Kỹ Thuật Phẫu Thuật Nâng Mũi Đỉnh Cao (Mastering Rhinoplasty)

44
Chapter 2  
A Basic Rhinoplasty Operation
All incisions are sutured. I begin with the transcolumellar incision: first, the midline suture
at the apex of the V for alignment; second, the lateral corner sutures to insure redraping of
the skin; and third, the columellar pillar sutures. Additional interrupted sutures of 6–0 nylon
are added as indicated. Then the infracartilaginous incisions are closed with two sutures of
5–0 plain catgut. Rather than lining up predetermined dots, I favor two angulated sutures
from lateral to dome. However, one must avoid notching the alar rim by suturing the mobile
alar rim to a retracted alar cartilage. This problem can be treated by insertion of an alar rim
graft. The transfixion incision is closed with 2–3 sutures of 4–0 plain catgut.
The classic nasal packing is not used It is not necessary, and patients hate it. If septal or
turbinate work was done, then Doyle splints lubricated with polysporin ointment are ­inserted
into the nasal airways (Fig. 2.18a, b). The splints are sutured together to compress the mucosal
leaflets with a single horizontal mattress suture of 4–0 nylon which is always tied on the left
side. These splints minimize the risk of a septal hematoma and prevent synechiae forma-
tion. The tubes are left on the Doyle splints when major septal straightening has been done
and removed in other cases to facilitate breathing. The nose is then taped with 0.5 in. wide
­Steri-strips which compress the skin envelope, reduce edema, and model the tip (Fig. 2.18c).
The tapes are applied in the following sequence: (1) three slightly overlapping transverse
tapes on the bridge from radix to supratip, (2) two longitudinal tapes placed along the edges
of the bridge of the nose and then pinched together to both narrow the tip and support it,
and (3) another transverse tape to compress the supratip skin. A small piece of Telfa gauze
(4 × 1 cm) is placed along the dorsum which will facilitate subsequent removal of the nasal
splint. The plastic polymer splint is placed in boiling water to become flexible, molded over
the bony portion of the nose, and then instantly “set” by pouring ice water over it.
The surgeon immediately dictates the operative report and fills out the operative flow
sheet and diagrams. The smoothness of the postoperative course is directly proportional to
the amount of time spent at the preoperative visit explaining to the patient what to expect.
The post-op medications are confirmed (Vicodin for pain, cephalosporin antibiotic for 5
days). The patient is reminded to clean all suture lines free of crusts – two to three times a day
with hydrogen peroxide and apply polysporin ointment. At 6 days, the dressings are removed
in the following sequence: (1) the external cast is rocked side to side and comes off easily
because of the Telfa sheet on the dorsum, (2) Steri-strips, (3) internal splints after cutting the
suture on the left side, and (4)columellar and alar sutures,
P R I N C I P L E S

 The ease of the postoperative course is directly related to the thoroughness of the pre-op
visit.

 Eversion of the nostril sill closure is critical, thus the horizontal mattress of 4–0 plain that
everts the edges.

 After the cast is removed, the nose is taped using same taping method as intraop. The
­patient tapes at night for 3 weeks.
Closure, Cast,
and Post-op
Management

Closure, Cast, and Post-op Management
45
Fig. 2.18 (a, b) Dressing, (c) postoperative taping

46
Chapter 2  
A Basic Rhinoplasty Operation
This fundamental rhinoplasty operation allows surgeons to achieve very good results with an
excellent margin of error. It is assumed that the surgeon has basic rhinoplasty skills acquired
during their residency training. Building from their own foundation, one should assimilate
the various parts of this standard operation. The surgeon does not need to use every step
in every nasal surgery. However, one can be sure that every step might be required in the
actual case one is doing that day. One cannot avoid correcting the anatomical causes of nasal
obstruction that preexist in 35% of the cosmetic cases. As the surgeon gains experience, the
operation can be expanded to an ever widening variety of cases and specific techniques
added. A good example is incorporation of add-on grafts to get greater tip definition in thick
skin patients and the use of alar rim grafts to minimize alar retraction. Some surgeons will
question ­various aspects of this basic operation and I will attempt to address their concerns.
Q. Originally, you thought that a basic rhinoplasty operation was impossible because
of the diversity of patients and operative techniques. What is different now?
A. I have concluded that a surgeon who does less than 35 rhinoplasties a year should
learn one expandable operation well, select cases that are within their comfort zone, and com-
mit to learning surgical cause and effect by keeping meticulous records of each procedure.
Over a 3-year period, the surgeon can then expand their comfort zone and case profile from
Level 1 to Level 2 which will cover 95% of the primary patients seen in a normal practice.
Q. Why the open approach in all cases?
A. A rhinoplasty is much easier to do open than closed. The variety of available tip pro-
cedures is much greater and 95% of the major secondary cases are done open. Therefore, it
makes sense to master the open approach. If one is comfortable with the endonasal approach
and wants to use it in some cases with limited tip deformities, that approach is certainly ap-
propriate. However, for those with the usual limited residency experience, it makes sense to
concentrate on one approach and that is the expandable open approach.
Q. Are you suggesting a septal harvest on all patients?
A. Yes, I am doing a septal harvest in most cases to obtain graft material. It is important
to realize that a rhinoplasty is really an “aesthetic septorhinoplasty” and one must deal with
all the functional aspects of a cosmetic case. I am convinced that 35% of the pure cosmetic
rhinoplasty patients have a fixed anatomical nasal obstruction that will cause postoperative
obstruction unless it is fixed during the operation. Thus, a septal harvest is also a septo-
plasty of the septal body that will improve nasal function in many cases. If one is going to do
rhinoplasty surgery, one must become comfortable with all aspects of septal surgery includ-
ing caudal septal relocation.
Q. How often do you do spreader grafts?
A. The percentage is around 75% with half for function and half for aesthetics. The
larger the reduction is, the more frequent the use of spreader grafts to avoid an inverted-V
deformity. Certainly, any reduction over 2 mm converts the Y-shape dorsum at the rhinion
into an I-shape central septum with potential collapse of the upper lateral cartilages and
blockage of the internal valve. Fully, half of my spreader grafts are made asymmetric in width
to correct preoperative asymmetries. I have never regretted inserting spreader grafts, but I
have regretted not doing them. It is my opinion that “spreader flaps” can be used for minimal
problems, but are not a full-service solution.
The Basic Rhino­
plasty Operation:
A 95% Solution

The Basic Rhino­plasty Operation: A 95% Solution
47
Q. Why the columellar strut?
A. The columellar strut is almost magical in its beneficial effects on the tip. The columellar
strut and its suture serve three purposes: tip stability, tip projection, and columellar shape.
The strut fosters verticality and projection of the tip while eliminating plunging of the tip on
smiling. Suturing the alars to the strut creates a unified tip complex and improves symmetry.
It is this tip that can be positioned with the tip position suture to create a supratip set off.
Equally important, the strut provides a rigid intrinsic shape for the columellar thus reducing
the influence of a deviated caudal septum.
Q. How flexible is the tip suture operation?
A. The tip suture technique that I advocate is essentially a “sew until its perfect” proce-
dure. One normally sets the foundation of the tip with the strut (strut suture), then creates
tip definition (domal creation suture), narrows tip width (interdomal suture), reduces asym-
metry (domal equalization suture), and then achieves the desired supratip break as well as
projection and rotation (tip position suture). One stops when the tip looks great with the
skin closed. Only those steps are done which the anatomy mandates. For example, one may
not need a domal creation suture on both sides, or the symmetry is excellent and a domal
equalization suture is not done. There are no special sutures or instruments required. All of
this is done with off the shelf sutures of 5–0 and 4–0 PDS.
Q. Why should I follow the Level approach and learn the basic operation?
A. If you have just entered practice, both your clinical experience and surgical skill set
are finite, while the variety of noses is infinite. If every good result brings you three referrals
and every bad result loses you nine, why start with the hardest cases? Obviously, one of the
goals of this text is to teach you to recognize the various levels of difficulty and help you select
appropriate patients. Surgically, most residents finish their training having done less than 20
cosmetic rhinoplasties with minimal follow-up. Their understanding of surgical cause and ef-
fect is marginal at best. For the first few years in practice, one should concentrate on learning
a single expandable operation. Meticulous records must be kept as they allow the surgeon to
evaluate their results at each postoperative visit. Although every step of the basic operation
does not need to be done in every patient, I am convinced that each step will be needed in
your first 25 rhinoplasties. Thus, it makes sense to learn the basic operation as a collection of
surgical techniques which the surgeon selects from to design the optimal operative plan for
the individual patient.

