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296
may become tightly adhered to the underlying
bony
or
cartilage
framework.
Therefore,
hydrodissection using local injections may
­facilitate undermining and dissection during
operation.
1. Changing the implant (material, size, and
shape)—For example, an implant with exces-
sive height may be exchanged for a lower
height implant. The type of implant may be
changed, or an alloplastic implant may be
changed with an autologous graft. The design
of the implant (i.e., width and height), and
reinforcement of nasal envelope are factors of
more paramount importance than the type of
implant (Fig. 24).
a
b
c
Fig. 18  Iatrogenic hump was shown after rhinoplasty using goretex implant. (a) Preoperative view, (b) preoperative
CT scan, and (c) postoperative view with autologous tissue
Fig. 19  Goretex implant should be removed completely without remnant during secondary operation. Otherwise,
chronic seroma can be followed
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297
2. Changing insertion plane (from superficial to
deep)—If the implant is situated in a superfi-
cial plane, a deeper neo-pocket should be
made by subperiosteal dissection.
3. Old, calcified silicone implants and capsules
should be removed and skin reinforcement
should be considered (Fig. 25).
4. Refinement of dorsal aesthetic line with oste-
otomies for wide nasal bone—When a dorsal
implant is used without correction of the wide
nasal bone framework, the dorsal aesthetic
line in front and lateral, may look unnatural.
In these cases, an osteotomy must be per-
formed to narrow bony structure (Fig. 26).
5. Reinforcement of nasal envelope using addi-
tional grafts—If a patient has thin skin or
soft tissue problems, skin reinforcement with
grafts such as deep temporal fascia, dermo-
fat, or ADM should be considered (Figs. 27
and 28).
a
b
c
Fig. 20  (a) HA filler was found incidentally during open approach, (b) HA filler was surrounded by a thin capsule, and
(c) removed capsule
Fig. 21  Nonabsorbable filler such as calcium hydroxyapatite can make dorsal irregularity
Secondary Rhinoplasty (1): Implant-Related Complications

298
6. Usage of the previous capsular flap—Healthy
capsule can be used for reinforcement of the
nasal envelope. However, the use of the previ-
ous capsular flap in secondary revision has
limitations. A previous capsular flap should
not be used when there is capsular thickening
or contracture due to inflammation, or calcifi-
cations or biofilms are observed around the
capsule (Figs. 29 and 30).
7. Fat graft or filler injection—Fat graft or filler
injection can be used for minor revision after
operation (Fig.  31). Triamcinolone injection
may be used to correct bumps and irregulari-
ties caused by remnant permanent fillers.
Nasal Skin Redness
Potential causes of dorsal skin redness are as
follows:
1. Nasal skin injury due to multiple surgeries on
the nose.
2. Prolonged time lapse after implantation with
excessively large, wide, or hard type silicone
implants.
3. Subcutaneous implantation close to nasal skin
envelope.
4. Thinned skin in old patient with calcification
of the silicone surface and capsule (Fig. 32).
Fig. 22  Previous thread is tightly tethering the tip skin
Fig. 23  Large PDO thread was visible through the nasal skin
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299
Fig. 24  Demarcation can be corrected with implant change. Previous goretex implant was switched into a silicone one.
Above, before operation. Below, after operation
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300
5. Foreign body or permanent filler injection his-
tory (Fig. 33).
6. Thin, erythematous skin quality as a preexist-
ing condition.
Potential Causes of Tip Skin Redness
Nasal tip redness may be a transient symptom
that may vary with changes in temperature or
other external stimuli. Although most of the
time, transient nasal tip redness does not pose a
serious problem, continuous redness may indi-
cate a significant clinical problem. Potential
causes of nasal tip skin redness are as follows:
1. Subcutaneous placement of implant or exces-
sive pressure at nasal tip irrelevant to implant
type (Fig. 34).
2. Presence of a foreign body or fillers at tip
(Fig. 35).
3. Chronic inflammation.
4. Calcification of an old implant and its
capsule.
Fig. 25  A case with old, calcified silicone. Silicone and capsule were removed and replaced with autologous tissue
Fig. 26  Osteotomies are a good option to correct the wide bony base
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301
5. Habitual touching of the nasal tip.
6. Preexisting skin conditions such as acne or
rosacea.
Treatment of Nasal Skin Redness
The most ideal treatment for dorsal skin or nasal
tip redness is reinforcement of erythematous skin
envelope with autologous material. However,
treatment may be difficult in cases where com-
plete removal of foreign material from the SSTE
is impossible or due to patient skin quality.
Repetitive and direct laser therapy over the nasal
skin area after rhinoplasty may cause a persistent
erythematous skin reaction or skin damage,
therefore, patients should be advised to avoid
them. Skin redness might not be alleviated and
may persist even after treatment varying on skin
conditions and severity of damage.
Fig. 27  Deep temporal fascia can be used to reinforce thin nasal skin with or without implant
Fig. 28  Acellular dermal matrix (ADM) can be one option to reinforce thin nasal skin with or without implant
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302
Tip Hardness and Discomfort
The nasal tip is naturally exposed to frequent
stimuli such as touching, blowing, and rubbing in
ordinary life. Occasionally, patients may seek
revisional surgery complaining of tip immobility,
hardness, and discomfort due to a previous oper-
ation. If the nasal tip is excessively firm, patients
may experience a foreign body sensation or dis-
comfort even when smiling or talking. Tip hard-
ness after rhinoplasty can vary with the surgical
methods by each surgeon. Tip hardness will
exacerbate relative to the strength of union
between the tip complex and the caudal and dor-
sal septal strut.
Causes of Tip Hardness
and Discomfort
Patients complain of nasal tip hardness with limi-
tations in tip mobility in the following cases:
1. When the dorsal implant extends over the
nasal tip.
2. Usage of an L-shaped nasal implant (Fig. 36).
3. Tip surgery with rigid materials such as irradi-
ated homologous costal cartilage (IHCC),
medpor, or mesh (Fig. 37).
4. Tip surgery with a type of septal extension
graft.
5. Sensitive patients may complain of discom-
fort even just with columellar strut and onlay
grafts.
6. Contracture due to chronic inflammation.
7. A history of multiple surgeries on the nose.
Treatment of Tip Hardness
and Discomfort
Depending on surgical methods, there may be
limitations in nasal tip mobility which could
result in tip hardness (Fig.  38). Patients who
have had surgery with a septal extension graft
Fig. 29  A case with a narrow implant located superficially. Intraoperative photos showing supplement envelope using
capsular flap by silicone implant
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303
may complain of tip hardness with ensuing
arrow tip or even smiling deformity (Fig.  39).
Therefore, surgical correction is usually manda-
tory for relief of symptoms. It is important that
the tip complex should be a separate structure
from the L-strut or caudal strut as much as
possible.
Visible Implant onto the Tip
Concomitant with symptoms of hardness and dis-
comfort, other problems such as tip skin redness,
skin thinning, demarcation, extending to varying
degrees of tip, columellar and nostril deformities
may arise (Fig.  40). These problems are often
observed in I-shaped implants that extend over
into the tip area, or in L-shaped implants. Implant
tip visibility is closely related to tip skin thick-
ness and the solidity of the grafted material and
can even be seen in autologous tip grafts. Hard
and stiff material will give a significant and con-
tinuous pressure over the overlying skin resulting
in thinning of the subcutaneous and dermal lay-
ers and consequent demarcation of the material
margin. Correction becomes more complicated
because surgical treatment involves multiple
modalities including removal of the implant, skin
reinforcement, and framework restoration. Skin
reinforcement alone is usually inadequate.
Crushed, diced or morselized cartilage can be
used to fill up the dead space. In some cases, it
may be necessary to use pull out sutures to fix
dermal or fascial grafts into defected space.
a
d
e
b
c
Fig. 30  Illustration of silicone-induced capsular flap. (a)
Previous silicone and capsule, (b) dissection between
nasal envelope and anterior capsule, (c) dissection
between posterior capsule and inner framework, (d)
removal of previous silicone implant, and (e) placement of
new silicone implant under the posterior capsule (Jeong
JY, Oh SH, Suh MK, Kim CK, Kim K. Effective Use of a
Silicone-induced Capsular Flap in Secondary Asian
Rhinoplasty. Plast Reconstr Surg Glob Open 2014;
2:e172)
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304
Fig. 31  Minor irregularity can be corrected with filler or micro-fat injection
Fig. 32  Calcified silicone stimulated nasal skin and showed redness on nasal skin. This case was corrected with der-
mofat graft from sacrococcygeal area
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305
a
b
c
Fig. 33  (a) Preoperative view of patient with previous injection of foreign material, (b) the removed foreign bodies.
Intraoperative view showing correction of nasal dorsum with dermofat graft, and (c) postoperative view
Secondary Rhinoplasty (1): Implant-Related Complications

