Decision Making: Level 2
143
Fig. 4.36 (b) Tip Refinement Grafts (TRG)
Fig. 4.36 (a) Lateral crural convexity sutures
6 m
Fig. 4.36 (c) Open structure tip grafts
Integrated
Projected
144
Chapter 4 Tip Techniques
Analysis
This 31-year-old woman disliked the beaky appearance of her nose (Fig. 4.37). The tip had a
flat dependent look – there was simply no intrinsic tip. On lateral view, a large nostril/small
tip disproportion was obvious (Fig. 4.37). Success in this case depended on being able to
increase the volume and definition of the intrinsic tip. The critical steps of her tip surgery
consisted of columellar strut insertion, tip projection, and add-on grafts. Following tip sutur-
ing, the entire tip complex was rotated and projected above the septal angle using the tip
position suture. Redraping of the skin indicated that more tip definition was required and
thus a double layer add-on graft of excised alar was placed across the domes. This patient
has the world’s fastest blink response.
Operative Technique
1) Open approach and confirmation of tip analysis and op plan
2) Creation of symmetrical rim strips and extramucosal tunnels
3) Incremental dorsal reduction – bony 1.5 mm, cartilage 5 mm
4) Excision of caudal septum (3 mm)
5) Fascia harvest. Septal harvest and caudal septal relocation, R to L
6) Low-to-high osteotomies then placement of spreader grafts
7) Insertion of columellar strut and tip sutures: CS, DC, ID, DE, TP
8) Add-on domal tip graft using a double layer of excised alar
9) A “ball and apron” fascia graft to augment the radix and smooth the dorsum
10) Nostril sill excisions (2.5 mm)
Case Study:
Intrinsic Tip
Deficiency
Fig. 4.37 (a–j)
Case Study: Intrinsic Tip Deficiency
145
Fig. 4.37 (continued)
146
Chapter 4 Tip Techniques
The Problem. Put simply, these patients hate their tip and want a new one. Success or failure
rests on the surgeon’s ability to create a new tip. These tips are often “extreme” deformi-
ties where the surgeon needs to deconstruct the existing tip followed by reconstruction
of an attractive tip. Further complicating the challenge is collapse of the external valve on
deep inspiration. The actual etiology is most often abnormal or extreme variations of alar
anatomy ensheathed in thin or thick skin. A typical comparison is that a Level 2 case would
have a broad tip while a Level 3 patient would have a severe alar malposition requiring alar
transposition. A true Pinocchio tip is a Level 3 deformity as the intrinsic anatomy of the
alar cartilage is deformed thereby requiring excision of the domes and replacement with
a structure tip graft. Due to the severity of the problem and the minimal margin of error,
these cases should be approached with caution.
Structure Tip Graft with Domal Excision. The ball tip ensheathed in thick skin is a clas-
sic example where sutures may prove inadequate, especially if there is over-projection
(Fig. 4.38a–d). Following the open approach, the alars are analyzed, symmetrical rim strips
created, and the definitive dorum established. A columellar strut is inserted and sutured.
Then, a mark is made about 6 mm above the columellar breakpoint and the alars divided.
The lateral portion is undermined and a domal segment is excised (2–6 mm). Depending
upon its location, the domal excision can reduce tip projection or tip width or a combination
of the two. The excised edges are repaired with 5–0 PDS. A tip graft is then sutured to the
repaired alars with the leading edge of the tip graft 1–2 mm above the repaired domes. The
skin is redraped, tip projection and definition assessed, and the graft shaped as necessary.
Then a transverse cap graft is sutured over the domes and behind the tip graft to prevent
flattening of the tip graft.
