396
Fig. 61 The patients with thick-skinned big tip. Correction by resection of cartilaginous hump, alar cartilage, and
subcutaneous tissue of the nasal tip
K. C. Lee
397
“As the septum goes, so goes the nose.” is the
important lesson to ours that the responsibility of
the nasal septum in defining the appearance of
the nasal tip. Therefore, the problems with caudal
septum, such as releasing the medial crus from the
septal attachments, correction of the caudal sep-
tum, and reposition the medial crura to a satisfac-
tory position, should be corrected as a top priority.
Additionally, the position of footplates of
medial crura is determined by nasal spine, if
anterior nasal spine is not situated in proper posi-
tion, deviation of footplates and columella can
occur (Fig. 67).
The shape, contour, and orientation of the
lower lateral cartilage affect the appearance of
the nasal tip and may make intrinsic asymmetries.
Especially, the orientation of the middle crura
may have a great effect on the shape of the nasal
tip. Severity of contour concavity in the middle
crura can significantly influence the shape of the
nasal tip. The angle of domal divergence and the
angle of domal definition are two different ele-
ments that determine the position and sharpness
of the tip defining point. Thus, asymmetry of
these angles may change projection, definition,
appearance, and rotation of the nasal tip.
Fig. 61 (continued)
Fig. 62 Cephalic trim for correction of big tip
Secondary Rhinoplasty (3): Tip
398
Fig. 63 Correction with cephalic trimming of alar cartilage, transdomal suture, and tip graft
K. C. Lee
399
Fig. 63 (continued)
Secondary Rhinoplasty (3): Tip
400
The more distinguished form of a contour
variation is the buckling of cartilage. This may
be the protuberance of the lower lateral cartilage
that makes conspicuous or palpable asymmetry.
They can be occurred inherited, traumatic injury,
or iatrogenic, especially prior rhinoplasty is the
most common cause.
2. Anterior nasal spine deviation
If the anterior nasal spine deviates from the
midline, the columella and the medial crus can be
pulled asymmetrically and then can change the
shape of the columella and disturb the dynamics
of the lower lateral cartilage.
Always operator must check the alignment
of the anterior nasal spine and understand the
contribution to the tip asymmetry and then, if a
deviation exists, realignment of an abnormally
positioned nasal spine (Fig. 68).
3. Tip Asymmetry due to prior surgery
An asymmetric procedure to the tip structure
may cause the asymmetry of the nasal tip. Using
cartilage-related procedures, such as asymmet-
ric cephalic trim or inaccurate suture techniques
can make a tip asymmetry, therefore, these pro-
cedures must be executed with careful attention
to symmetric trimming and precise suture place-
ment to prevent tip asymmetry. And grafts may
be a cause of asymmetry. If, irregular shaping
or improper positioning of graft is done during
operation, delayed migration, and graft resorp-
tion can make an asymmetric tip.
Another important thing is the postoperative
scar contracture, which can affect unpredictable
results, even though when accurate tip plasty was
performed. As time passes, contraction of the
nasal skin may alter the shape of the underlying
cartilaginous structure of the tip, and scar of ves-
Fig. 63 (continued)
K. C. Lee
401
tibule can make a notching the alar rim, rotation
of the nasal tip unbalanced, or distortion of the
columella. Therefore, the appearance of the nasal
tip can be changed as time goes on.
Most of the secondary rhinoplasty patients
with nasal asymmetry can be found in the buck-
ling of the alar cartilages, which is the most com-
mon etiology of nasal tip asymmetry and can be
visible or irregular palpated (Fig. 69).
These buckling of the alar cartilages can
be occurred by the result of dynamic forces of
scar contraction on a weakened cartilaginous
structure. If lower lateral cartilages are strongly
buckled, complete freeing of the cartilage from
its attachment is necessary to reduce the soft tis-
sue resist maintaining its native irregular contour.
Excessive weakening of the remnant cartilage
due to excessive resection of cephalic trim, dis-
ruption of lower lateral cartilage continuity, and
unpredictable migration of the alar cartilages are
risk factors of formation of buckling. Therefore,
at least leaving 6 to 8 mm of intact lateral crura is
important to avoid these problems after operation
and if, disruption of the alar cartilage continuity,
suture the cartilage together to minimize the risk.
Another risk is the separation of the lower
lateral cartilage with unsecured interdomal
distance, which results in lateral migration of the
domes. Therefore, accurate preoperative analysis
is essential to decide the optimal surgical pro-
cedure that reduces the occurrence of nasal tip
asymmetry after operation.
4. Nasal septal deviation
Nasal septum problems including displace-
ment of the nasal septum from the maxilla, injury
of cartilages, and impingement of the caudal
septum on the alar cartilage are the most com-
mon etiology of nasal tip asymmetry in the post-
Fig. 64 Tip suturing and tip grafts for correction of bulbous tip
Secondary Rhinoplasty (3): Tip
402
Fig. 64 (continued)
K. C. Lee
403
traumatic patients. Even in the case of nasal bone
fractures, a deviated nasal dorsum may move the
soft tissue of caudal nose and distort the intrinsi-
cally symmetric, and traumatic subluxation of the
upper lateral cartilage may realign the position
and projection of the alar cartilage by adherence
in the scroll area (Fig. 70).
Correction of Asymmetric Tip
The goal of the operation is to make a stable,
symmetric, and esthetically pleasing nasal tip.
Factors to affect the tip asymmetry of the nose
are many anatomical variations. Therefore, the
problems of the nasal bones, upper lateral carti-
lage, anterior nasal spine, and nasal septum must
be corrected before manipulation of lower lateral
cartilage.
An approach to the cartilage with defor-
mity, which is resection and modification of
buckling of cartilage and reestablish tip struc-
ture. Without reestablish of tip structure, only
resection or modification procedure is easy
and initially effective, but prone to provides to
weaken the lower lateral cartilage and destroy
the nasal tip framework, it may recur or lead to
more severe asymmetry, therefore, resecure of
intact strip integrity of lower lateral cartilage is
important.
If deformed cartilage is resistant to recontour-
ing by use of suture technique or strut grafts, sur-
geon must divide the strip of cartilage and release
the cartilage from its unfavorable attacchment.
Then repositoning of the lower lateral cartilage
can be easier.
1. Alar cartilage repositioning
In case of tip asymmetry due to deviation of
caudal septum, the septum must be realignment
to the midline. If, septal deviation was occurred,
asymmetric force can affect to the alar cartilage
and then asymmetric oriented of the alar carti-
lage by their ligamentous attachment to a devi-
ated caudal septum can lead to deformity of alar
cartilage and caudal nasal deviation.
Fig. 65 Vertical asymmetry is associated with septal
deviation, not parallel positioned of dome defining point
and asymmetry of the domes in vertical direction
Fig. 66 The reason why this patient’s dome is different is that the shape of the alar cartilage is different
Secondary Rhinoplasty (3): Tip
404
Fig. 67 Long-standing caudal deviation of the septum, asymmetry of the footplates, and columella. In this case, require
repositioning of the footplates of lower lateral cartilage due to not respond to straightening of the septum
Fig. 68 Anterior nasal spine deviation, realignment of an abnormally positioned nasal spine
K. C. Lee
405
After deviated caudal septum was corrected,
using a columellar strut to reestablish tip sup-
port and reposition each lower lateral cartilage
independently when this ligamentous attach-
ment has been destroyed during operation
(Fig. 71).
2. Cartilage graft techniques
Using contour grafts for correction of tip
asymmetry is a direct approach to mask asym-
metries of the underlying cartilaginous structure.
A unilateral cap graft placed just above one
dome can make equally the projection of the
tip defining point without disruption of the alar
cartilage and tip graft can make a new tip defin-
ing point and correct asymmetries in the domes.
The type of morselized or diced cartilage grafts
can be used. But autogenous grafts are at risk for
resorption, malposition, and migration.
Contour grafts may balance one side of tip
asymmetry, such as projection of tip defining
point, but the nostril or alar rim asymmetry is not
corrected in the severe malposition of the lower
lateral cartilage. Additionally, edge of contour
graft in thin-skinned patients may be noticeable,
therefore morselize the edge of graft or fascia
graft may be necessary to conceal.
Fig. 69 Asymmetric damage to alar cartilage is also
directly related to the shape of the nostril. After removing
the implant and the capsule in the lobule, you can see the
destroyed and displaced LLC. There is called bossa.