306
Fig. 34  A case with continuous rash and redness on nose after repeated revisional rhinoplasty. Goretex implant and
foreign bodies were removed and dermofat graft was used for dorsum
Fig. 35  Persistent supratip redness due to foreign material injected a long time ago
Fig. 36  Large L-shaped implant was switched into tapered tail-shaped one in secondary rhinoplasty
J. Jeong

307
a
b
c
Fig. 37  (a) Irradiated homologous costal cartilage (IHCC), (b) polyethylene (medpor), and (c) polycaprolactone (PCL)
Fig. 38  A degree of tip hardness differs from surgical method
Secondary Rhinoplasty (1): Implant-Related Complications

308
Implant Exposure Through
the Nasal Skin
When chronic inflammation or contracture is left
untreated, or when there is an aggravation of irri-
tation by the implanted material to overlying nasal
envelope, implant exposure at the external or ves-
tibular skin may occur with localized inflamma-
tion (Fig. 41). Generally, various other deformities
that are difficult to treat manifest alongside expo-
sure. The perforation of the skin in conjunction
with skin thinning will negatively impact progno-
sis and affect successful treatment. Therefore, it is
very important that problematic issues be
Fig. 39  Arrow tip while smiling after septal extension graft
Fig. 40  Variable features of tip demarcation
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309
addressed before implant exposure (Fig.  42).
Treatment for exposure includes prompt removal
of the prosthetic implant with autologous recon-
struction and a staged treatment process may be
necessary depending on severity. Primarily, with
severe infection, inflammation and prolonged
exposure, the implant should be removed, and
inflammation should be controlled. Then, the cos-
metic aspects should be addressed in a secondary
surgery. Using the prosthetic implant should be
avoided in reconstruction, and autologous grafts
with fascia, dermis, or cartilage may be helpful to
reconstruct and reinforce the damaged skin to pre-
vent further deformities.
Fig. 41  Variable features of implant exposure
Fig. 42  A case with impending extrusion of silicone implant through the tip skin. Correction was done with ear carti-
lage after removal of implant and thickened capsule
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310
Implant Exposure Through
the Intranasal Mucosa
The causes of implant exposure to the intranasal
mucosa are the same as exposure to the nasal
skin (Fig.  43). However, diagnosis might be
delayed when there is exposure to the intranasal
mucosa (Fig. 44). Due to the rising propensity
for open rhinoplasty and increasing uses of vari-
ous materials such as medpor, mesh, and scaf-
folds, the incidence of septal problems is rising,
and treatment is becoming more complex.
Inappropriate or aggressive septal management
such as mucoperichondrial tearing, nasal pack-
ing, or trans-­septal suturing increases the risk of
septal perforation. Therefore, using an endos-
copy for direct visualization to evaluate the
intranasal cavity is advisable after surgery
(Fig. 45). Treatment includes the removal of all
implanted materials and immediate or staged
reconstruction with autologous tissue.
Inflammation and Infection
Inflammation after rhinoplasty is a major issue,
leading to severe complications and irreversible
disaster if not treated properly. The causes of
inflammation and infection after rhinoplasty are
similar to the causes after any surgical procedure,
but their etiologic factors in rhinoplasty can be
explained in detail as shown in Table  1.
Furthermore, it may be difficult to clearly identify
the specific cause of inflammation immediately, so
in the clinical setting, it is more important to alle-
viate and treat the inflammation promptly rather
than to identify the cause. Thus, the aim of treat-
ment is to curtail the duration of the inflammation
Fig. 44  Persistent exposure of implant caused contracted nose and discoloration of exposed implant. Although implant
has been exposed for a long time, patient did not recognize it
Fig. 43  A case with extrusion of silicone implant through the vestibular skin. Correction was done with septal cartilage
and dermofat graft after removal of implant and thickened capsule
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311
period and prevent the formation of abnormal scar
tissue or contracture. The aim of treatment is
applicable to other operations but because the nose
is a small organ with relatively thin soft tissue, the
results of untreated or delayed treatment can bring
more devastating consequences.
Rhinoplasty falls in the category of clean con-
taminated surgery and the rate of infection is
relatively low. Although the reported rates of
inflammation and infection related to implants
vary widely, in reference to available literature,
the mean rate is approximately 2.5–5.3%.
According to the author’s experiences, among
the approximately 2300 total patients available
for serial clinical assessment, from serious to
minimal inflammations were observed in 34
patients (1.48%). Viral infections comprised
approximately 0.61% of total cases (Table 2).
With the exclusion of incidences directly or
indirectly related to individual patient factors
such as underlying disease and sterilization
problems, the following factors can contribute to
the risk of inflammation after rhinoplasty:
1. Prolonged operation time.
2. Excessive size of implant after humpectomy
or bony reduction.
3. Poor intranasal hygiene (heavy smoker and
intraoral device).
4. The presence of intranasal disorders such as
chronic sinusitis and rhinitis.
5. Dorsal / septal hematoma—increased suscep-
tibility to inflammation and infection.
6. Abnormal, continuous physical stimulations
(habitual touching, rubbing, blowing, or
picking).
7. History of permanent filler injection or
unknown foreign body material.
8. Secondary surgery or history of successive
revision rhinoplasties.
9. Concomitant septal work (septoplasty) and
rhinoplasty using implant.
a
b
c
Fig. 45  (a) Medpor exposure, (b) PCL mesh exposure, and (c) silicone implant exposure
Table 1  Various predisposing factors causing inflamma-
tion in rhinoplasty
Causes
Predisposing factors
Contamination
Instruments and implant
Operation environment
Patient
Surgeon and assistant
Tissue damage
Prolonged operation time
Swelling/hematoma
d/t previous operation, trauma Hx
d/t foreign body or filler injection
Surgical
mistakes
Prolonged operation time
Aggressive handling (or retraction)
Incorrect procedure
Invasive management
Improper bleeding control
