of the
nostril can also be reduced.
Among all the factors that influence the intera-
lar distance, the two most essential elements
regarding the indication of the alar base reduction
are the inclination of the alar axis and the nostril
size. The patient with a divergent axis is the best
candidate for alar base reduction (Fig. 37).
And if the axis is vertically or inwardly ori-
ented, the shape of the alar base with natural
flaring will be compromised after resection
(Fig. 38). Regardless of the excision pattern, the
alar base reduction tends to decrease the nostril
size, especially when the excision is extended to
the nostril sill (Fig. 39). The straight or conver-
gent axis and small nostril size before surgery
all can contribute to an unfavorable result after
resection.
To maintain the natural flaring of the alar base,
it is recommended to avoid the design of the
elliptical excision that is too short in length and
too wide in width (Fig. 40). The posterior inci-
sion line is recommended to be 1 mm anterior to
the alar facial groove to minimize the scar.
Although the elliptical excision is a simple, effec-
tive procedure in correcting wide alar base, it
should be carried out conservatively to a mini-
mum, always keeping in mind that it is an irre-
versible procedure, considering the correlation of
other procedures on the nasal tip (Fig. 14). Alar
cinching suture is rarely used because the effect
is not as dramatic as the excision technique in the
long-term follow-up.
m
n
Fig. 25 (continued)
Surgery of Columella, Alar Rim and Alar Base
204
a
b
Fig. 26 Assuming that the alar rim is the web of a hand, the graft directly on the alar rim have varying effects in
retracted ala depending on the extensibility of the soft tissue envelope
M. H. Paik and L. S. Chu
205
Fig. 27 (Red arrow) Lateral crural steal causes retracted ala with more tip projection and narrowing. (Blue arrow)
Medial crural steal improves retracted ala, lowing the tip projection and tip widening
Surgery of Columella, Alar Rim and Alar Base
206
a
b
c
Fig. 28 The typical clinical manifestations of retracted ala due to lateral crural steal are excessively long columella and
elongated nostril
M. H. Paik and L. S. Chu
207
a
b
c
Fig. 29 Retracted ala caused by tip narrowing. (a) Normal alar rim and lateral crural position. The narrowing suture
moves the caudal margin of lateral crura in a cephalomedial direction retracting the nostril (b), causing retracted ala (c)
Surgery of Columella, Alar Rim and Alar Base
208
Fig. 30 A patient shows retracted ala and pinched tip
induced by excessive narrowing (e). Before (a, c) and
after (b, d) correction. (f) Release of lateral crura to widen
the gap. (g) Alar spreader type derotation graft to maintain
the gap between lateral crura
a
b
c
d
M. H. Paik and L. S. Chu
209
e
f
g
Fig. 30 (continued)
a
b
Fig. 31 The distance between the caudal margin of the lateral crura and the columella is an important indicator in
retracted ala management. Before (a) and after (b) the correction
Surgery of Columella, Alar Rim and Alar Base
210
Fig. 32 A case of retracted ala derived from excessive
cephalic trimming (e). Before (a, c) and after (b, d) the
surgery. (f) Alar spreader type derotation graft for
retracted ala correction and columellar septal suture for
treating combined hanging columella
a
b
c
d
M. H. Paik and L. S. Chu
211
e
f
Fig. 32 (continued)
Surgery of Columella, Alar Rim and Alar Base
212
Fig. 33 A patient with retracted ala caused by the distor-
tion of lateral crura due to silicone implant (g, h, i, j).
Preoperative (a, c, e) and postoperative (b, d, f) views. (k,
l) The convexity of lateral crura was normalized and sup-
ported with ear cartilage graft
a
b
c
d
M. H. Paik and L. S. Chu
213
e
f
g
h
Fig. 33 (continued)
Surgery of Columella, Alar Rim and Alar Base
214
i
j
k
l
Fig. 33 (continued)
M. H. Paik and L. S. Chu
215
Fig. 34 The hanging ala was corrected with tip narrowing sutures, lateral crural steal, cephalic rotation, and projection
of the nasal tip without alar rim excision. Preoperative (a, c, e, g) and postoperative (b, d, f, h) views
a
b
c
d
Surgery of Columella, Alar Rim and Alar Base
216
e
f
g
h
Fig. 34 (continued)
M. H. Paik and L. S. Chu
217
Fig. 35 The alar base becomes narrower as the tip is projected. Preoperative (a, c, e) and postoperative (b, d, f) views.