48
Chapter 2  
A Basic Rhinoplasty Operation
Step #1: The Consultation. A rhinoplasty will be successful only if it achieves what the patient
wants. Therefore, you must have the patient point in the mirror at what three things bother
him or her the most. Write them down on the operative planning sheet. Most women want a
smaller more feminine nose with a lower profile, narrower width, and a more refined tip. Next,
it is your turn to examine the nose externally and internally. Decide what the negatives are and
what can be achieved realistically given the patients anatomy. Sketch out a proposed operative
plan – how much reduction, what type of osteotomies, tip surgery, any base modification, and
functional factors. Assess the level of difficulty and whether this case fits within your comfort
zone. After talking with the patient, determine whether you want this patient in your practice.
Standard nasal photos of the patient are taken assuming you both wish to proceed. The patient
is asked to bring photos of noses they like to the next appointment. As shown in the DVD of
Fig. 6.2, the importance of the intranasal exam cannot be over emphasized.
Step #2: The Pre-op Visit. Early in one’s practice you should do a photo analysis on all patients
as it trains you to “see” the deformity and the solution. The critical sequence is to define the
deformity, to superimpose the ideal, and then determine what is surgically feasible. When
the patient returns, examine the nose again without looking at your notes – you want to see
what is wrong with the nose and visualize what a rhinoplasty can achieve. Then open your
notes, give the patient a mirror and ask her to tell you what bothers her the most in the order
of importance. Check her requests against your operative plan. Then look at the pictures
of the noses that the patient likes. Then review the operative plan and make any necessary
changes. Write out a step-by-step individualized operative plan.
Step #3: The Operation. The advantage of spending the time to write out a detail step-by-step
operative plan is that the vast majority of operations go according to plan. You can concen-
trate on surgical execution and efficiency rather than surgical decision making. Yes, slight
changes may be necessary based on actual anatomy (add-on graft, alar rim graft, etc.), but
you are not staring at the nose wondering what to do next. It is wise to take a four-view set
of photos of the exposed finished tip before closing. At the end of the operation, a detailed
op diagram is made which records every step and any questions you might have as to surgi-
cal cause and effect (Fig. 2.20).
Step #4: Postoperative Follow-Up. The patient is seen a week later and the cast removed. The
chart is opened to the op diagram page which allows you to assess surgical cause and effect.
With the patient holding a mirror, the patient is taught how to tape their nose for compression.
They are urged to wear the tapes for another 2–3 days and then tape at night for 3 weeks.
They are given a set of their preoperative photographs. Return visits are scheduled at 1, 3,
and 6 weeks with additional visits at 4 and 12 months.
Decision Making
Level 1:
­Planning a
­Rhinoplasty

Decision Making Level 1: ­Planning a ­Rhinoplasty
49
A Basic ­Rhinoplasty Operation: Operative Sequence
  1) Essentials – 2.5x loupes, fiberoptic headlight, own instruments.
  2) General anesthesia with appropriate monitors.
  3) Local anesthesia injection, then preparation – wait for 10–15 min.
  4) Remove intranasal nasal pack and shave vibrissae.
  5) Open approach using infralobular and transcolumellar incisions.
  6) Elevation of skin envelope.
  7) Septal exposure via transfixion incision and extramucosal tunnels.
  8) Reassess operative plan based on alar and septal anatomy.
  9) Creation of symmetrical alar rim strips.
10) Incremental hump reduction – rasp:bony, scissors:cartilage.
11) Caudal septum/ANS excision.
12) Septal harvest/septoplasty.
13) Osteotomies.
14) Graft preparation.
15) Spreader grafts.
16) Columellar strut and suture.
17) Tip sutures.
18) Closure.
19) Alar base modification.
20) Alar rim support grafts (ARS).
21) Doyle splints and external cast and nasal block.
Note: all steps are considered, but only those steps indicated are actually used.
What Are the Most Common Variations?
1) Cartilaginous dorsal reduction is achieved primarily by excising the isolated dorsal sep-
tum, while dorsal narrowing is achieved by excision of upper lateral cartilage. The ratio is
often 3:1 with minimal ULC resection.
2) The caudal septum is altered in less than 50% of the cases and the ANS in less than 5%.
3) The majority of septal problems in cosmetic cases are deviations of the septal body or cau-
dal septum. A septal harvest often corrects the former while a relocation fixes the caudal
septum.
4) Osteotomies are not done in 10% of the cases as the bony vault is quite narrow preopera-
tively and one does not want to reduce the nasal airway.
5) Spreader grafts are not done in 25% of the cases because the dorsum was reduced less than
2 mm. The majority of paired grafts are asymmetric and 50% are inserted for aesthetic
reasons.
6) Tip sutures are sufficient in 75% of the patients with 20% having add-on grafts of excised
alar cartilage. A true tip graft of septal cartilage is used in less than 5% of Caucasian pa-
tients, but 95% of Asian patients.
7) Initially, alar base modification should be something that the patient requests (smaller
nostrils) rather than something that the surgeon suggests. Conservatism is essential.
8) Alar rim grafts may be necessary to minimize alar rim weakness. They are easily placed in
subcutaneous pockets that parallel the alar rim.

50
Chapter 2  
A Basic Rhinoplasty Operation
a
b
c
Fig. 2.19 (a–c)
Anterior
Lateral
N-Ti = 0.67 × MFH
AC-Ti = 0.67 × N-Ti
C-Ni = 0.28 × N-Ti
N-Ti =
AC-Ti=
C-Ni=
EN-EN =
C-N =
X-X =
AC-T =
AL-AL =
N-C’ =
Actual
Ideal
Change
AC-AC =
N-SN =
N
IDD =
N-FA =
T
MFH =
TA =
SN
LFH =
CIA =
NFA
SME =
CLA =
TA
CIA
C-N
N-T
AC-T
Table 2.3 Photographic analysis

Operative Procedure Diagram
51
Fig. 2.20

52
Chapter 2  
A Basic Rhinoplasty Operation
Analysis. A 16-year-old girl presented for a rhinoplasty (Fig. 2.21). She stated that she did not
like her profile and that her breathing was normal. The external exam revealed a deviation
of the caudal septum to the left. On profile and oblique view, she had a “tension nose” and
a high potential for an inverted-V deformity. On internal exam, the septum totally blocked
the right airway while the caudal deflection blocked the left external valve. Aesthetically, this
is an easy case to obtain an excellent result. An incremental dorsal reduction (2 mm bone,
4 mm cartilage) and 4 mm of caudal septal resection was done. In addition, a chin implant
gave better balance to the face. Yet the case illustrates the necessity of being able to correct
septal deviations and doing spreader grafts for functional and aesthetic purposes. Thus, both
techniques are part of the basic rhinoplasty operation.
Case Study:
Aesthetic
Septorhino­
plasty (Level 1)
Fig. 2.21 (a-l) (a) Endoscopic view of septal deviation, (b) Septal harvest corrected deviation of septal
body, (c,d) caudal septal relocation

Case Study: Aesthetic Septorhinoplasty (Level 1)
53
Fig. 2.21 (continued)

54
Chapter 2  
A Basic Rhinoplasty Operation
Each surgeon must develop their own criteria for assigning a degree of difficulty to each nose,
from Level 1–3. Perhaps, the best method is to use a classic “standard deviation” system based
on deviation from normal (Fig. 2.22). Each of the six tip criteria can be analyzed as well as
skin thickness. After assessing the tip, a degree of difficulty is assigned for the dorsum, base,
and septum. Added to the mix are patient factors and history of trauma or nasal obstruction.
Here are a few of my own criteria and concerns.
Patient Factors. Is this patient psychologically a candidate for surgery and would a rhino-
plasty make a real difference in their appearance? How would this patient cope with a com-
plication? What is my margin of error? How close can I come to achieving what the patient
wants? Am I comfortable with this patient and the operative plan?
Surgical Factors.
1. Tip. In most Level 2 cases, the challenge is bringing the tip back into the normal range
without having to fundamentally change its shape. An example is the difference between
a broad tip (Level 2) which requires aggressive suturing and perhaps add-on grafts versus
an over projecting ball tip (Level 3) which may require alar transposition plus lateral crura
strut grafts.
2. Dorsum. Level 2 cases often differ from Level 1 cases quantitatively – the amount of re-
duction and its cephalic extent are often greater. Spreader grafts are now a necessity. Any
radix graft will be fascia and occasionally have diced cartilage beneath it. All full-length
augmentations or major radix reductions are Level 3.
3. Base. Assigning a level for the base is most easily determined from the surgical plan. For
example: Level 1 (nostril sill or alar wedge), Level 2 (combined nostril sill/alar wedge with
alar rim graft), or Level 3 (major combined excisions in the ethnic nose). In Level 2 cases,
one must be comfortable with all types of base excision and the standard alar rim grafts
(ARG, ARS).
4. Septum. The more difficult septums are those with severe deviations due to developmental
or traumatic etiologies. Correction may require dorsal splinting and division which can
be challenging. Once comfortable with restoring dorsal stability and replacing the caudal
septum, one can do a total septoplasty – a very frightening maneuver when done for the
first time. Severe posttraumatic and secondary septums are considered Level 3 as there is
no certainty as to how complex the surgery will become including possible rib grafts.
P R I N C I P L E S

 The simpler the operative plan is, the greater the chance of success.

 Transition from Level 1 to Level 2 cases by picking cases where only one or two areas of the
nose are harder – not all aspects.

 Make sure the nose looks significantly better at the end of the operation – continue until
it is as good as you can do.