Foreign body
Nasal implant (silicone/gore-texⓇ/
medporⓇ/alloderm)
Unknown foreign material
Fillers
Threads
Patient’s
condition
Multiple operations
Previous medical history
Smoking/alcohol
Intranasal disease (chronic rhinitis,
sinusitis)
Poor hygiene (oral, nasal)
Patient’s habits
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312
The incidence of inflammation in Asian rhino-
plasty is closely correlated with the use of
implants. However, according to the author’s
17-year experience with rhinoplasty, the causes
of inflammation and infection were mainly attrib-
uted to improper surgical technique, vascular
insufficiency, and other patient factors including
psychological state and smoking as described in
Table 1, and not necessarily by the implant itself.
As demonstrated in numerous studies, smoking
has a significant effect on healing and moderation
of inflammation. Also, usage of excessively over-
sized implants should be avoided, and care should
be taken not to cause unnecessary damage by
overaggressive manipulation on tissues to avoid
complications.
Inflammation Related to Implants
In general, acute symptoms of inflammation
related to implants appear within a week after
surgery. Localized tenderness and heating sensa-
tions occur approximately 3–5 days after surgery
accompanied by general symptoms such as fever,
chills, and malaise. The dorsal skin usually shows
erythematous and painful swelling (Fig.  46).
Purulent drainage from the nasal dorsum usually
includes traces of blood, inflammatory, and
necrotic cells.
Purulent exudates should be cultured to evalu-
ate and guide antibiotic treatment but, symptoms
of acute inflammation related to dorsal implants
should be addressed for early removal of the
implant and control of the inflammation. If the
inflammation is controlled by irrigation and
implant removal within 2  weeks after onset of
symptoms, not only inflammation symptoms are
usually controlled 2–3  days after removal, but
also autologous cartilage grafts used for tip work
and structural framework can be salvaged.
Antibiotic treatment alone can alleviate acute
symptoms of inflammation but can mask the
severity of the underlying inflammation. This
may cause tissue damage and increased scar tis-
sue in the long run, leading to more difficulties in
Table 2  The incidence of inflammation and infection during author’s own rhinoplasty for recent 3 years
Cases
No.
Inflammation and infection
Viral infection
Dorsum
Tip
Septum
Primary
1777
10
3
3
11
Secondary
537
8
6
4
3
Total
2314
18
9
7
14
%
100
0.78
0.39
0.3
0.61
Fig. 46  Acute inflammation
J. Jeong

313
management and increase the risk of contracture.
When
symptoms
of
acute
inflammation
­completely subside with sufficient treatment
including implant removal, a revision surgery
with an implant may be attempted after at least
6  months. However, it is recommended that
autologous graft materials are used in case with
inflammation history.
Persistent swelling or swelling with a wax
and wane pattern is highly indicative of chronic
inflammation (Fig. 47). If the implant is removed
after more than two weeks after surgery, treat-
ment should consist of complete removal of
implant and rigorous irrigation and gentle curet-
ting to eliminate any traces of inflammatory
­granulation tissue that may be a cause of chronic
inflammation. Even with such measures, patients
may experience persistent pericapsular seromas
or cysts. Caution should be taken to avoid the
formation of irregular scar tissue at the nasal root
area due to tearing or displacement of the cap-
sule during removal. If the inflammation is con-
fined within the capsule in chronic patients, a
one-­stage revision surgery can be performed
with total capsulectomy (Fig. 48). If the inflam-
mation has extended to adjacent soft tissue,
treatment should aim to control soft tissue
inflammation, and when symptoms of chronic
inflammation manifest, all implant materials
should be removed in their entirety and inflam-
matory granulation should be debrided to sal-
vage soft tissue. When inflammation is under
complete control, a staged revision to shape the
nose can be done (Fig. 49).
Fig. 47  Chronic inflammation. Turbid, purulent discharge was observed
Fig. 48  Chronic swelling on dorsum should be suspected as inflammation. Previously used implant and capsule were
removed and replaced with autologous rib cartilage
Secondary Rhinoplasty (1): Implant-Related Complications

314
Biofilms in the Operated Nose
Staphylococcus epidermidis is known as the main
cause of biofilms. This bacterial strain is strongly
resistant to antibiotics and can cause inflamma-
tory reactions that cannot be cultured in a labora-
tory. Biofilms cause severe capsular contracture
by stimulating the capsule and facilitating fibrotic
reactions in a continuous manner which exacer-
bates inflammation and subsequent tissue defor-
mity by sustained maturation steps. (Fig.  50).
Unless the etiologic factors are removed, the
excessive proliferation of fibrosis continues by
the signaling pathway observed in fibromatosis,
Dupuytren’s disease, and hypertrophic scars.
Confirmation of a biofilm with culture studies
remains unclear, but clinical manifestations can
help predict its presence and molecular studies
such as PCR (polymerase chain reaction) and
electron microscopy can be utilized if needed.
Inflammation: As an Initiator
for Contracture
Contracture deformity in rhinoplasty is closely
related to silicone implants and their capsules.
Inflammation caused by dorsal implants is con-
tinuously exacerbated by biofilms and granula-
tion tissue within the capsule, leading to increased
severity of fibrosis and capsular thickening.
Consequently, the elasticity of the capsule is
compromised which eventually predisposes the
capsule to shorten. A traction force on the alar
cartilage, or entire distal mobile framework,
results in upturned tip deformity, alar notching,
and nostril show (Fig. 51). Chronic inflammation
due to implants (medpor, mesh, or scaffold) in
septum can lead to more devastating deformities.
When the elastic nature of the membrane is com-
promised, the membranous septum, void of carti-
lage framework, shortens, and the columella
a
b
c
Fig. 49  A case with staged operation. (a) Purulent dis-
charge on tip due to chronic inflammation. First stage
operation was done to remove goretex implant and granu-
lation tissue, (b) Two weeks later after inflammation sub-
sided, second stage operation was done for tip
reconstruction using ear cartilage and dermofat graft, and
(c) final postoperative view
J. Jeong