The alar base reduction was not performed in this case
a
b
c
d
Surgery of Columella, Alar Rim and Alar Base
218
e
f
Fig. 35 (continued)
M. H. Paik and L. S. Chu
219
a
b
c
d
Fig. 36 The upturned tip reduces the interalar distance, and the longer the tip of the nose, the wider the width of the
alar base. Before (a, c) and after (b, d) the elongation of the nasal tip
Surgery of Columella, Alar Rim and Alar Base
220
a
b
Fig. 38 If the alar axis is vertically (a) or inwardly (b) oriented, the shape of the alar base with natural flaring will be
compromised after resection
Fig. 37 A patient with a divergent axis of the lateral mar-
gin of alar in frontal view is a good candidate for alar base
reduction
M. H. Paik and L. S. Chu
221
a
b
c
d
Fig. 39 (a) A good indication for alar base reduction with large nostrils. A bad candidate with small nostrils (b) can
lead to unfavorable results (c, d) after alar base excision
Surgery of Columella, Alar Rim and Alar Base
222
Fig. 40 A case of wide interalar distance corrected with
elliptical excision of alar base and nostril sill combined
with tip plasty. Preoperative (a, c, e, g, i) and postopera-
tive (b, d, f, h, j) views. (k) Finished tip plasty. (l, m)
Design of excision. (n–p) After excision and wound
closure
a
a
c
d
M. H. Paik and L. S. Chu
223
e
f
g
h
Fig. 40 (continued)
Surgery of Columella, Alar Rim and Alar Base
224
i
j
k
l
Fig. 40 (continued)
M. H. Paik and L. S. Chu
225
m
n
o
p
Fig. 40 (continued)
Surgery of Columella, Alar Rim and Alar Base
226
Further Reading
Bruber RP, Freeman BM, Hsu C, Elyassnia D, Reddy
V. Nasal base reduction: a treatment algorithm includ-
ing alar release with medialization. Plast Reconstr
Surg. 2009;123(2):716–25.
Gruber RP, Kryger G, Chang D. The intercartilaginous
graft for actual and potential alar retraction. Plast
Reconstr Surg. 2008;121(5):288e–96e.
Gunter JP, Rohrich RJ. Correction of the pinched nasal
tip with alar spreader grafts. Plast Reconstr Surg.
1992;90(5):821–9.
Guyuron B, Bigdeli Y. Sajjadian Ali. Dynamics of the alar
rim graft. Plast Reconstr Surg. 2015;135(4):981–6.
Guyuron B, Ponsky D. Alar base disharmonies. Clin Plast
Surg. 2010;37(2):245–51.
Hackney FL. Diagnosis and correction of alar rim deformi-
ties in rhinoplasty. Clin Plast Surg. 2010;37(2):223–9.
Hirohi T, Ng D, Nagai K, Yoshimura K. Alar cinching
with subcutaneous flaps: a procedure to achieve nar-
rowing of the nasal base while controlling the alar
axis and sidewall curvature. Plast Reconstr Surg.
2018;142(5):1165–76.
Hirohi T, Yoshimura K. Surgical correction of retracted
nostril rim with auricular composite grafts and
anchoring
suspension.
Aesthetic
Plast
Surg.
2003;27(5):418–22.
Joseph EM, Glasgold AI. Anatomical considerations in
the management of the hanging columella. Arch Facial
Plast Surg. 2000;2(3):173–7.
Kim JH, Park SW, Oh WS, Lee JH. New classification
for correction of alar retraction using the alar spreader
graft. Aesthetic Plast Surg. 2012;36(4):832–41.