Alar Transposition. In cases of significant alar malposition, it is often necessary to mobilize
the lateral crura and reposition them toward the nostril rim (Fig. 4.38e–h). These cases
frequently have nostril rim weakness that may lead to total collapse on deep inspiration
preoperatively. Alar transposition plus lateral crura strut grafts have revolutionized our
treatment of the unstable boxy tip. If the alars are too vertically oriented (malposition),
then alar transposition is indicated. The lateral crura are dissected laterally and transected
at their juncture with the accessory cartilages. The domal notches are marked. A columellar
strut is sutured between the middle crura. With the lateral crura mobilized, domal creation
and interdomal sutures are inserted. The skin is redraped. Lateral crura strut grafts are of-
ten necessary to stabilize and contour the nostrils. Most of these cases have thin skin and a
fascial blanket graft is added over the tip.
Secondary Cases. As will be discussed in Chapter 10, a wide variation of tip grafts may be
needed as the alar cartilages have often been excised or severely compromised. In certain
cases, an isolated tip graft is inserted and alar rim support grafts added along the rims
without any replacement of the lateral crura. Secondary cases are truly demanding and one
must be comfortable with complex primary cases before attempting them.
Decision
Making:
Level 3
Decision Making: Level 3
147
Fig. 4.38 (a–d) Open structure tip graft with dome excision, (e–h) alar transposition with lateral crura strut grafts
148
Chapter 4 Tip Techniques
Analysis
A 38-year-old patient felt that her nose and upper eyelids made her look older. The nasal
challenge was obvious – a ball tip sheathed in thick skin (Fig. 4.39). The goal was not to make
the tip better, but rather to create an entirely new tip, both smaller and with more definition.
Compounding the problem was a profile that needed minimal change thus emphasizing the
dorsal/base disproportion. At 4 years post-op, the patient’s nasal tip looks much more refined
and narrower. When major changes are needed, an open structure tip graft with domal exci-
sion is the answer. Note: A short DVD of this case is available (Fig 4.39
).
Operative Technique
1) Upper lid blepharoplasty and harvest of fascia
2) Open approach with tip analysis and symmetrical rim strips
3) Minimal dorsal modification – bony smoothing, cartilage <1 mm
4) Septal harvest
5) Low-to-high osteotomies and asymmetric spreader grafts: R 2.5 mm, L 1 mm
6) Insertion and suture fixation of columellar strut
7) Excision of a 4 mm domal segment
8) Open structure tip graft
9) Alar wedge excision (4 mm) and insertion of alar rim grafts
Case Study:
Open Structure
Tip Graft
Fig. 4.39 (a–j) Open Structure Tip Graft
Case Study: Open Structure Tip Graft
149
Fig. 4.39 (continued)
150
Chapter 4 Tip Techniques
Over the years, I have found that a variety of specialized sutures do no not work for me.
Since I also find them in secondary cases, it appears that they do not work for others. The
explanation may be that these sutures are technically demanding and unforgiving for sur-
geons who do not use them frequently. Obviously, the proponents of these sutures can make
them work, but I find them challenging. The latter three sutures illustrated come from the
case study that follows (Fig. 4.41).
Lateral Crural Spanning Sutures (LCSS). As originally conceived by Tebbetts (1994), the
LCSS is designed to shape and reposition the lateral crura, especially reducing their con-
vexity (Fig. 4.40a, b). The key steps are the following: (1) place a needle across both lateral
crura at their point of maximum convexity, (2) insert a horizontal mattress suture, and (3)
tighten incrementally to reduce convexity and narrow the tip. The problem with the LCSS
is its tendency to cause true alar rim retraction. The LCSS has been supplanted by Gruber’s
LCMS which is more effective in fixing a convexity in a single lateral crura and has minimal
risk of causing alar retraction as a by product.
Midline Sutures. I have no idea who proposed multiple midline sutures between the cau-
dal border of the two crura, but it can have devastating consequences (Fig. 4.40c, d). These
sutures produce real distortion in the columellar resulting in a narrow hanging columella.
As the midline suturing progresses toward the tip, a unified single point tip is produced fol-
lowed by retraction of the alar rims resulting in a snarl tip. Do not even think about using
midline sutures.