315
retracts with scarring and fibrosis and the entire
tip complex is retracted in the cephalic direction
(Fig. 52).
Inflammation Due to Autologous
Graft Failure
Inflammation can also occur in patients who have
undergone rhinoplasty using only autologous mate-
rials. However, the prognosis is generally better, and
treatment is less complex. Causes that can contrib-
ute to autologous graft inflammation and failure
include contamination of the graft, hematoma,
chronic smoking, multiple rhinoplasties, aggressive
handling of graft materials, and tissue damage due
to prolonged surgical time. Early wound healing is
important because delayed wound healing due to
such tissue injury can serve as a precondition for
scarring and contracture. When inflammation or
infection of the tip grafts is suspected, prompt surgi-
cal intervention can help efforts to alleviate inflam-
mation and salvage the grafts (Fig.  53). As
mentioned previously, attempts to control inflam-
mation through the sole use of antibiotics cannot
manage chronic inflammation and permanent
deformity to the nasal tip. Therefore, surgical inter-
vention should always be contemplated. Septal
inflammation can result in especially dire conse-
quences and serious deformities. Efforts should be
made to prevent septal hematomas during surgery
and prompt treatment and inflammation control
should be implemented when suspected (Fig. 54).
Viral Infection around Nose
Eczema herpeticum or Karposis varicelliform
eruptions of the perinasal skin are the most com-
mon viral infections affecting the nose. Infection
with the herpes simplex or coxsackie A16 virus is
the cause and symptoms appear suddenly around
Fig. 50  Chronic inflammatory capsule and silicone implant are closely related to contracture. The principle of correc-
tion is the total removal of all foreign material and granulation tissue
Nasal envelope (SSTE)
•
•
•
•
•
•
Upturned or contracted tip
Changing of SSTE texture
Persistent subclinical infection
Skin change and neovascularization
Columellar deformity
firmly adhered to the inner layer
•
•
•
•
Overlapping cartilages due to SSTE contraction
Fibrosis, thinning or thickening
capsular contracture
implant position change
due to alar cartilage damage


Fig. 51  The pattern of nasal contracture
Secondary Rhinoplasty (1): Implant-Related Complications

316
Fig. 53  Failure of autologous graft showing discharge and granulation tissue. Early intervention with curettage and
irrigation is necessary for salvage the grafts
a
b
Fig. 52  Variable features of contracted nose. (a) preoperative view and (b) postoperative view
J. Jeong

317
the nasal area or at the incision site (Fig.  55).
Skin lesions appear approximately one week
after surgery and patients who have a recurrent
history of perioral, intraoral, or intranasal herpes
eruptions are usually afflicted, although infec-
tions can be observed in patients who do not have
a history as well. Viral presentations include sud-
den disruption of the incision site after removal
of sutures, erythematous lesions at the incision
site accompanied by pain, tenderness, and umbil-
icated vesicular lesions that can lead to multiple
ulcerations in severe cases. The lesions are usu-
ally refractory to treatment by disinfection or
sterilization, IV antibiotics, or bacterial oint-
ments. Antiviral agents such as acyclovir or fam-
ciclovir and antiviral topical ointments can be
used effectively for treatment. Oral antiviral
agents taken for approximately 5–7 days can usu-
ally eliminate any symptoms uneventfully with-
out any scar (Fig.  56). However, delayed
diagnosis of viral infection after the surgery can
lead to secondary bacterial infections that can
cause permanent scarring and deformation.
Although the occurrence is rare, the surgeon
should be aware of such possible complications
to prevent disfiguring sequelae. Diagnosis can be
confirmed with viral analysis and pathohistologic
tests, but prompt diagnosis based on the clinical
presentation of symptoms is more important. In
addition, oral antiviral prophylaxis 3–5  days
prior to rhinoplasty is recommended in patients
with a history of herpes infections.
Fig. 54  Serial photos showing inflammation in septum developed after septoplasty
Fig. 55  Variable features of viral infection (Eczema herpeticum)
Secondary Rhinoplasty (1): Implant-Related Complications

318
Further Reading
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Cabouli JL, Guerrissi JO, Mileto A, et  al. Local infec-
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a
b
Fig. 56  A follow-up of viral infections after the operation around. (a) Columella and alar base and (b) incision site for
percutaneous lateral osteotomy
J. Jeong

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Secondary Rhinoplasty (1): Implant-Related Complications

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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 (2):
Mid-­vault Correction
Man Koon SUH
There are a variety of mid-vault problems that
occur after mid-vault and septal surgery. Among
them, the most common are dorsal irregularity,
open roof deformity, inverted-V deformity after
hump reduction, and saddle nose deformity after
septal surgery.
Post-humpectomy Dorsal
Irregularities
Dorsal irregularities after hump reduction include
residual hump and focal dorsal depression.
Residual Dorsal Hump
Small residual hump is difficult to detect due to
swelling during dorsal hump reduction surgery.
Reduced hump area should not be evaluated
purely based on sight but should also be checked
by finger palpation several times. In spite of this
precaution, small hump can be revealed as the
swelling subsides.
A small residual bony hump can be cor-
rected by rasping with a file, which can be eas-
ily accomplished through closed approach.
Intercartilaginous incision is close to residual
hump and allows greater visualization of the
residual hump. After mucosal incision between
upper and lower cartilage, the soft tissue and
periosteum is elevated from the upper lateral car-
tilage and nasal bone. The scar tissue from prior
operation makes this a difficult step that requires
a meticulous and tenacious approach. Application
of excessive force through the elevator can result
in penetration injury to the underlying bone or
cartilage. In addition, incompletely elevated soft
tissue on the framework will be eliminated by
rasping. This decrease in soft tissue thickness can
worsen the dorsal irregularity.
A bony hump can be removed by rasping,
while a cartilaginous residual hump will require
excision using No. 15 blade under direct vision.
Large dorsal septal hump should be removed
after the upper lateral cartilages are separated
from the dorsal septum to avoid inverted-V
deformity (component resection). Component
resection is easier to perform through an open
approach.
Spreader graft may be required for the preven-
tion of inverted-V deformity and for filling the
large open roof in narrow nasal bone in which
osteotomy cannot be performed.
Depressed Dorsum
Dorsal depression from the excessive removal of
hump is treated with filling up the depression
with crushed cartilage graft.
M. K. SUH (*)
JW Plastic Surgery Center, Seoul, South Korea