Kridel RWH, Chiu RJ. The management of alar columel-
lar disproportion in revision rhinoplasty. Facial Plast
Surg Clin North Am. 2006;14(4):313–29.
Paik MH, Chu LS. Correction of short nose deformity
using a septal extension graft combined with a derota-
tion graft. Arch Plast Surg. 2014;41(1):1–7.
Paik MH, Chu LS. Correction of the short nose
using derotation graft. Arch Aesthetic Plast Surg.
2012;18(1):35–44.
Rohrich RJ, Afrooz PN. Components of the hanging colu-
mella: strategies for refinement. Plast Reconstr Surg.
2018;141(1):46e–54e.
Rohrich RJ, Afrooz PN. Revisiting the alar-columellar
relationship: classification and correction. Plast
Reconstr Surg. 2019;144(2):340–6.
Tardy ME Jr, Toriumi D. Alar retraction: composite graft
correction. Facial Plast Surg. 1989;6(2):101–7.
Toriumi DM, Checcone MA. New concepts in nasal
tip contouring. Facial Plast Surg Clin North Am.
2009;17(1):55–90.
M. H. Paik and L. S. Chu
227
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
M. K. SUH (ed.), State of the Art Rhinoplasty Techniques,
Mid-vault Surgery
Jong-Woo Choi
Introduction
“Nasal Septum Theory”
• The growth of Nasal Septal Cartilage is the
major driving force for the growth of the
midface.
• The nasal septum is active in late prenatal and
through 3–4 years of age.
• Cranial base synchondrosis: lasting effect of
craniofacial growth.
Have you ever heard “Nasal septum theory?”
Regardless of the feasibility of this theory, I believe
this theory is worthwhile taking a consideration.
Nasal septum theory means that the maxilla, con-
sisting of the nasal septum and nasomaxillary
complex, which is made up of cartilage, moves
forward and downward also by the forces from the
nasal septum. Therefore, the cartilage at condyle,
cranial base synchondroses and nasal septum can
act as growth centers (Fig. 1a, b).
Nasal septum in neonate consists of various
components such as ventrocentral area of thin
cartilage, sphenospinal zone, sphenodorsal zone
of thick cartilage, sphenoid, ANS, and vomer
analge. The Sphenodorsal zone of thick cartilage
is responsible for a normal increase in nasal
length and height of the nasal dorsum. The grow-
ing cartilaginous septum is known to be a signifi-
cant organizer of the facial skeleton (Fig. 1c, d).
The middle vault is the composite of this
growth. Overcorrection of the middle vault leads
to the hump nose. On the contrary, underdevelop-
ment of the middle vault leads to saddle nose. We
need to understand the origin of the hump nose
and saddle nose in order to find out the ideal solu-
tion for middle vault surgery.
Among the various components of the nose,
middle vault surgery was not the center of inter-
est in terms of esthetic point of view in Asian rhi-
noplasty. In the past, management of the nasal
dorsum in Asian rhinoplasty mainly focused on
dorsal and nasal tip augmentations. In the Asian
population, the nasal skeleton is generally less
prominent and, thus, requires a more delicate sur-
gical approach than that required in the Western
population. In addition, the alar cartilage portion
is smaller in the Asian population than in the
Western population. Thus, many Asian plastic
surgeons preferred augmentation with the vari-
ous materials with some modification of the
lower lateral cartilage, which would greatly affect
the morphology of the nasal tip. Currently,
increasing attention is being given to these ana-
tomical and ethical considerations in Asian
patients (Fig. 2a).
However, the middle vault is the center of the
nose. It plays an important role not only in the
functional perspective but also in the esthetic
J.-W. Choi (*)
Department of Plastic and Reconstructive Surgery,
Seoul Asan Medical Center, Seoul, South Korea
228
point of view. In functional aspects, the internal
valve is the crucial functional anatomy for breath-
ing. As for the esthetic perspective, the dorsal
esthetic line should be connected along with the
middle vault on the frontal view. On the lateral
profile view, the dorsal esthetic line should be
determined based on the patient’s preference and
the surgeon’s suggestion.