 Never hesitate to take out sutures or grafts that are not perfect.
Decision Making
Level 2:
The Harder Nose

Decision Making Level 2: The Harder Nose
55
Septum (Level 2+)
Fig. 2.22 (a–d) (Level 1–3) cases
Nasal base (Level 1–3)
Dorsum (Level 1–3)
Tip width (Level 1–3)

56
Chapter 2  
A Basic Rhinoplasty Operation
A 17-year-old Hispanic girl complained of her profile view and that the nose plunged when
she smiled (Fig. 2.23). On lateral view, the dorsum was normal height while the radix was low.
On anterior view, the dorsum was wide both dorsally and laterally. A “balanced approach”
was used with radix augmentation and tip support. The caudal septum was shortened 6 mm
which eliminated downward pull on the tip when smiling. The ability to rotate the tip upward
was achieved with the columellar strut and a dorsal positioning suture. Narrowing of the
dorsal and lateral width without lowering the dorsum was achieved using parallel dorsal and
lateral osteotomies. At 4 years post-op, the patient has done well.
Operative Technique Highlights
1) Exposure of the nose – no dorsal reduction
2) Caudal septal resection of 6 mm and septal harvest
3) Paramedain and low-to-low osteotomies
4) Crural strut and tip sutures: CS×2, DC, ID, DE, C-S
5) Radix graft of diced cartilage in fascia (0.5 cc)
6) Nostril sill excisions 2.5 mm
7) Small chin implant
Case Study: The
Plunging Tip
(Level 2)
Fig. 2.23 (a-j)

Case Study: The Plunging Tip (Level 2)
57
Fig. 2.23 (continued)

58
Chapter 2  
A Basic Rhinoplasty Operation
Level of Difficulty. Put simply, a Level 3 nose is one whose anatomical deformity limits the
achievement of an excellent result. Often, the skin will be too thick, the alars too asymmet-
ric, or the entire nose is unattractive. Early in my practice, I could always recognize these
cases because I did not sleep well the night before surgery. The result was that I spent hours
in the operating room sweating the details and then months in the exam room listening to
the patients complain. A smarter surgeon would have recognized them at consultation and
passed on doing them until their surgical skill set had expanded. What should you do?
First, you have to develop your own individual set of “aesthetic” criteria for grading
Level 1–3 cases based on the presenting deformity. You must reconcile both the patient’s de-
formity and requests with your surgical ability to achieve the patient’s goal. In the first few
years of practice, there is nothing wrong with a “one third distribution” for each level of
difficulty. Second, as you gain experience and progress from Level 1 to Level 2 cases you can
shrink the percentage of cases assigned to Level 3. Third, experience will give you the judg-
ment and confidence to do more difficult cases.
Expansion of Operative Techniques. Level 3 cases demand both excellence of the fundamental
steps in a rhinoplasty operation and expansion of the skill set. For example, virtually all types
of grafts may be required from columellar struts to tip grafts to alar grafts. A radix reduction
is a magnitude harder than a radix augmentation. A combined nostril sill/alar base resection
is a grade more difficult than an alar base resection. Ethnic noses are more challenging than
the usual Caucasian nose. As regards the tip, an open structure tip graft signals a harder case
than a suture tip. Yet, an open tip graft added to sutured domes is easier than one where the
domes are excised to drop projection. One may encounter severe alar malposition under thin
skin which requires alar transposition and coverage with a fascial blanket graft.
Transitioning from Level 2 to Level 3. For most surgeons, the transition from Level 2 to 3 cases
will be gradual and sometimes unplanned. For example, when dealing with a combined large
nose and tip, it becomes necessary to reduce both. The dorsum is reduced first in increments
and suddenly the tip looks relatively enormous. The planned open tip suture procedure will
not reduce the tip. Rather, domal excision and tip grafting becomes obligatory. Yes, it would
have been ideal to have decided on this op plan first, but the unexpected happens. Obviously,
preoperative planning is better and identification of a subset of patients that require more
sophisticated techniques is the goal. In my own practice, the transition from Level 2 to 3
was possible by operating on easier Asian and Type II Hispanic noses. Preoperatively, one
knows that the skin envelope will be thick, the need for structure great, dorsal augmentation
frequent, and alar base reduction demanding. These cases require sophistication and are
probably Level 2.5 which makes them ideal for transitioning to Level 3 (Fig. 2.24).
Decision Making
Level 3:
The Difficult Nose

Decision Making Level 3: The Difficult Nose
59
Fig. 2.24 (a–d) Level 3 cases

60
Chapter 2  
A Basic Rhinoplasty Operation
A 44-year-old woman wanted a rhinoplasty because she hated her large round tip (Fig. 2.25).
The size of the tip was compounded by the juxtaposition of a narrow dorsum. There was
no alar malposition. She had a deep alar cartilage – A1 junction compressing the vestibular
valve that collapsed on deep inspiration. After extensive discussion, she made it clear that
she wanted a “smaller model’s tip.”
There was nothing simple about this nose from either an aesthetic or a functional per-
spective. One had to excise the strong ball-shaped alar cartilages in the presence of vestibular
and nostril valve collapse. Six functional steps were done to provide structure: (1) a columel-
lar strut, (2) lateral crural strut grafts, (3) the septoplasty aspect of the septal harvest, (4)
major spreader grafts, (5) out fracture of the turbinates, and (6) the decision not to do lateral
osteotomies. By comparison, direct excision of a domal segment and coverage with a tip graft
of excised cartilage was straightforward.
Operative Technique
1) Exposure disclosed round alar cartilages 14 mm in width.
2) Incremental dorsal reduction (bone 1 mm, cartilage 4 mm).
3) Septal and fascial harvest.
4) No osteotomies.
5) Bilateral spreader grafts.
6) Create 6 mm rim strips.
7) Insertion of crural strut. Excision 5 mm domal segment.
8) Repair of domal excision. Coverage with an alar concealer graft.
9) Excision of alar – A1 junction. Insertion of lateral crural strut grafts Type I.
Case Study:
The Ball Tip
(Level 3)
Fig. 2.25 (a-j)

Case Study: The Ball Tip (Level 3)
61
Fig. 2.25 (continued)

62
Chapter 2  
A Basic Rhinoplasty Operation
The smoothness of the postoperative course is directly proportional to the thoroughness
of the preoperative preparation. Another copy of the “10 Most Frequently Asked Post-Op
Questions” is given to the patient’s caregiver. The patient is instructed to begin pain medica-
tion and oral antibiotics (Ciprof 500 mg BID for 5 days). Head elevation and ice compresses
over the eyes for 36 h are recommended. The drip pad is changed as necessary. Meticulous
cleaning of all suture lines two to three times a day with hydrogen peroxide and coverage
with antibiotic ointment is stressed. The patient is seen 1 week later. On the morning that
the cast is to be removed, the patient is instructed to take a shower and get the cast and nose
wet. They are also told to take a pain pill 30 min before coming to the office. The sequence of
removing the dressing is as follows: (1) the acrylic cast is lifted off by gentle rocking (the Telfa
dorsal strip allows it to come off without pulling the skin), (2) the Steri-strips are removed,
(3) the intranasal splints are extracted after the suture is cut on the left side, (4) all external
sutures are removed, and (5) the nose is gently cleansed with hydrogen peroxide. The patient
is allowed to see the nose with a mirror; especially the profile view with the preoperative
lateral photograph held beside the head for comparison. Then the patient is taught how to
tape and also given a step-by-step “taping diagram” plus a roll of tape. The technique is as
follows: (1) four 2 cm pieces, one 4 cm piece, and one 6 cm piece of 0.5 in. flesh-colored paper
tape are cut, (2) three short pieces are slightly overlapped on the dorsum, (3) the medium
and long piece are placed longitudinally along the edge of the dorsum, (4) the distal ends
are pinched together to narrow the tip and the longer piece rotated to the opposite side, and
(5) the final short piece is placed transversely to set off the tip. The patient is encouraged to
tape the nose at night for 3 weeks to reduce swelling. In patients with thick skin, taping may
be done for 4–6 weeks. If the nostrils have been narrowed extensively or I am concerned
about their shape then “nostril splints” are inserted prior to the taping. Patients will use the
nostril splints at night, unilateral or bilateral, for 1–3 weeks. When turbinates and complex
septal surgery are done, the patient is encouraged to irrigate the nose with a generic salt water
spray. The patient is seen 2 weeks later and then at regular intervals: 3, 6, and 12 months and
then annually, thereafter. The usual concerns include bruising, swelling, breathing, smiling,
numbness, and initial appearance.
Ecchymosis and Edema
Bruising and swelling are a normal occurrence following a rhinoplasty. Since the patient must
be off aspirin for 2 weeks prior to surgery, bruising rarely persists for more than 1 week.
Some patients do have a residual bruising in the malar area that can be covered up with
makeup and an unfortunate few do get scleral hemorrhage that may persist for 3–6 weeks.
Very rarely, a patient of Mediterranean descent will get dark circles beneath their eyes which
require a course of 4% solaquin forte. Patients are told preoperatively to expect swelling and
that it will regress in two stages. Stage I is a generalized swelling that reduces uniformally
over the first 2–3 weeks. Stage II is a more gradual period of scar remodelling that follows
a constant pattern: bony dorsum 3 months, cartilaginous dorsum 6 months, supratip area 9
months, and tip 12 months. I emphasize to the patient that they loose one third of their tip
Postoperative
Management

Postoperative Management
63
swelling by 2 months, the next third between 3 and 9 months, and the final third between 9
and 12 months.
Breathing
Most patients breathe well, especially after removal of the intranasal splints. They are warned
that the splints have been compressing the mucosa and that a rebound swelling may occur
for a week or so. They are encouraged to use a nasal spray to replace normal nasal secretions
and mechanical cleansing, both of which are often reduced temporarily following surgery.
During the winter, a humidifier and coating the vestibule/caudal septum with vaseline is
often encouraged to counteract the drying of forced air heating.
Initial Appearance
Before the cast is removed, the patient is reminded of the preoperative admonitions: (1)
the nose will be swollen, (2) the nose will look swollen on front view, but the lines of the
nose will be visible on profile view, and (3) the tip may appear a bit turned up at first. The
patient is reassured that their nose will look better the minute the cast is removed than it
did preoperatively and that it will gradually get better and better. Also, they are told that
the nose will swell on recumbency and not to be surprised if the nose swells more on one
side than the other depending on which side they sleep on. Night time taping is encouraged.
Smiling
When extensive septal work is done including relocation of the caudal septum, it is not
uncommon for the patient to complain of a weak smile and limited exposure of their upper
teeth. Release of the depressor septi nasalis is the cause and complete return usually occurs
by 4–6 weeks. It is best to warn the patient of this potential occurrence preoperatively.
Numbness
Many patients complain that their nose is numb postoperatively. Its occurrence is due to
the severance of the continuation of the anterior ethmoidal nerves. Although most surgeons
consider it a minor problem and one that always resolves within 6 months, my experience
has been different. It is my impression that the return is often much longer (12–18 months)
and often partial rather than complete. Again, a prepared patient will more easily accept
some reduction in sensation.

