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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,

Deviated Nose Correction
and Functional Surgery 1
Yong Ju Jang
A deviated nose is a condition characterized by
the axis of the external nose not being located at
the very center of the face; alternative terms such
as the twisted nose, crooked nose, hooked nose,
asymmetric nose, scoliotic nose, and deflected
nose are used to describe the condition. The devi-
ated nose presents a tremendous challenge for
rhinoplasty surgeons. Causes for deviated noses
include congenital deformities, injury during
childbirth, repetitive minor trauma, obvious
external nasal trauma, a complication of surgery,
and infection, etc.
The authors categorize deviated noses into
five different types (Fig. 1). The following clas-
sification system divides the nasal dorsum into
the bony and cartilaginous parts and makes the
distinctions according to the directions of each
part in relation to the facial midline.
• Type I: A straight tilted bony pyramid with a
straight tilted cartilaginous vault in the oppo-
site direction (Fig. 1a).
• Type II: A straight tilted bony pyramid with a
concavely or convexly bent cartilaginous vault
(Fig. 1b).
• Type III: A straight bony pyramid parallel to
the facial midline and a tilted cartilaginous
vault (Fig. 1c).
• Type IV: A straight bony pyramid parallel to
the facial midline and a bent cartilaginous
vault (Fig. 1d).
• Type V: A straight tilted bony pyramid and a
tilted cartilaginous dorsum in the same direc-
tion (Fi‑g. 1e).
The above classification is useful in establish-
ing the treatment plan prior to surgery. These
classifications can be applied by analyzing the
frontal photograph of the patient. However, more
complex deviations may be observed during the
actual surgery, thus requiring an appropriate
application of various surgical techniques based
on an intraoperative diagnosis.
Esthetic Analysis and Nasal
Breathing Function
To analyze the deviation and the asymmetry of
the patient, the patient’s nose can be divided into
three, consisting of the upper, middle, and lower
thirds, to be evaluated with regard to the central
facial axis. The upper third consists of the bony
pyramid; the middle third of the dorsal septum
and the upper lateral cartilages; and the lower
third of the alar cartilage, the caudal septum, and
alar base. Many patients seeking correction of
Y. J. Jang (*)
Department of Otorhinolaryngology-Head and Neck
Surgery, Asan Medical Center, University of Ulsan
College of Medicine, Seoul, South Korea
e-mail: jangyj@amc.seoul.kr

248
their deviated noses have unnoticed facial asym-
metry of different degrees. With these patients,
correcting the deviation will not guarantee har-
mony between the nose and the overall face, and
their nose still can appear deviated even after a
well-conducted rhinoplasty. Also, these patients
with facial asymmetry often show disharmony in
the level of their alar base. This means that these
patients’ overall satisfaction will most likely be
lesser than those without facial asymmetry. Thus,
it is important to have a thorough consultation
regarding the possible outcome of surgery in
patients that have facial asymmetry and inform
the limitation of the surgery in achieving a
straight-looking nose. In patients with severely
asymmetric faces, it is better to suggest the
patient undergo orthognathic surgery first to cor-
rect facial asymmetry. Rhinoplasty can be per-
formed as a second operation for them.
Technically, it is very difficult to make the nose
look perfectly straight in these facial asymmetry
patients; on the other hand, improved deviation
of the nose after rhinoplasty can improve the
asymmetric look of the overall face to some
degree (Fig. 2).
The majority of patients with a deviated nose
have an accompanying septal deviation of differ-
ent degrees. However, not all these patients suffer
from nasal obstruction. According to a study con-
ducted by the author, nearly 80% of patients with
a deviated nose complained of nasal obstruction.
The most common cause of nasal obstruction
among deviated nose patients is the deviation of
the nasal septum (Fig. 3a–c). There are different
forms of nasal septal deviation, including caudal
deviation, dorsal deviation, mid-segment devia-
tion, and bony deviation. In addition, turbinate
hypertrophy, internal nasal valve narrowing
caused by the collapse and deviation of the upper
lateral cartilage, deviation of the nostril due to
caudal septal deformity, and dynamic collapse
during inspiration arising from a weakened lower
lateral cartilage also cause nasal obstruction
(Fig. 3d–f).
Surgical Treatment
The objective of surgery is to achieve symmetry
of the nasal airway and the external appearance.
However, obtaining symmetry does not necessar-
ily guarantee a successful surgery. For the sur-
gery to be a success, the different parts of the
nose, such as the nasal dorsum and nasal tip,
must be in good esthetic harmony based on the
secured symmetry. A closed approach in correct-
ing a deviated nose can be performed using an
intercartilaginous incision to access the nasal
dorsum, a hemitransfixion incision to access the
septum, and a marginal incision to manipulate
the tip. For easier suture reconstruction of the
nasal dorsum, the wide undermining of nasal dor-
sal soft tissue using an extended marginal inci-
sion may be useful. Because of this technical
a
b
c
d
e
Fig. 1  Classification of deviated nose. Type 1 (a), Type 1 (b), Type 1 (c), Type 1 (d), Type 1 (e)
Y. J. Jang

249
Before
After
Fig. 2  With the correction of the deviated nose, it is noticeable that the patient’s face looks more symmetric than the
preoperative state
a
b
c
d
e
f
Fig. 3  In patients with the deviated nose, deviation of the nasal septum (a–c), turbinate hypertrophy (d), and abnormal
upper lateral cartilage (e, f) can be frequently accompanied, causing subjective nasal obstruction sensation
Deviated Nose Correction and Functional Surgery 1

250
difficulty, trimming the convex area of the nasal
dorsum and creating a pocket at a concave area of
the dorsum to insert a camouflage graft made of
the cartilage or Gore-Tex is the more commonly
performed surgical procedures in the closed
approach. Using a closed approach for correcting
deviated noses has its limits in that it is difficult
to fully execute the various surgical procedures
required for correcting the deviation, in particular
(in cases of the severely deviated dorsal septum)
the various structural reconstruction and suture
techniques required. Applying the external
approach has the advantage in that it is easier to
diagnose the anatomical problems causing the
deviation and that the cartilage can be exposed
more extensively—making the surgery much
easier. The authors highly recommend using the
external approach in correcting deviated noses.
The various surgical techniques to be described
are usually performed under the external
approach.
Correction According to Anatomical
Location
Correction of the Bony Pyramid
The surgical procedures used for correcting the
upper third of the bony dorsum are osteotomy,
rasping, and onlay grafting.
1. Osteotomy
To correct the deviated bony pyramid, it is
important to execute osteotomies to mobilize and
reshape the nasal bone properly. The objective of
the osteotomy in the correction of the deviated
nose is fracturing the deviated bony vault to
reconstruct and reshape into the desired form.
(a) Medial Osteotomy
Medial osteotomies are used for correcting a
broad bony dorsum or severely asymmetric bony
pyramid. The bony dorsum must be incised to
enable the nasal bone to be separated and mobi-
lized while maintaining height. Basically, it is
performed to ensure that the result of the lateral
osteotomy takes effect properly. As such, it is a
supplementary surgical technique to lateral oste-
otomy. A medial osteotomy alone cannot directly
influence the correction of the shape and direc-
tion of the bony pyramid. The significance of this
surgical technique, then, lies in the fact that it is a
process whereby the rhinion of the bony pyramid
and the bony septum connected to the cartilagi-
nous septum is preserved while creating a bend-
ing area in advance so that the incised triangular
bone fragment made after a lateral osteotomy can
be manipulated to the desired area. Thus, it is
preferable to perform the medial osteotomy first,
followed by the lateral osteotomy. When per-
forming a medial osteotomy through an open
approach, after separating the upper lateral carti-
lages from the septum, the osteotome should be
engaged on the caudal nasal bone and continued
in an oblique direction towards the inner canthus
or in a paramedian direction almost parallel to the
central line (Fig. 4). When performing a medial
osteotomy for correcting bony deviation in cases
of deviated noses, a paramedian position should
be maintained to make a narrow midline bony
segment. In this way, this narrow bony segment
can be fractured easily by manual compression
(Fig. 5). It is best to start the medial osteotomy
from the point of origin and proceed 15–25° in an
oblique direction because a medial osteotomy
carried properly in this direction can be con-
nected naturally with the lateral osteotomy, one
needs not go to extreme lengths in creating a back
fracture. In patients with small nasal bones, how-
ever, bony comminution can complicate the lat-
eral osteotomy if the medial osteotomy is
performed too obliquely. After medialization of
the nasal bones following a lateral osteotomy, the
mobilized bony segments can be asymmetric in
height on the two sides, or both segments are
symmetrical but higher than the midline segment.
In such situations, the most prominent portion of
the bony segment should be removed by bone-­
cutting scissors to equalize the level.
Y. J. Jang

251
(b) Lateral Osteotomy
Lateral osteotomies are used to make the lat-
eral outline of the bony pyramid symmetrical.
This is used to incise the nasal bony sidewall in
order to push it inward. At 10–15 min before the
execution of the osteotomy, injection of a local
anesthetic agent mixed with epinephrine should
be infiltrated along the anticipated path of the
osteotomy. Then, using a #15 blade, make an
incision to the periosteum at the pyriform aper-
ture above the attachment of the inferior turbi-
nate. Once the pyriform aperture bone is exposed,
conduct the osteotomy along the planned osteot-
omy line using a curved osteotome or straight
osteotome. Depending on the preference of the
surgeon, there are instances where a subperios-
teal tunnel is created along the incision line using
a periosteal elevator. According to the vertical
level of lateral osteotomy, it is described as low to
low, low to high, high to high, etc. Considering
the nasal dorsum as the apex, the area situated far
from this apex is defined as “low,” and the area
close to it is defined as “high.” When performing
an osteotomy along the sidewalls of the nose, one
can perform the osteotomy by following the
nasofacial groove. Once the osteotomy gets
closer to the lacrimal crest, the direction of the
osteotomy should be changed so that it proceeds
towards the apex of the nose. Often, there are
many instances of high osteotomies being formed
in this area due to the excessive fear of damaging
the lacrimal apparatus. Should such a high oste-
otomy be formed, it can bring about a stair-step
deformity that is both visible and palpable when
cut bones are pushed inward.
If a greenstick fracture occurs during the cor-
rection in question, there is a high risk of the
recurrence of the original deviation after surgery.
Thus, the execution of a complete osteotomy
ensures a predictable post-operative result. After
Fig. 4  After medial
osteotomy followed by
lateral osteotomy, the
nasal bony dorsum can
be mobilized
Fig. 5  Following medial and lateral osteotomy, the devi-
ated nasal bone can be manually fractured and mobilized
at the midline
Deviated Nose Correction and Functional Surgery 1