Restore the symmetry of both cartilage by suturing and
grafting. In particular, pay attention to the LLC caudal
margin, columella position, and soft triangle
Secondary Rhinoplasty (3): Tip
406
Fig. 69 (continued)
K. C. Lee
407
Fig. 70 Preoperative view. Displaced caudal septum on
anterior nasal spine, interoperative view. Displaced caudal
septum on anterior nasal spine, repositioning of caudal
septum to anterior nasal spine using fixation suture,
Postoperative view
Fig. 71 Alar cartilage reposition using columella strut, suture technique, and tip graft
Secondary Rhinoplasty (3): Tip
408
Lower lateral cartilage
Asmmetry
Lower lateral cartilage
rearrangement
Nasal septum deviation
Septoplasty
Fig. 71 (continued)
Fig. 72 Release and restore symmetry using structural graft and columella strut for correction of asymmetric tip
If the alar cartilage is weak and buckled due to
over-resection of the lateral crus in the prior rhino-
plasty, lateral crural strut graft is needed to provide
support, strength, and the balanced contour and
can be useful to correct the unnatural concavity or
convexity of the lateral crus with the nasal valve
support and the columellar strut is used to prevent
downward rotation of the nasal tip (Fig. 72).
Although alar extension graft is a procedure
designed to correct alar retraction, it can be
applied to the reconstruction of the tip of the nose
because it can give structural strength to the alar
cartilage that is congenitally weakened or dam-
aged by surgery. It can be used to reconstruct
the lateral crus of the alar cartilage, and the alar
cartilage structurally reinforced by a graft has the
advantage of improving the shape of the nasal tip
and alar.
3. Cartilage suture techniques
Sometimes, cartilage preservation procedures
using suture techniques to recontour and reposi-
tion the lower lateral cartilage are needed.
K. C. Lee
409
Fig. 73 Correction of asymmetric tip using transdomal sutures, interdomal suture, and columellar strut
Fig. 74 Columella strut, transdomal suture, interdomal suture for correction of asymmetric tip
The transdomal suture can change the dome
contour, increase definition, and projection to the
tip defining point as the angle of domal definition
decreases. Each dome can be contoured sepa-
rately from each other (Fig. 73). Therefore, cor-
rection of asymmetry is possible. Additionally, if
transdomal suture is done obliquely, a unilateral
change in the angle of domal divergence and
change tip defining point from lateral to medial
is also possible. If transdomal suture is done in
the caudal-cephalic dimension, the change of
the orientation of the lateral crus is possible. For
more cephalic rotation of the lateral crus, the
transdomal suture should be performed on more
cephalic side of the dome. In contrast, for more
caudal rotation, the transdomal suture must be
moved to the caudal side of the dome. But the
most important thing that affects the outcome is
Secondary Rhinoplasty (3): Tip
410
precise suture placement and control of tension.
Even sutures are placed properly, pinching of the
tip is noticed in very pliable alar cartilages, there-
fore, lateral crural strut grafts can be needed for
strengthening of alar cartilage.
Intradomal and dome defining sutures can
make narrowing of the single dome accurately
and approximate the domes at the desired
distance.
Interdomal sutures must be placed in the cor-
rect position where the suture passes through
each dome to correct any discrepancies in their
caudal-cephalic relationship and the interdomal
suture is a vertical suture placed between the
domes of the middle crura to modify the desired
interdomal distance (Fig. 74).
Domal equalization suture approximates the
cephalic edges of the two convex domal seg-
ments to correct tip asymmetry.
The dome-equalizing suture is a simple
technique, but useful to mask minor asym-
metries in the position of the domes. If a dif-
ference in dome rotation is too great, alar rim
retraction may have happened after the
procedure.
The lateral crural convexity suture may alter
the shape of the lateral crus and the lateral crural-
spanning suture may correct the unilateral con-
vexity of the lateral crus.
Alar cartilage flaring is modified by a span-
ning suture that is strengthened with a tip suspen-
sion suture.
Columellar-septal suture may be used for the
projection control and tip rotation.
Further Reading
Behrbohm H. 13 sutures and structural grafts in secondary
nasal tip surgery. In: Behrbohm H, Brehm J, Eugene
Tardy Jr M, Walter CD, editors. The nose-revision &
reconstruction. Stuttagart: Thieme; 2016.
Behrbohm H, Tardy ME. Chapter 1: The dual character of
nasal surgery. In: Behrbohm H, Tardy ME, Behrbohm
W, editors. Essentials of septorhinoplasty. New York:
Thieme; 2017.
Bermudez P, Quereshy FA. Nasal tip deformities after
primary rhinoplasty. Oral Maxillofac Surg Clin North
Am. 2021;33(1):111–7.
Burge GC. Reconstruction of the alar cartilage arches.
Oper Tech Plast Reconstr Surg. 1995;2(1):55–66.
Byrd S, Andodochick S, Copit S, et al. Septal extension
grafts: a method of controlling tip projection, rotation
and shape. Plast Reconstr Surg. 1997;100:999.
Cerkes N. Structural grafting of the nasal tip. In: Rohrich
RJ, Adams WP, Ahmad J, editors. Dallas rhino-
plasty nasal surgery by the masters. St Louis, MO:
Quality Medical Publishing & CRC Press; 2014.
p. 393–440.
Cerkes N. Nasal tip deficiency. Clin Plast Surg.
2016;43(01):135–50.
Çerkeş N. 18 - the middle eastern–Mediterranean nose.
In: Frame JD, Bagheri SC, Smith J, Khan HA, editors.
Aesthetic surgery techniques. A case-based approach.
Ann Arbor: Elsevier; 2019. p. 137–46.
Cingi C, Muluk NB. All around the nose. Cham: Springer
Science and Business Media LLC; 2020.
Cobo R. 18 primary rhinoplasty techniques: use of costal
cartilage. In: Cobo R, editor. Ethnic considerations in
facial plastic surgery. Thieme: New York; 2016.
Constantian M. The boxy nasal tip, the ball tip, and alar
cartilage malposition: variations on a theme—a study
in 200 consecutive primary and secondary rhinoplasty
patients. Plast Reconstr Surg. 2005;116(1):268–81.
Converse JM. LXXII corrective surgery of the nasal tip.
Ann Otol Rhinol Laryngol. 1940;49(4):895–911.
Issue published: December 1, 1940
Daniel RK. Rhinoplasty: an atlas of surgical techniques.
New York: Springer; 2002.
Daniel RK, Pálházi P. Rhinoplasty: an anatomical and
clinical atlas. New York: Springer; 2018.
Denecke HJ, Meyer R. Plastic surgery of head and neck.
Volume I: Corrective and reconstructive rhinoplasty.
Heidelberg: Springer; 1967.
DeRosa, Jamie. (2014) Open rhinoplasty, Facial surgery.
DeRosa J, Watson D, Toriumi DM. Structural grafting
in secondary rhinoplasty. In: Gunter JP, Rohrich RJ,
Adams WP, editors. Dallas rhinoplasty nasal sur-
gery by the masters. St Louis, MO: Quality Medical
Publishing; 2007. p. 719–40.
Dhir K, Ghavami A. Reshaping of the broad and bulbous
nasal tip. Clin Plast Surg. 2016;43(1):115–26.
Fuleihan NS. The Transvestibular approach to the nasal
tip and dorsum: a new refinement in rhinoplasty. Plast
Reconstr Surg. 1998;101(2):453–60.
Ghavami A, Janis JE, Acikel C, Rohrich RJ. Tip shaping
in primary rhinoplasty: an algorithmic approach. Plast
Reconstr Surg. 2008;122(4):1229–41.
Gubisch W. Mastering advanced rhinoplasty. Cham:
Springer Nature; 2017.
Gunter JP, Cochran CS. The tripod concept for correct-
ing severely deformed nasal tip cartilages. In: Gunter
JP, Rohrich RJ, Adams WP, editors. Dallas rhinoplasty
nasal surgery by the masters. St Louis, MO: Quality
Medical Publishing; 2007. p. 841–50.
Gunter JP, Friedman RM. Lateral crural strut graft: tech-
nique and clinical applications in rhinoplasty. Plast
Reconstr Surg. 1997;99(4):943–52.