Lower lateral cartilage (LLC) to Upper lateral cartilage (ULC) Suture. Several surgeons have
suggested suturing the cephalic border of the lateral crura to the caudal border of the upper
lateral cartilages to achieve upward tip rotation and stabilization (Fig. 4.40e, f). A significant
degree of sophistication and experience is required to make this suture work. Unfortunately,
these sutures are difficult to execute and can produce bulging in the area similar to excessive
scroll formation. I do not recommend it.
Columellar to Caudal Septum Overlap. The concept of suturing the columellar to the caudal
septum has been used by surgeons ever since rhinoplasties were first done and it can be effec-
tive. However, other surgeons have extended this concept to the tongue-in-groove technique.
In this procedure, the medial crura are sutured to the caudal septum in a more upwardly
rotated position thereby using the caudal septum as a columellar strut (Fig. 4.40 g, h). For the
surgeon who performs this technique rarely, it can be difficult to position the crura correctly.
Once fixed in position, the surgeon cannot make the fine adjustments in tip projection as
the tip has been fixed caudally, i.e., a tip position suture will not be effective in creating the
supratip break. I do not recommend this suture for occasional use as too much judgment is
required and there is too little flexibility for finesse.
Tip Sutures That
Do Not Work for
Me
Tip Sutures That Do Not Work for Me
151
Fig. 4.40 (a, b) Lateral crural spanning suture, (c, d) midline sutures. (e, f) LLC to ULC suture, (g, h) tongue-in-groove
152
Chapter 4 Tip Techniques
Analysis
A 28-year-old woman had a rhinoplasty at age 18. Ten years later, her primary complaints
were that her nose looked “done” and stuck out too far (Fig. 4.41). This case illustrates why
a surgeon has to be prepared for any and all surprises during a secondary rhinoplasty. It
was hard to decide which surprise was greater – the extent of previous tip suturing or the
Skoog dorsal graft. Certainly, removal of the dorsal graft meant that the tip was grossly
over-projected. The alar cartilages were encased in scar tissue and the prior suturing was
certainly not “reversible.” Also, the vestibular valve collapse meant that the alars had to be
transposed and lateral crural strut grafts added. This case illustrates why secondaries can
be extraordinarily difficult – there is always a moment when you wish that you had never
agreed to do the case.
Operative Technique
1) Transfixion incision revealed tongue-in-groove sutures (Fig 4.40b).
2) Open approach using the previous transcolumellar incision. Thin skin encountered.
3) Visible midline sutures explaining alar retraction and pointy tip (Fig 4.40d).
4) Dorsal dissection revealed “Skoog” graft of reinserted dorsum.
5) Incremental dorsal reduction – cartilage only, tapered 3 mm.
6) Caudal septal resection (3 mm). Septal and fascial harvest.
7) Medial oblique, transverse, and low-to-low osteotomies.
8) Insertion of bilateral spreader grafts.
9) Transposition of the alars revealed LLC to ULC sutures (Fig 4.40f).
10) Insertion of columellar strut and 5 mm domal excision to drop projection.
11) Concealer tip graft of excised cartilage with fascia graft coverage.
12) Dorsal fascia graft.
Case Study:
An Over-
Sutured Nose
Fig. 4.41 (a–j)
Case Study: An Over- Sutured Nose
153
Fig. 4.41 (continued)
154
Chapter 4 Tip Techniques
Byrd HS, Hobar PC. Rhinoplasty: A practical guide for surgical planning. Plast Reconstr
Surg 91: 642, 1993
Byrd HS, Andochick S, Copit S, and Walton KG. Septal extension grafts: A method of control-
ling tip projection shape. Plast Reconstr Surg 100: 999, 1997
Daniel RK. Rhinoplasty: Creating an aesthetic tip. Plast Reconstr Surg 80: 775, 1987
Daniel RK. Anatomy and aesthetics of the nasal tip. Plast Reconstr Surg 89: 216, 1992
Daniel RK. The nasal tip. In: 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. Broad, boxy, and ball tips. Open Tech Plast Surg 4: 7, 2000
Daniel RK. Tip refinement grafts: the designer tip. Aesth Surg J 29: 528, 2009
Gruber RP, Nahai F, Bogdan MA, et al Changing the convexity and concavity of nasal carti-
lages and cartilage grafts with horizontal mattress sutures. Part I. Experimetnal results.