252
completion of medial and lateral osteotomy, tri-
angular bone segments are formed bilaterally.
The triangular segments can be medialized in
case of convexity or lateralized to correct concav-
ity of bony sidewall.
(c) Root Osteotomy
A root osteotomy is used for mobilizing the
central bony area into the midline, executed by
horizontally incising the space between both
sides of the medial osteotomy right under the
nasion. In correcting deviated noses, a medial
osteotomy is executed and then connected with a
lateral osteotomy. The middle part of the nasal
bone manifests as a triangular-shaped bony sep-
tum. If the bony septum’s direction is deviated
and not corrected, the axis of the nose cannot be
placed in the center. If the surgeon uses fingers to
fracture the middle part to correct it, the fracture
might not occur in the right place and tend to
occur in an area close to the keystone. Therefore,
percutaneous root osteotomy can be executed to
mobilize the middle part to the desired location.
This is executed by using a 2 mm osteotome at
the intercanthal level (Figs. 6 and 7). This should
be done after the dorsal part of the cartilaginous
septum is separated from the upper lateral carti-
lages. There is a chance of saddle nose deformity
after the procedure but it can be prevented if the
connection between the caudal septum and the
anterior nasal spine is well maintained.
2. Rasping
Rasping can be performed on any partially
protruding bone or asymmetry following an oste-
otomy. If rasping is performed after undergoing
an osteotomy, the bone fragments might fall out.
Therefore, whenever possible, it is highly recom-
mended to perform rasping before carrying out
the osteotomy. The rasping of the bony pyramid
can be done using a manual rasp or powered
instruments such as piezotome. Reshaping of the
bony pyramid using a piezotome is called
osteoplasty.
3. Onlay Grafting
Even after the axis of the nasal bone has been
straightened after an osteotomy, irregularity from
an uneven skeletal surface can still remain. In
such a situation, an Onlay graft can be positioned
at the partially concave area. Materials for Onlay
grafts include the ethmoid bone harvested during
septoplasty, septal cartilage, ear cartilage, fascia,
or Gore-Tex. When there are only localized con-
cavities of the nasal bone, Onlay grafting will be
the only procedure that need to be done, obviat-
ing the need for osteotomy (Fig. 8).
Fig. 6  In order to make more controlled fracture of the middle portion of the nasal bone, percutaneous root osteotomy
can be applied
Y. J. Jang

253
Before
After
Before
After
Fig. 7  A male patient with a severe bony deviation of the nose. After medial and lateral osteotomy, a percutaneous root
osteotomy was applied to correct the deviated bony axis
Deviated Nose Correction and Functional Surgery 1

254
Correction of the Septal Cartilage,
Upper Lateral Cartilages, and Lower
Lateral Cartilages
Correction of the nasal septum is the most impor-
tant, yet difficult procedure in deviated nose sur-
gery. The nasal septum is located at the center of
the nose and plays a decisive role in maintaining
structural integrity. Including the septal cartilage,
all cartilages have a tendency of maintaining
their preexisting shape; thus it is difficult to cor-
rect cartilaginous deviations. The correction of
the deviated nasal septum primarily can be
achieved by means of a traditional septoplasty
using the unilateral transfixion incision. The
closed approach for the management of the septal
cartilage has certain disadvantages in the correc-
tion of high septal deviation. However, it is more
reasonable to correct the septum of a deviated
nose patient using the open approach because
this approach will allow the surgeon a very good
surgical exposure through which a multitude of
different surgical techniques are designed to
straighten the caudal and dorsal septum can be
applied with improved precision. A twist in the
underlying nasal septal cartilage often causes the
cartilaginous dorsum deformity and nasal tip
malposition. Different types of septal cartilage
deformities require different treatment strategies.
The authors divide the corrective techniques of
septal cartilage into two categories (Table 1). In
situ correction is a method that involves deglov-
ing the septal cartilage and then correcting the
deviated L-strut, utilizing various techniques in
straightening the L-strut or the septal cartilage is
left
unresected.
Extracorporeal
septoplasty
involves a near-total removal of the severely
deviated septal cartilage and bone from its origi-
Fig. 8  Partial concavity of the bony dorsum can be corrected with Onlay grafting
Y. J. Jang

255
nal position for correction and reimplanting it
back where it was after making it into a desired
shape extracorporeally (Table 1).
In Situ Septal Correction
Spreader Grafts
A spreader graft is a linear cartilaginous graft
inserted between the separated upper lateral car-
tilages and the dorsal septal cartilage. It is useful
when the patient’s nasal valve is narrow, as it
widens the middle third of the nose—keeping the
dorsal line natural. It is probably the most com-
monly used technique in correcting deviated
noses (Fig. 9). A spreader graft is made from the
central part of the septal cartilage that was har-
vested, leaving an L-strut. However, it is often
difficult to fashion cartilage long enough to be
used as a spreader graft from patients with small
septal cartilages. Even if the cartilage is long
enough, there are cases where the cartilage is
overly crooked for making a suitable spreader
graft. When the cartilage is not sufficient in its
quantity, the graft is placed only on one either the
concave side or the convex side. However, to
widen the nasal valve angle and to keep the dor-
sal septum straight, it is highly recommended to
place grafts on both the concave and convex
sides. If the spreader graft is long enough, it is
best to place it through the gap created by the
incision of the bone via medial osteotomy to the
anterior septal angle. A combination of the
extended spreader graft and unilaterally placed
caudal septal extension graft is an ideal way of
correcting the deviated lower two-thirds (Fig. 10).
When the cartilaginous dorsum is tilted to one
side, a new center of the tip is formed with a cau-
dal septal extension graft, and this graft is sand-
wiched by the native septal cartilage and extended
spreader graft (Fig. 11). We found that the unilat-
eral placement of a caudal septal extension graft
and extended spreader grafts was useful,
­especially in patients with an off-centered caudal
septum. To execute this maneuver, after exposing
the nasal septum, we first observed the direction
of the nasal septal deviation in the cephalo-­caudal
direction. A unilateral batten-type caudal septal
extension graft is then placed on the side contra-
lateral to the septal deviation, located diagonally
across the caudal septum toward the nasal tip,
and suture-fixated to the septum. Subsequently, a
unilaterally extended spreader graft is suture-­
fixated also on the side contralateral to the septal
deviation, with its caudal border and the native
dorsal septum sandwiching the caudal septal
extension graft (the new center of the cartilagi-
nous dorsum). Splaying of the extended spreader
graft added additional volume to the concave
nasal sidewall and made the nose appear
straighter, and the caudal end of the extended
spreader graft was meticulously trimmed to pre-
vent internal nasal valve obstruction. It is also
possible to do the scoring on the concave side of
the L-strut before inserting the spreader graft or
to insert the spreader graft without scoring inci-
sion. Sometimes, scoring can weaken the carti-
lage and cause secondary deformities. If the
spreader graft is too thick, it will cause mid vault
widening, making the nose not esthetically pleas-
ing (Fig. 12).
Dorsal L-Strut Cutting and Suture
Technique
When the dorsal L-strut is severely bent, spreader
grafts alone will not overcome the intrinsic elas-
ticity of the cartilage, which results in an incom-
plete correction. In these situations, a dorsal
L-strut cutting and suture technique can be
applied to correct the severe cephalo-caudal con-
vexity of the dorsal L-strut (Fig. 13). This surgi-
cal technique preserves the keystone area and
involves cutting the mid-section of the dorsal
septum and reconnecting it using overlapping
sutures (Fig.  14). Theoretically, this technique
Table 1  Techniques for septal straightening
In Situ Technique
Spreader graft
Dorsal L-strut cut and suture
Caudal batten graft
Caudal L-strut cut and suture
Interposition batten graft
Resection of the posterior angle and reconnection to
the anterior nasal spine
Caudal L-strut relocation suture
Extracorporeal septoplasty
Deviated Nose Correction and Functional Surgery 1

256
can shorten the length of the dorsal septum,
thereby increasing the cephalic rotation of the tip.
However, this adverse effect can be prevented by
inserting an extended spreader graft on one side
or both sides of the L-strut.
Cutting and Suture Technique
of the Caudal Septum
In cases of caudal septal deviation in the antero-
posterior direction, a C-shaped convexity or acute
angulations can be observed occasionally. To cor-
rect these deformities, the convex-most part of
the caudal L-strut septum can be incised and
repaired with overlapping sutures. After the inci-
sion is made, the upper part is medialized and
overlapped with the lower part using 3–4 stitches.
When cutting and overlapping sutures are
applied, immediate correction of the cartilage is
identifiable. When overlapping the cut cartilages,
the surgeon must be cautious not to make the new
height of the caudal septum shorter than its origi-
nal height. If the stability of the newly built cau-
dal septum is in question, a septal batten graft
made from the central part of the cartilage or
bone should be placed on the concave side for
additional support (Fig. 15). If an increase in tip
projection is needed, a septal extension graft
should be applied.
Septal Batten Graft
The authors believe that the strength of the caudal
septum is the most important factor in support of
Fig. 9  Bilaterally inserted spreader grafts can straighten and stabilize the dorsal septal cartilage
Y. J. Jang

257
Before
After
Before
After
Fig. 10  In this male patient with deviated nose, caudal septal extension graft was inserted between the native septum
and unilatal extended spreader graft, correcting the lower two-thirds of the nose
Deviated Nose Correction and Functional Surgery 1