64
Chapter 2  
A Basic Rhinoplasty Operation
In contrast to the expected associated morbidity of any operation, complications are neither
desired nor easily accepted by the patient. The surgeon must inform the patient about the
usual risks and give some idea of their incidence and management. For some surgeons, their
biggest error is not the occurrence of the complication, but rather their attempt to ignore it
or mismanage it. The admonition to be forthright, honest, compulsive, and caring will resolve
even the most trying of situations.
Incidence
It is virtually impossible to get an accurate indication of postoperative complications. In
absolute terms, my complications for the 100 cosmetic cases with a mean 18-month follow-up
would be as follows: hemorrhage 1%, infection 0%, septal perforation 1%, skin slough 0%,
scar visibility 0%, nasal obstruction 1%, and revisions 5%. Although the data is accurate, the
conclusions are merely a “snapshot” of my practice over a specific time period. For example, I
went 7 years without a postoperative bleed and then had three in 3 months. To my knowledge,
this is the first septal perforation I have had in over 1,000 rhinoplasties in the last 6 years.
Thus, is the true incidence of septal perforation 1% or 0.1%? The surgical saying is “if one
does enough surgery, one will eventually have every complication” be prepared.
Hemorrhage
Following recognition of the role that aspirin played in postoperative bleeding, the inci-
dence of hemorrhage decreased significantly. In most cases, intraoperative bleeding can be
controlled by cauterization and judicious packing with epinephrine-soaked gauze. Gentle
compression over 5–10 min will allow better visualization and cauterization. My impression is
that most major bleeds follow medial osteotomies or turbiectomy. In cases involving extensive
septal and turbinate surgery, I insert Doyle splints plus gelfoam gauze to completely pack the
airway and leave them for 5–7 days. Certainly, the management of postoperative hemorrhage
has been greatly simplified by the introduction of nasal tampons (RhinoRocket). In my last
three bleeding episodes, I have found that insertion of a nasal tampon was an excellent first
step, and there was no need to progress to cauterization or a posterior pack.
Infection
Acute infection following rhinoplasty has decreased to less than 1%. I continue to use pro-
phylactic antibiotics for 5 days postoperatively due to the large number of grafts. I have had
two acute infections, both in small revision cases without any septal work or grafts. In both
instances, they require aggressive treatment:
(1) incision and drainage, (2) gauze packing, (3) immediate broad spectrum antibiotic cover-
age plus high doses of penicillin, (4) cultures with subsequent adjustment of the antibiotic,
and (5) daily office visits until resolution. Despite a horrendous appearance initially, both
wounds healed without scarring, and no further surgery was required. Chronic infections
with periodic swelling and erythema may be associated with an underlying mucosal cyst.
Toxic shock syndrome (TSS) does occur following rhinoplasty and one must be aware of
Complications

Complications
65
its symptoms: (1) fever (101–103), (2) hypotension, (3) gastrointestinal tract symptoms
(diarrhea, vomiting), (4) errythematous macular rash with eventual desquamation, and
(5) exclusion of other infectious diseases. In all of the case studies, it is the combination of a
lethargic, hypotensive, and very sick patient that is apparent. These patients must be treated
as in a life-threatening emergency, admitted to the hospital, an infectious disease consultant
brought in, all nasal packs removed, and the nasal airways cleansed.
Septal Problems
Unfortunately, septal hematomas, abscesses, and perforations still occur. I have seen one
postoperative septal hematoma that required drainage. I made a unilateral inferior incision
and then inserted bilateral silastic splints. The septal abscess followed a minor dorsal revision
without any septal surgery. A fluctulant mucosa was obvious bilaterally. Purulent drainage
occurred following incision and small length of 0.25 in. Penrose drain was sutured into the
space to promote drainage. The drain was removed at 4 days, and there were no subsequent
problems. Septal perforations following rhinoplasty are an infrequent occurrence. I am aware
of producing at least three, but all have been small asymptomatic posterior holes which have
not required treatment. Why did they occur? My explanation would be poor technique in
one (perichondrium was removed with the septum on one side), mucosal factors in another
(chronic friable mucosa in a woodworker), and nonspecific etiology in the latest one. In each
case, the patient was told that the perforation was present and that surgical correction or a
silastic button was the option if they became symptomatic.
Nasal Obstruction
The reported etiology and incidence of nasal obstruction following rhinoplasty is diverse.
In the early period, the usual cause is intranasal swelling and lack of normal physiological
functions. Certainly, mucociliary transport slows, resulting in stagnation and even obstruc-
tion. Cleansing the inside of the nose either by the physician or the patient using an over-
the-counter saline spray will usually improve the condition. In the late period, one tends to
consider either medical or anatomical etiologies. Obviously, a preoperative questionnaire
should have revealed the extent of allergic or vasomotor rhinitis which on occasion will
be exacerbated by greater airflow and associated environmental exposure. The appropriate
combination of decongestants and nasal sprays can be instituted.

66
Chapter 2  
A Basic Rhinoplasty Operation
Aiach O. Atlas of Rhinoplasty (2nd ed). St. Louis: Quality Medical Publishing, 1996
Daniel RK. Rhinoplasty: Creating an aesthetic tip. Plast Reconstr Surg 80: 775, 1987
Daniel RK. (ed) Aesthetic Plastic Surgery: Rhinoplasty. Boston: Little, Brown, 1993
Daniel RK. Open tip suture techniques. Part I: Primary rhinoplasty. Part II: Secondary rhi-
noplasty. Plast Reconstr Surg 103: 1491, 1999
Daniel RK. Rhinoplasty: Nostril/tip disproportion. Plast Reconstr Surg 107: 1454, 2001
Daniel RK. Rhinoplasty: An Atlas of Surgical Techniques. Berlin: Springer-Verlag, 2002
Daniel RK. Rhinoplasty: Septal saddle nose deformity and composite reconstruction. Plast
Reconstr Surg 119: 1029, 2007
Daniel RK, Calvert JC. Diced cartilage in rhinoplasty surgery. PlastRreconstr Surg 113: 2156,
2004. Follow-up in: Daniel RK. Diced cartilage grafts in rhinoplasty surgery: Current tech-
niques and applications. Plast Reconstr Surg 122: 1883, 2008
Daniel RK. Tip refinement grafts: the designer tip. Aesth Surg J 29: 528, 2009
Goodman WS. External approach to rhinoplasty. Can J Otolaryngol 2: 207 (Entire Issue de-
voted to Open Rhinoplasty) 1973
Gorney M. Patient selection in rhinoplasty: Practical guidelines. In: Daniel RK (ed) Aesthetic
Plastic Surgery: Rhinoplasty. Boston: Little, Brown, 1993
Gruber RP, Nahai F, Bogdan MA, et al Changing the convexity and concavity of nasal cartilages
and cartilage grafts with horizontal mattress sutures. Part I. Experimental results. Plast
Reconstr Surg 115:589, 2005. Part II Clinical Results. Plast Reconstr Surg 115: 595, 2005
Gruber R, Chang TN, Kahn D, et al Broad nasal bone reduction: an algorithm for osteotomies.
Plast Reconstr Surg 119:1044, 2007
Gubisch W. Twenty-five years experience with extracorporeal septoplasty. Facial Plast Surg
22: 230, 2006 (Note: entire journal issue is devoted to septal surgery)
Gunter JP. Secondary rhinoplasty: The open approach. In: Daniel RK (ed) Aesthetics Plastic
Surgery: Rhinoplasty. Boston: Little, Brown, 1993
Gunter JP, Rohrich RJ, and Friedman RM. Classification and correction of alar-columellar
discrepancies in rhinoplasty. Plast Reconstr Surg 97: 643, 1996
Gunter JP, Rohrich RJ, and Adams WP. (eds) Dallas Rhinoplasty: Nasal Surgery by the Mas-
ters. QMP,757, 2007
Guyuron B. Dynamic interplays during rhinoplasty. Clin Plast Surg 23: 223, 1996. (Entire
Issue)
Guyuron B. Precision rhinoplasty. Part I: The role of life-size photographs and soft-tissue
cephalometric analysis. Plast Reconstr Surg 81: 489, 1988
Johnson CM Jr. and Toriumi DM. Open Structure Rhinoplasty. Philadelphia: Saunders, 1990.
Additional information in Johnson CM, Wyatt CT. A Case Approach to Open Structure
Rhinoplasty. 2nd ed. New York: Elsevier, 2006
Meyer R Secondary Rhinoplasty. Berlin: Springer, 2002
Sheen JH. Rhinoplasty: Personal evolution and milestones. Plast Reconstr Surg 105: 1820,
2000
Sheen JH, and Sheen AP. Aesthetic Rhinoplasty (2nd ed.) St. Louis: Mosby, 1987
Tardy ME. Rhinoplasty: The Art and the Science. Philadelphia: Saunders, 1997
Tebbetts JB. Rethinking the logic and techniques of primary tip rhinoplasty. Clin Plast Surg
23: 245, 1996. (Entire Issue)
Toriumi DM and Johnson CM. Open structure rhinoplasty: Featured technical points and
long-term follow-up. Facial Plast Clin 1: 1, 1993. (Entire Issue)
Toriumi, DM. New concepts in nasal tip contouring. Arch Facial Plast Surg 8: 156, 2006
Thomas JR. The relationship of lateral osteotomies in rhinoplasty to the lacrimal drainage
system. Otolaryngology 94: 362, 1986
Reading List