Plast Reconstr Surg 115: 589, 2005. Part II: Clinical results. Plast Reconstr Surg 115: 595,
2005
Gruber RP, Bates SJ, Le JL. Advanced suture techniques in rhinoplasty. In Gunter, JP, Rohrich
RJ, Adams WP Dallas Rhinoplasty: Nasal Surgery by the Masters. (2nd ed.), St. Louis: QMP
Publishing, 411–446, 2007
Guyuron B, Behmand RA. Nasal tip sutures. Part II: The interplays. Plast Recon Surg 112:
1130, 2003. Part I: The evolution. Plast Reconstr Surg, 112: 125, 2003
Johnson CM, and Toriumi DM. Open Structure Rhinoplasty. Philadelphia: Saunders, 1990
Kridel RWH, Scott BA, Fonda HMT. The tongue-in-groove technique in septorhinoplasty: a
10 year experience. Arch Facial Plast Surg 1: 246–256, 1995
McCollough EG. Nasal Plastic Surgery. Philadelphia: Saunders, 1994
Natvig P, Setler LA, and Dingman RO. Skin abuts skin at the alar margin of the nose. Ann
Plast Surg 2: 248, 1979
Rees TD, and La Trenta OS. Aesthetic Plastic Surgery (2nd ed.) Philadelphia: Saunders, 1994
Rohrich RJ, Adams WP Jr. The boxy nasal tip: classification and management based of alar
cartilage suture techniques. Plast Reconstr Surg 107: 1849, 2001
Sheen JH. Middle crus: The missing link in alar cartilage anatomy. Perspect Plast Surg 5:3
1, 1991a
Sheen JH. Tip graft: A 20-year retrospective. Plast Reconstr Surg 91: 48, 1991b
Sheen JH. Rhinoplasty: personal evolution and milestones. Plast Reconstr Surg 105: 1820,
2000
Sheen JH, Sheen AP. Aesthetic Rhinoplasty (2nd ed.) St. Louis: Mosby, 1987
Tardy ME. Rhinoplasty: The Art and the Science. Philadelphia: Saunders, 1997
Tardy ME, and Cheng E. Transdomal suture refinement of the nasal tip. Facial Plast Surg 4:
317, 1987
Tebbetts JB. Shaping and positioning the nasal tip without structural disruption: A new,
systematic approach. Plast Reconstr Surg 1994;94:61. Additional information in Tebbetts
JB. Primary Rhinoplasty: A New Approach to the Logic arid Techniques. St. Louis: Mosby,
1998
Toriumi, DM. New concepts in nasal tip contouring. Arch Facial Plast Surg 8: 156, 2006
Toriumi DM, Johnson CM. Open structure rhinoplasty. Featured technical points and long-
term follow-up in Facial Plast Clin 1: 1, 1993
Zelnik J, Gingrass RP. Anatomy of the alar cartilage. Plast Reconstr Surg 64: 650, 1979
Reading List
The nasal base is probably the least understood and most complex area of the nose.
Surgical errors of omission lead to less than optimal results, while errors of commission
can produce irreparable deformities. Errors occur because surgeons assume that these are
“ancillary techniques” rather than an integral part of a rhinoplasty. Or perhaps not enough
time is taken to study the aesthetic and anatomical subtleties of the area. Unfortunately,
analysis can be complex and the etiology of a problem multifactorial. Anatomically, the
nasal base is not a distinct anatomical entity. The impact of adjacent structures is of critical
importance. One must always assess the influence of the caudal septum on the columella
which can result in deviation, retraction, or a hanging deformity. Despite the analytical
complexity, most of the surgical solutions are straightforward once the correct diagnosis
is made. The procedure must be done meticulously or permanent deformities can occur.
Although challenging, it is my belief that a properly planned and executed alar base modi-
fication can have as great an impact on a rhinoplasty result as a tip graft.