322
A piece of crushed conchal or septal carti-
lage can be a good solution for a small defect,
but a diced cartilage wrapped in deep temporal
fascia will be required for large defect. Crushed
cartilage graft can be placed through a closed
approach (Fig. 1).
Depression can also be filled with an autog-
enous dermal or allodermal graft. However, this
will require overcorrection to compensate for
partial resorption, and this will be less predict-
able than cartilage graft.
Open Roof Deformity
Nasal dorsum of the nose appears flat after large
hump reduction, which is an open roof deformity.
This deformity is characterized by the visibility
a
b
c
Fig. 1  Correction of dorsal irregularity. (a) Focal point of
dorsal irregularity after hump reduction, (b) Crushed sep-
tal cartilage, (c) Photographs at 3 months after operation
(rasping of bony hump and crushed cartilage graft on the
depressed lower dorsum)
M. K. SUH

323
or palpability of dorsal groove between the nasal
bone and the bony septum.
It is not uncommon to observe an open roof
deformity despite attempts at closing the roof
with osteotomy after bony hump reduction. This
deformity comes from several causes. First,
osteotomy was not accomplished successfully
in closing the roof. Second, the roof was closed
during the operation but was distracted from an
incomplete greenstick fracture. Other causes
include high septal deviation and large hump
with thick nasal bone.
Correction of open roof deformity requires
revisional lateral and medial osteotomies to close
open roof (Fig. 2). Sometimes spreader graft to
fill the bony gap is needed, and camouflage lay-
ers like perichondrium or fascial graft maybe
required.
a
b
c
d
Fig. 2  Open roof deformity. (a) Flat open roof deformity
is observed on mid-dorsal area which occurred after hump
reduction surgery. This patient also has a deviated dorsal
septum. (b) Operative markings for medial and lateral
osteotomy. (c) Intraoperative picture showing spreader
graft on both sides of the dorsal septum to fill the open
roof and to correct the dorsal septal deviation. Two layers
of conchal cartilage graft were placed on right side of the
dorsal septum while one layer of conchal cartilage was
placed on left side of the septum. (d) Open roof deformity
was well corrected after surgery
Secondary Rhinoplasty (2): Mid-vault Correction

324
Inverted-V Deformity
Inverted-V deformity is an inverted V-shaped
indentation between the caudal margin of nasal
bones and the upper lateral cartilages (Fig.  3).
This deformity can result from removal of dorsal
hump, if the upper lateral cartilages collapse
inferomedially against the septum. The deformity
interrupts dorsal esthetic line and may also cause
respiratory dysfunction.
The deformity occurs following a composite
hump removal surgery. After hump resection of
nasal bone and upper lateral cartilages as one
block, the upper lateral cartilages are mobilized
medially (Fig. 4). To prevent inverted-V defor-
mity, component resection is more recommended
than composite hump removal.
When performing the component resection of
the hump, if the lateral wing of dorsal septum is
incorporated into dorsal hump resection, it will
decrease the dorsal width and result in inverted-V
deformity (Fig. 5). The correct component resec-
tion preserves the lateral wing of dorsal septum
with the upper lateral cartilages.
Even if the lateral wing is preserved through
the component resection, the operator should
have low threshold for employing the spreader
graft to counter any medialization of the upper
lateral cartilage.
Correction Technique
Spreader Graft
Spreader graft is the most commonly performed
procedure to correct the inverted-V deformity
and internal valve collapse by spread out upper
lateral cartilage laterally. The graft is a long piece
of cartilage inserted between the dorsal septum
and upper lateral cartilages. It can act as a spacer
graft to push the upper lateral cartilages laterally
and to widen the space between the upper lateral
cartilage and dorsal septum (Figs. 6 and 7). The
ideal source for the graft is the septal cartilage. It
can also be prepared from auricular cartilage or
costal cartilage. The prepared graft is 3 mm in
height, 1–2 cm in length, and 1–3 mm in width.
After the separation of upper lateral cartilages
from dorsal septum, spreader grafts are inserted
bilaterally between the dorsal septum and upper
lateral cartilages. The grafts span from the nasal
bone to the caudal margin of upper lateral car-
tilages. If the upper lateral cartilage collapse is
uneven on both sides, the thickness of spreader
grafts is varied to make up for the difference
between both sides.
Splay Graft
The best donor for splay graft is conchal cartilage
and this technique is used for severe collapse of
lower lateral cartilages (Fig. 8). From the under-
side of both upper lateral cartilages, the mucop-
erichondrium is dissected and detached. The
graft is placed deep to the left and right upper
lateral cartilages and inserted between the under-
surface of the upper lateral cartilage and detached
mucoperichondrium. The intrinsic spring power
of the splay graft elevates upper lateral cartilages
with the septum as the fulcrum, which can cor-
rect the middle vault collapse (inverted-V
Fig. 3  Inverted-V deformity
M. K. SUH

325
­deformity) and open the internal valve. If there is
a pre-existing collapse or deficiency in the dorsal
septum, the deficient area is augmented using the
thickness of splay graft. If the dorsal septum is
not low, the splay graft can cause a dorsal hump.
As such, the dorsal septum should be lowered
before placement of the splay graft.
The powerful splay effect, however, can
result in excessive widening of caudal portion of
dorsum.
Fig. 4  Composite
resection of hump can
result in inferomedial
collapse of upper lateral
cartilages
a
b
Fig. 5  Component resection of hump. (a) During compo-
nent resection, if the lateral wing of dorsal septum is
incorporated into dorsal hump resection, it will decrease
the dorsal width and result in inverted-V deformity. (b)
The correct component resection preserves the lateral
wing of dorsal septum with the upper lateral cartilages
Secondary Rhinoplasty (2): Mid-vault Correction