The radix and dorsum are fused anatomically, aesthetically, and surgically. For the vast
majority of patients, their three main complaints in order of importance are the “bump” on
profile, the lack of tip definition, and the wide nose. Thus, two of three complaints are located
in the radix and dorsum. Anatomically and embryologically, the bony vault and the carti-
laginous vault are a single entity – the osseocartilaginous vault (hereinafter the dorsum).
The key to designing the optimal surgical solution is the nasofacial angle (NFA), which most
surgeons consider to be the most important aesthetic angle in the entire face. The setting
of the ideal nasion point determines the nasofacial angle and also whether the radix area
needs to be augmented or reduced. Equally, the line connecting the nasion to the tip reveals
the need for dorsal modification. This linkage is expressed in the “balanced approach” to
the dorsum. For example, a radix augmentation decreases the amount of dorsal reduction
required thereby preserving a more natural profile. Osteotomies to narrow the bony vault are
neither an automatic maneuver nor a single technique. The cartilage vault requires equal
emphasis with spreader grafts done to preserve function and to improve aesthetics. Failure
to stabilize the midvault can lead to a visible inverted-V deformity with internal valve col-
lapse. The importance of understanding the dorsum and selecting the optimal operation is
obvious in examining a large number of secondary rhinoplasty patients where the sign of
a “nose job” is now dorsal deformities rather than tip problems.
Introduction
Radix
and Dorsum3

68
Chapter 3  
Radix and Dorsum
Approximately 90% of my Caucasian rhinoplasty patients want a smaller natural nose which
leads to dorsal reduction. The actual amount of dorsal reduction can be limited if one uses a
“balanced approach.” The combination of a radix graft and greater tip projection minimizes
the amount of dorsal height reduction. The surgeon does not reduce the dorsum to fit the
tip, but rather seeks the ideal dorsum and then fits the tip to the dorsum.
Level 1
Radix. In reviewing 100 primary rhinoplasties, I modified the radix as follows: (1) nothing
to the radix (80%), (2) augment it with fascia (12%) (3) augment it with fascia plus diced
cartilage (4%), and(4) reduce it (4%) (Fig. 3.1). Early on, one should be able to do a basic
fascia graft to the radix – do not use solid cartilage grafts as they always show.
Dorsum. I feel strongly that an incremental dorsal reduction using rasps and straight scissors
is the most controlled, flexible, and safest method of dorsal reduction (Fig. 3.2). In addition,
one must perfect a method of doing lateral osteotomies. I prefer the endonasal approach as
it allows me to do both low-to-high and low-to-low osteotomies. Spreader grafts are done
for both aesthetic and functional reasons. There is no way to avoid learning and doing
spreader grafts.
Level 2
Radix. As the radix deficiency increases in depth and/or extends caudally into the dorsum,
it becomes necessary to add diced cartilage below the fascia graft. For significant defects,
diced cartilage is placed on the bone and covered with a fascial graft (DC+F). As the defect
extends onto the bony vault, a true diced cartilage in fascia graft is used (DC−F) for these
half-length dorsal defects. When the radix is full due to soft tissue, excision of muscle tissue
can reduce the radix.
Dorsum. Management of the asymmetrical, deviated dorsum mandates modifications in the
spreader graft design and the selection of osteotomies. When confronted with the wide dor-
sum, medial oblique or even paramedian osteotomies may be necessary. Changes in lateral
wall convexity may require double-level osteotomies.
Level 3
Radix. Bony reduction of the radix is never easy and is less effective than one would want.
Minor to moderate reductions imply either soft tissue excision or extension of the hump
reduction cephalically. In contrast, major reductions require a total excision of the bony radix
as a separate entity using a double-guarded osteotome or burr.
Dorsum. Due to the advances in diced cartilage in fascia (DC−F), augmentation of the dor-
sum can be done successfully and with few problems. Previously, solid dorsal grafts of septum
or layered conchal grafts were always disappointing due to either visibility or displacement.
As the number of ethnic rhinoplasties has increased, the use of DC−F grafts has provided a
wonderful solution to the challenge of dorsal augmentation.
Overview

Overview
69
Fig. 3.1 Radix, (a) augmentation, (b) reduction
Fig. 3.2 Dorsum, (a, b) incremental reduction, (c, d) spreader grafts, (e, f) dorsal augmentation

70
Chapter 3  
Radix and Dorsum
Radix. The soft tissue of the radix area is often heavy and consists of thicker skin, ­subcutaneous
fat, and muscle (7.2 mm in adults, range 3.5–9.5 mm). In contrast, the skin of many adolescent
patients is a tight yoke which reveals any underlying cartilage graft. The bone in the radix
area is a fused solid triangle of multiple bones which can be reduced only with difficulty
(Fig. 3.3c). The bone has the contour of the nasofrontal angle within it. Preoperatively, it is
important to differentiate by palpation whether radix fullness is due to soft tissue or bone.
Dorsum. The anatomy of the osseocartilaginous vault reflects its embryology. The laying
down of the nasal bones over the cartilaginous vault is reflected in their broad overlap,
which measures 11 mm in the midline and 4 mm laterally (Fig. 3.3a, b). Thus, the bony and
cartilaginous vaults are not simply joined at a seam, but rather have an overlapped integra-
tion. The importance of this overlap is evident in reduction rhinoplasty – the hump is far
more cartilaginous than bony. Technically, the implication is that rasping the bony hump first
brings the larger underlying cartilaginous hump into relief and avoids overresection of the
bony dorsum. In childhood, nasal height is mainly due to the nasal bones. During puberty,
the nose undergoes radical changes due to the foreword thrust of the maxilla and the absorp-
tion/deposition along the nasal profile line. Thus, lateral osteotomies are done within, or pass
across, the frontal process of the maxilla in order to narrow the base bony width.
Perhaps, the greatest anatomical misunderstanding in the entire nose concerns the
­cartilaginous vault – it is a single anatomical entity, not a septum with two juxtaposed upper
lateral cartilages. Reduction of the cartilaginous dorsum destroys the normal architecture
permanently and creates a tripartite entity, which can be visible as an inverted-V deformity.
Spreader grafts are an attempt to recreate normal nasal anatomy. Another important point is
the change in the shape of the cartilaginous dorsum as it progresses from a broad “T” shape
beneath the bony dorsum, to a “Y” shape at the midvault (Fig. 3.3d), and to a narrower “I” near
the septal angle (Fig. 3.3e).
The overlying soft tissue envelope varies dramatically from its thickest portion in the
radix area, to its thinnest at the rhinion, and to its most unpredictable in the supratip area
(Fig. 3.4). The rhinion is the thinnest because there is minimal subcutaneous fat, and the
transverse nasalis muscle fibers have given way to an aponeurosis. The supratip area is often
filled with subcutaneous fat which masks the downward descent of the cartilaginous dorsum.
These soft tissue layers constitute a Superficial Muscular Aponeurotic System (SMAS). Surgi-
cally, the most avascular and the least traumatic plane of dissection is supraperichondrally in
the subaponeurotic space. As one elevates the soft tissue envelope, one should see the shining
white cartilage underneath.
Anatomy

Anatomy
71
c
d
e
a
b
Fig. 3.3 (a–e) Osseocartilaginous vault
Fig. 3.4 (a, b) Soft tissue coverage

72
Chapter 3  
Radix and Dorsum
Radix. Nasion (N) refers to a specific point – the deepest point of the nasofrontal angle. The
ideal nasion level or vertical position is set between lash and crease line of the upper eyelid
(Fig. 3.5). The nasion height or projection can be measured from the vertical tangent to the
cornea or glabella. These two factors determine the nasion location, which in turn sets the
critical starting point of the nose with regard to the nasofacial angle and the nasal length.
Thus, setting the nasion is often the first step in planning a rhinoplasty.
Dorsum. On anterior view, one assesses the dorsal lines, base bony width, and lateral wall
inclinations (Fig. 3.6). The parallel dorsal lines begin at the supraorbital ridge, narrow at the
radix, and continue down to the tip defining points. The ideal width of the dorsal lines often
corresponds to the width of the tip defining points and philtral columns. A general rule of
thumb is 6–8 mm for females and 8–10 mm for males. A visual break in the continuity of
the dorsal lines creates the inverted-V deformity that one can see following a rhinoplasty.
The base bony width (X-point on either side, X-X for total width) is the widest point of the
nose at the level of the maxilla. It is easily measured with a caliper. One compares base bony
width (X-X) to the intercanthal width (EN-EN) to determine the need for, and the type of,
lateral osteotomies. If the bones are wider than the intercanthal width, then I usually perform
transverse and low-to-low osteotomies to achieve complete movement. Otherwise a simple
low-to-high osteotomy is done plus a gentle greenstick fracture. The inclination of the bony
vault is checked and only rarely is excessive bowing or verticalization noted. However, asym-
metries are seen in over 25% of the primary cases, and these differences are always pointed
out to the patient preoperatively.
On lateral analysis, the key determinant is the nasofacial angle. In classical art, a naso-
facial angle of approximately 34° for females and 36° for males is the accepted standard. The
nasofacial angle (NFA) is measured from a vertical through the ideal nasion (Ni) and a line
dawn from the nasion to the ideal tip (Ti). If a hump is present, the line is drawn through it.
The final aesthetic line is often concave for females and straight for males. Patients with too
great an angle complain that their noses stick out too far and those with a low angle do not
like their flat noses. One must be careful in using this angle rigidly for operative planning. In
certain cases, the nasion/radix may be wrong and perhaps even noncorrectable which in turn
will limit the angle’s value. Second, there is a relatively ideal dorsal height which is indepen-
dent of the angles. A classic example is the patient with a low radix and underprojecting tip
whose intervening dorsum appears quite prominent. The balanced approach is to graft both
the radix and the tip with minimal reduction of the dorsum. The importance of maintaining
a high natural dorsum is seen in recent changes in operative technique away from “make the
dorsum fit the tip” to “make the tip fit the ideal dorsum.”
Aesthetics