In Asian rhinoplasty, the middle vault surgery
would be a bit different from that of Western rhi-
noplasty. Western rhinoplasty has emphasized the
ideal dorsal esthetic line based on structural or
conservational rhinoplasty techniques. By con-
trast, given the fact that many surgical techniques
in Asian rhinoplasty include dorsal augmentation,
the emphasis on the middle vault surgery was not
put enough, in my opinion. However, even in
Asian rhinoplasty, the middle vault surgery is also
very important functionally and esthetically. In
this chapter, I will address the implications of mid-
dle vault surgery in Asian rhinoplasty. At first, I
will discuss the middle vault surgery related to the
Asian hump nose. Then, I will deal with how to
manage the saddle nose deformity in Asians.
a
c
b
d
1
1. Ventrocentral area of thin cartilage
2. Sphenospinal zone,
3. sphenodorsal zone of thick cartilage
4. Spehnoid,
5. ANS
6. Vomer anlage
3
2
5
4
6
Fig. 1 Nasal septum theory. (a) Nasal septum theory
means that the maxilla, consisting of the nasal septum and
nasomaxillary complex, which is made up of cartilage,
moves forward and downward also by the forces from the
nasal septum. (b) Therefore, the cartilage at condyle, cra-
nial base synchondroses and nasal septum can act as
growth centers. (c) Nasal septum in neonate consists of
various components such as ventrocentral area of thin car-
tilage, sphenospinal zone, sphenodorsal zone of thick car-
tilage, sphenoid, ANS, and vomer analge. The
Sphenodorsal zone of thick cartilage is responsible for a
normal increase in nasal length and height of the nasal
dorsum. The growing cartilaginous septum is known to be
a significant organizer of the facial skeleton
J.-W. Choi
229
a
b
c
Fig. 2 (a) Anatomy of Middle vault. (b) Ideal nasal esthetic line. (c) Various options in how to deal with the hump nose
in Asians
Mid-vault Surgery
230
Hump Nose
Generally, management of the nasal dorsum in
Asian rhinoplasty focuses on augmentation with
various materials. Even for hump nose correction
surgery, many Asian plastic surgeons prefer to
perform dorsal augmentation after humpectomy
as patients often want to highlight the nasal dor-
sal profile. There would be many reasons for this.
Firstly, many Asian patients want to augment the
nasal dorsum. Secondly, simple humpectomy
results in unesthetic results in the frontal view,
such as an inverted V deformity, flat nasal dor-
sum, and reduction of the upper and middle
vaults. In order to camouflage these deformities,
many Asian rhinoplastic surgeons prefer to
choose the dorsal implant as an alternative
(Fig. 2b).
However, given the fact that a balance between
the nose and the rest of the face is crucial, I have
previously found that excessive augmentation of
the nasal dorsum, even in the Asian population,
does not usually achieve balance with the nasal
tip. According to my experience, dorsal augmen-
tation after the simple humpectomy does not pro-
vide adequate satisfaction for the majority of our
patients with a hump nose, even in Asians. I think
the Asian patient with a hump nose tends to have
a relatively strong and well-developed upper and
lower latera cartilage different from those of
usual Asian patients who are presented with the
lower profile nose. Therefore, I believe that dor-
sal augmentation would not be necessary in most
Asians with a hump nose. But, compared to
Western people, most Asians seems to have a
relatively smaller nose profile. If the humpec-
tomy were done alone, the overall nose profile
and volume would not be ideal esthetically. That
would be the reason why I prefer to balance the
dorsal height and nasal tip with the nasal tip
plasty in the Asian hump nose. In the lateral pro-
file, a balance between the optimal dorsal height
and projection of the nasal tip should be deter-
mined to achieve the ideal nose balance for the
face (Fig. 2c).
When it comes to how to deal with the bony
hump, I prefer humpectomy with chisel in severe
cases while rasping in milder cases based on the
component
hump
management
concept.