Introduction
Nasal
Base5
156
Chapter 5
Nasal Base
Patients frequently complain about the width of their nasal base, the size of their nostrils, or
their plunging tip. Many surgeons try to ignore these complaints as they do not feel confident
that they can correct them. Yet these deformities can be improved quite easily provided the
surgeon analyzes their etiology and design an effective operative plan (Fig. 5.1). The key is
to think of the ABCs of the nasal base – Alar Rim, Base, and Columellar.
Level 1
Alar Rim. The most effective way of supporting the alar rim is the alar rim graft (ARG). A
small tapered piece of cartilage (3 × 10 mm) is placed in a subcutaneous pocket paralleling
the alar rim. It corrects most preexisting rim weaknesses or any that might occur following
tip suturing.
Base. The surgeon must master the nostril sill excision which reduces nostril show on anterior
view, and the alar wedge excision which reduces alar flare. These excisions are extraordinarily
effective with minimal risk when properly executed.
Columellar. Excisions of the caudal septum and anterior nasal spine (ANS) are tailored to
upwardly rotate or shorten the long nose. Their effect on tip position is perhaps as important
as alar anatomy.
Level 2
Alar Rim. As alar rim retraction and abnormal nostril shape become greater, the surgical
solution becomes the direct suturing of the alar rim graft into a marginal rim incision – the
alar rim support graft (ARS). Essentially, one is using the same graft but suturing it directly
along the nostril rim for greater support and shaping.
Base. As alar flare and nostril width both increase, the surgical solution becomes a combined
nostril sill/alar wedge resection.
Columellar. The insertion of a columellar strut between the crura is extremely effective in push-
ing down the columellar inclination. In most cases, straightening a deviated columellar requires
both correction of the deviated caudal septum and insertion of a major columellar strut.
Level 3
Alar Rim. As rim retraction becomes severe, one adds composite grafts of conchal cartilage
and skin to correct the deficiency. When alar rim support is totally absent, rigid alar battens
of rib cartilage may be necessary.
Base. In certain ethnic and cleft cases, cinch procedures are used to maximally narrow the
nostril sill width. A great deal of imagination is needed to revise secondary nostril deformities.
Columellar. Retraction of the columellar can be due to telescoping of the septum or prior resec-
tion of either the caudal septum or membranous septum. Reconstruction can be demanding.
Overview
Overview
157
Fig. 5.1 Overview – illustrations, (a, b) correcting deviation and assymetry, (c, d) supporting and changing intrinsic
nostril shape, (e, f) external valve splinting, (g, h) total collapse of the nostril treated with alar battens
158
Chapter 5
Nasal Base
Anatomical Components. From both an anatomical and an aesthetic perspective, the nasal
base is subdivided into eight components: (1) columella base, (2)central columellar pillar, (3)
infralobular triangle, (4) soft triangle, (5) lateral wall, (6) alar base, (7) nostril sill, and (8)
nostril (Fig. 5.2). This component approach is best appreciated on basilar view. The transverse
width of the columella base is related to the separation of the footplates and the quantity
of the intervening soft tissue. The caudal septum/ANS is the critical factor in determining
the columellar labial angle as seen on lateral view. The central columellar pillar is created
by medial crura apposition and their termination at the columellar lobular junction. The
infralobular triangle and soft triangle are the capstone of the basilar pyramid. The length
of the columella segment of the middle crura determines the height of the triangle and the
width of its divergence. The soft triangle is a reflection of the width of the domal notch and
consists of a web of surface and vestibular skin devoid of cartilage. The lateral wall reflects
the support and proximity of the lateral crura to the alar rim. It is the cephalic sweep of the
lateral cartilage away from the rim that creates the alar rim breakpoint and marks the junc-
tion between lobule and alar base. The alar base is composed of subcutaneous tissue and
muscles. It serves as an external baffle for the nose as influenced by the facial musculature.