Aesthetics
73
a
b
c
Radix
area
N
Ideal
Low
High
11 mm
7 mm
15 mm
4–6 mm
posterior to
glabella
Fig. 3.5 (a–c) Radix aesthetics
Fig. 3.6 (a–f) Dorsal aesthetics

74
Chapter 3  
Radix and Dorsum
Sheen (1978) popularized radix augmentation as a “balancing procedure” to minimize hump
reduction, thereby maintaining both dorsal height and a more natural nose. His dramatic
results validated a simple principle, but minimized the vexing problems of visibility and
excessive height. Currently, I use fascia for radix augmentation, and post-op problems are
less than 1%.
Fascia Graft (F). The radix area to be grafted is marked with the patient sitting. The amount
of tissue required is either a complete (5 × 5 cm) or partial sheet of deep temporal fascia
(Fig. 3.7). The fascia graft is harvested in the standard fashion (see Chapter 6). The graft is
folded and then sutured into a ball with 4–0 plain catgut leaving the needle attached. A slight
overcorrection (<20%) is planned. The radix graft is guided into the radix area by lifting up
the skin, inserting the attached needle through the nasion point from underneath, and then
pulling the graft into place. A Steri strip is placed on the dorsal skin to prevent displace­-
ment. At 1 week when the cast is removed, the suture is either teased out or cut flush with
the skin.
Diced Cartilage and Fascia (DC+F). In these cases, the defect is greater particularly with
regard to the radix depression (Fig. 3.8). The operative sequence is precise. First, a fairly tight
recipient pocket is made, avoiding excessive lateral dissection. Second, a limited-size fascia
radix graft is placed into the defect using the usual percutaneous technique. Then, with the
fascia graft held up by an Aufricht retractor, diced cartilage is placed underneath against
the bony radix, usually 0.1–0.3 cc of a tuberculin syringe. The diced cartilage will fuse to
the bone while the fascia graft prevents visible irregularities, even under the tightest skin.
Diced Cartilage in Fascia (DC−F). The “half-length” dorsal graft is the most challenging of
all dorsal grafts. Inevitably, the junction between a solid graft and the dorsum always shows
through the thin skin at the rhinion. In contrast, diced cartilage in fascia has solved this
problem (Fig. 3.9). Following the dorsal reduction, the “DC−F construct” is made on the back
table. One simply fills the fascia with diced cartilage, 0.2–0.5 cc of a tuberculin syringe, and
sutures it closed with 4–0 plain catgut. The graft is slipped into the pocket with the cephalic
percutaneous suture. The caudal end can be opened and any excess cartilage removed. It is
important to drape the skin tightly on either side and mold the graft to fit exactly. Diced
cartilage grafts are never overcorrected.
P R I N C I P L E S

 Radix modification is an integral part of rhinoplasty planning.

 Most patients can accept an under-correction, but not a visible overcorrection. Use fascia
and you will have fewer revisions.

 In significant cases of radix hypoplasia, one can put the diced cartilage deep and cover it
with a fascia graft.
Radix
­Augmentation

Radix ­Augmentation
75
Fig. 3.9 (a–c)
DC−F radix/dorsal graft
Fig. 3.7 (a–c)
Fascia radix graft
Fig. 3.8 (a–c)
DC+F radix graft

76
Chapter 3  
Radix and Dorsum
The author has developed a new approach to radix reduction by dividing the radix ­components
into soft tissue and bone based on preoperative palpation. It is important to assign a relative
importance to each component in selecting the best operative technique (Fig. 3.10).
Soft Tissue Reduction. Preoperatively, one must assess both the soft tissue fullness that
blunts the nasofrontal angle and the width of the medial orbital lines that continue into the
dorsal lines. In younger patients, one can excise the soft tissue fullness using the following
technique: (1) elevate the skin over the radix and glabellar region, (2) then dissect upward
on top of the dorsal bones, (3) excise the intervening soft tissue, and (4) place a drain and
compressive dressing (Fig. 3.11). In older patients, one may need to do a concurrent endo-
scopic central forehead lift.
Bony Reduction. The first step is to visually separate radix from dorsum using a transverse
line through the lateral canthus. Then the ideal nasion is determined and the nasofacial angle
set, which reveals the new dorsal line. Since both areas are usually excessive, dorsal reduction
is necessary and it is done first. Contrary to the classic en bloc osteotome excision which
often resulted in dorsal destruction, a two-step technique is preferred (Fig. 3.12). First, the
dorsum is lowered using rasps for the bony vault and a scissor for the cartilage vault. Once
satisfied with the dorsal line, the radix area is undermined extensively using a Joseph eleva-
tor. Complete freeing of the soft tissue facilitates subsequent removal of the bone. Then a
12 mm wide, sharp, double-guarded osteotome is inserted until it catches on the dorsal/radix
junction, which often marks the upper limit of effective rasping. The handle of the guard is
rotated upward 45–60° depending on the amount of bone to be excised. With multiple strikes,
the osteotome is engaged and the bony radix becomes palpable on top of the osteotome.
The amount of bone being removed may seem frighteningly large. The osteotome is driven
upward to the glabella where a distinct change in sound occurs as the guards strike the skull.
Then the osteotome is rotated upward and twisted, which disarticulates the bone from the
nasofrontal suture line. If the bone cannot be dislodged, then a 2 mm osteotome is inserted
beneath the medial eyebrow and “walked across” the nasofrontal suture line going down to
the guarded osteotome, which has been left in place. In major cases involving both the radix
and dorsum, it is necessary to use either spreader grafts or a full-length dorsal graft to fill
the dorsal void. Following a radix reduction, bleeding is significant and I routinely drain the
nose with a 7 Fr suction drain. A curved trochar is inserted from the nose and made to exit
in the hairline. The drain is removed after 3 days.
P R I N C I P L E S

 The radix area is made of solid bone and its reduction requires significant removal – often
10–12 mm long, 4–8 mm thick.

 Never try to do an en bloc dorsum/radix reduction as you will remove too much dorsum
and too little radix.
Radix
­Reduction

Radix ­Reduction
77
Fig. 3.11 (a–c)
Soft tissue excision
Fig. 3.12 (a–c)
Bony excision
a
b
c
Fig. 3.10 (a–c)
Radix reduction

78
Chapter 3  
Radix and Dorsum
The first step in operative planning is to decide whether the dorsum should be reduced,
augmented, balanced, or maintained. Excluding ethnic patients, primary rhinoplasties are
reduced (89%), modified (7%), or augmented as part of a balanced approach (4%). Although
numerous instruments and sequences are possible for dorsal reduction, I have found graded
incremental bony rasping followed by a split-hump cartilaginous excision using scissors to
be the most effective method with the least risk. The incremental approach allows one to fine
tune the dorsal reduction at least three times: during the initial resection, then the graded
adjustment, and finally following the osteotomies.
Bony Vault Reduction. The soft tissue envelope is elevated in two stages. First, scissor dissection
is done in close contact with the cartilage over the cartilaginous vault. Second, a Joseph elevator
is used in the subperiosteal plane over the bony vault. In most cases, extramucosal tunnels are
then made to avoid transecting the underlying mucosa when the cartilaginous hump is excised.
A sharp puller rasp is used first in the midline and then progressively on either side (Fig. 3.13).
As the rasping continues, two changes occur – the cartilaginous hump becomes more obvious,
and one needs to rasp each nasal bone separately and on an angle. The rasping continues until
one is satisfied with the height of the bony dorsum as it relates to the nasion, i.e., the upper half
of the ideal dorsal line has been achieved. Then the cartilaginous dorsum is lowered.
Cartilaginous Vault Reduction. Two methods are available for reducing the cartilaginous vault:
a split-hump technique using scissors or a transverse en bloc reduction using a broken-off #11
blade (Fig. 3.14). The classical vertical split-hump reduction involves making paraseptal verti-
cal cuts with straight scissors on either side of the septum following the creation of extramu-
cosal tunnels. The scissor blades vertically straddle the cartilaginous vault. The cut produces
a narrow septum with two upper lateral cartilages often with curved dorsal edges. Then, the
scissors are turned transversely and each of the three components of the cartilaginous vault is
lowered incrementally. Excision of the dorsal septum lowers dorsal height, while excision of the
upper lateral narrows dorsal width. In absolute terms of height reduction, excision of the upper
laterals is much more conservative than the dorsal septal resection. One must be aware that
upward traction on the soft tissue envelope tends to raise the upper lateral cartilages artificially
high. Once the osteotomies are completed, additional rasping of the bony vault and minimal
excision of both septum and upper lateral cartilages may be necessary. The one method which
I do not recommend for routine use is en bloc hump removal using an osteotome because of
the risk of overresecting the bony vault and underresecting the cartilaginous vault.
P R I N C I P L E S
 Exposure consists of two steps – soft tissue elevation above and extramucosal tunnels below.

 A cartilaginous hump reduction of more than 1 mm requires extramucosal tunnels while
one greater than 3 mm requires spreader grafts.

 A rasp is much easier to control than an osteotome.