Especially, given the fact that the Asian nose is
relatively smaller, if the excessive humpectomy
were done, the maintenance of the nasal skeletal
framework could be unstable. The keystone con-
nection should be preserved while preserving the
internal nasal mucosa as well in Asian humpec-
tomy (Fig. 3a–d).
With regards to how to manage the cartilage
hump, two methods are known. One is compo-
nent dorsal cartilage removal and spreader graft
which would be the traditional one. The other is
the spreader flap which is introduced. Although
some surgeons advocate the spreader flaps could
be very useful in many western patients, I think
the application of spreader flap might be a little
limited in Asian patients because of the relatively
smaller upper lateral cartilages. Therefore, I pre-
fer the traditional spreader graft concept in terms
of dealing with the middle vault. However, the
difference from the traditional spreader graft in
Western rhinoplasty exists in Asian spreader
graft. In order to project the nasal tip, a septal
extension graft is commonly used as an alterna-
tive for the spreader graft. Septal extension graft
accompanied by batten graft can play a role as a
traditional spreader graft in Western rhinoplasty
(Fig. 4a, b).
Strategy-wise, from the esthetic perspective of
Asian hump nose management, I suggest a com-
bination of mild humpectomy and nasal tip pro-
jection for hump nose correction in Asian
rhinoplasty. Then you may ask some questions.
How much should the dorsum, including the
nasal bone and cephalic septum, be resected?
How much should the nasal tip be projected? It
could be decided based on the balance between
the nose and face. After determining the optimal
nasal dorsal height and nasal tip projection, the
extent of humpectomy and tip projection can be
planned. In terms of balancing the humpectomy
and nasal tip projection, I suggested effective
J.-W. Choi
231
Fig. 3 Hump nose in Asians. Asian patient with hump
nose tends to have a relatively strong and well-developed
upper and lower latera cartilage different from those of
usual Asian patients who are presented with the lower pro-
file nose. Therefore, I believe that dorsal augmentation
would not be necessary for most Asians with hump nose
Mid-vault Surgery
232
Fig. 4 Comparison between Asians and Westerns in terms of facial balance
methods for hump nose correction without nasal
dorsal augmentation in Asian rhinoplasty.
I introduce one of my strategy of Asian hump
nose for a better understanding of the readers. I
retrospectively evaluated patients who underwent
hump nose correction with rhinoplasty between
March 2012 and July 2015 at our medical center
in Seoul, Korea. Patients who underwent nasal
tip plasty with humpectomy were evaluated with
3D photogrammetry and were eligible for inclu-
sion in this study.
Surgical Details: Nasal Tip Projection
with Humpectomy
All patients underwent surgery under general
anesthesia. The tip-defining point, supratip break,
and alar junction were marked and measured.
Routine columellar and marginal rim incisions
were performed. Instead of the conventional dor-
sal augmentation after humpectomy using a sili-
cone implant or dermofat graft, wherein
humpectomy is performed with nasal tip projec-
tion, we adopted the septal extension graft or
double-layered conchal extension graft tech-
nique. Nasal dorsal augmentation was not per-
formed, except in cases in which the insertion of
a
very
thin AlloDerm
(Life-Cell
Corp.,
Branchburg, N.J.) for smooth dorsal contouring
was required. After routine transcolumellar inci-
sion to obtain full mobility of the lower lateral
cartilages, the scroll ligaments between the lower
and upper lateral cartilages were adequately
released, and care was taken to preserve the nasal
mucosa. Thereafter, approximately 1–1.5 cm of
the caudal septum was exposed to allow fixation
of the folded conchal cartilages. Lidocaine
hydrochloride (1%) with epinephrine (1:100,000)
was injected at the harvest site for vasoconstric-
tion and hydrodissection. The auricular cartilage
was harvested using the standard anterior
approach by making an incision 3–4 mm below
the anterior helical rim with a No. 15 blades. A
J.-W. Choi
233
combination of blunt and sharp dissection was
used to elevate the soft tissue away from the
cymba-cavum conchal cartilage complex. The
cartilage and perichondrium were incised and
elevated from the posterior soft tissues for graft
harvesting. The incision was closed with a 6-0
nylon suture, and a bolster was placed to prevent
postoperative hematoma. All intranasal and
extranasal incisions were repaired after achieving
hemostasis.