It is an area of surgical importance as it determines the amount of alar flare and interalar
width. The nostril sill varies widely in its vestibular and cutaneous surfaces. The alar base
can end abruptly creating a flat nostril sill or it can have a rolled continuous border. Equally,
the footplates can extend laterally leaving an ill-defined nostril sill. The nostril is obviously
the void whose shape is determined by the surrounding structures.
Extrinsic Influences. It is on lateral view that one begins to appreciate the important inter-
relationship between the nasal base and its abutting structures. The columellar labial angle
is a critical aesthetic landmark. As seen on cadaver dissection, the key anatomical finding
is that the distance from the maxilla’s A-point to the tip of the nose is often 4 cm. It breaks
down into four 1 cm segments: anterior nasal spine, caudal septum, medial crura, and middle
crura. The ANS determines the projection from the maxilla and may have a webbed bony
ridge beneath it. The caudal septum determines the columellar limb as it is covered by soft
tissue centrally, but no cartilage for 1 cm before the medial crura meets in the midline. The
labial limb is determined by the shape of the maxilla and its relationship with the soft tissues
that comprise the upper lip. On anterior view, the key anatomical factor is the alar flare (AL)
and the width of the alar bases (AC).
Anatomy
Anatomy
159
Fig. 5.2 (a–f) Basilar anatomy
160
Chapter 5
Nasal Base
The aesthetics of the four nasal base components are carefully analyzed: alar flare/width,
columella, columella labial angle, and nostril (Figs. 5.3 and 5.4).
Alar flare (AL-AL) refers to the widest point between the alar bases which usually oc-
curs several millimeters above the alar crease. In contrast, interalar width (AC-AC) denotes
the distance between the alar creases which is usually less than alar flare. The distinction is
important in that alar flare can be easily reduced by alar wedge excision, whereas interalar
width requires combined excision of the alar base and the nostril sill. Aesthetically, the alar
bases should be narrower than the intercanthal width (EN-EN). These values are easily mea-
sured with a ruler or caliper on anterior or basilar view.
The columella relationship to the tip and the presence of a hanging columellar can be
assessed by the “seagull-in-flight” concept on anterior view. Essentially, the columella break-
point and each alar rim breakpoint are connected in such a way that it represents a seagull in
flight. The more vertical the wings are, the more the columellar hangs (see Fig. 10.15 p377).
As previously noted, the columella labial angle (CLA) is created by the intersection of
the columella tangent and the lip tangent at the subnasale (SN). Each component must be
analyzed separately. The columella limb is a very powerful indicator of upward nasal rotation.
A true columellar angle is measured by extending the columellar tangent line back to the ver-
tical axis passing through the alar base. It should parallel the tip angle and be approximately
105° in females and 100° in males. The columella should have a slight convexity rather than a
retrudding concavity or a hanging prominence. The labial limb relates to the upper lip with
the ideal at −6° from the upper lip vertical while avoiding either retrussion or prominence.
One must consider the obvious influences of maxilla, occlusal relationship, teeth inclination,
and upper lip composition. The subnasal segment should be a gradual curve interconnecting
the two limbs, not a sharp acute point nor a blunted convex web which shortens the upper
lip. Next, careful assessment of the caudal septum and ANS is mandatory. The examination is
done mainly by palpation which often indicates either bony or soft tissue etiologies. Note: the
term nasolabial angle is no longer used as CLA is of greater accuracy and surgical relevance.
Analysis of the alar rim–nostril–columellar complex (ARNC) requires careful scrutiny
of multiple factors. The first step is to assess four inclinations on lateral view: (1) tip angle,
(2) tangent of alar rim, (3) nostril inclination, and (4) columellar inclination. Second, tip
angle and columellar inclination will be critical factors in determining the overall result of
the rhinoplasty and must be addressed before the nostril. Third, one assesses the size, shape,
and inclination of the nostril itself. Fourth, the alar rim configuration becomes a primary
determinant of nostril show and its retraction is a common post-rhinoplasty stigmata.