K. C. Lee
411
Hackney FL. Primary rhinoplasty. In: McCarthy JG,
Galiano RD, Boutros SG, editors. Current therapy in
plastic surgery. Elsevier: Philadelphia; 2006. p. 290–8.
Hsieh T-y, Dedhia R, Toro DD, Tollefson TT. Cleft
Septorhinoplasty: form and function. Facial Plast Surg
Clin North Am. 2017;25(2):223–38.
Hyman AJ, Khayat S, Toriumi DM. Correction of
nasal pinching. Facial Plast Surg Clin North Am.
2019;27(4):477–89.
Kim JH, Koeran Society of Rhinoplasty Surgeons.
Current trends in Asian rhinoplasty: operation guide.
Seoul: Koonja; 2011. p. 349–69.
Kim HS, Roh S-G. The alar extension graft for retracted
alar. Arch Plast Surg. 2009;36(1):66–74.
Kim S-K, Kim J-C, Lee K-C, Kim H-S. Correction of
the supratip deformity of the nose. Aesthet Surg J.
2012a;32(8):943–55.
Kim JH, Park SW, Won Suk O, Lee JH. New classification
for correction of alar retraction using the alar spreader
graft. Aesthet Plast Surg. 2012b;36:832–41.
Kim JH, Song JW, Park SW, Won Suk O, Lee JH. Effective
septal extension graft for Asian rhinoplasty. Arch Plast
Surg. 2014a;41(1):3–11.
Kim JH, Song JW, Park SW, Oh WS, Lee JH. Tip exten-
sion suture. Plast Reconstr Surg. 2014b;134(5):
907–16.
Kim JH, Song JW, Park SW, Won Suk O, Lee JH. Tip
extension suture: a new tool tailored for Asian rhino-
plasty. Plast Reconstr Surg. 2014c;134(5):907–16.
Lutaif EL, Dolci JELD. Algorithm for the treat-
ment of external nasal valve insufficiency. Braz J
Otorhinolaryngol. 2020;86(5):579–86.
Malekzadeh S. Otolaryngology lifelong learning manual.
104 Rhinoplasty. New York: Thieme; 2015.
Man Koon SUH. Atlas of Asian rhinoplasty. Singapore:
Springer; 2018.
Meneghini F. Basic open rhinoplasty. Cham: Springer;
2021.
Metin Önerci T. Nasal physiology and pathophysiology of
nasal disorders. Springer: Heidelberg; 2013.
Nazım C. Commentary on 3D photogrammetric analysis
of the nasal tip projection and derotation based on
the nasal tip quadripod concept. Aesthet Plast Surg.
2017;41:1164–6.
Paik MH, Chu LS. Correction of the short nose
using derotation graft. Arch Aesthetic Plast Surg.
2012;18(1):35–44.
Petroff MA, McCollough EG, Hom D, et al. Nasal
tip projection. Arch Otolaryngol Head Neck Surg.
1991;117:783.
Rikimaru H, Kiyokawa K, Watanabe K, Koga N, Nishi
Y. A new therapeutic strategy for lengthening severe
short nose. J Craniofac Surg. 2010;21(2):495–8.
Rohrich RJ, Griffin JR. Correction of intrinsic nasal tip
asymmetries in primary rhinoplasty. Plast Reconstr
Surg. 2003;112(6):1699–712. discussion 713-5
Rod J. Rohrich, Ronald E. Hoxworth. (2019) Primary rhi-
noplasty. In Plastic surgery key.
Rohrich RJ, Raniere J Jr, Ha RY. The alar con-
tour graft: correction and prevention of alar rim
deformities in rhinoplasty. Plast Reconstr Surg.
2002;109(7):2495–505.
Rohrich RJ, Janis JE, Kenkel JM. Male rhinoplasty. Plast
Reconstr Surg. 2003;112(4):1071–86.
Sajjadian A. Rhinoplasty in middle eastern patients. Clin
Plast Surg. 2016;43(1):P281–94.
Sclafani AP. The asymmetric nasal tip. In: Sclafani AP,
editor. Rhinoplasty. New York: Thieme; 2015.
Scuderi N, Toth BA. International textbook of aesthetic
surgery. Heidelberg: Springer; 2016.
Sheen JH. Spreader graft: a method of reconstructing the
roof of the middle nasal vault following rhinoplasty.
Plast Reconstr Surg. 1984;73:230.
Shiffman MA, Di Giuseppe A. Advanced aesthetic rhi-
noplasty; art, science, and new clinical techniques.
Heidelberg: Springer; 2013a.
Shiffman MA, Di Giuseppe A. Advanced aesthetic rhino-
plasty: art, science, and new clinical techniques. Cham:
Springer Science and Business media LLC; 2013b.
Slupchynskyj O, Cranford J. Quantitative measurements
of the bulbous tip in ethnic rhinoplasty. Ann Plast
Surg. 2017;78(5):569–75.
Stephan S, Wang TD. Asymmetric nasal tip. Facial Plast
Surg. 2012;28(02):177–86.
Stucker FJ, de Souza C, Kenyon GS, Lian TS, Draf W,
Schick B. Rhinology and facial plastic surgery. Berlin:
Springer; 2009.
Sugawara Y. A practical approach to Asian rhinoplasty;
how to design a fine nasal shape. Tokyo: Springer;
2020.
Toriumi DM. Structure approach in rhinoplasty. Facial
Plast Surg Clin North Am. 2002;10:1.
Torres S, Marianetti T. Management of Common
Complications in rhinoplasty and medical rhinoplasty.
In: A textbook of advanced oral and maxillofacial sur-
gery, vol. 3. Rijeka: InTech; 2016.
Tremp M, Haack S, Mijuskovic B, Haug M. Suture
techniques and cartilage grafts in nasal tip surgery:
an algorithm in primary and secondary rhinoplasty.
JPRAS. 2020;73(3):563–70.
Yap EC. Aesthetic plastic surgery of the east Asian face.
In: Jin HR, editor. Aesthetic plastic surgery of the east
Asian face. New York: Thieme; 2016.
Yoon SH, Kim CS, Jae Wook O, Lee KC. Optimal har-
vest and efficient use of septal cartilage in rhinoplasty.
Arch Craniofac Surg. 2021;22(1):11–6.
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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,
Contracted Nose: My Preferred
Technique
Hong Ryul Jin
Introduction
In rhinoplasty, a short, contracted nose is a quite
unique and common complication, especially in
Asians, although it also develops in a Caucasian
nose.
Most short nose development in an Asian nose
is related to use of an alloplastic implant. Another
contributing factor is a recent obsession of Asians
for tip surgery. Patients want a more projected
tip, which often leads to aggressive manipula-
tions of tip cartilage and caudal septum. Failure
to adequately control tip projection and rotation,
repeated revisions due to esthetic dissatisfaction,
and indiscreet use of alloplastic material on the
tip area all contribute to the increased develop-
ment of a short, contracted nose in Asian
persons.
Correction of this deformity is challenging for
various reasons. First, the causes for develop-
ment are complex. Patients typically have multi-
ple surgery histories with multiple manipulations
of the tip and the dorsum. Second, all three com-
ponents of the nose (skin envelope, cartilaginous
framework, and inner lining) are involved and
damaged. Septum is weak, lower lateral carti-
lages are rudimentary, scarring is severe, and the
skin is hard. Third, not only tip rotation, but also
dorsum augmentation is necessary in most
patients with a short nose deformity.
This chapter discusses the pathogenesis, eval-
uation, timing and strategy of surgery, and surgi-
cal techniques. All information presented was
acquired through the author’s 25 years of learn-
ing, teaching, and practice of rhinoplasty. I sin-
cerely hope rhinoplasty surgeons will benefit
from this presentation to prevent and treat the
short, contracted nose in their daily practice.
Pathogenesis of a Short,
Contracted Nose
The pathogenesis of a contracted, short nose is
not well known. Acute development of a short
nose after surgery is mainly due to overzealous
augmentation of the tip without considering the
vector of the tip projection. It is due to an esthetic
misjudgment on the part of the surgeon or the
patients themselves wanting an overly-projected
tip without considering the overall harmony of
the nose. Short nose development due to over
resection of tip cartilage is rather rare in Asian
countries.