Hump nose correction is one of the most com-
mon procedures in Western rhinoplasty. As the
prevalence of hump noses is lower in the Asian
population than in the Western population, the
emphasis on the management of the hump nose
was not made often. In the past, the Asian patients
would be happy if they get the augmented nose
profile itself by the augmentation materials.
However, as the general public becomes to under-
stand the current esthetic facial plastic surgery,
the patients become to want more such as the
nasal tip shaping. Moreover, recently, the more
patients want, the more natural looks.
Therefore, a new surgical approach with new
concepts on Asian hump nose correction is evi-
dently required. Since the classical 3:4:5 rule for
the ideal nose does not reflect the actual charac-
teristics of an Asian facial profile, our surgical
procedure was not based on this rule. Previously,
we have reported 3D photogrammetry analysis of
the ideal Asian facial profile. Because many
Asian patients with a hump nose seek a natural
straight dorsum accompanied by the sharp ante-
rior dorsal esthetic line, nasal tip projection with
nasal bone osteotomy should be used to balance
the overall nasal shape.
Many Asian rhinoplasty surgeons perform
dorsal augmentation with a silicone implant after
humpectomy. The reason for this could be that in
Asian hump nose correction, excessive humpec-
tomy can cause several problems such as an
inverted V-shaped or an open roof deformity. In
such cases, lateral and medial nasal osteotomies
could be more effective (Fig. 5a–c). However,
given the small overall dimension of the Asian
nose, I think many Asian surgeons are worried
that simple humpectomy accompanied by medial
and lateral osteotomies can lead to further reduc-
tion. However, in our experience, the result of
silicone implantation after humpectomy is often
unsatisfactory. Instead, I prefer to allow the
implantation site to heal spontaneously based on
the meticulous middle vault cartilage manage-
ment. Sometimes I insert a thin AlloDerm or fas-
cia for excessive hump correction for camouflage.
This approach is usually found to be effective.
But, there is one thing to remember in Asian
hump nose. We need to balance the nose and face
in Asians. In order to balance the nose with the
face, I prefer the nasal tip projection accompa-
nied by a humpectomy (Fig. 6a, b).
Sometimes, a simple humpectomy can result in
a flat or irregular dorsal shape (Fig. 7). In case of
excessive humpectomy, I perform medial and lat-
eral nasal osteotomies in order to prevent the
inverted V shape deformity; in case of a mild hump
nose, we insert a thin AlloDerm or fascia; and in
case of a very small nose, we rarely augment the
nasal dorsum with autogenous or alloplastic mate-
rial to achieve a balance between the nose and the
face in Asian hump nose (Fig. 8a–e).
Finally, I think the surgeons should discrimi-
nate between the true hump and pseudo hump.
Pseudo hump is known to be corrected with radix
graft. However, in Asian viewpoint, the most
pseudo hump refers to the under projection of the
nasal tip. Different from the true hump nose in
Asians, I believe that the pseudo hump can be
corrected by the dorsal augmentation with the
nasal tip plasty. This would be the reason why
many Asian rhinoplasty surgeons fear that the
dorsal height may decrease after humpectomy
and perform augmentation to prevent this. If we
could differentiate the true hump and pseudo
hump, it would be more clear when the surgeons
should consider the nasal dorsal augmentation as
an option. If the pseudo hump were diagnosed,
the nasal tip and dorsum could be projected and
augmented (Fig. 9a, b).