 Excision of cartilaginous septum reduces height, and excision of upper laterals reduces
width.
Dorsal
­Reduction

Dorsal ­Reduction
79
Fig. 3.13 (a, b) Bony reduction: rasp 
Fig. 3.14 (a–d) Cartilage reduction: split hump

80
Chapter 3  
Radix and Dorsum
With few exceptions, the type of osteotomies can be decided upon preoperatively and ­executed
without change intraoperatively. For years, lateral osteotomies were classified according to
their location or level rather than their purpose. The critical factor is how much movement
of the lateral nasal wall is required to narrow the base bony width. If a great deal of move-
ment is necessary, then one needs complete osteotomies with bony separation. In contrast,
if one only needs a more limited narrowing, then a greenstick fracture along the transverse
component is sufficient. Second, the lateral osteotomy should go beneath the widest point of
the base bony width (X-point). With these parameters, 95% of my osteotomies can be divided
into two types: (1) a low-to-high osteotomy followed by a digital compression to produce a
transverse greenstick fracture (limited movement), and (2) a transverse osteotomy followed
by a low-to-low osteotomy which results in a continuous osteotomy (complete movement).
I perform the lateral osteotomies intranasally because I have found the intraoral approach
to be too low and inflexible, while the percutaneous method results in too many segmental
bony bridges and mucosal perforations. There are no medial osteotomies nor “outfractures.”
Eliminating medial osteotomies has reduced dramatically bony irregularities and major
bleeds. The classical outfracture leads to excessive mobility and verticalization of the nasal
bones, and thus has been eliminated.
Low-to-High Osteotomy. I inject the area with local anesthesia immediately prior to the
osteotomies. I do not create a subperiosteal tunnel as it damages blood vessels and increases
bruising. The pyriform aperture is straddled with a small speculum and a transverse mucosal
cut is made. When doing a low-to-high osteotomy, I use a slightly curved osteotome and place
it low on the pyriform aperture (Fig. 3.15a, b). Then, with the assistant tapping at a sequenced
pace, the osteotome is driven from low on the pyriform aperture across the frontal process
of the maxilla to end high at the nasal bone suture line at the level of the medial canthus.
There is no need to drive the osteotome up to the skull base. Then, I use my thumb to make
a transverse fracture across the thin nasal bone extending from the lateral osteotomy into the
open roof. The lateral nasal wall does two things: it hinges along the transverse greenstick
fracture while moving medially, and it tilts with the dorsal portion closing the open roof.
Low-to Low Osteotomy. When greater movement is required, I do a two-part combined
osteotomy: first a transverse percutaneous osteotomy followed by a low-to-low osteotomy
(Fig. 3.15c, d). A vertical stab incision is made just above the medial canthus with a #15
blade and then a 2 mm osteotome is used to completely fracture the lateral wall transversely
from just above the medial canthus upward. Next, the low-to-low lateral osteotomy is done
using a straight osteotome. Essentially, the osteotome is driven along the base of the frontal
process of maxilla, not across it in an ascending fashion as with the low-to-high osteotomy.
Once the level of the preceding transverse osteotomy is reached, the osteotome is rotated
medially forcing the lateral wall medially and achieving maximum movement. The reason
for the transverse osteotomy is to insure that the thick frontal process of maxilla breaks at
the desired level and separates to allow complete movement.
Osteotomies

Osteotomies
81
Fig. 3.15 (a–f) Osteotomy, (a, b) Low-to-high osteotomy 
  (c, d) low-to-low osteotomy 
  (e, f) medial
oblique ­osteotomy

82
Chapter 3  
Radix and Dorsum
On occasion, other osteotomies will be required including the medial oblique, the double-
level, the paramedian, and the microosteotomy. The medial oblique osteotomy is designed
to  narrow the broad bony dorsum and is coupled with a low-to-low lateral osteotomy
(Fig. 3.15e, f). A curved osteotome is placed at the cephalic end of the open roof and driven
downward toward the medial canthus. The double-level osteotomy consists of an osteotomy
along the inferior border of the nasal bone parallel to, and combined with, a low-to-low
osteotomy (Fig. 3.15g–i). The goal is to reduce the convexity of the lateral wall. The higher
osteotomy must be done first. The paramedian osteotomy is used in the broad nose when
one does not wish to change dorsal height. These are essentially straight osteotomies made
3–5 mm parallel to the dorsal midline. Microosteotomies are done with the 2 mm osteotome
and are used to correct asymmetries or irregularities intrinsic to the bones.
Spreader grafts are used to treat or prevent internal valve collapse in primary cases
(Fig 3–15j–l). Currently, I am using spreader grafts in the majority of my primary cases with
equal emphasis on function and aesthetics. I have found spreader grafts to be extraordinarily
valuable for maintaining the width of the cartilaginous vault and also reducing asymmetries.
Technical considerations are as follows: (1) the grafts are 15–20 mm long, 3 mm high, and the
width is determined by aesthetic requirements, (2) extramucosal tunnels are made begin-
ning near the junction of the upper lateral cartilage with the septum and extending beneath
the bony vault, (3) the tapered end of the spreader grafts is inserted into the pocket and
then the grafts are held in place with two percutaneous #25 needles, and (4) two horizontal
sutures of 4–0 polydioxanone suture (PDS) are used to fix the grafts in place. The cephalic
portion rests beneath the intact bony vault or within a defined submucosal tunnel, which
avoids postoperative displacement and visibility. In general, I prefer to suture upper lateral
cartilages, spreader grafts, and septum (five layers). A three-layer suture is required high in
the bony vault. Failure to suture the grafts in place can result in subsequent extrusion at the
time of dressing application.
P R I N C I P L E S

 Tailor the osteotomies to fit the bony vault deformity. No osteotomies are done in 7% of
the primary cases.

 Movement and stability of the lateral walls are critical factors in the decision process.

 There is no need for medial osteotomies nor dramatic outfractures.

 Consider spreader grafts as an integral part of a rhinoplasty for both functional and aes-
thetic reasons. They prevent internal valve collapse and the inverted-V deformity.
Specialized
Osteotomies
Spreader Grafts

Spreader Grafts
83
Fig. 3.15 (g–i) Double-level osteotomy note narrowing of bony walls
Fig. 3.15 (j–l) Spreader grafts

84
Chapter 3  
Radix and Dorsum
Approximately, 5–7% of the primary noses do not require reduction. Modification of
­asymmetry and width are the primary issues.
Narrow Asymmetric Dorsum. The narrow asymmetric dorsum must be carefully analyzed
as problems can occur in any of the following three areas: (1) the dorsal or lateral wall com-
ponent of each vault, (2) the septum, and (3) adjacent lateral crura (Fig. 3.16). The operative
sequence is as follows: (1) dorsal modification, (2) septal straightening, (3) osteotomies, (4)
asymmetric and occasionally unilateral spreader grafts, (5) anatomical onlay grafts over the
upper lateral cartilages, and (6) tip modification. The critical step is to achieve as straight a
septum as possible and harvest cartilage for grafts. In most minor cases, asymmetric spreader
grafts of differing widths will achieve improved symmetry in the dorsal lines. For moder-
ate cases, one often has to add an anatomically designed lateral wall graft which replicates
the upper lateral cartilage and is sutured onto the hypoplastic cartilage. The difficulty with
these grafts is excessive thickness and visibility. For major deformities, one often has to do
asymmetric and sophisticated osteotomies to achieve more symmetrical lateral walls. The
goal is to meet in the middle of the discrepancy as it is impossible surgically to make one
side match its unoperated counterpart.
Wide Dorsum. A wide dorsum is corrected in most rhinoplasties by reducing the wide hump
and infracturing the lateral nasal walls. For minor width excesses, I achieve narrowing with
hump reduction plus transverse and low-to-low osteotomies. For moderate width problems,
I do the hump reduction and then a medial oblique osteotomy coming from the open roof
and angling out about 45° followed by a low-to-low lateral osteotomy. The reason for the
medial oblique osteotomy is that it insures that narrowing will occur at the dorsum. For major
width deformities and especially those with a normal dorsal height, I have devised the fol-
lowing procedure (Figs. 3.17 and 3.18): (1) the dorsum is exposed through an open approach
and extramucosal tunnels are made, (2) the midline is marked, (3) the ideal dorsal width is
marked on the osseocartilaginous vault (5–8 mm), (4) paramedian cuts are made along the
cartilaginous vault up to the keystone area, (5) these cuts are extended through the bone
as paramedian osteotomies using a straight guarded osteotome, (6) lateral osteotomies are
done usually consisting of transverse and low-to-low osteotomies, (7) after the infractures,
excessive height of the upper lateral cartilages is excised (often 3–6 mm), and (8) the upper
lateral cartilages are sutured adjacent to, or underneath, the T-shaped septum.
P R I N C I P L E S

 The asymmetric dorsum requires asymmetric spreader grafts.

 The asymmetric nose usually has a deviated septum.