From the author’s experience, a typical con-
tracted, short nose has two clear time frames,
subacute vs. chronic. The subacute cause of con-
traction is an infection of an alloplast implanted
nose. Patients clearly say that their noses became
short and upturned in a relatively short time
H. R. Jin (*)
Dr. Jin’s Premium Nose Clinic, Seoul, South Korea
414
period after an infection. This contraction pro-
cess is a kind of subacute process, occurring in
the months after certain events. Surgery on these
patients shows abundant, thick scar tissue around
the implant with a meltdown or flimsy lower lat-
eral cartilages.
Chronic short nose development is presumed
to be caused by silicone capsular contraction or a
dormant infection around the silicone implant.
Over the years, after silicone insertion on the dor-
sum, the tip slowly becomes upturned with skin
contraction. It can take several months or years to
develop a shortening of the nose. No clear infec-
tion history can be found, however, a detailed his-
tory taking often reveals recurrent swelling
around the implanted dorsum. This indicates a
recurrent, dormant inflammation, which does not
cause a clear purulent infection, and can be an
underlying cause of chronic short nose develop-
ment. Revision on these cases often reveals weak,
necrotic lower lateral cartilage due to long-term
pressure from the implant and scarring along
with thin fibrous capsules around the implant.
As contraction progresses, the soft nasal tip
becomes constricted and a so-called snub nose
develops (Fig. 1). The nose is characterized by a
decrease in nasal length with an exaggerated nos-
tril shown from the frontal view. The tip is rotated
cephalically and the columella is retracted with a
more obtuse nasolabial angle on the lateral view.
The deep nasofrontal angle that is formed after
the removal of an implant makes the nose appear
even shorter. Another cause for chronic short
nose development is multiple traumatic revision
rhinoplasties in a relatively short time period.
Repeated traumatic elevation of the skin flap and
damage of the framework cartilage cause the skin
contract, the tip collapse with slow development
of a short nose. Often caudal septum loss, septal
perforation, or vestibular stenosis is combined. In
many patients, short, contracted nose develops
due to combination of repeated, traumatic revi-
Fig. 1 Typical contracted, short nose developed after sili-
cone rhinoplasty 30 years ago. This 67-year-old female
still has a silicone implant on the dorsum but her tip shows
excessive nostril show in frontal view and severely
retruded columella with obtuse nasolabial angle in lateral
view
H. R. Jin
415
sion and the implant-related problems such as
infection.
Most postoperative contracted, short noses
have both structural problems, such as weak alar
cartilage, and decreased skin compliance caused
by a damaged skin–soft tissue envelope. These
framework and skin envelope problems can ham-
per efforts to lengthen the nasal tip.
Patient Evaluation
Understanding the etiology, evaluating the ana-
tomic peculiarities, and patient’s level of expecta-
tions are the most important factors to take into
account at the initial consultation of a patient
seeking correction of a short, contracted nose.
It is important to try to obtain as much infor-
mation about previous operations as possible: the
kind of surgery the patient had, the type of
implant used, the number of previous surgeries,
and specific problems that were present such as
infection. Getting a patient’s preoperative photos
helps to predict the surgical results.
Surgeons run into unpredictable situations in
revising a short nose despite careful planning. The
anatomic structure has often changed significantly
and markedly differs from what was initially
expected. This is especially true when an alloplas-
tic implant related infection has occurred. Tip car-
tilages are deformed, or sometimes missing due to
previous manipulations, necrosis by infection, or
by pressure necrosis (Fig. 2). Often the upper lat-
eral cartilages are also weak and collapsed causing
a narrow airway with a saddle deformity.
Experience in and understanding of common
rhinoplasty techniques or materials currently
used by other rhinoplasty surgeons or clinic is
also important. The surgical records of referred
patients are often too simple and do not give full
information on the procedures of previous
surgery.
When examining the nose, first check skin
quality and note its thickness, character, and elas-
ticity and any damage. Hard, thick, fixed, inelas-
tic skin with a foreshortened nose has a high
tendency to have a less than ideal result. On the
contrary, elastic skin over a mobile alloplastic
implant gives a better surgical result.
If any implant is already on the nose, which is
quite common in Asian countries, a dorsal
implant needs to be palpated to check for size,
position, and mobility. Sometimes an implant tip
is protruding into the vestibular skin with painful
tenderness. If there are any skin eruptions with
crusting on the vestibular skin, remove the crust
and wash the wound carefully. While squeezing
on the dorsum, pus or serous discharge can come
out from the skin defect, which means an infec-
tion of the implant.
Take a nasal bone X-ray to evaluate implant
position, length, thickness, and skin thickness or
to find any other foreign materials inside the nose
(Fig. 3). Silicone or Gore-Tex can sometimes be
found on the dorsum, while the tip area can show
other shadows that the patient did not tell you or
does not know about. In many cases, the patient
does not know exactly what kind of material they
have in their nose. Even the operation record
from a previous surgeon is often not obtainable
due to many causes, so the information on the
previous surgery is often very limited.
Tip rotation and projection, tip cartilage size,
position, support, columellar-lobular ratio are
assessed. Septum and ear cartilage status is
assessed. Ear cartilage is an important source of
composite graft that may be needed to cover the
vestibular defect. Often they were already har-
vested in previous surgeries, so careful palpation
of the available source of ear cartilage is very
important.
The condition of the nasal septum and turbinates
is examined using anterior rhinoscopy and/or an
endoscope. The presence of any synechiae should
Fig. 2 Right intermediate and lateral crus were destroyed
due to infection and pressure necrosis
Contracted Nose: My Preferred Technique
416
be noted. The nasal septum should be palpated with
a cotton swab to check whether any cartilage
remains. Nasal endoscopy enables the surgeon to
check the septal perforation, any synechiae, and the
status of the internal nasal valve, unlike doing ante-
rior rhinoscopy alone, which sometimes does not
allow full visualization of the nasal airway.
Maintaining a good relationship with the
patient is important. Pay close attention to the
patient’s problems, identify possible causes, and
advise potential solutions. When the patient’s
expectations are not realistic or if the patient’s
complaints are different from the problems that
you observe, it is wise to delay the operation or
ask the patient to find another surgeon to perform
the secondary rhinoplasty.
Timing of Revision Rhinoplasty
Timing of revision surgery for a short, contracted
nose differs from case to case. Many surgeons
and patients mention a one-year rule in revision
rhinoplasty, meaning waiting at least a year
before attempting surgery.
If the short, upturned nose developed after pri-
mary surgery without using any implant or previ-
ous silicone removal, at least a year is necessary
before starting any revision. Scar maturation and
softening of the skin envelope needs at least a
year, thus correction within a year may have a
limitation in lengthening the nose due to inelastic
skin.
However, if a short, contracted nose has devel-
oped with any alloplastic implant on the dorsum,
the timing of surgery varies according to the indi-
vidual situation.
When there is no infection on the nose, it is
advantageous to elongate the nose together with
removal of the implant, because the already
enlarged nasal soft tissue envelope easily adapts
to an elongated structure. Immediate recon-
struction also has advantages such as reduced
social downtime, avoidance of multiple surger-
ies, and less surgical expense. It can also elimi-
nate the psychological stress caused by the
dramatic nasal shape difference after alloplast
removal.
However, when there is an infection in alloplast
together with a short nose, deciding the time of
revision surgery requires a few considerations.
Immediate reconstruction carries an increased
chance for reinfection even when using an autolo-
gous tissue. Furthermore, the patient may have
damaged, scarred, swollen skin, thus, it becomes
more challenging to predict an exact shape, and
makes it difficult to create an esthetically fine-
tuned nose shape during the reconstruction.
Therefore, the surgeon needs to consider all these
factors when determining the best timing for
reconstruction.
In my experience, reconstruction with the
patient’s own cartilage is safe even if the surgery
is simultaneously carried out with the removal of
an infected implant and inflamed tissue (Figs. 19,
20, and 21). Although subsequent re-creation of a
perfectly shaped nose can be challenging, filling
up the space created by the previous implant can
prevent contraction of the wound, laying the
groundwork for further revision and improve-
ment. The patient must be well supported psy-
chologically in case further secondary rhinoplasty
is required later. In patients who stick to a perfect
nose shape after removal of infected alloplast, it
Fig. 3 Nasal bone X-ray shows an I-shaped silicone
implant on the nose. The tip is upturned, while the radix is
high due to silicone implant
H. R. Jin
417
is wise to delay the esthetic reconstruction after
alloplast removal.