However, if the patient were presented with a
true hump nose, it would lead to a sufficient nasal
dorsal height and strong cartilage framework,
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compared to that usually encountered in the
Asian population. The growth of the nasal septal
cartilage is a major driving force for the growth
of the midface. The nasal septum actively grows
in the late prenatal phase and up to 3–4 years of
age. Therefore, if a patient has a hump nose, the
overall midface growth is satisfactory. Even in
the Asian population, additional nasal dorsal aug-
mentation is unnecessary; rather, nasal tip projec-
tion is necessary. Therefore, we recommend
considering nasal tip projection in hump nose
correction for Asian patients.
However, the application of this concept
should be based on individual cases. Small noses
with a mild hump should be augmented; how-
ever, an average nose with an excessive hump is
ideal for this approach. Fortunately, most patients
with a moderate-to-severe hump nose have
sufficient septal cartilage for the septal extension
graft on the nasal tip. Using the concept of
“septum-based nasal tip plasty,” we can obtain
satisfactory results in terms of balancing the
nasal shape (Fig. 10a–d).
This concept may be routine for rhinoplasty
surgeons in Western countries; however, it could
be a unique approach for Asian rhinoplasty sur-
geons. Thus, I believe that my strategy could pro-
vide Asian surgeons with a different view
regarding the management of hump noses in the
Asian population.
a
b
c
Fig. 5 Problems and solution in the management of hump nose. (a) Component resection. (b) Inverted V-shaped defor-
mity. (c) Medial and lateral osteotomy
J.-W. Choi
235
a
b
Fig. 6 (a) Traditional spreader graft. (b) Spreader flap.
With regards to how to manage the cartilage hump, two
methods are known. One is component dorsal cartilage
removal and spreader graft which would be the traditional
one. The other is the spreader flap which is introduced
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Saddle Nose
Saddle nose deformity is a pathologic entity
resulting from loss of dorsal height caused by a
substantial decrease in the cartilaginous vault or
bony vault. It may include numerous features,
such as a middle vault and dorsal depression, loss
of tip support and definition, columellar retru-
sion, a shortened vertical length, tip overrotation,
and retrusion of the nasal spine and caudal sep-
tum. Saddle nose deformity derives its name
from the appearance of the nose on a lateral view
on which the dorsal curve resembles the depres-
sion in a horse’s saddle. Regardless of the etiol-
ogy, the gross deficiency that exists in the dorsum
of the nose creates an obvious and progressive
scooped-out deformity. When viewed frontally,
an illusory excessive width exists across the
bridge. The first article written on the treatment
of saddle nose deformity was published by John
Orlando Roe in 1887 (Rollin K. Daniel, Clinics)
(Fig. 11).
It could have congenital, traumatic, infectious,
or iatrogenic origin. The saddle nose is a condition
associated with nasal trauma, congenital syphilis,
relapsing polychondritis, granulomatosis with
polyangiitis, cocaine abuse, and leprosy, among
other conditions. The most common cause is
nasal trauma. It is characterized by a loss of
height of the nose, because of the collapse of the
bridge. The depressed nasal dorsum may involve
bony, cartilaginous, or both bony and cartilagi-
nous components of the nasal dorsum.
Its correction consists not only in a camou-
flage but also it is important to reconstruct the
missing structure. In this chapter, I will discuss
Fig. 7 Functional point of view in spreader graft
J.-W. Choi
237
Fig. 8 Balanced rhinoplasty for management of hump nose in Asians. In order to get the ideal nasal lateral profile, the
humpectomy and nasal tip projection can be balanced
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238
all aspects of the saddle nose, and I will propose
a different therapeutical approach (septum, con-
cha, or costal grafts) in relation to the severity of
the defects (with a personal classification). The
classification is also based on the presence or
absence of the nasal septum, which is a funda-
mental aspect that we must take into account
when approaching nasal reconstruction. We will
discuss the technical aspect of rib graft harvest-
ing and its use to reconstruct the nasal structure.