 The wide nose with normal dorsal height can be easily narrowed with multiple osteoto-
mies, including the paramedian.
Dorsal
­Modification

Dorsal ­Modification
85
Fig. 3.16 (a–c) Narrow asymmetric nose
Fig. 3.17 (a–c) Wide dorsum
a
b
c
Fig. 3.18 (a–c) Narrowing wide dorsum

86
Chapter 3  
Radix and Dorsum
I use only autogenous tissue for dorsal augmentation, and am adamantly opposed to
­alloplastic grafts, especially in secondary cases. Any alloplastic material or cadaver cartilage
put over the nasal dorsum is essentially subdermal and prone to visibility, extrusion, infec-
tion, or absorption. It is in the patient’s best interest to use autogenous tissues. In primary
cases, most dorsal grafts are done for aesthetic reasons, whereas in secondaries they are used
for aesthetic, functional, and structural reasons.
Fascia Grafts. When one wants to insure a smooth dorsum or create a more natural curvature
under thin skin, then I will often insert deep temporal fascia as a single sheet or folded for
double thickness (Fig. 3.19). The graft is guided into the pocket up to the radix with per-
cutaneous sutures and then sutured caudally in the supratip area to the cartilaginous vault.
The dorsal skin is then taped down with external Steri strips.
DC−F Grafts. Traditionally, a straight piece of septal cartilage measuring 35 mm in length
and 5–6 mm in width was the gold standard of dorsal grafts. These grafts can be difficult
to obtain in secondary cases and prone to visible edges. Due to the ease of diced cartilage
grafts, I have not used a septal dorsal graft for the last 7 years and they are no longer a part
of my surgical armamentarium. Instead, I employ diced cartilage in fascia grafts which
are extremely variable in shape and efficient in donor material (Fig. 3.20). The cartilage is
diced to 0.5 mm cubes and then placed in fascia which is sutured with 4–0 plain catgut. The
construct is “made to measure” on the back table and guided into the dorsal pocket using
percutaneous sutures. Any excess cartilage is milked out at the caudal end and then the graft
is closed and sutured to the cartilaginous dorsum.
Structural Osseocartilaginous Rib Grafts. Although cranial bone enjoyed a decade’s prefer-
ence for nasal augmentation, I quickly found its disadvantages very real (complex harvest,
only bony tissue, and limited patient acceptance). When major structural support is essential,
I find the osseocartilaginous rib graft to be extremely flexible for the nasal dorsum and the
cartilaginous rib tip is used for the columella (Fig. 3.21). A straight osseocartilaginous seg-
ment of the ninth rib is harvested and then shaped circumferentially using a power burr.
Most of the grafts are 40–45 mm in length, 5–8 mm in width, and a tapered thickness of 4 mm
at the nasion to 7–10 mm in the supratip area. The graft is fixed cephalically with percutane-
ous K-wires which are removed at 10 days post-op. These grafts provide excellent structural
support with little risk of warping.
P R I N C I P L E S

 Dorsal grafts are infinitely easier than a decade ago.

 Fascia is the ideal camouflage material under thin skin.

 DC-F grafts allow variations in length and height to fill any dorsal defect using all types
of cartilage pieces.
Dorsal
­Augmentation

Dorsal ­Augmentation
87
Fig. 3.19 (a–c) Fascia dorsal graft 
Fig. 3.20 (a–c) DC-F dorsal grafts 
Fig. 3.21 (a–c) Structural osseocartilaginous rib grafts

88
Chapter 3  
Radix and Dorsum
Operative Planning. As always, operative planning begins with “what does the patient want
and what will her tissues allow me to achieve?” Next comes a relatively simple photo analysis.
On lateral view, the nasion, as well as its level and height, usually at the eyelash level is marked
(Fig. 3.22). When in doubt, do not attempt major radix changes. Any change greater than 4 mm
is unrealistic in either direction. Next the ideal profile line is drawn through any preexisting
dorsal hump. One must decide whether the dorsum should be reduced, augmented, balanced,
or maintained. On anterior view, the dorsal lines are drawn and the X-X distance measured.
One should decide on the aesthetic indications for spreader grafts and type of osteotomies.
Technique
Step #1. Radix changes are done out of necessity with reduction rarely performed (<5%).
Radix augmentation (15%) is frequently done as part of a balanced approach. The dorsum
is reduced first and then fascia is placed in the radix area (Fig. 3.23).
Step #2. Excluding ethnic noses, dorsal reduction is done in almost 90% of the cases as most
female patients want a smaller cuter nose. An incremental approach to dorsal reduction is
the safest and easiest approach. Sequentially, the bony dorsum is reduced first with rasps
and the cartilaginous dorsum is then reduced using a “split hump” technique with scissors.
Note: the septal harvest is always done after the dorsal reduction, but before the osteotomies.
Step #3. Osteotomies are employed to narrow the base bony width and close the open roof,
although spreader grafts can also achieve the latter. The options for osteotomies are as fol-
lows: (1) none (7%), (2) low-to-high (45%), (3) low-to-low plus transverse (45%), and (4)
double level (3%).
Step #4. Spreader grafts are always considered as their functional and aesthetic benefits far
exceed any technical demands (Fig. 3.24). Avoidance of internal valve collapse and inverted-V
deformity justifies any tediousness of inserting spreader grafts.
Lessons Learned
  1) Think “balance” rhinoplasty and especially a balanced reduction.
  2) The ideal nasion is at the lash line ±2 mm.
  3) When in doubt, do not change the radix.
  4) Print out two lateral photos. Have the patient draw their desired profile change and
compare it to your analysis when planning a major profile change.
  5) Incremental dorsal reduction with rasps and scissors is the safest and easiest technique
to master.
  6) Begin with bony vault reduction as it exposes the true cartilaginous hump deformity.
  7) A “split hump” reduction of the cartilaginous vault is very precise.
  8) Reduction of the septal component decreases dorsal height. Upper lateral excision
­decreases width. Septal excision is often 3 × upper lateral cartilage (ULC) excision.
  9) Osteotomies narrow base bony width (X-X width on anterior view).
10) Spreader grafts are a functional and aesthetic necessity.
Decision Making
Level 1

Decision Making Level 1
89
Fig. 3.24 (a–c) Spreader grafts
Fig. 3.23 (a–c) “Balanced” reduction with radix augmentation
Fig. 3.22 (a–c) Analysis/operative planning

90
Chapter 3  
Radix and Dorsum
Analysis
A 19-year-old 5’ 3” girl wanted a smaller, cuter nose (Fig. 3.25). She felt that her profile was too
much of a beak, especially when she smiled. Incremental dorsal reduction and shortening of
the caudal septum resulted in a smaller cuter nose. Supporting the tip on a columellar strut
prevents it from plunging when she smiles. Different types of lateral osteotomies reduced
the preexisting asymmetry of the bony vault. Functionally, the patient breathed fine, but the
caudal septum was deviated. Surgically, the goal was to achieve a “functional reduction” –
make the nose significantly smaller without compromising the airway.
Operative Technique Highlights
1) Open exposure of nose and septum including extramucosal tunnels
2) Incremental dorsal reduction: bony (1.5 mm), cartilage (4 mm)
3) Caudal septum shortening (4 mm) and contouring of anterior nasal spine (ANS)
4) Major septoplasty/septal harvest including 7 mm bony spur
5) Caudal septum relocation, R to L
6) Asymmetric osteotomies: R (low-tolow), L (low-to-high)
7) Columellar strut plus tip sutures: CS, DC, ID, DE, and TP
Case Study:
­Profile
­Correction
Fig. 3.25 (a,b) Incremental dorsal reduction, (c) caudal septul shortening, (d) tip projection and position

Case Study: ­Profile ­Correction
91
Fig. 3.25 (e–l)

92
Chapter 3  
Radix and Dorsum
Radix. The majority of the radix grafts are done with fascia. However, as radix hypoplasia
increases, augmentation with “fascia only” is no longer sufficient (Fig. 3.26). One either adds
diced cartilage below the fascia graft (DC+F) or wraps diced cartilage in the fascia (DC−F).
The majority of DC+F grafts are done to raise the height of the radix area with the diced
cartilage fusing to the bone and the fascia providing a smooth coverage. When one encounters
a hypoplastic radix and upper half of dorsum, a DC−F graft is used to augment the more
longitudinal deficiency.
Dorsum. As the height and cephalic extent of the dorsal reduction progresses upward, longer
spreader grafts and more exotic osteotomies become necessary (Fig. 3.27a). Once the dorsal
reduction reaches the level of the medial canthus, the open roof deformity is quite extended.
Lateral osteotomies cannot mobilize the lateral walls sufficiently and spreader grafts must
be used to avoid an inverted-V deformity.
1) The dorsal width can be quite wide at the junction level of the two vaults. In these cases, I
will often do a medial oblique osteotomy prior to a low-to-low osteotomy as the combina-
tion produces a major narrowing of the dorsal width (Fig. 3.27b). I do not use this tech-
nique routinely as there is often a palpable bony step-off in the radix area.
2) The lateral walls can be very convex due to angulation at the nasal bone/frontal process of
the maxilla suture line. Thus, one must achieve a true change in the intrinsic shape of the
lateral walls rather than mere mobilization. A “double-level” osteotomy is required (Fig.
3.27c). The upper osteotomy fractures the lateral wall at the junction of the nasal bone and
the frontal process of maxilla. The lower osteotomy goes across the frontal process of the
maxilla as close to the maxilla as possible. Finally, a transverse osteotomy is done. Often
three osteotomies per side are necessary with the sequence being high, transverse, and
low-to-low.
3) Spreader grafts must be cut longer and placed more cephalically to insure closure of the
bony vault following the osteotomies. One may have to do a three-layer suture fixation
high-up within the bony vault area.
P R I N C I P L E S

 Radix augmentation is progressive with regard to height and length, beginning with F, then
DC+F, and finally DC−F for combined radix and upper dorsal deficiencies.

 Selection of lateral osteotomies is based on the degree of movement with none, low-­
to-high, and low-to-low sufficient in 95% of the cases.

 Medial oblique osteotomies are useful for the very wide flared dorsum. Note: one should
concentrate on narrowing dorsal width, not just base bony width.

 A double-level and transverse osteotomy can effectively change the most convex lateral
wall.
Decision
Making
Level 2