258
the nose. Furthermore, deformities in the caudal
septum are most responsible for causing the
symptoms of nasal obstruction. This means that
straightening and strengthening the caudal sep-
tum is the most important step in a functionally
and esthetically successful surgery for deviated
noses.
Placement of a septal batten graft made
from the cartilage of the mid-part of the septum
at the caudal L-strut with or without scoring on
the concave side of the caudal septum is a reliable
and effective technique in correcting caudal sep-
tal deviation. When placing a batten graft without
scoring, suturing cartilage bent in the opposite
direction of the caudal septal deviation can help
straighten the cartilaginous deviation. The batten
graft should be placed on the concave side; other-
wise, a batten placed on the convex side can fur-
ther narrow the nasal airway (Fig. 16). The length
of the septal batten graft will differ according to
the size of the cartilage available. If the batten
graft is extended to the caudal or the anterior
direction to induce a change in the shape of the
tip, this can be called a caudal septal extension
graft. When the caudal septum is weakened and
shows an S-shaped deviation, the paired batten
graft technique can be applied. This technique
involves placing batten grafts on both sides of the
caudal strut. This can be done if enough cartilage
was harvested from the central compartment. The
paired batten graft technique is useful in straight-
ening and strengthening the caudal septum.
However, using thick cartilage for this procedure
could induce airway narrowing.
Interposition Batten Graft
This is the technical variation of the cutting and
suture combined with batten graft. In a certain
situation, the use of conventional techniques is
insufficient and may result in unsatisfactory out-
comes. The ideal shape of the caudal septum that
Fig. 11  With a caudal septal extension graft, a new center of the tip is formed. Afterwards, caudal septal extension graft
is sandwiched by the native septal cartilage and extended spreader graft
Y. J. Jang

259
we sought to create is a straight structure, of
which the base sits on the midline, strong enough
to bear the weight of the nasal tip, thicker at the
base, and smoothly gets thinner as it reaches the
top. However, in certain situations, when we con-
duct the cutting and suture technique, we have
noticed that, rather than using the side-by-side
placement of the batten graft, the interposition of
the batten graft in the mid-portion of the cut ends
of the caudal septum can transform the caudal
septum, such that it exhibits the desired shape
and strength (Fig. 17).
In this technique, the L-strut is cut at the most-­
bent portion of the caudal part; a batten graft
comprising septal cartilage or bone is interposed
between the cut ends of the caudal L-strut, mobi-
lizing the upper part of the caudal septum toward
the concave side of the nasal cavity (Fig. 18). The
position of the upper and lower parts of the cau-
dal septal cartilage and interposed batten graft
were adjusted with tooth forceps to generate the
caudal septal length as desired. A surgeon can
easily control the caudal septal height by adjust-
ing the suture fixation points of the upper and
lower portions of the caudal septum, centered by
the interposed batten graft.
The Use of Septal Bone for Correction
of the Septal Cartilage
In some cases, the quantity of septal cartilage
will not be sufficient for septal batten grafting or
spreader grafting. Furthermore, the harvested
septal cartilage is very useful in tip surgery,
which means that the surgeon needs to secure
enough cartilage for both septal straightening and
tip work. The insufficiency of septal cartilage can
be solved through harvesting the costal cartilage,
but this will lengthen the time required for sur-
gery and can induce an increase in morbidity.
Performing septoplasty for deviated noses
Before
After
Fig. 12  Placement of the bilateral extended spreader grafts may result in a widened nasal dorsum as shown in this
patient
Deviated Nose Correction and Functional Surgery 1

260
Before
After
Before
After
Fig. 13  In this patient, correction of the cartilaginous dorsum deviation was achieved with the dorsal L-strut cutting
and suturing technique
Y. J. Jang

261
Fig. 14  Cutting and suture technique to straighten the deviated dorsal L-strut
Fig. 15  Cutting and suture technique to correct the caudal septal deviation. Batten graft was placed on the concave side
to compensate for the weakened caudal septum
a
b
Fig. 16  Septal batten graft was placed at the concave side of the caudal septum after scoring (a). Placement of a septal
batten graft, bent in the opposite direction of the caudal septal deviation (b)
Deviated Nose Correction and Functional Surgery 1

262
Before
After
Before
After
Fig. 17  Correction of the deviated nose in this male patient was achieved by applying the interposition batten graft
technique
Y. J. Jang

263
involves removing the central part of the quad-
rangular cartilage, and the perpendicular plate,
and parts of the vomer of the ethmoid bone. The
removed bones are usually disposed of. However,
if the surgeon uses the removed bones for graft-
ing purposes, enough cartilage for tip work can
be saved. This will ensure that the surgeon has
decreased demand for additional harvesting carti-
lage such as the conchal or costal cartilages.
In order to get a nice bony piece suitable for
use, the surgeon needs to remove the septal bone
from both the vomer and the perpendicular plate
of the ethmoid in one piece, using septal scissors.
Using scissors and a drill, the harvested bone
graft is designed to the appropriate size and
shape. Then several holes need to be drilled,
which will ensure easier suturing. The author
performs quilting mattress sutures or through and
through sutures to fix the bone graft to the L-strut
(Fig. 19). These methods will ensure sturdy fixa-
tion of the graft to either one or both sides of the
caudal or dorsal part of the L-strut. This septal
bone can be used as a batten graft at the caudal
septum or at the dorsal septum as a stenting graft
(Fig.  20). The septal bone is thin and strong,
which means that a stable caudal septum-strut
complex can be made without affecting airway
patency. Also, this surgical technique will avoid
donor site morbidity caused by additional har-
vesting and will not require foreign material. The
caveat of using the bone is that harvesting of the
septal bone increases the chance of septal hema-
toma formation and olfactory dysfunction.
Resection of the Posterior Angle
of the Septum
Caudal septal deviation in anteroposterior direc-
tion is caused by excessive nasal septal cartilage
between the maxillary crest and the nasal roof. To
straighten this, a small piece of septal cartilage
from the junctional area between the anterior
nasal spine can be removed, which will enable
the caudal septum to become straight (Fig. 21).
However, the cartilage needs to be reconnected to
the anterior nasal spine and the maxillary crest,
but it is difficult to reconstruct it with the same
stability as before the removal. This reconstruc-
tion is difficult due to the three-dimensional rela-
tionship between the cartilage and the bony
shelf—the nasal spine and the maxillary crest is
bent inwards in the nasal cavity. In cases where
the posterior angle of the septal cartilage is dislo-
cated from the anterior nasal spine, the excess
portion of the dislocated caudal septum should be
excised, and the connection with the anterior
nasal spine reestablished. When performing this
maneuver, instantaneous straightening of the
caudal septum can be verified but could result in
Fig. 18  Batten graft is interposed between the cut ends of the caudal L-strut
Deviated Nose Correction and Functional Surgery 1

264
saddling due to the shortening of the caudal sep-
tum. Also, if the cartilage is very stiff and thick,
incising the lower part will not ensure straighten-
ing. In these cases, additional placement of bat-
ten grafts is required. The most important part in
correctly performing this fixation is to leave
enough soft tissue around the spine during the
dissection of the anterior nasal spine. If there is
not enough soft tissue around the spine, holes
need to be drilled in the bone to be able to fix it to
the septal cartilage.
Caudal Septal Relocation Suture
In cases of linear deviation where the nose
appears to deviate to one side, the caudal septum
needs to be separated from the anterior nasal
spine and then relocated to the opposite side—
making the connection between the anterior nasal
Fig. 19  Intraoperative photograph of a bony batten graft delivered from the septal bone, placed on the concave side of
the caudal septum
Fig. 20  Bone grafts can be applied at various locations in various shapes
Y. J. Jang

265
spine in a side-to-side manner (Fig. 22). If there
is enough soft tissue around the anterior nasal
spine, suturing will suffice for the procedure.
Correction of Cephalo-Caudal
Deviation
The caudal septum could only show deviation
towards the anterior-posterior direction but could
also show severe deviation in the cephalo-caudal
direction. In many cases of cephalo-caudal devia-
tion, overly developed cartilages are seen in the
caudal part. In these situations, the author first
cuts off the overly developed excess cartilage in
the caudal part perpendicularly. Then the removed
cartilage is used as a caudal septal extension graft
placed on the wider nasal cavity to correct the
deviation (Fig. 23). This maneuver can compen-
sate for the shortening of the caudal septum
caused by the excision of cartilage. Dislocated
and projected caudal septum should be resected.
This maneuver will shorten the horizontal caudal
septal length increasing the length of membra-
nous septum. This change can be compensated
by placement of septal batten graft place on the
opposite side. The cartilage should be wide and
project more caudally to the cut native caudal
septum.
Extracorporeal Septoplasty
If the deviation of the nasal septum is too severe
to correct with the aforementioned in situ tech-
niques, extracorporeal septoplasty can be uti-
lized. This method involves removing the
near-total part of the nasal septum from its loca-
tion and reimplanting it into position after reshap-
ing it extracorporeally (Fig. 24). Extracorporeal
septoplasty is a highly effective method in cor-
recting severe deviations but risks weakening the
septal cartilage (especially the keystone area and
the anterior nasal spine area) and is technically
challenging (Fig. 25). The following are various
methods for stabilizing the reimplanted cartilage
graft in extracorporeal septoplasty. The author
Fig. 21  To straighten the deviated caudal septum, a small
piece of septal cartilage from the junction between the
anterior nasal spine can be removed, which will enable the
caudal septum to become straight
Fig. 22  Caudal septal relocation suture
Deviated Nose Correction and Functional Surgery 1

266
prefers to perform his modification of the extra-
corporeal septoplasty technique. First, the osseo-
cartilaginous skeleton needs to be exposed
through an external rhinoplasty approach. Then
the septal mucoperichondrial flaps are elevated.
The septum is freed from the extrinsic forces of
the deformed upper and lower lateral cartilages.
Septal cartilage is removed except for the remain-
ing few millimeters of the dorsal strip at the key-
stone area. Multiple techniques, including
scoring, wedge excisions and splinting with car-
tilage or bone, are performed to straighten the
removed cartilage. The dorsal aspect of the new
L-strut is fashioned into a “Y” shape by suturing
one cartilage strip to the existing L-strut. The pre-
served cartilage tail at the keystone area is placed
in the middle of the arms of the Y-shaped carti-
lage and then fixed. Caudal septum stability is
obtained by suturing the newly shaped septal car-
tilage to the soft tissue around the anterior nasal
spine (ANS) such that the ANS was positioned in
the middle and the arms of the new septum create
Fig. 23  Excision of the deviated caudal septum and using the excised segment as caudal septal extension graft
Fig. 24  For extracorporeal septoplasty, septal cartilage is removed except for the remaining few millimeters of the
dorsal strip at the keystone area. Straight and strong L-strut is extracorporeally assembled, ready to be reimplanted
Y. J. Jang