326
Saddle Nose Deformity
As the frequency of using septal cartilage for rhi-
noplasty increases, the saddle nose deformity
becomes an extremely familiar clinical entity for
a rhinoplasty surgeon. The deformity refers to
sunken nasal dorsum from loss of septal support
and/or nasal bone height loss (Fig. 9). It is char-
acterized by mid-vault collapse and involves car-
tilaginous component and/or bony component of
a
b
c
d
Fig. 6  Spreader graft to correct the inverted-V deformity. (a, b) inverted-V deformity, (c, d) Bilateral spreader grafts
were placed between the dorsal septum and upper lateral cartilages
a
b
Fig. 7  Correction of inverted-V deformity using bilateral spreader graft. (a) Preoperative photograph, (b) Postoperative
photograph at 4 months
M. K. SUH

327
Fig. 8  Splay graft
a
b
Fig. 9  Saddle nose deformity after submucosal resection (SMR) (a, b)
Secondary Rhinoplasty (2): Mid-vault Correction

328
the dorsum. The deformity has various clinical
features:
1. Mid-vault depression due to loss of cartilagi-
nous and bony support of mid-dorsum.
2. Tip de-projection.
3. Cephalic rotation of the tip (upturned tip).
4. Columellar retrusion.
The collapse in upper and lower lateral carti-
lages can lead to internal and external valve col-
lapse leading to nasal obstruction.
Causes and Classification
Saddle nose can be caused by prior septal surgery,
septal hematoma, septal infection leading to
abscess, severe external trauma to the nose, recur-
rent polychondritis, Wegener’s granulomatosis,
sarcoidosis, congenital syphilis, leprosy, and
cocaine abuse. Even if the most common cause of
mid-vault collapse is nasal trauma, the most impor-
tant cause of saddle nose is insufficient septal
L-strut from a prior SMR or septal cartilage har-
vest. The usual recommendation is to leave a strut
with 10–12 mm of width. However, the dorsal strut
may need to be up to 12–15 mm wide, depending
on the thickness of septal cartilage. An L-strut of
inadequate width may appear to be normal during
the operation, but can result in dorsal collapse over
several years due to contracture of scar tissue and
aging process (Fig. 10). Sometimes, even if septal
L-strut of appropriate width is left, acute collapse
can occur due to external trauma on nasal dorsum.
The classification of saddle nose deformity
has been introduced by a number of authors.
The classification based on septal condition and
tip and columellar deformity is important for
correlating the severity of deformity and treat-
ment modality. Daniel and Brenner classified the
deformity according to the severity, with treat-
ment modality for each classification.
Each classification has its own advantage, but
a new classification is needed to reflect the hidden
septal collapse that is not uncommon in Asians.
As such, the author uses the following modified
classification for Asian saddle nose (Fig. 11).
• Type I: mild supratip depression with/without
slight columellar retraction, while tip projec-
tion is not affected. Deformity is stable and
not progressive.
• Type IIa: mild supratip depression and colu-
mellar retraction (like in type I deformity) but
supratip depression becomes worse with man-
ual pressure and the deformity is progressive
recently. The manual palpation to evaluate for
depression is very important in determining
the treatment method (Fig. 12).
• Type IIb: advanced deformity with mild loss
of tip projection and columella retraction.
• Type III: total loss of cartilage vault integrity,
flattening of the nasal lobule, and severely
retracted columella.
• Type IV: Type III and loss of bony vault
integrity.
Correction of Saddle Nose Deformity
As described above, the saddle nose deformity
exists in a wide spectrum from minimal mid-­
dorsal depression to severe collapse of whole
dorsum. Depending on the severity, the treatment
option can range from simple camouflage tech-
nique to structural reconstruction.
Fig. 10  Without a robust septal L-strut, the dorsal and
caudal septum will gradually collapse with the contracture
of scar tissue and aging process
M. K. SUH

329
Camouflage Operation for Type I Static
Saddle Nose
The author believes that camouflage technique
can be very useful in type I mild saddle nose. For
the camouflage technique to be possible, the most
important prerequisite is that the septal support
compromise should be static, not progressive
without functional problem. To confirm this, it is
necessary to obtain information from the patient
that supratip sinking has not progressed in recent
Fig. 11  Author’s classification for Asian saddle nose deformity
Type I: mild supratip depression with/ without slight columellar retraction, while tip projection is not affected. Deformity
is stable and not progressive.
Type IIa: mild supratip depression and columellar retraction (like in type I deformity) but with supratip depression with
manual pressure with progressive deformity. The manual palpation to evaluate for depression is very important in deter-
mining the treatment method (Fig. 16–100).
Type IIb: advanced deformity with mild loss of tip projection and columella retraction.
Type III: total loss of cartilage vault integrity, flattening of the nasal lobule, and severely retracted columella.
Type IV: Type III and loss of bony vault integrity
Secondary Rhinoplasty (2): Mid-vault Correction

330
years. A more important factor is: when manual
compression is applied to supratip area, sinking
should not be more severe and should be stable.
This supplies extremely important information
regarding stability of supratip and tip support.
Cotton swab palpation and rhinoscopy can pro-
vide supplemental information.
Type I saddle nose (mild supratip depression
and columella retraction, without tip projec-
tion problem with static dorsal septal cartilage)
can be treated with camouflage technique using
cartilage onlay graft on mid-dorsal sunken area
(Fig. 13).
For the camouflage technique to be valid, the
surgeon must palpate the mid-vault to confirm
that the dorsal septum is stable. One or multiple
layers of crushed conchal or rib cartilage can be
grafted for camouflage purpose (Fig.  14). The
graft can be placed to the sunken area through
the intercartilaginous or inframarginal incision.
Cartilage graft does not undergo significant
resorption, and overcorrection is unnecessary.
Camouflage graft for columellar retrusion can be
placed through transfixion incision. Diced carti-
lage can also be used but is not as predictable as
solid cartilage grafts due to resorption.
The camouflage technique can be performed
with alloplastic implant (Fig. 15). Among implants,
a
b
Fig. 12  An example of Type IIa saddle nose. The saddle is not readily visible (a) but becomes apparent with gentle
pressure on the dorsum (b)
Fig. 13  Camouflage technique (cartilage dorsal onlay
graft) for Type I saddle nose
M. K. SUH