In Asian plastic surgeons’ perspective, the
management of the saddle nose deformity looks
easier than hump nose because dorsal augmenta-
tion is one of the most common procedures in
Asian rhinoplasty. However, correction of the
saddle nose deformity requires a different level of
expertise. Now that the structural support, such
as the nasal bone and cartilage frameworks, were
collapsed in saddle nose deformity, the structural
restoration should be done at first. Without
Fig. 8 (continued)
J.-W. Choi
239
restructuring the skeletal framework, the simple
augmentation with the alloplastic materials often
fails to get the optimal outcomes in saddle nose
deformity. Although the insertion of some mate-
rials for the purpose of nasal augmentation could
be a little helpful, the nose is not that simple. I
believe the nose profile is the composite of the
hard and soft tissue. Thus the nasal contour
should be made based on the framework covered
with the thin skin envelope. Each skeletal frame-
work represents each characteristic contour of
the nasal components. I introduce my strategy for
the management of the saddle nose deformity.
As a first step for the correction of the saddle
nose deformity, the L strut of the septum should
be reconstructed. Without the reconstruction of
the collapsed septum, the whole framework could
be fragile. I prefer to use the rib cartilage for the
reconstruction of the L strut. To my experience,
most patients with saddle nose deformity tend to
have crushed septum. Therefore, the remaining
septum does not provide enough support. In order
to prevent too stiff a nasal tip, I prefer the use of
the thin thickness sliced rib cartilage ranging
from 1 to 2 mm thickness. If the nasal skin were
collapsed with a severe scar, 3 mm thickness rib
cartilage struts are used sometimes. Mostly, I pre-
fer the thinner thickness rib cartilage slice
(Fig. 12a–d).
Then, the upper lateral cartilage should be
relocated. Given the fact that the strength of the
upper lateral cartilage, it could be restored mostly
in my experiences. If the relocation of the upper
lateral cartilage were not possible, the diced rib
cartilage could be used for the additional dorsal
shaping. However, to provide adequate width of
the middle vault, the restoration of the upper lat-
eral cartilage is very important.
The lower lateral cartilage should be managed
accordingly. Although the unique features of the
saddle nose deformity especially include the
middle vault collapse, the nasal tip shape is often
affected simultaneously because the upper and
lower lateral cartilages were connected. After
releasing the connection between the upper and
lower lateral cartilage, the lower lateral cartilage
should be repositioned into the ideal tip position.
Reconstructed L strut could be used for the pro-
jection and lengthening of the nasal tip
(Fig. 13a–d).
Fig. 9 Pseuo Hump. Pseudohump should be discriminated against from the true hump. The pseudo hump can be cor-
rected with nasal tip projection accompanied by nasal dorsal augmentation
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240
Fig. 10 True Hump. True hump should be discriminated from the pseudo hump. True hump in Asian can be corrected
with balanced rhinoplasty, including the humpectomy and nasal tip projection
J.-W. Choi
241
The final part is dealing with the collapsed
nasal bone, which would be the most challeng-
ing. Given the thin thickness of the nasal bone,
relocation of the communited nasal bone is often
not possible. Rather, I prefer to use rib cartilage.
There is two ways to use rib cartilage. One is the
rib cartilage insertion as a one-piece after carv-
ing. The other is diced rib cartilage. I prefer to
use the diced rib cartilage wrapped with deep
temporal fascia. In order to minimize the unpre-
dictability of the diced rib cartilage, I do use the
ultra-diced rib cartilage. It turned out to be very
predictable and reliable in dorsal augmentation
(Fig. 14).
Fig. 11 Saddle nose deformity. Saddle nose deformity is
a pathologic entity resulting from loss of dorsal height
caused by a substantial decrease in the cartilaginous vault
or bony vault. It may include numerous features, such as a
middle vault and dorsal depression, loss of tip support and
definition, columellar retrusion, a shortened vertical
length, tip overrotation, and retrusion of the nasal spine
and caudal septum
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242
Fig. 12 Reestablishment of nasal framework with rib cartilage in posttraumatic nose deformity
J.-W. Choi
243
Fig. 13 Correction of saddle nose deformity using the ultra-thin diced rib cartilage and thin thickness rib cartilage L
strut
Mid-vault Surgery