267
Fig. 25  In this male patient presenting with the severely deviated nose, straightening of the nose was achieved by uti-
lizing the extracorporeal septoplasty
Before
After
Before
After
Deviated Nose Correction and Functional Surgery 1

268
an inverted “Y” (Fig. 26). After fixing the new
L-strut, the dorsal aspect of the septal cartilage is
reconnected to the upper lateral cartilages to pro-
vide additional stability. If necessary, septal bone
or conchal cartilage can be harvested for spreader
grafts or batten grafts for additional support. To
ensure a successful surgery, it is important to
leave about 1 cm of the dorsal tip in removing the
nasal septal cartilage. Leaving a sufficient amount
of soft tissue around the anterior nasal spine is
also important. If the anterior nasal spine has
deviated towards one side, the new septum should
be sutured with the soft tissue of the contralateral
side. If the keystone itself has deviated, after the
fixation of the graft, wedge-shaped cartilage can
be inserted to get a straight dorsal septum.
Correction of the Upper Lateral
Cartilaginous Deformity
Because the deformity of the upper lateral carti-
lage is usually a secondary deformity due to a
deformed dorsal septum, the deviation of the
upper lateral cartilage can be solved by straight-
ening the septum, followed by placements of
spreader grafts. Once the surgeon fixes all the
components, the deviation will most likely be
corrected. However, this method might leave
some concavity or convexity in certain areas. If
so, placing an Onlay graft made from cartilage or
Gore-Tex on the concave side will correct the
deformities (Fig. 27).
Correction of the Lower Lateral
Cartilage
In most cases, external nose deviation is caused
by either bony deviation or the deformity of the
cartilaginous dorsum constituted by the upper
lateral cartilage and the septal cartilage. However,
with some patients, the size, shape, and dimen-
sion of the lower lateral cartilage are asymmetric,
deforming the lower third of the nose. To these
patients, the asymmetry or deformity of the lat-
Before
After
Fig. 25  (continued)
Y. J. Jang

269
eral crus as shown on the frontal view is respon-
sible for the deviated nasal appearance. This can
be seen in patients with lateral crus that is con-
cave on one side and convex on the other. These
deformities can be corrected by flipping the lat-
eral crus upside down (flip-flop technique)
(Fig. 28), cephalic resection, lateral crural Onlay,
or lateral crural strut graft. Nostril asymmetry is
commonly found in deviated nose patients. These
asymmetries could be derived from the deviation
of the cartilaginous mid vault extending to the tip
or the lower lateral cartilage itself being
deformed. Therefore, the deviation in the lower
lateral cartilage should be first treated by correct-
ing the deformities in the septum and then be
reevaluated after disconnecting the lower lateral
cartilage from the upper lateral cartilage. If the
lower lateral cartilage itself is deformed, various
methods to acquire symmetric alar cartilage
shape should be applied to correct tip asymmetry.
Such methods include cephalic trim, columellar
strut, lateral crural overlay, medial crural overlay,
interdomal suture, or various grafting methods.
Significance of Dorsal
Augmentation in Deviated Noses
Correction of a deviated nose is a complex issue
that cannot be simplified, where dorsal augmen-
tation is often the neglected procedure. Dorsal
augmentation is one of the last steps in correcting
deviated noses. To correct the deviation, proce-
dures such as osteotomy or spreader graft are fre-
quently employed, but these maneuvers can
cause dorsum irregularities in patients with thin
skin. Also, unpredictable situations such as the
inadvertent collapse of the keystone area can take
place. In these situations, the need for dorsal aug-
mentation arises. Moreover, surgical maneuvers
to straighten the cartilaginous dorsum and bony
dorsum cannot perfectly correct the deviated
Fig. 26  Newly formed L-strut is reconnected with the cartilage tail at the keystone area and soft tissue around the
anterior nasal spine
Deviated Nose Correction and Functional Surgery 1

270
appearance of the nose. As such, when the under-
lying nasal skeleton is not straight in the midline,
rather tiled, dorsal augmentation can neutralize
and mitigate the deviated nasal skeleton, so that
the final shape of the nose looks straight. Subjects
with deviated noses also show a contraction of
the tissue and the soft tissue where their deviation
was originally located; appropriate dorsal aug-
mentation and camouflage can correct the soft
tissue deformities that cause deviation (Fig. 29).
Implant materials for augmentation should be
small in volume and soft. Because the correction
Fig. 27  Deviation of the upper lateral cartilage can be corrected by straightening the septum, then placing spreader
grafts. The remaining concavity is corrected by placing an Onlay graft
Fig. 28  Concave lateral crus can be corrected using the flip-flop technique
Y. J. Jang

271
Before
After
Before
After
Fig. 29  A male patient with severe tilting of the face. Appropriate dorsal augmentation may attenuate the degree of the
nasal deviation, resulting in the straighter appearance of the nose
Deviated Nose Correction and Functional Surgery 1

272
of deviation requires extensive dissection and
may weaken the underlying structure due to oste-
otomy and septal correction, dorsal augmentation
with solid materials such as silicone or costal car-
tilage can easily be displaced or deform the
underlying nasal skeleton by its weight. It is
therefore recommended to use soft implant mate-
rials such as ePTFE, fascia, conchal cartilage,
crushed septal cartilage, diced cartilage, and fas-
cia
wrapped
diced
cartilage
for
dorsal
augmentation.
Alar Base Modification and Tilted
Ala Correction
Some patients with deviated noses show asymme-
try of the alar base, which means that one of their
alar soft tissue is hypertrophic, and their nostrils
differ in size. For these patients, either unilateral
alar base resection or asymmetric alar base resec-
tion can be performed. Failure to noticing and
correcting this problem will cause dissatisfaction
in patients. A tilted alar base, characterized by a
discrepant vertical level of the lowermost part of
alar insertion between both sides, is a common
deformity that is encountered in patients with
deviated noses and facial asymmetry. The tilted
alar base can develop due to various reasons, such
as premaxillary level discrepancy, scar contrac-
ture due to previous surgery or trauma, asymme-
try of lower lateral cartilage structure, or
asymmetry of alar soft tissue. A tilted alar base
could be alleviated with the correction of underly-
ing cartilage problems, but in many cases, it needs
soft tissue work to balance the alar insertion
height to correct this deformity appropriately. To
correct a tilted alar base, the alar lifting technique
can be performed unilaterally on the lower side
ala, as the last stage of rhinoplasty (Fig. 30). An
elliptical incision is made horizontally just inside
the nostril sill and positioned slightly laterally.
The average size of the elliptical incision was
approximately 7 mm on the major axis and 5 mm
on the minor axis. Subsequently, the vestibular
skin and a minimal amount of soft tissue under-
neath the skin are removed. Both skin edges are
approximated using 5-0 monocryl sutures.
Concomitant V-Y advancement of the alar inser-
tion site or cartilage grafting on pyriform aperture
is performed if needed.
Turbinoplasty
For patients who complain of nasal obstruction
prior to surgery, decreasing the volume of the
inferior turbinate or the middle turbinate needs to
be performed. However, patients that do not have
nasal obstruction might still have severely hyper-
trophied turbinates. Even if their septum is cor-
rected, the hypertrophied turbinate could put
pressure on the septum. This can cause a relapse
of the septal deviation, eventually causing nasal
deviation. To reduce the turbinate volume on the
concave nasal cavity, I usually perform lateral out
fracture of the inferior turbinate with or without
radiofrequency volume reduction. In case there is
hypertrophic middle turbinate especially due to
concha bullosa, debalooning of the pneumatized
Fig. 30  Alar base lifting technique can be applied to correct a tilted alar base
Y. J. Jang

273
turbinate by crushing with forceps and subse-
quent lateralization can safely reduce turbinate
volume, providing room for septal mobilization.
Prognosis and Complications
of Surgery
Surgical correction of deviated noses is consid-
ered to be one of the most difficult surgeries in
rhinoplasty. The reason being is that there are
various forms of deformities that are very com-
plicated. Each patient will require different meth-
ods of surgery, and the chances of relapses are
high. The reason why relapses are common is
that cartilaginous deformities have a huge impact
on deviation, and their elasticity will keep on
inducing them to return to their original shape
before surgery. Excising out the deviated area of
the cartilage is of course the most certain way of
correcting it, but it could cause more structural
instability. With patients with more severe devia-
tions, their septal cartilage, upper lateral carti-
lages, and lower lateral cartilage will be deformed
more severely. Surgical results will not always be
satisfactory, even if the surgeon performs all the
right things. Structural weakening, inevitably fol-
lowing aggressive corrective procedures, also
hamper acquiring a good surgical outcome.
Especially, if preoperative planning is done
poorly, or if there is a lack of thorough under-
standing of the dynamics of cartilages, the sur-
gery itself and the results will not be successful.
The following are the complications of surgery.
1. Incomplete
correction
and
relapse
of
deviation
The probable causes of incomplete correc-
tion or recurrence of deviation are
• Secondary deformity of the bony vault as a
result of osteotomy
• Failure to overcome the intrinsic memory
of deformed cartilage
• Weakened cartilaginous supporting struc-
ture due to various surgical maneuvers
• Displacement or deformation of the dorsal
implant material
2. Nasal tip deprojection due to weakened sup-
porting structure after surgery
3. Short nose deformity
This deformity may occur due to the fol-
lowing reasons
• Skin contraction due to immune or tissue
reaction to the dorsally implanted material
• Loss of cartilaginous supporting power
• Resorption of the tip graft or septal exten-
sion graft
4. Saddle nose deformity
Saddle deformities can occur with similar
etiologies that cause short nose deformities.
Resorption of the dorsal implant can also be
an important factor
5. Incomplete correction of the nasal obstruction
or newly developed nasal obstruction as a
result of surgery
Causes of disturbed nasal breathing function
are:
• Incomplete correction of the septal deviation
• Inadequate
treatment
for
turbinate
hypertrophy
• Stenosis, or dynamic collapse of the external
valve or internal valve
• Collapsed bony dorsum as a result of
osteotomy
In my experience, failed correction of the cau-
dal septal deviation was the most common reason
for functional dissatisfaction after rhinoplasty for
correction of the deviated nose.
Other than the aforementioned complications,
several other complications might take place.
Conflict of Interest Disclosures  None to
declare.
Further Reading
Chen YY, Kim SA, Jang YJ. Centering a deviated nose
by caudal septal extension graft and unilaterally
extended spreader grafts. Ann Otol Rhinol Laryngol.
2020;129(5):448–55.
Deviated Nose Correction and Functional Surgery 1