331
e-PTFE implant is more recommended, because
when the implant is placed on the supraperichon-
drial plane, e-PTFE implant is less movable and
fixated more firmly compared to silicone implant.
Soft tissue like dermis or fascia graft is less
predictable from resorption and is not generally
recommended for this camouflage purpose.
Camouflage technique can provide a rela-
tively easy technique to correct the mid-vault
depression of a saddle nose with stable septum,
while allowing for a soft movable tip. However,
patients should understand that it is not without
recurrent sunken deformity.
Camouflage technique should be performed
only after a sufficient amount of time has passed
for a saddle nose to have stabilized. Also, this tech-
nique should not be used where a wide dissection
is required for additional procedures, in order to
minimize the effect of scar contracture. In Asian
patients with thick skin, scar contracture can rarely
lead to sudden worsening of saddle nose.
Anatomical Structural Reconstruction
Type IIb and more severe saddle nose type III
require anatomical L-strut reconstruction costal
cartilage. This reconstruction consists of bilateral
extended spreader grafts and a columellar strut
(Fig. 16).
The harvested costal cartilage is sliced into
thin lengthwise slices and allowed to warp in an
antibiotic solution for at least one hour. There are
two ways to slice costal cartilage. One is a coro-
nal slicing and the other is a sagittal (anterior-to-­
posterior direction) slicing (Fig. 17). Which of the
two methods is suggested depends on the case.
Generally, sagittal slicing is more recommended
because it is easier to perform and has less warp-
ing. A symmetric pair of warped pieces of sliced
a
b
Fig. 14  Correction of Type I saddle nose using cartilage onlay graft. (a) Preoperative photograph, (b) Postoperative
photograph at 7 months
Secondary Rhinoplasty (2): Mid-vault Correction

332
costal cartilage are chosen and placed on both
sides of the dorsal cephalic septal stump (Fig. 18).
The cephalic end of extended spreader grafts
is inserted cephalically under the nasal bone and
fixed to the remaining dorsal septal stump. If the
septal stump is unstable, the cephalic end of rib
cartilage is placed under the nasal bone and fix-
ated with a suture through a hole drilled in the
nasal bone (Fig.  19). Alternatively, the caudal
border of the nasal bone is excised in a wedge
a
b
c
Fig. 15  Saddle nose correction using an e-PTFE implant.
(a) In this patient with history of submucosal resection, an
episode of nasal trauma onto the weakened septum was
the cause of saddle nose deformity, which was addressed
with dorsal augmentation (e-PTFE implant) and tip plasty
(columellar strut graft using conchal cartilage), (b)
Postoperative photograph after 1 year. (c) At 3 years after
the operation, the patient returned to the clinic after an
episode of trauma to the nasal dorsum. No deformity is
appreciated except for the minor soft tissue trauma
M. K. SUH

333
shape, and the proximal end of grafts is secured
to the wedge and fixated with a suture through
a drilled hole. Extended spreader grafts enhance
the function of internal valve.
Shorter, wider straight piece of sliced costal
cartilage is placed between the two caudal ends
of extended spreader grafts. This is the fixed type
of columellar strut graft, which should be wide
enough (10–15 mm) and designed to push down
the columellar labial angle and project the tip.
This strut graft is sutured to or in front of the ante-
rior nasal spine. Firm fixation of the graft to pre-
maxilla area is critical for stable reconstruction of
L-strut. The fixation suture may be easier to fix to
the periosteum of anterior nasal spine. However,
if that is not possible, drilling a hole in the ante-
rior nasal spine is required. Anterior end and cau-
dal margin of the strut graft should be positioned
more anteriorly and caudally, respectively, to the
caudal end of spreader graft to project the tip and
move the columella caudally (Fig.  18). Upper
lateral cartilages are lifted, pulled caudally, and
fixated to the strut graft. Additional tip projection
or elongation can be achieved by cartilage onlay
or shield grafts.
Fig. 16  Septal L-strut reconstruction using bilateral
extended spreader grafts and a columellar strut
a
b
c
d
Fig. 17  Two techniques of slicing costal cartilage. (a, b) Coronal slicing, (c, d) Sagittal (anterior-to-posterior) slicing
Secondary Rhinoplasty (2): Mid-vault Correction

334
a
b
c
d
e
Fig. 18  L-strut reconstruction using the costal cartilage.
(a) Sliced costal cartilage, (b, c, d) After upper lateral car-
tilages were detached from the dorsal septum, the col-
lapsed septal L-strut is reconstructed using bilateral
extended spreader type of septal extension graft and colu-
mellar strut graft using costal cartilage. Caudal margin of
the columellar strut graft is positioned more caudally and
anterior end of the graft placed more anteriorly to the cau-
dal end of spreader graft to project the columella and nasal
tip. (e) Lower lateral cartilages are fixed to the strut graft.
Tip shield graft, plunging graft, and dorsal onlay graft
were performed using costal cartilage
M. K. SUH

335
In Fig. 20, a female patient has sunken mid-­
vault concealed by dorsal implant and upturned
tip. She underwent removal of dorsal silicone
implant, capsulectomy, lateral osteotomy to
reduce nasal bony width, L-strut reconstruction
using extended spreader graft and columellar
strut graft (costal cartilage), and dorsal augmen-
tation (allograft dermal graft).
A longer and wider slice obtained from coro-
nal section of harvested costal cartilage can used
as an alternative to a tongue-and-groove tech-
nique (septal extension graft plus columellar strut
graft) described above and allow a single block
technique (Fig. 21).
The operator is likely to be tempted to correct
a Type IIa deformity with a camouflage tech-
nique. However, the camouflage technique does
not resolve any underlying structural weakness
and can result in progressive dorsal collapse,
which will require another revisional operation.
Operator must fight temptation to correct Type
IIa with simple dorsal onlay graft. The author
recommends anatomical structural reconstruc-
tion for Type IIa, whenever possible.
One of disadvantages of structural reconstruc-
tion (L-strut reconstruction) using costal carti-
lage is very rigid nasal tip. For a soft and mobile
tip when performing L-strut reconstruction, the
costal cartilage graft for columellar strut support-
ing the caudal end of bilateral extended spreader
graft can be placed in a more cephalic position
without contacting the medial crura of lower lat-
eral cartilages, while the columellar strut and der-
otation grafts using conchal cartilage are placed
more caudally for the tip projection.
Dorsal Augmentation
In Asian patients with low dorsum, dorsal aug-
mentation is necessary in addition to mid-vault
reconstruction. The stability of L-strut and tip
position are established using the techniques
mentioned above. The dorsal augmentation is
performed as the last step because strong stable
L-strut and firm tip posture is fundamental to dor-
sal augmentation.
Autogenous tissue is ideal for correction of
saddle nose. Among them, choice of autogenous
material for dorsal augmentation is costal carti-
lage. Costal cartilage can be used as block type,
multilayered type, or diced cartilage wrapped in
temporal fascia.
The typical solid costal cartilage graft tech-
nique is the block rib cartilage technique. A graft
with balanced intrinsic stress can be obtained
by using the core portion of the cartilage (Figs.
2.16 and 2.17). The graft is fixed to the cephalic
portion of the upper lateral cartilage and caudal
portion of extended spreader graft using PDS 5-0
sutures.
Multilayered costal cartilage grafting devel-
oped to minimize the complication of graft warp-
ing can be an effective alternative technique
of solid costal cartilage graft for nasal dorsal
augmentation.
Harvested costal cartilage is sliced into thin
pieces and then submerged in a saline-filled con-
tainer for at least 30 min to expose the warping
tendencies. Several pieces of thinly sliced carti-
lage are piled-up according to the desired height
using a 5-0 PDS suture. A block of piled-up, mul-
Fig. 19  Cephalic end of the graft can be fixed to the nasal
bone after drilling the holes on the nasal bone
Secondary Rhinoplasty (2): Mid-vault Correction