Materials and Approach
Correcting a short, contracted nose requires a
large quantity of graft materials for structural
support and volume replacement. Although sur-
geons agree that structural reinforcement needs
autologous tissue, alloplast is commonly used for
dorsal volume replacement. I prefer autologous
cartilage even for dorsal work to prevent poten-
tial complications such as infection or soft tissue
contraction. Although septal and ear cartilage are
the first choice of graft material for minor correc-
tions, rib cartilage is mostly needed when consid-
ering a deficient structural framework and the
amount of cartilage to modify the tip.
I rarely use homologous grafts, because they
are fragile to carve, and need thicker pieces to
resist the same skin tension compared to an autol-
ogous piece. This often makes the caudal septum
thick and causes nasal obstruction. Most of all,
grafted homologous rib cartilage is unpredictable
in maintaining the dorsal volume due to long-
term resorption.
In patients with problems of the skin–soft tis-
sue envelope, temporalis fascia, rib perichon-
drium, mastoid periosteum, or autologous dermis
are used to reinforce skin that may have been
overly thinned or damaged. Loose fat tissue from
the rib harvest site helps to fill the void skin–soft
tissue envelope and helps to prevent long-term
skin thinning and recurrence of skin contracture
(Fig. 4). A product of homologous fascia or
homologous dermis from cadaver skin (Alloderm,
Surederm) can be feasible alternatives.
Artificial implants are generally not used to
correct a short nose deformity, but they can be
used if the patient understands and agrees to the
risk of complications and has relatively thick skin
with no demonstrable infection. If an alloplast is
used in revision, its use is strictly confined to
only augment the dorsum.
I use a closed approach when the short nose
deformity is not severe and only slight tip graft-
ing is necessary to correct it. When significant
structural reconstruction of the septum and tip
are needed, an open approach is necessary to
ensure sufficient visualization and manipulation
of the structures.
Opening a nose in Asian secondary rhino-
plasty is like opening a box of chocolates, and
you will never know what you are going to get till
you open it. Securing good vision with sufficient
graft material is a prerequisite to allow a surgeon
to improvise when encountering an unexpected
situation.
Strategies for Correction
The main surgical goals are caudal rotation of the
tip-defining point. Dorsal elevation helps to give
an illusion of nasal lengthening, especially in
patients with a low-profile nose.
Caudal rotation of the tip-defining point is
obtained by caudally readjusting the lower lateral
cartilage on the septal extension graft with or
without additional onlay tip grafts. The lower lat-
eral cartilages are weak or missing due to necro-
sis and reconstructing the tip cartilage is
necessary.
Because stretching the contracted skin is lim-
ited, achieving both caudal rotation and projec-
tion increase is often difficult. When a
considerable amount of caudal rotation is needed,
I need to tell the patient that tip projection needs
to be lower than compared to the current nose.
Fig. 4 Loose soft tissue harvested from the chest. Filling
the dead space between the cartilage graft and thinned,
damaged skin with this tissue helps to heal the skin and to
prevent recontraction
Contracted Nose: My Preferred Technique
418
To caudally rotate the tip and maintain the pro-
jection against redraped skin tension, a firm struc-
tural support reinforcing and lengthening all three
legs of the “tripod” of the nasal tip is needed.
Even minor derotation of the tip needs a consider-
able amount of work under the contracted skin.
When the central part of the nose (the colu-
mella and the tip lobule) is lengthened with a sep-
tal extension graft, the lateral crus is prone to
realign in a more vertical direction. The alar mar-
gins also need to be lowered to create a more bal-
anced nostril after the septal extension graft is
placed. A slight imbalance can be adjusted with a
lateral crus onlay or lateral crural strut grafts.
Placing a long lateral crural strut graft and
relocating the lateral crural complex into a pocket
made in the piriform aperture may lower the alar
margin in thin-skinned white patients, but this
maneuver is not as effective for Asians who have
thicker skin. A stiff and inelastic skin envelope
and deficient vestibular skin are the most com-
monly encountered limiting factors to lowering
the alar rim.
Often, the dissected skin–soft envelope can be
draped to the new septal extension graft, but the
internal vestibular mucosa does not follow the
elongated envelope, resulting in a gap, especially
at the alar rim margin. I prefer to use a conchal
composite graft from the cymba concha to fill the
gap, so that alar margin lifting does not occur due
to scar contracture.
Surgical Techniques
Rib Cartilage Harvesting and Carving
The availability and status of the rib cartilage are
preoperatively assessed with a rib series X-ray
(Fig. 5). The images show the presence, type and
degree of calcification, shape, and size of the rib
cartilage. Thus, the surgeon can easily decide before
surgery whether rib cartilage is available or not and
which cartilage is best suitable for harvesting.
Costal cartilage is commonly harvested from
the sixth or seventh rib. The incision is made
directly over the chosen rib in male patients and
just above the infra-mammary crease in female
patients to conceal the chest scar. The size of the
incision may vary but is usually less than 1.5 cm
in length in thin-skinned patients and 2-3 cm in
thick-skinned patients. The costochondral junc-
tion is located by performing serial puncture with
a 26-gauge needle for precise placement of the
incision. The skin and subcutaneous tissue are
incised with a no. 10 blade, and the subcutaneous
tissue is retracted using retractors until the exter-
nal oblique muscles are exposed. Instead of cut-
ting with a Bovie, the muscle fibers are separated
with mosquito forceps and retracted with a Senn
retractor, which can minimize postoperative pain.
After adequate exposure, two parallel incisions
are made along the superior and inferior borders
of the rib cartilage, leaving an intact central strip
of perichondrium on the anterior surface. Several
small incisions are made perpendicular to the
longitudinal incision to facilitate reflection of the
perichondrium.
Harvesting is facilitated by performing a
medial cut before completing the dissection of
the posterior surface of the costal cartilage. The
Fig. 5 Rib series X-ray shows almost totally calcified rib
cartilage. This type of rib cartilage cannot be used for
short nose correction, which requires enough cartilage for
structural graft
H. R. Jin
419
initial incision is made with a blade and the carti-
lage cut is completed with a Freer elevator to
avoid inadvertent pleural injury. After the lateral
cut, a small two-pronged retractor is used to pull
the costal cartilage and expose the posterior sur-
face. The perichondrium of the posterior surface
is dissected with a curved elevator and the carti-
lage is taken out. Typically, a 3-4 cm piece of cos-
tal cartilage can be harvested together with the
central strip of perichondrium. When necessary,
the cartilaginous cut can be extended up to the
synchondrosis portion to obtain a longer graft.
Testing for air leakage is performed by filling
the dissection pocket with saline and performing
positive-pressure hyperventilation. If no air leak-
age is confirmed, the donor site is packed with
antibiotic-soaked gauze until the end of the oper-
ation. As such, extra cartilage can be harvested
during the operation or remnant cartilage can be
reinserted for future use.
If pleural tears are excluded intraoperatively, a
postoperative chest X-ray is not routinely per-
formed. However, it should be performed if the
patient develops respiratory signs and symptoms.
After harvesting, the rib cartilage is carved for
various grafts. Commonly needed grafts in short
nose correction are septal replacement graft, sep-
tal extension graft, extended spreader grafts, sep-
tal splinting/batten graft, lateral crural onlay/strut
grafts, and dorsal augmentation graft. These
kinds of structural supporting grafts are best
carved from a sagittal split, leaving both cortical
ends at both sides of a core (Fig. 6). Carving is
modified strategically according to the necessary
graft shape and size.
Thin and naturally straight pieces of cartilage
such as the septal cartilage are best for septal
extension grafts. However, a certain degree of
cartilage bending or warping is unavoidable in
rib cartilage carving, thus strategic use of bent
cartilage is needed. For example, in designing
extended spreader grafts, an affected fragment
can be split in half and used bilaterally, compen-
sating for the curvature.
For minor dorsal augmentation, either thin
cortical cartilage or longitudinally sectioned car-
tilage is used while major dorsal augmentation
needs grafts carved from the center of the rib car-
tilage or layering of longitudinally sectioned,
thin cartilages.