274
Cho GS, Jang YJ. Deviated nose correction: different out-
comes according to the deviation type. Laryngoscope.
2013;123(5):1136–42.
Jang YJ, Kim JM, Yeo NK.  Use of nasal septal bone
to straighten deviated septal cartilage in correc-
tion of deviated nose. Ann Otol Rhino Laryngol.
2009;118(7):488–94.
Jang YJ, Kwon M.  Modified extracorporeal septoplasty
technique in rhinoplasty for severely deviated noses.
Ann Otol Rhinol Laryngol. 2010;119(5):331–5.
Jang YJ, Sinha V.  Spreader graft in septo-rhinoplasty.
Indian J Otolaryngol Head Neck Surg. 2007;59:100–2.
Jang YJ, Song HM, Yoon YJ, Sykes JM. Combined use of
crushed cartilage and processed fascia lata for dorsal
augmentation in rhinoplasty for Asians. Laryngoscope.
2009;119(6):1088–92.
Jang YJ, Wang JH, Lee BJ. Classification of the deviated
nose and its treatment. Arch Otolaryngol Head Neck
Surg. 2008;134(3):311–5.
Jang YJ, Wang JH, Sinha V, Lee BJ. Percutaneous root
osteotomy for correction of deviated nose. Am J
Rhinol. 2007;21(4):515–9.
Jang YJ, Wang JH, Sinha V, Song HM, Lee BJ. Tutoplast
processed fascia lata for dorsal augmentation
in rhinoplasty. Otolaryngol Head Neck Surg.
2007;137(1):88–92.
Jang YJ, Yeo NK, Wang JH. Cutting and suture technique
of the caudal septal cartilage for the management of
caudal septal deviation. Arch Otolaryngol Head Neck
Surg. 2009;135(12):1256–60.
Joo YH, Jang YJ. Comparison of the surgical outcomes of
dorsal augmentation using expanded polytetrafluoro-
ethylene or autologous costal cartilage. JAMA Facial
Plast Surg. 2016;18(5):327–32.
Kim DY, Nam SH, Alharethy SE, Jang YJ. Surgical out-
comes of bony batten grafting to correct caudal sep-
tal deviation in septoplasty. JAMA Facial Plast Surg.
2017;19(6):470–5.
Kim JH, Jang YJ. Use of diced conchal cartilage with peri-
chondrial attachment in rhinoplasty. Plast Reconstr
Surg. 2015;135(6):1545–53.
Kim JH, Kim DY, Jang YJ.  Outcomes after endonasal
septoplasty using caudal septal batten grafting. Am J
Rhinol Allergy. 2011;25:166–70.
Kim JH, Park JP, Jang YJ. Aesthetic Outcomes Of Alar Base
Resection In Asian Patients Undergoing Rhinoplasty.
JAMA Facial Plast Surg. 2016;18(6):462–6.
Kim SA, Jang YJ. Caudal septal division and interposition
batten graft: a novel technique to correct caudal septal
deviation in septoplasty. Ann Otol Rhinol Laryngol.
2019;128(12):1158–64.
Lee SB, Jang YJ.  Treatment outcomes of extracorpo-
real septoplasty compared with in situ septal cor-
rection in rhinoplasty. JAMA Facial Plast Surg.
2014;16(5):328–34.
Song HM, Kim JS, Lee BJ, Jang YJ.  Deviated nose
cartilaginous dorsum correction using a dorsal
L-strut cutting and suture technique. Laryngoscope.
2008;118(6):981–6.
Yi JS, Jang YJ.  Frequency and characteristics of facial
asymmetry in patients with deviated noses. JAMA
Facial Plast Surg. 2015;17(4):265–9.
Y. J. Jang

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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,

Functional Surgery 2:
Consideration of Internal Valve
Problems in Asian Rhinoplasty,
and Turbinate Reduction
Eun-Sang Dhong
Asian rhinoplasty can be divided into two com-
pletely different categories: a primary operation
and a secondary operation. In Asian rhinoplasty,
these two surgeries have few shared concepts.
Among the Asian rhinoplasty techniques, sec-
ondary rhinoplasty has an entirely different con-
cept of dissection from the primary operation.
The reason for this is that most of the previous
surgery uses alloplastic implants. Primary rhino-
plasty is mainly confined to an anteroposterior or
cephalocaudal enhancement of the nose. Most of
the secondary rhinoplasty are surgeries fighting
against the scars caused by alloplastic materials
and thriving to manage the previously removed
quadrangular cartilage and the previously applied
grafts.
Apart from the distinction between primary
and secondary operations, another criterion is
divided into surgery that requires septal dissec-
tion and surgery that does not.
In Asian rhinoplasty, septoplasty is rarely
done to improve the function of the nose. Most of
the surgeries require cartilage graft, so the septal
dissection is for collecting the septal cartilage. In
most cases, tip projection is required even after
the hump removal in reduction rhinoplasty, not to
mention the deviated nose correction.
The purpose of harvesting the quadrangular
cartilage from primary rhinoplasty of Asian rhi-
noplasty is not to correct the septal deviation but
to obtain grafts for septal extension or tip plasty.
Most grafts are applied to the tip to improve the
profile rather than the spreader graft to correct the
function after hump removal or deviation correc-
tion. Paradoxically, there are many clinical cases
in which the nasal function worsens after Asian
rhinoplasty because the nasal septum is resected
for the projection rather than the functional
improvement. Below comes from the reality of
Asian rhinoplasty, 180 degrees different from
western rhinoplasty, so it needs the wisdom to
decide whether to perform subdivision projection
between normal and abnormal cases.
Functional Aspects of Internal Valve
Anatomy
An internal valve representing the most signifi-
cant resistance to air intake from the nose is pres-
ent at a distance of 1.3  cm from the external
nares. Most of the causes of nasal congestion
occur at a distance from the outer valve to the
nasal valve and account for the highest nasal
resistance to airflow. As for the anatomical struc-
ture, the roof consists of the junction of the cau-
dal portion of the upper lateral cartilage (ULC)
and the cephalic portion of the lower lateral
E.-S. Dhong (*)
Department of Plastic and Reconstructive Surgery,
Korea University Guro Hospital, Seoul, South Korea

276
­cartilage (LLC), the medial wall of the inferior
turbinate, the nasal septum, and choana. Nasal
obstruction is present in the area seen by nasos-
copy. In other words, even if there is no endo-
scopic instrument, nasal obstruction can be
observed with the simplest nasoscopy. As such,
nasal obstruction is located in the front part of the
entrance (Fig. 1).
Cottle Test
Cottle test is to measure the function of the navel
valve. It determines the positivity of the test as
the nasal obstruction is improved when the cheek
outside the alar crease junction is pulled out. The
modified Cottle test is a method to measure the
improvement of the nasal obstruction by lifting
the roof of the internal nasal valve more directly.
The valve is lifted using a small freer elevator.
Many studies have different views on the useful-
ness of this test result. Instead, studies are show-
ing that the nasal strip test shows more valid
results than the Cottle test. The sensitivity and
specificity of the Cottle test differ according to
the various reports. Although there are various
cohort studies, the author has never seen a patient
whose mild nasal obstruction is not resolved by
this Cottle test. Mild nasal obstruction is resolved
in all patients with the Cottle test. Therefore, the
result of this test is not directly judged by the
extent of the patient’s nasal obstruction. Even in
the outpatient clinic, direct observation, CT find-
ings, and more detailed medical history listening
are prioritized rather than the Cottle test.
Physiology
With olfaction, respiration is the most critical
function of the nose. Warm, moist air should be
inhaled through the nasal cavity without vortices
to avoid stuffiness. The critical concept is the nasal
cycle. The nasal cycle is an unconscious phenom-
enon: partial congestion and decongestion of the
nose. Thus, there is a greater airflow through one
of the nostrils, alternating between the left and
right. It is a physiological blockage called a nasal
cycle due to selective activation of half of the auto-
nomic nervous system by the hypothalamus. It
should not be confused with a pathological stuffy
nose. The total nasal resistance is usually kept con-
stant and is less than the resistance of each nose, so
ordinary people are usually not aware of this phe-
nomenon. The circulation of the nose subcon-
sciously alternates between partial congestion and
decongestion. It is essential to compare records
before and after surgery using NOSE SCALE for
objective measurement. There are also objective
methods such as rhinomanometry and mask peak
flow, but the author uses acoustic rhinometry and
CT scan as the most direct modality. The most cru-
cial method is taking medical history. In acoustic
rhinometry, it is essential to observe the overall
flow as the observation of the pattern. The quanti-
tative measurement of the curve is not directly pro-
portional to the nasal obstruction (Fig.  2). As
shown in the figure, two minimal cross-sectional
areas (MCA) are shown, and the front one is
judged as the external nares and the second MCA
as the internal nasal valve.
The Shape of Internal Valve
and Collapse of ULC
Many studies have reported whether the shape of
the internal nasal valve (INV) is related to the
actual intake function. However, the evidence is
Fig. 1  Nasal obstruction is located in the area seen by the
nasoscope. The internal nasal valve is easily found
E.-S. Dhong