336
Fig. 20  L-strut reconstruction for the correction of sad-
dle nose deformity. (a, b, c) This patient has Type III
saddle concealed by dorsal implant and short nose. (d, e,
f) She underwent removal of dorsal silicone implant, cap-
sulectomy, lateral osteotomy, L-strut reconstruction using
extended spreader graft and columellar strut graft (costal
cartilage), and dorsal augmentation (allograft dermal
graft), (g, h, i) Postoperative photographs after 3 years
a
b
c
d
M. K. SUH

337
e
f
g
h
Fig. 20  (continued)
Secondary Rhinoplasty (2): Mid-vault Correction

338
tilayered cartilages is trimmed into shape with
a No. 15 blade scalpel (Fig. 2.18). Figure 22 is
an example of saddle nose correction by L-strut
reconstruction using costal cartilage graft and
dorsal augmentation with multilayered costal
cartilage graft.
The author sometimes considers silicone or
e-PTFE implants to be acceptable in selected
cases when the autogenous tissue is not
available.
Correction of Type IV Saddle Nose
Type IV saddle nose represents the end stage of
septal collapse. Type IV saddle nose is not only
accompanied by total collapse of mid-vault but
also suffers from bony vault collapse. It is charac-
terized by collapse and flatness of whole nasal
dorsum, upturned nasal tip with loss of projec-
tion, columellar retrusion and shortening, and
occasionally external/internal valvular insuffi-
ciency. Reconstructing this type of severe saddle
nose usually requires a cantilever dorsal graft
with columellar strut graft.
Long and more straight 7th rib cartilage is pre-
pared into a solid block dorsal graft and a colu-
mellar strut graft in a tongue-in-groove formation
(Fig. 23). The dorsal graft is inserted into a dor-
sal bed and fixed using a percutaneous K-wire,
which is removed after 7 days.
In summary, correction of saddle nose requires
a graduated stepwise approach. Reconstruction
and stabilization of L-strut is a key to saddle nose
correction and provides the foundation neces-
sary for tip and columellar repositioning. And,
firm and stable mid-vault and correct tip posi-
tioning are fundamental to dorsal augmentation.
Stepwise progressive reconstruction of these
structures provides stable long-standing esthetic
contour and counteracts the contractile forces of
scar tissue.
Despite the stepwise reconstruction, a slight
mid-vault collapse can occur due to structural
instability, aging process, and contractile forces.
The first method to reduce the potential for this
complication is to apply firm fixation of cephalic
portion of the graft and secure premaxilla fixa-
tion of the fixed type columellar strut graft. If the
fixation of proximal portion of the graft cannot
be assured, the nasal bone should be drilled and
the graft fixated with a wire. The second method
to reduce the mid-vault collapse is to minimize
all forms of scarring. The force of scar contrac-
i
Fig. 20  (continued)
M. K. SUH

339
a
b
c
d
Fig. 21  L-strut reconstruction using single-piece costal
cartilage grafts. (a, b) Each of the bilateral grafts is pre-
pared from a single piece of costal cartilage slice. Right
graft is placed as spreader graft caudal end reaching ante-
rior nasal spine without the need for columellar strut graft.
(c) Small graft is placed under left side extended spreader
graft for supporting. D: Upper and lower lateral cartilage
are fixed to the costal cartilage grafts
ture is extremely high, and the effort to minimize
scarring is very important. For this, the operation
must be performed at an optimal time, with gentle
and minimal dissection, prevention of ­infection,
and postoperative medication to minimize the
risk of contracture.
The surgeon and patient should understand
the complexities of saddle nose correction and
the unexpected problem of nasal frame weak-
ness caused by aging and scar contracture.
Both parties must acknowledge that revisional
surgery may be needed down the road, and the
need for revision should not be regarded as fail-
ure of previous operation but as a consequence
of unpredictability in the complex healing
process.
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340
Fig. 22  Multilayered costal cartilage graft for saddle
nose. (a, b, c, d) This female patient who has dorsal sili-
cone implant shows a Type III saddle nose combined with
columellar retrusion and deviation. (e, f) L-strut was
reconstructed with costal cartilage, (g) Lower lateral car-
tilages are sutured to the L-strut. H: Multilayered costal
cartilage graft is ready for dorsal augmentation. (h) This
three-piece costal cartilage graft is ready for dorsal aug-
mentation. (i, j, k, l): Postoperative photographs after
3 months
a
b
c
d
M. K. SUH

341
e
f
g
h
Fig. 22  (continued)
Secondary Rhinoplasty (2): Mid-vault Correction

342
l
i
j
k
Fig. 22  (continued)
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343
Fig. 23  Correction of Type IV saddle nose. (a, b, c) This
patient suffered a significant midface injury during a
motor vehicle collision. The patient presented with saddle
nose, collapsed nasal bone, and upturned nasal tip in spite
of multiple rhinoplasties. (d) The lower lateral cartilages
are released from scar tissue and rotated caudally. Septal
support is lost. (e) Costal cartilage has been harvested. (f)
Two-layer carved costal cartilage is ready for dorsal aug-
mentation of about 10  mm in height. To lengthen the
upturned nasal tip, a small piece of costal cartilage graft is
attached to the caudal end of dorsal graft in the tongue-in-­
groove pattern. (g, h) Graft is placed in position. (i) Lower
lateral cartilages are sutured to the end of graft. (j, k, l)
Postoperative photographs at 2 years after reconstruction
a
b
c
d
Secondary Rhinoplasty (2): Mid-vault Correction

344
e
f
g
h
Fig. 23  (continued)
M. K. SUH

345
i
j
k
l
Fig. 23  (continued)
Secondary Rhinoplasty (2): Mid-vault Correction