Skin Dissection
Wide dissection of the skin–soft tissue envelope
is important to allow maximal stretching of the
skin when it is redraped. Releasing the skin from
underlying scar tissue needs extreme caution to
prevent incidental skin damage. First, the skin on
the lateral crura is dissected, then cartilaginous
and bony dorsum are dissected. From the bony
dorsum, lateral dorsal skin dissection with a
15-blade starts and comes down to the upper lat-
eral cartilage. The lateral dissection margin goes
down to the nasofacial junction. Release of lat-
eral crus to the piriform aperture is done follow-
Fig. 6 Longitudinal sectioning of rib cartilage leaving equal amounts of cortex on both sides prevents warping of the
carved cartilage
Contracted Nose: My Preferred Technique
420
ing dorsal skin dissection. Thick scars need to be
excised or released to make the skin more flexible
and easily manipulated.
When silicone is removed, anterior and poste-
rior capsules need to be moved.
A posterior capsule hinders stable fixation of
cartilage grafts on the nasal dorsum. An anterior
capsule is often very thick, especially when there
are histories of infection. Dorsal skin is inelastic
when the thick capsule is attached, thus lengthen-
ing is difficult without removing the capsule.
If the dissected skin is thick and wound clo-
sure leaves considerable tension even after
removal of scar tissue and the silicone capsule,
the dorsal skin is lengthened using multiple hori-
zontal hatching incisions underneath. These cuts
are only made on the scarred subcutaneous tis-
sue, not on the dermis.
Building Structures to Lengthen
the Tip
The septum acts as a strong structure to hold and
keep the supporting structure to reposition and fix
the lower lateral cartilages. After dividing the
lower lateral cartilage and elevating the submu-
coperichondrial flap, the septum is observed first.
The septal flap elevation needs to be minimized
to the level where grafts are placed and fixed
unless you plan to correct the deviated septum.
Caudal and dorsal septal stability is of utmost
importance for a stable septal extension graft.
Any deviation of the L-strut needs to be corrected
before adding grafts on the septum (Fig. 7). If the
caudal septum is weak, it should first be stabi-
lized. Meticulous strong suture fixation of the
posterior septal angle to the anterior nasal spine
is necessary when this junction is unstable.
An overlapping (side-to-side) septal extension
graft or an end-to-end septal extension graft is
necessary to reposition the lower lateral cartilage
(Fig. 8). If the remaining L-strut is not stable, the
septal extension graft fails to resist the skin ten-
sion and is prone to twist or deviate, thus it is
necessary to reinforce the L-strut and septal
extension graft.
Reinforcement of the septal extension graft is
usually done by applying extended spreader
grafts because the dorsal border of the septum is
quite stable (Fig. 9). For end-to-end septal exten-
sion graft, the grafts are further stabilized at the
base with a thin strip of splinting grafts to prevent
distortion (Fig. 10).
When applying the side-to-side septal exten-
sion graft, the graft is designed to reach the nasal
floor unless the junction of the posterior septal
angle and anterior nasal spine is stable and the
septum–graft complex is suture-fixed to the ante-
rior nasal spine.
Release of Lower Lateral Cartilage
The lower lateral cartilage is released from the
upper lateral cartilage and piriform aperture and
repositioned on the new grafted septal extension
graft (Fig. 11). A lengthening effect can be
obtained by lowering the nasal tip and rotating it
caudally. Care needs to be taken not to tear the
underlying nasal mucosa when dissecting the
lower lateral cartilage from the joining upper lat-
eral cartilage.
Lateral crural strut grafts (Fig. 12) help to
reposition the lower lateral cartilage to a more
caudal position, to strengthen the alar to prevent
pinching or collapse, thus making the tip shape
more natural. Many Asians have a thick tip skin
while the cartilages are weak, and in comparison,
Fig. 7 Deviation and stability of the caudal septum is
observed. If there is any deviation, it should be fixed first
before adding any grafts on the septum
H. R. Jin
421
a lateral crural strut is not as often necessary as in
Caucasians.
Often lower lateral cartilages are rudimentary
and all scarred. In this case, it is better not to dis-
sect the lower lateral cartilage from the underly-
ing mucosa. Instead, adding cartilage on top of
the lateral crus and using a composite graft to
bridge the gap between the external skin and ves-
tibular skin is more beneficial.
Additional Lengthening
Additional lengthening of the tip can be gained
through the use of various grafts on the newly
positioned lower lateral cartilage. Shield grafts
and cap grafts are commonly used (Fig. 13).
Lateral crural onlay grafts are placed to rein-
force weak lateral crura (Fig. 13). If a significant
amount of rotation and projection of the nasal tip
Fig. 8 Two patterns of septal extension grafts: a side-to-side and an end-to-end type
Fig. 9 Note the side-to-side (overlapping) septal exten-
sion graft on the left side of caudal septum and both
extended spreader grafts reinforcing the graft
Fig. 10 An end-to-end septal extension graft before final
carving strengthened by extended spreader grafts above
and thin splinting grafts below (arrow)
Contracted Nose: My Preferred Technique
422
were achieved, the alar margin can appear unnat-
ural, slightly retracted, or collapsed. Alar contour
grafts can be used to provide a smoother natural
continuation from the nasal tip to the alar
margin.
Dorsal Augmentation
A dorsal onlay graft is used when the dorsal
height needs augmentation to match the elon-
gated and projected nasal tip. Dorsal onlay grafts
can be extended to include the nasion to make the
dorsum higher and the nose appear longer. If you
Fig. 11 Released lower lateral cartilages are pulled caudally and secured to the septal extension graft with sutures
Fig. 12 Lateral crural strut grafts strengthen the weak
alar wall and reposition the lateral crus into a more ideal
position, thus help to lengthen the short tip
Fig. 13 Lateral crural onlay graft helps to strengthen the
weak, flail lateral crus. Tip onlay graft is done to lengthen
the tip more
H. R. Jin
423
augment the dorsum too high, the skin envelope
available to the tip lengthening would be limited,
so an optimal plan considering ideal dorsal and
tip position should be implemented to effectively
redistribute the skin.
Augmenting the dorsum using cartilage needs
a whole chapter for detailed surgical information,
thus it will be dealt with separately.
Closure of Wound
When closing the wound, there should be no or
little tension on the wound margin. Skin closure
that is too tight can result in a noticeable scar,
wound dehiscence, or even skin necrosis.
When short nasal skin is elongated and
redraped over the lengthened framework, a supra-
tip fullness can remain after skin closure
(Fig. 14). This is caused by difficulty from a pre-
viously highly projected tip skin to sink down to
redrape the lower supratip area because of long-
time molding. A single supratip suture anchoring
molded skin on the supratip area helps to flatten
that area and to obtain a better profile view.
The septal mucosal flap and vestibular skin
are moved forward and upwards by dissection to
match the elongated skin envelope. However,
sometimes the lengthened skin and vestibular
skin cannot be primarily closed. If this gap is not
filled, the alar rim may retract due to scar con-
tracture and a balanced lowering of the central
and lateral parts of the tip is not possible.
A chondrocutaneous composite graft taken
from the cymba concha is prudently used to fill
the gap, especially in area of the soft tissue tri-
angle. Before primary closure of the columella,
the caudal part of the conchal composite graft is
first sutured at the infracartilaginous incision,
then the cephalic part is sutured to the vestibular
Fig. 14 Supratip fullness (arrow) after short nose correction. Presurgical convex skin by long-term molding maintains
its shape after redraping. Supratip suture helps to flatten this portion, while severe case needs skin excision
Contracted Nose: My Preferred Technique
424
skin to fill the defect (Fig. 15). After composite
graft, silastic sheets are put under and over the
grafted site to adapt the grafts to the vestibular
skin.
Adding Soft Tissue to the Skin
Envelope
When contracted skin quality is poor, recontrac-
tion occurs even with successful framework
reconstruction and skin redraping. Poor blood
supply on the stretched, damaged skin will even-
tually make the skin contract again. Extra work to
strengthen and reinforce the damaged skin is nec-
essary. A micro or nanofat infused temporalis
fascia covering can be an alternative. Loose soft
tissue from the chest covering the dead space and
graft material helps to minimize skin contracture
(Fig. 4). Infection risk can rise if soft tissue is
covered on the grafts, so every effort should be
made to decrease postoperative infection.
To prevent potential infection, IV antibiotics
are used for 2-3 days after surgery. Thorough
nasal
dressing
with
betadine
and
anti-
staphylococcal antibody ointment is necessary.