277
still insufficient, but when convexity exists at the
anterior edge of the septal cartilage, it is consid-
ered an acute angle, which can also be associated
with poor airflow. Conversely, in the case of a
round shape INV, the frequency of nasal obstruc-
tion was minor. These shreds of phenomenon
need more evidence. According to the INV angle,
when considering the size of the graft, the exces-
sive width of the spreader graft may change the
shape of INV.  An extensive spreader graft can
change INV to an acute angle. So far, there is no
study on how the shape of the internal valve acts
in the airflow of directly inhaled air. The nar-
rower the angle of the internal nasal valve, the
less airflow will be, but there is only a physical
simulation of the total volume: many studies on
whether the shape of the internal nasal valve is
related to the actual intake function. However, the
evidence is still insufficient, but when convexity
exists at the anterior edge of the septal cartilage,
it is considered an acute angle, which can be con-
sidered to be associated with nasal obstruction.
Conversely, in the case of a round shape INV, the
frequency of nasal obstruction was minor. . The
smaller the internal nasal valve angle, the less air-
flow will be, but there is only a physical simula-
tion of the total volume (Fig. 3).
Poiseuille’s law explains the resistance and
physiologic flow related to the radius, tube length,
viscosity, resistance, and pressure difference.
Two different flows are laminar flow and turbu-
lent flow. Irregular tubes, such as the nose cause
turbulent flow. Moreover, nasal turbinate and
septum regulate nasal airflow.
This law explains the relationship between
resistance and flow velocity and the relationship
between laminar flow and turbulent flow in a
structure with possible obstruction. Surgery
Fig. 2  Acoustic rhinometry: Internal nasal valve located
at the minimal cross-sectional area (MCA)
Fig. 3  Two different types of INV angle: (Lt) obtuse angle and (Rt) acute angle
Functional Surgery 2: Consideration of Internal Valve Problems in Asian Rhinoplasty, and Turbinate…

278
related to the internal nasal valve (INV) is limited
to constantly improving the collapsibility of the
valve. Surgery on the nasal septum to secure the
rest of the nasal cavity on the curved nasal sep-
tum. The angle between the ULC and Septum
must be 10–15 degrees or more for expansion in
this area. The purpose is to secure the roundness
of the roof as it is opened by inserting a spreader
graft having a length of 1–1.5 cm and a width of
4–5 mm. It is more purposeful to prevent collapse
with ULC spreading rather than improving INV
shape. Therefore, if a sufficient length spreader is
not secured, there is a problem in the function of
INV. In other words, the purpose of the spreader
graft is to expand the gap between the ULC and
septum, including INV. Also, a spreader graft can
correct the shape of the cartilaginous dorsum to
the left or right sides and the s-shaped deformity.
In primary rhinoplasty, surgery can be considered
as a primary choice, but there are two problems,
especially for Asians:
1. There is a limit to express the dorsal profile
with the spreader graft itself in Asians. In
other words, the spreader graft is the invisible
graft that can repel the ULC to be straight-
ened. Spreader graft can correct the deforma-
tion of deviation; however, there is no
scientific background on how the graft will
function when an alloplastic implant is
inserted thereon. Spreader graft under the
alloplastic implant is to be studied in the
future for the current abusive applications.
2. The spreader graft can ruin the shape of the
nose. In particular, there is concern that the dor-
sal esthetic line may deteriorate after the change
of the width if it must be inserted in the second
surgery. In other words, serious consideration
needs to be given to how far the role of the
invisible graft will be limited. Since many carti-
lage grafts are needed in Asians, using the vast
amount of cartilage in the spreader graft on the
invisible area makes tip surgery impossible.
Spreader Graft
The spreader graft is defined as a graft that inserts
a cartilage strip with a length of 2–3 cm, a width
of 3–5 mm, and a thickness of 1.5 mm between
the upper lateral cartilage to spread the gap
between the anterior septum and the sidewall.
This graft has the following functional aspects
and the esthetic aspect of the dorsal profile at the
same time (Fig. 4).
1. Prevent mid nasal collapse.
2. Improve inverted V deformity.
Fig. 4  Spreader graft
E.-S. Dhong

279
3. Restore “T” appearance of the dorsal septum.
4. Restore the internal valve angle more than 15
degrees by obtuse the acute angle of the roof
of the internal valve.
5. Correct left to right deviation of the anterior
septum.
6. Make the dorsum wide and maintain the width
of 7–12 mm or more.
Since, inevitably, the removal of the dorsal
“T” shape cartilage that occurs after reduction
rhinoplasty leaves the internal valve angle acute,
it is necessary to perform a spreader graft at this
time. When removing the generalized hump, the
larger the removal, the wider the width of the
spreader graft is required. The spreader graft is
invisible. In other words, it is not a concept of
applying spreader graft more anteriorly than
ULC. However, in Asians, you should have a dif-
ferent perspective. Here, the anteriorly extended
spreader graft determines the dorsal profile as a
correct physiologic operation.
Extended Spreader Graft
The length of 2–3  cm mentioned above corre-
sponds to the length from the dorsal septum to at
least the cephalic border of the lower lateral
­cartilage in Westerners. In Asians, it will be
within 2–2.5 cm.
For correcting a contracted nose or short nose,
a longer spreader is required, and an extension
that allows the caudal end to reach the middle
crus is required.
In addition to this, the author mainly uses an
anteriorly extended spreader graft. It is a form of
anterior extension of the spreader graft for pro-
jecting the dorsal profile. This method is a “ vis-
ible spreader graft” and has the advantage of
making the dorsal profile with the spreader graft
itself. For dorsal augmentation, there is no need
to put alloplastic material, and it has the advan-
tage of expressing cartilaginous dorsum as the
anterior septum (Fig. 5).
Specific Perspectives in Asian
Rhinoplasty
1. Lack of size of the septal quadrangular cartilage.
The biggest obstacle is that the size of the
quadrangular cartilage is limited. In most
patients, the abovementioned 2–3 cm length graft
is not possible. If the rib cartilage or ear cartilage
is not harvested, the ethmoid perpendicular plate
is connected to the cartilage to use the small
quadrangular cartilage properly (Fig. 6).
2. Invisible graft under alloplastic implants.
Another problem mentioned briefly above is
onlaying the alloplastic implant on the dorsum
FIg. 5  Anteriorly extended spreader graft: visible spreader
graft
Fig. 6  Quadrangular cartilage harvest connected with
ethmoid perpendicular plate
Functional Surgery 2: Consideration of Internal Valve Problems in Asian Rhinoplasty, and Turbinate…

280
over the spreader graft. Is it physiologically cor-
rect? There are several risks. Even if there is no
laceration perforating to the nasal cavity with the
well-preserved mucoperichondrium, there will
be risks about putting the alloplastic implant in
the widely dissected dorsum, which is thought to
be the cause of late-onset inflammation. Another
problem is its functional aspect. It can be argued
that rationale is made to create a flat platform for
alloplastic implants to be inserted by spreader
grafts on the dorsum. However, clinically,
implants located straight in the middle of the
nasal axis are rarely found in the author’s experi-
ences; a more significant problem may occur if
the implant sinks to either side. The author
believes applying the alloplastic implant to the
dorsum after the spreader graft is physiologically
lacking evidence.
Spreader Flap
As a method possible in reduction rhinoplasty,
the anterior septal cartilage is first removed dur-
ing component dorsal reduction, and then the
medial flap of the remaining upper lateral carti-
lage is rolled down to create a spreader graft. For
Asian rhinoplasty, its application is minimal.
This is possible for a large nose with a lot of
ULC, but in most Asians, it cannot be used as a
flap on the cartilaginous dorsum, and then the
ULC must be cut off (Fig. 7).
Splay Graft (Spring Graft)
The splay graft is a method that can be applied
when the collapse of the internal nasal valve is
judged as the cause of nasal obstruction. The
anterior edge of the septal cartilage is used as a
tent pole, and flat cartilage is inserted into the
undersurface of the ULC on both sides. However,
it has the disadvantage of widening the width of
the nose and should be used with care in patients
with thin skin. In other words, it is called spring
graft, and it is the same surgical method that has
the same meaning. This is the best way to get an
obtuse internal nasal valve angle (Fig. 8).
Internal Valve: The Impact on Asian
Septorhinoplasty
The More Reduction, the More
Spreader Graft
As the size of the hump increases, the size of the
spreader graft to be applied increases. This is
Fig. 7  Spreader flap
E.-S. Dhong

281
because the overall INV angle changes in the lat-
eral inward fracture to improve the open roof
deformity after hump removal. However, Asians’
humpectomy should be operated with a slightly
different view. The entire dorsal profile should be
considered after the humpectomy in Asians. In
other words, there are many cases in which
humpectomy cannot be performed as much as
desired, but rather the nasion area is augmented,
and the reduction in the rhinion area is mini-
mized. The amount of humpectomy can be
reduced, and the projection of the nasion and car-
tilaginous dorsum can be considered in consider-
ation of the entire dorsal profile. In many Asians,
hypoplastic lower 2/3 is a typical characteristic
with a bony hump or pseudo hump deformity.
However, it is a misconception that cases of
nasal obstruction after humpectomy are less
compared to those of Westerners. The reduction
of cartilaginous dorsum should be well planned
by distinguishing between generalized hump,
isolated hump, and pseudo hump.
What Is the Cause of Nasal
Obstruction after Septorhinoplasty?
The most common cause is the residual septal
deviation. Most of the surgery is submucous
resection rather than septoplasty in Asian
­septorhinoplasty. Conventional septoplasty pre-
serving most of the quadrangular cartilage is
impossible in many Asian septorhinoplasties
unless the patients have huge noses. This is
because the quadrangular cartilage is required as
a graft donor. In Westerners, after hump resec-
tion, the acute angle of the internal valve is the
most significant cause, but in Asians, some other
causes are as follows.
Nasal Synechia
Mucosal wounds after packing removal cause
intranasal adhesion, and most of the adhesion
occurs in a high portion of the nasal cavity.
Although the preference of nasal packing materi-
als differs from author to author, damaging the
mucosal barrier is frequently found when gauze
use. Minor mucosal erosion may occur while
removing the gauze. When such adhesions are
found during secondary rhinoplasty, simple cut-
ting with the freer elevator is performed first
(Fig. 9). However, it is also essential to manage
using appropriate smooth packing material even
after adhesiolysis.
Ignorance of Internal Valve
Since most patients visit the plastic surgery clinic
to improve their appearance, functional problems
are apt to be ignored. So the patient’s history and
careful internal nasal inspection should be
focused.
If a patient whose nose is not obstructive
preoperatively, obstructive symptoms after cos-
metic surgery, in severe cases, maybe a legal
problem. The safest device, NOSE SCALE,
needs to be actively conducted to receive legal
protection.
It is the safest policy and the path for patients
to measure and record the clinical severity of
existing nasal obstruction through a simple ques-
tionnaire that takes less than 5 minutes.
Fig. 8  Splay graft (spring graft)
Functional Surgery 2: Consideration of Internal Valve Problems in Asian Rhinoplasty, and Turbinate…

282
Unique Internal Valve Problems
in Asian Rhinoplasty
Exaggerated Tip Sutures
For the tip projection, in specific techniques, the
lateral crus is rotated excessively cephalically,
and the middle of the lateral crus is anchored
together with the high septum. This tip anchoring
can obtain the projection. As mentioned earlier,
tip tripod support with stiff LLC is hardly adopted
in Asian rhinoplasty and Asian secondary rhino-
plasty. No matter how strong the medial crus are
held up, that is, in other words, even if the septal
extension grafts or the columellar strut was
applied, excessively anchored lateral crus may
press the high septum paradoxically (Fig.  10).
The minimal cross-sectional area (MCA) may
abruptly be reduced in the cephalic portion of the
INV in the CT axial view, as shown in the case
below.
Exaggerated Supratip Graft
In many patients, septal extension graft or colu-
mella strut is used for tip projection, but recently
batten type graft in the supratip area, including
derotation graft, has gained popularity. The big-
gest problem is that even with this batten graft,
the dorsal profile usually cannot be obtained by
itself. Therefore, another dorsal graft, including
the alloplastic implant, is required. Almost all
Asian rhinoplasty only pay attention to the power
of the tip projection; the dorsum is, of course,
taken as implanting or grafting. The abovemen-
tioned INV area’s step ladder deformity, some-
thing like supratip depression, can be found
(Fig.  11). INV depression at the supratip area
results from the fragile septum. The tension
caused by graft or alloplastic implant at the dor-
sum with tight soft tissue envelope and gravity
may play a role.
Possible Solutions
The surgery to open the nasal airway using the
spring graft or spreader graft mentioned earlier is
necessary. There are no data on the effectiveness
or usefulness of placing an alloplastic implant on
a spring graft or spreader graft in the literature
yet. What is certain is that the stability of the high
septum determines whether or not the strong
anchoring suture can withstand and whether or
not the heavy graft of the supratip area can be
sustained. In other words, there is a possibility
that derangement may occur in the function of
Fig. 9  Nasal synechia: (Lt) preoperative view, (middle) release of synechia, and (Rt) silastic sheet dressing
Fig. 10  Paradoxical INV depression after excessive tip
projection anchoring
E.-S. Dhong

283
the nose, unless a physiologic INV lift is accom-
panied by an appropriate projection of the ante-
rior septum. The dorsal profile created by the
anterior septum will prevent the decrease in the
INV angle even after the excessive tip projection.
If LLC cannot be lifted because of its poor
strength, it will not overcome the MCA differ-
ence between the LLC and ULC, thereby result-
ing in step ladder deformity. This problem will
ultimately be solved only when the anterior sep-
tal is extended too like the septal L-strut exten-
sion graft (Fig.  12). In numerous Asian
rhinoplasty, the concept of focusing on the tip
only, then controlling the dorsum with alloplastic
materials will result in an unanticipated derange-
ment in function as the above patient.
Turbinate
Inferior Turbinate Surgery
Septum and concha are one unit. Even if the sep-
tal surgery is successful, nasal obstruction is not
resolved with conchal hypertrophy. The septum
and concha should be considered simultaneously.
If one side of the nasal septum concave, compen-
satory ipsilateral turbinate hypertrophy occurs.
Therefore, it is necessary to reduce the inferior
turbinate. There are several types of surgery
related to inferior turbinates, but from a plastic
surgery point of view, out fracture with a simple
freer elevator and packing can expand the nasal
cavity easily. A conventional method of reducing
turbinate is inferior submucosal turbinectomy
(SMT). This method has been used to preserve
the function of the nose by minimizing the resec-
tion of the conchal mucosa by preserving it and
removing mainly the bony part inside. In the
review of the effects of out fracture and SMT, the
short-term results are similar, but in the long
term, it can be seen that the Sino-nasal outcome
is excellent in SMT. The predominant layer of the
inferior turbinate is an intrinsic lamina propria
made of loose connective tissue and superficially
harboring inflammatory cell infiltration. The cav-
ernous medial bone layer is made of a woven tra-
beculae mass and houses the major arterial supply
of the turbinate. From this point of view, SMT
may not be effective because the focus of reduc-
tion should be lamina propria. Direct contraction
of lamina propria using radiofrequency-assisted
inferior turbinoplasty (RAIT) is frequently com-
pared with microdebrider-assisted reduction sur-
gery outcomes (MAIT). The direct mechanical
treatment method, the MAIT, is considered more
effective in two years postoperatively. As a plas-
tic surgeon, the simple minimal invasive tech-
nique can avoid unwanted complications, and
can be stably operated with local anesthesia. Out
fracture with RAIT is a reliable method to pre-
vent paradoxical nasal stuffiness caused by
excessive resection.
RAIT
Radiofrequency turbinate reduction (RFTR) is a
minimally invasive technique that can reduce tis-
sue volume. This technique uses high frequency
to create lesions within the submucosal tissue of
the turbinate to reduce tissue volume. The long-­
term evaluation revealed a reduction in resis-
tance, and subjective benefits that are maintained
for two years after the procedure.
Fig. 11  INV depression after supra tip graft and dorsal
implanting
Functional Surgery 2: Consideration of Internal Valve Problems in Asian Rhinoplasty, and Turbinate…

284
MAIT
Microdebrider is a tool made up of mechanical
components. The disposable blade is a hollow
metal tube coupled with suction, which cuts the
obstructive tissue and removes it from the air-
ways. The handpiece drives the blades through an
electric motor and is compatible with blades of
various sizes. Microdebreather blades are
5–7 mm in diameter with a rigid endoscope so
that tissue dissection can be performed with opti-
mal visualization and control. Appropriately used
microdebreathers allow better preservation of the
normal airway mucosa than conventional inferior
turbinectomy.
Further Reading
Garzaro M, Pezzoli M, Landolfo V, Defilippi S,
Giordano C, Pecorari G.  Radiofrequency inferior
turbinate reduction: long-term olfactory and func-
tional outcomes. Otolaryngol Head Neck Surg. 2012
Jan;146(1):146–50.
Gruber RP, Lin AY, Richards T. Nasal strips for evaluat-
ing and classifying valvular nasal obstruction. Aesthet
Plast Surg. 2011 Apr;35(2):211–5.
Guyuron B, Michelow BJ, Englebardt C.  Upper
lateral splay graft. Plast Reconstr Surg. 1998
Nov;102(6):2169–77.
Jang YJ, Alfanta EM. Rhinoplasty in the Asian nose. Facial
Plast Surg Clin North Am. 2014 Aug;22(3):357–77.
Jang YJ, Moon H. Special consideration in the manage-
ment of hump noses in Asians. Facial Plast Surg. 2020
Oct;36(5):554–62.
Mirza AA, Alandejani TA, Shawli HY, Alsamel MS,
Albakrei MO, Abdulazeem HM.  Outcomes of
microdebrider-­assisted versus radiofrequency-assisted
inferior turbinate reduction surgery: a systematic
review and meta-analysis of interventional randomised
studies. Rhinology. 2020 Dec 1;58(6):530–7.
Omranifard M, Adib M, Ebrahimpour Boroujeni S,
Dadkhah Tirani F, Asadi S. Comparative study of the
effectiveness of sub mucosal partial inferior turbinec-
tomy and out fracture of inferior turbinate in the nasal
respiratory function of rhinoplasty patients. Aesthet
Plast Surg. 2019 Oct;43(5):1281–5.
Stewart MG, Witsell DL, Smith TL, Weaver EM,
Yueh B, Hannley MT.  Development and valida-
tion of the nasal obstruction symptom evaluation
(NOSE) scale. Otolaryngol Head Neck Surg. 2004
Feb;130(2):157–63.
Toriumi DM, Swartout B. Asian rhinoplasty. Facial Plast
Surg Clin North Am. 2007;15(3):293–307. v
Won T-B, Jin HR. Nuances with the Asian tip. Facial Plast
Surg. 2012 Apr;28(2):187–93.
Fig. 12  INV lift using
septal L-strut extension
graft (SLEG): (Lt)
SLEG, (Rt) INV lift
based on high septal
support
E.-S. Dhong

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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,

Secondary Rhinoplasty (1):
Implant-Related Complications
Jaeyong Jeong
Introduction
The popularity of revisional rhinoplasty in Asians
tends to be higher than other aesthetic surgeries.
The reason for this, is because, in Asian rhino-
plasty, there is a higher frequency of implant
usage which may lead to a higher risk of cosmetic
and physiologic problems over time. Due to these
reasons, secondary rhinoplasty in Asians is gen-
erally difficult and complex and should be
addressed with meticulous preoperative prepara-
tion and planning.
Types of dorsal implants frequently used in
Asian rhinoplasty include silicone, Goretex, chi-
meric types (silicone + Goretex), and more
recently, acellular dermal matrix (ADM).
Although many surgeons prefer to use autolo-
gous materials for the nasal tip, there is persistent
usage of Medpor, irradiated homologous costal
cartilage (IHCC), PDS plate, and scaffolds with
PCL. This chapter will explore the various com-
plications that can arise from the array of implant
materials used in Asian countries and suggest
available treatments.
Dorsal Implant Movability
and Migration
Causes of Movability (Unstable
Moving) and Migration
The characteristics of movability and migration
vary depending on the type of implant. However,
implant movability and migration are generally
more common with the use of silicone implants.
Silicone implants form a capsule, which may
cause movability of the implant within its cap-
sule. On the other hand, Goretex implants are
porous, and tightly adhere to the surrounding
structure by tissue ingrowth. Silicone implants
tend to move or migrate because of these cap-
sules. The most common cause for silicone
implant movability is subcutaneous implantation
(Fig.  1). Implant demarcation or deviation is
often accompanied by other symptoms. The rate
of these complications may increase with multi-
ple revisions. Although rare, movability can be
observed in some cases where the Goretex
implant has been placed inside the previous cap-
sule of a silicone implant. Mild-to-minimal mov-
ability can be seen even when the implants are
situated properly in the subperiosteal plane.
These cases rarely lead to serious problems, but
patients should be advised not to forcefully move
or touch their implants to prevent displacement
or migration.
J. Jeong (*)
THE PLUS Plastic Surgery Clinic, Seoul,
South Korea