When the blood supply is poor and the wound is
insufficiently clean, a drain is placed inside the
nasal flap and postoperative irrigation with anti-
biotic solution for 3-4 days helps to prevent
potential infection.
Case 1
A 38-year-old woman visited a clinic for revision
rhinoplasty. She previously had silicone rhino-
plasty and had the implant removed due to infec-
tion. At the time of her visit, her nose showed
typical short, contracted nose deformity: exces-
sive nostril show from the frontal view, upturned
tip and low dorsum and radix from the lateral
view (Fig. 16).
Her rib cartilage was harvested and used for
the tip lengthening and dorsum augmentation.
Skin was elevated widely and two layers of
small cartilage grafts were removed from the tip.
Thick scar tissue on the tip area was removed.
Multiple horizontal incisions were applied to the
subcutaneous scar tissue to obtain a more flexi-
ble, released skin envelope at the tip and supratip
area. An end-to-end type septal extension graft
was placed at the edge of caudal septum using
figure-of-eight sutures. This was reinforced
using both a septal splinting graft at the base and
partial extended spreader grafts on the dorsal
side. The septum was minimally dissected to
only allow placement of the reinforcing grafts.
On the tip, a shield graft, bilateral lateral crural
onlay graft, and tip onlay graft carved from the
rib cartilage were used to obtain more lengthen-
ing and tip refinement (Fig. 17). Dorsal onlay
graft was done with a carved, one-piece rib
cartilage.
Fig. 15 A chondrocutaneous composite graft harvested
from cymba concha is suture-fixed to fill the gap between
the lengthened skin and the vestibular lining
H. R. Jin
425
Fig. 16 Preoperative frontal and oblique views
a
b
Fig. 17 (a) Boat shaped carved rib cartilage graft for dorsal augmentation. (b) Dorsal onlay graft, lateral crural onlay
graft, shield and cap grafts are all carved with rib cartilage
Contracted Nose: My Preferred Technique
426
Two-year postoperative photos show an
improved tip shape with naturally augmented
dorsal profile. The upturned tip became
normalized with a natural increase of her tip pro-
jection (Fig. 18).
Case 2
A 22-year-old women visited the clinic due to her
short looking nose and nasal obstruction. She had
augmentation rhinoplasty using silicone 4 years
ago. On physical examination, her dorsal silicone
looked deviated and her tip looked short, upturned
(Fig. 19). Caudal septum was severely convex to
the right side.
During the surgery, a considerable amount of
yellow pus drained from the undersurface of the
silicone implant (Fig. 20a). Silicone was removed
with the capsule and the dorsum was thoroughly
irrigated with necrotic tissue debridement. Right
lateral crus was melt down probably due to the
infection (Fig. 20b). Caudal septal deviation was
corrected. Using harvested rib cartilage, septal
extension graft was done and it was fixed with
bilateral spreader grafts. Tip was repositioned to
the new dome and dorsal onlay graft was done
with two-layer rib graft (Fig. 20c). Right lateral
crural graft and tip grafts were done for further
tip modification (Fig. 20d).
After surgery, her nose looks natural and the
tip does not look upturned anymore. Her dorsum
is straight and dorsal height is optimal. She can
breathe well through her nose (Fig. 21).
Case 3
A 66-year-old woman visited the clinic to correct
her short looking nose (Fig. 22). She previously
had a rhinoplasty using silicone about 30 years
ago and her nose slowly became shortened.
Currently, she has a large silicone implant on her
nose (Fig. 23). Physical exam showed excessive
nostril show with an upturned tip, too high radix,
and contracted skin on her tip.
Fig. 18 Two-year postoperative photos show a well augmented dorsum and harmonious tip shape
H. R. Jin
427
Fig. 19 Preoperative views. Deviated silicone implant and slight swelling of dorsum are observed. Tip is upturned with
excessive nostril show. Silicone implant is seen from the nasal X-ray view
Contracted Nose: My Preferred Technique
428
Surgery material included rib cartilage, loose
soft tissue, and fat from her chest and cymba con-
cha skin and cartilage composite tissue. After flap
elevation, abundant scar tissue was removed from
the dome and the lateral crus. From the dorsum, a
large silicone implant was removed together with
the capsule. After septal exploration, an end-to-
end septal extension graft was applied and they
were reinforced with extended spreader grafts on
the dorsal border and splinting grafts at the bot-
tom of the caudal septum. Lower lateral cartilages
were released from the upper lateral cartilage and
scar tissues, and moved into an elongated position
using the septal extension graft. Domal and infra-
domal onlay grafts were added with rib cartilage
and folded perichondrium. Both lateral crural
onlay grafts were done with a thin sleeve of carved
rib cartilage. Deficient dorsum was filled with
carved rib cartilage, and diced rib cartilage/loose
soft tissue mixture on top (Fig. 24). During the
skin closure, the gap between the dorsal envelope
and vestibular skin was filled with cymba conchal
composite graft bilaterally.
Two months after surgery, her tip was rotated
caudally and the retracted columella was normal-
ized. Her radix was lowered while her dorsum
maintained her preoperative height, which made
the nose look natural (Fig. 25).
Fig. 13.19 (continued)
H. R. Jin
429
a
b
c
d
Fig. 20 (a) Yellow pus is draining from undersurface of
the silicone implant when the nose is opened. (b) Right
intermediate crus and lateral crus are missing due to infec-
tion necrosis. (c) A two-layer carved rib cartilage graft for
the dorsum. (d) Right lateral crural restoration graft and
tip grafts are in position for tip modification
Contracted Nose: My Preferred Technique
430
Fig. 21 Two-month postoperative view shows a well healed, normal looking nose. Tip has been lowered considerably
H. R. Jin
431
Fig. 22 Preoperative views of a 66-year-old woman show short, contracted nose, upturned tip, and severely retruded
columella
Contracted Nose: My Preferred Technique
432
f
Fig. 23 Her nasal bone view shows a large silicone
implant on the dorsum
Fig. 24 Carved rib cartilage and diced costal cartilage
wrapped with chest soft tissue for dorsal graft
H. R. Jin
433
Fig. 25 Two-month postoperative views show a much
improved nose shape. Dorsum is maintaining a normal
height by replacing the silicone with rib cartilage, tip was
rotated caudally, and the retracted columella gained the
normal volume
Contracted Nose: My Preferred Technique
434
Further Reading
Jung DH, Moon HJ, Choi SH, et al. Secondary rhino-
plasty of the Asian nose: correction of the contracted
nose. Aesth Plast Surg. 2004;28:1.
Park JH, Jin HR. Use of autologous costal cartilage in
Asian rhinoplasty. Plast Reconstr Surg. 2012;130:
1338.
Park JH, Mangoba DC, Mun SJ, et al. Lengthening the
short nose in Asians: key maneuvers and surgical
results. JAMA Facial Plast Surg. 2013;15:439.
Suh MK, Ahn ES, Kim HR, et al. A 2-year follow-up of
irradiated homologous costal cartilage used as a septal
extension graft for the correction of contracted nose in
Asians. Ann Plast Surg. 2013;71:45.
Sunwoo
W,
Jung
H,
Kim
DW,
Jin
HR. Immunohistochemical analysis of capsular con-
tracture in silicone implant rhinoplasty. JAMA Facial
Plast Surg. 2017;19(5):436–7.
Toriumi DM. Foreshortened nose and severe alar retrac-
tion, two prior rhinoplasty surgeries. Facial Plast Surg
Clin North Am. 2006;14:401.
Wee JH, Park MH, Oh S, Jin HR. Complications associ-
ated with autologous rib cartilage use in rhinoplasty:
a meta-analysis. JAMA Facial Plast Surg. 2014;17:49.
Won TB, Jin HR. Revision rhinoplasty in Asians. Ann
Plast Surg. 2010;65:379.
Won TB, Jin HR. Immediate reconstruction with autolo-
gous cartilage after removal of infected alloplast in
revision rhinoplasty. Otolaryngol Head Neck Surg.
2012;147:1054.
H. R. Jin
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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,
Contracted Nose and Difficult
Complication Cases: My Preferred
Technique
Moo Hyun Paik and Lo Shui Chu
The most common cause of contracted nose is
chronic infection derived from remaining for-
eign materials, infected allograft, and rarely
autograft. To prevent the aggravation of contrac-
tion is the removal of causing foreign materials.