286
Common causes of implant movability are
listed below:
1. Subcutaneous placement of the implant.
2. Chronic seroma or hematoma.
3. Habitual behavior of the patient including fre-
quent touching, moving, or massaging of the
nose.
4. Formation of a biofilm around the capsule due
to subclinical infection.
5. Using the same pocket and capsule from prior
surgery as revision.
Significant migration of the implant may be a
phenomenon following severe complications. In
other words, it is a common deformity seen in
inflammation or contracture, where the implant
may be moved or displaced in a cephalic or cau-
dal direction. These cases are generally accompa-
nied by tip problems as well (Fig. 2).
Treatment of Movability
and Migration
Treatment modalities differ for each pathogene-
sis. In cases of subcutaneous implantation, a new
subperiosteal pocket for the implant should be
made during the revision. When movability and
migration are the result of inflammation or con-
tracture, the treatment process becomes compli-
cated (Fig.  3). Therefore, the underlying
instigating factors should be initially treated and
resolved.
Dorsal Implant Deviation
Deviation occurs more frequently in silicone
implants than in other types of ones. The right-­
handed surgeon must be cautious not to dissect
asymmetrically during endonasal approach via
Fig. 1  Movable implant due to subcutaneous implantation
J. Jeong

287
one side. Also, extensive or inadequate pocket
making may result in unstable insetting of the
implant over the course of time. Furthermore,
because detailed evaluation of the underlying
framework structure may be difficult, it is impor-
tant to precisely carve and design the posterior
surface of the implant during surgery.
Potential causes of deviation are listed below:
1. Inadequate pocket formation for dorsal
implant during surgery.
2. Inadequate correction of the deviated nasal
framework under the implant.
3. Asymmetric or deviated capsule formation
due to seroma or hematoma.
4. Discordance between the nasal structural
framework and posterior aspect of the implant.
5. Long-term effects of asymmetric facial mus-
cle movements and contractions.
6. Habitual behavior of the patient including fre-
quent touching, moving, or massaging of the
nose.
Treatment of Dorsal Implant
Deviation
The presence of a hematoma immediately after
surgery disrupts the stable formation of a peri-­
implant capsule, and consequently hinders the
stable inset of the implant. Therefore, it is para-
mount to remove any fluid including hematoma,
around the implant in the early days after surgery
to prevent deviation. Deviation that occurs gradu-
ally over time after surgery can be seen often in
patients with asymmetric facial muscle move-
ments or asymmetrical nasal bone base. Delayed
implant deviation is most likely attributed to asym-
metry of the face or nasal framework (Fig. 4).
When signs of implant deviation are present
immediately following surgery, patients are most
likely very disconcerted, and the performing sur-
geon will likely be under incredible stress.
Deviation of the implant may be classified as
proximal, distal, or total deviation of the entire
nose. Correction of the deviation may be carried
out at 6 months, or when there is proximal devia-
tion of the silicone implant, early intervention
within 3 months after surgery may be done by
way of intranasal capsulotomy with a closed
approach (Fig. 5). Distal deviation of the implant
is often accompanied by septal or tip deviation
thus, an open approach is usually recommended
for correction of these deformities. The author
experienced 20 cases of dorsal implant deviation
out of approximately 4300 patients over the last
10 years. Of these, 80% of the cases were cor-
rected promptly with good results by intranasal
capsulotomy in the early stages. Intranasal capsu-
lotomy was insufficient in the remaining 20% of
cases and required correction with an open
approach (Figs. 6 and 7).
a
b
c
Fig. 2  Migration of implant. (a) Caudally migrated implant, (b) cephalically migrated implant, (c) migrated implant
invaded into frontal sinus
Secondary Rhinoplasty (1): Implant-Related Complications

288
a
b
c
d
Fig. 3  The implant was cephalically migrated due to severe contracture in this case. (a) Preoperative views, (b, c)
intraoperative photos, (d) postoperative views
J. Jeong

289
Dorsal Implant Demarcation, Dorsal
Irregularity and Envelope Thinning
Causes of Dorsal Implant
Demarcation
The potential causes of “implant visibility” or an
“operated look” after rhinoplasty are as follows
(Fig. 8):
1. Excessively oversized implant size.
2. Patients with very thin skin.
3. Subcutaneous implantation.
4. Too wide or too narrow implant in relation to
the bony base width.
5. Severe calcification of old silicone implant.
6. An implant situated on the wide bony base.
7. Visible margin of the implant caused by con-
tracture of the silicone capsule.
Cause of Dorsal Skin Irregularity
The nasal envelope over the keystone area (mid-
dorsal portion) is the thinnest and even minor
irregularities may be evidently visible. In addi-
tion, transition zone from thin skin to thick skin
at supratip area is also vulnerable to dorsal irreg-
ularity. The dorsal aesthetic contour may be
interrupted by these irregularities (Fig. 9). Dorsal
irregularities may also result from the rough and
irregular anterior surface of dorsal implants or
a
b
c
d
Fig. 4  Facial asymmetry can affect implant deviation in the long run. (a) Preoperative view, (b) preoperative smiling
view, (c) Implant deviation was shown after operation, (d) minor correction was done for deviation
Fig. 5  Capsulotomy can be effective to correct minor implant deviation of implant as simple revision
Secondary Rhinoplasty (1): Implant-Related Complications

290
a
b
Fig. 6  Correction with open approach. (a) Preoperative view and (b) postoperative view
a
b
Fig. 7  Correction with open approach. (a) Preoperative view and (b) postoperative view
J. Jeong

291
calcified implants. Calcification directly affect to
dorsal irregularity and may result in changes in
skin texture and visibility of the implant contour
in cases of prolonged implantation. Calcification
usually manifests in the beginning as microcalci-
fications approximately 5 years after rhinoplasty
and differs from the characteristics of silicone
implants. In my experiences, harder implants
tend to have higher chances of calcification.
Visible calcification, which may cause skin prob-
lems, can be seen in a patient who had undergone
rhinoplasty more than ten years ago (Fig.  10).
Fig. 8  Various features of dorsal demarcation
a
b
Fig. 9  (a) Skin irregularity at supratip area due to repeated damage on nasal envelope and (b) postoperative view
Secondary Rhinoplasty (1): Implant-Related Complications

292
Calcified capsules and silicone implants lose
their original elasticity and consequently become
hard and irregular. As a result, the continuous
irritation and stimulation on the nasal envelope
may lead to complications such as dorsal irregu-
larity, redness and thinning of the nasal skin
(Fig. 11). Therefore, during revisional surgery of
the patient with an old implant, reinforcement of
the dorsal skin thickness with the removal of cal-
cified implant and capsule should always be con-
sidered (Fig. 12).
Irregular deformities of dorsum are often
observed as a result of technical error during sur-
gery, such as anterior surface carving of the
implant, or usage of a distally thick implant or
two-piece silicone implant. Distally thick
implants may lead to an irregular dorsal contour
such as supratip breakage or fullness in long
term. These deformities might be aggressive,
concomitant with loss of tip projection. Supratip
breakage is often caused by a disruption in the
continuity of the dorsal implant and tip graft.
Surgeons must be aware that the supratip area is
difficult to manage in secondary operations
because this area is the transition zone of the dor-
sal thinner skin into thicker tip skin (Figs. 13 and
14). In some cases, the cause of dorsal irregular-
ity was attributed to technical mistakes such as
the presence of implant pieces left inadvertently
Fig. 10  Various features of calcification on CT scan
a
b
Fig. 11  Calcification of old silicone and capsule. (a)
Anterior surface and (b) posterior surface
J. Jeong

293
during prior surgery. These technical errors
should be prevented during surgery with copious
meticulous irrigation and visual confirmation of a
clean surgical pocket (Fig. 15). Rarely, an over-
sized implant may lead to sinking of the underly-
ing dorsal septal lining due to excessive pressure,
which may eventually lead to dorsal contour
deformities such as saddle nose (Fig. 16).
Goretex implants are pliable and show excel-
lent adherence to surrounding tissue. Because of
these characteristics, the implant borders may be
more discernible and carving of the Goretex
implants should be done scrupulously (Fig. 17).
Also, an incomplete humpectomy may become
more pronounced over time as the Goretex
implant loses its initial height. (Fig.  18).
a
b
c
d
Fig. 12  (a) Palpable nodule on dorsum in lateral view,
(b, c) calcification over the silicone was shown on CT
scan, (d) postoperative view. Calcified silicone and cap-
sule were removed and replaced with deep temporal fascia
for nasal envelope reinforcement
a
b
c
Fig. 13  Supratip demarcation was shown due to caudally thick implant. (a) Preoperative view, (b) preoperative CT
scan, and (c) postoperative view
Secondary Rhinoplasty (1): Implant-Related Complications

294
Dedicated removal of Goretex is recommended
in secondary rhinoplasty because remnant pieces
may be a cause of chronic seroma or inflamma-
tion after surgery (Fig. 19).
Previously injected fillers may be a cause of
dorsal irregularity after surgery. Absorbable fill-
ers are usually dissolved with hyaluronidase prior
to surgery, however, occasionally the surgeon
may observe some remnant filler usually at the
tip during surgery. Hyaluronic acid-based fillers,
when injected, form a very thin capsule, and dor-
sal irregularity can be minimized by not remov-
ing these capsules excessively (Fig. 20). Irregular
injection and ununiform distribution of foreign
bodies or nonabsorbable filler into the skin may
be impossible to remove completely (Fig.  21).
Nasal thread lifts can be a quick noninvasive sur-
gical alternative to rhinoplasty but may cause
irregularity and depression by dermal tethering,
and complete removal of the thread may be dif-
a
b
c
Fig. 14  Supratip fullness was shown due to two pieces of silicone. (a) Preoperative view, (b) preoperative CT scan, and
(c) postoperative view
a
b
c
d
Fig. 15  Palpable mass was shown in lateral wall. (a) Preoperative view, (b) preoperative CT scan, (c) removed silicone
implant and fragment, and (d) postoperative view
J. Jeong