Definitive correction can be done at the same
time as removal of causative materials in the
case of the inactive infectious condition, but
maybe delayed until scar maturation after
removal of causative materials. My principle to
correct the severely contracted nose or other
challenging deformed nose is: disassembling the
remaining every structure, and rearranging them
at the ideal position, and reconstructing the
defect components with a graft similar to the
original structures, and maintaining the rear-
ranged structure into the ideal position with
autogenous graft with a similar physical prop-
erty, therefore, that the tip mobility will have
preserved in the post-operative state. Among the
severely deformed nose, many patients may not
be corrected at once, so they need a staged oper-
ation. Some patients need skeletal framework
reconstruction first. In some patients whose skin
envelop is extremely bad to reconstruct skeletal
framework, skin envelope restoration is the pri-
ority. Sometimes, extension of the skin flap is
limited, and we should wait quite a long time
after the 1st stage of the operation to get more
extension of the skin.
The cases in this chapter all underwent rhino-
plasties before, and many of them had multiple
surgeries.
Most of my preferred techniques and basic
principle were described in detail in Chapters
“Nasal Tip Techniques (1): Tip Augmentation
Techniques” and “Surgery of Columella, Alar
Rim & Alar Base”.
M. H. Paik (*)
Department of Plastic and Reconstructive Surgery,
Ulaanbaatar Agape Christian Hospital,
Ulaanbaatar, Mongolia
L. S. Chu
Gok Saem Aesthetic Plastic Surgery Clinic,
Seoul, South Korea
436
a
b
Fig. 1 A patient presents with short nasal length, asymmetric nostrils, right side retracted ala, low dorsal height, devi-
ated columella, and tip skin irregularity
Fig. 2 Surgical procedures
a
b
c
d
e
f
Case 1
Pre-operative Findings
Short nasal length, asymmetric nostrils, right
retracted ala, low dorsal height, deviated colu-
mella, tip skin irregularity (Fig. 1a, b).
Intra-operative Findings
Symmetric and severely distorted alar cartilages,
defect on right alar cartilage.
Operative Procedures
The skin flap was elevated from underlying scar
tissue for skin extension (Fig. 2a).
M. H. Paik and L. S. Chu
437
Alar cartilage was released from scar tissue,
upper lateral cartilage, and septum for a freely
movable tip in the ideal position (Fig. 2b).
An umbrella-shaped columellar strut was used
for the symmetry of the medial crura and dome
area (Fig. 2c).
The defect portion of the right Lateral crus
was covered with a conchal cartilage graft
(Fig. 2d).
The position of rearranged alar cartilages was
maintained with derotation graft (Fig. 2e).
Dermofat graft was used for dorsal augmenta-
tion, and dermis graft was done to restore tip skin
thickness (Fig. 2f).
Pre-operative and
Post-operative Photographs
(Fig. 3a, c, e, g and b, d, f, h)
Fig. 3 Preoperative (a, c, e, g) and post-operative (b, d, f, h) views
a
c
e
g
b
d
f
h
Contracted Nose and Difficult Complication Cases: My Preferred Technique
438
Case 2
Pre-operative Findings
Short nasal length, retracted ala, thin tip skin over
the implant, excessive nostril show (Fig. 4a–c).
Intra-operative Findings
L-shaped silicone implant (Fig. 5).
Cephalically located both domes and upwardly
retracted alar rim.
a
b
c
Fig. 4 A patient with short nasal length, retracted ala, thin tip skin over the implant, and excessive nostril show
Fig. 5 Previously used L-shaped silicone implant
M. H. Paik and L. S. Chu
439
Operative Procedures
The skin flap was elevated from the underlying
scar tissue (Fig. 6a).
Silicone implant was removed (Fig. 6b, c).
Alar cartilage was released from the scar
tissue, upper lateral cartilage, and septum
(Fig. 6d, e).
Transdomal suture was performed on a more
caudal portion of the alar cartilage, and down-
ward reposition of the alar cartilage was per-
formed (Fig. 6f, g).
Caudally rearranged alar cartilages were fixed
with an umbrella-shaped columellar strut and
multilayered derotation graft. Columellar septal
suture was done on columellar base. Dermofat
graft was used on dorsum and tip (Fig. 6h, i).
Fig. 6 Surgical procedures
a
b
c
d
e
f
g
h
i
Contracted Nose and Difficult Complication Cases: My Preferred Technique
440
Pre-operative and
Post-operative Photographs
(Fig. 7a, c, e, g, i and b, d, f, h, j)
Case 3
Pre-operative Findings
Upturned tip, a severe form of the retracted colu-
mella, pinched tip, low nasal bridge, acute-angled
nostril apex (Fig. 8a–d).
Fig. 7 Preoperative (a, c, e, g, i) and post-operative (b, d, f, h, j) views
a
b
c
d
e
f
g
h
i
j
a
b
c
d
Fig. 8 A patient shows an upturned tip, severely retracted columella, pinched tip, low nasal bridge, and acute-angled
nostril apex
M. H. Paik and L. S. Chu
441
Intra-operative Findings
Alar cartilages were poorly distorted, retracted
upwardly, and intermingled with thick scar tissue.
Some defects on the left lateral crus of the alar
cartilage were found.
Operative Procedures
The skin flap was elevated from underlying scar
tissue for an extension (Fig. 9a).
Alar cartilages are released from the scar tis-
sue, upper lateral cartilages, and septum so that it
can move downwardly without resistance
(Fig. 9b, c).
The defect area on the left lateral crus was
covered with ear cartilage (Fig. 9d).
Columella strut was performed (Fig. 9e).
The membranous septum was free from any
solid material such as cartilage can be pushed up
without resistance. Caudally repositioned alar
cartilages were fixed with a double-layered dero-
tation graft (Fig. 9f, g).
Dorsal augmentation was performed with a
dermofat graft (Fig. 9h).
Fig. 9 Surgical procedures
a
b
c
d
e
f
g
h
Contracted Nose and Difficult Complication Cases: My Preferred Technique
442
Pre-operative and
Post-operative Photographs
(Fig. 10a, c, e, g, i and b, d, f, h, j)
Fig. 10 Preoperative (a, c, e, g, i) and post-operative (b, d, f, h, j) views
e
f
g
h
a
c
i
b
d
j
M. H. Paik and L. S. Chu
443
Case 4
Pre-operative Findings
Short nasal length, severely retracted columella,
low nasal bridge (Fig. 11a, b).
a
b
Fig. 11 A patient with Short nasal length, severely retracted columella, low nasal bridge
Contracted Nose and Difficult Complication Cases: My Preferred Technique
444
Intra-operative Findings
Alar cartilages were tightly adhered to each other
and retracted upwardly by heavy scar tissue. Two
layers of rib cartilages were found in the intercru-
ral space as a columellar strut.
Operative Procedures
The skin flap was elevated from underlying inelas-
tic scar tissue for skin extension (Fig. 12a, b).
Scar flap was elevated from the underlying
cartilage framework (Fig. 12c).
Columellar strut with two layers of rib carti-
lage graft was removed (Fig. 12d).
Alar cartilages were released from each other,
from upper lateral cartilages, and septal struc-
tures to move downwardly without resistance
(Fig. 12e).
Umbrella-shaped columellar strut with two
layers of the conchal cartilage graft was done
(Fig. 12f).
One layer of derotation graft, two layers of
onlay tip graft, and one layer of shield graft
with
conchal
cartilage
were
performed
(Fig. 12g, h, i).
Scar flap was redraped over derotation graft
(Fig. 12j).
Dermofat graft was used on nasal bridge and
tip (Fig. 12k).
Fig. 12 Surgical procedures
a
b
c
d
e
f
g
h
i
j
k
M. H. Paik and L. S. Chu
445
Fig. 13 Preoperative (a, c, e, g, i) and post-operative (b, d, f, h, j) views
a
b
c
d
e
f
g
h
i
j
Pre-operative and
Post-operative Photographs
(Fig. 13a, c, e, g, i and b, d, f, h, j)
Contracted Nose and Difficult Complication Cases: My Preferred Technique
446
Case 5
Pre-operative Findings
Short nasal length, retracted columella, retracted
ala (medial type), pinched tip, low nasal bridge
(Fig. 14a, b).
a
b
Fig. 14 A patient shows short nasal length, retracted columella, retracted ala, pinched tip, and low nasal bridge
M. H. Paik and L. S. Chu