Aesthetics/
Analysis
Aesthetics/Analysis
161
105°
a
b
c
EN
EN
x
x
AC
AC
AC
AL
2/3
1/3
T
AR
N
C
x
45°
“ARC” Inclination
Alar rim
Nostril
Columella
x
x = 2 mm
Fig. 5.3 (a–c) Aesthetics/analysis
Fig. 5.4 (a–c) Case analysis
162
Chapter 5
Nasal Base
Although many excisional configurations exist for narrowing the alar bases, I have simpli-
fied them into three types of excisions: nostril sill, alar wedge, and combined (Fig. 5.5). A
few technical points: (1) the decision as to the indication and type is made preoperatively,
(2) the alar crease is marked preoperatively and all alar incisions are made in the crease, (3)
all excisions are carefully measured with a caliper prior to injection of local anesthesia, (4)
98% of the time, similar procedures are done on each side with only the size of the excision
varied to accommodate asymmetries, (5) a fresh #15 blade is used and all cuts are made with
the area under skin hook traction, (6) the sill is closed with a horizontal mattress suture of
4–0 plain catgut to insure eversion and thus avoid a depressed scar (Q sign), (7) the skin is
closed with interrupted 6–0 nylon and no deep sutures, and (8)the sutures are kept clean
until removal at 1 week.
Nostril Sill Excision
This excision is designed to reduce “nostril show” on anterior or oblique view. The wedge
is centered in the floor vertically and is not angulated laterally nor does it have a comma
shape (Fig. 5.6a, b). It is essentially a vertical trapezoidal wedge excision measuring 2–4 mm
in width at the nostril sill with vertical side walls of 2–4 mm height that taper downward.
Closure is begun with a horizontal mattress suture of 4–0 plain catgut in the vestibule fol-
lowed by one or two 6–0 nylon sutures. The goal is a smooth scar not a depressed scar that
distorts the floor of the nostril (Q sign).
Alar Wedge Excision
The alar wedge excision is an elliptical excision with an inferior border placed in the alar
crease and a width 2–5 mm that may approach 7–9 mm in certain Black noses (Fig. 5.6c, d).
The alar wedge is designed to reduce alar flare. Using a #15 blade, a V-excision is done down
to the mid-muscle level, but without penetrating the underlying vestibular skin. Cauterization
is necessary. The ellipse is closed from either end toward the middle with the knots tied on
the lower side. With rare exception, I have not found the scars to be a problem and disagree
with those who limit their alar base modification.
Combined Sill/Base Excision
This combined excision is designed to narrow the alar base maximally while reducing flare
at the same time (Fig. 5.6e, f). Essentially, one draws the lower portion of the alar wedge
excision around to the medial vertical wall of the nostril sill excision. Then using the calipers,
one determines the sill width component and then the height of the alar wedge component.
Under skin hook traction, the vertical sills are cut first, then the lower alar incision, and last
the superior wedge incision. Following cauterization, the sill is closed first with 4–0 plain
catgut and then the rest with 6–0 nylon. Note: throughout the text, I will denote the sill
component first and alar component second so that a 3/4 excision is 3 mm of sill and 4 mm
of alar wedge.
Base
Modification
Base Modification
163
Fig. 5.5 (a, b) Clinical deformities
Fig. 5.6 Base modifications, (a, b) nostril sill excision (c, d) alar wedge excision (e, f) combined
sill/alar wedge excision
164
Chapter 5
Nasal Base
Careful visual and tactile analysis of the columella labial angle (CLA) in repose and smiling is
essential in determining whether the etiology of a deformity is isolated or combined. Surgical
modification consists of preservation, resection, or augmentation of either the columellar or
the anterior nasal spine (ANS).
Columella
The vast majority of columellar problems are deviations due to the caudal septum which
require caudal septal relocation. The next most common deformity is the hanging colu-
mellar due to a prominent caudal septum which can be resected to affect either shortening
and/or rotation (Fig. 5.7). In most cosmetic rhinoplasties, only the upper half of the caudal
septum is resected to achieve tip rotation without altering the columellar limb. Resection of
the lower half of the caudal septum affects the columella limb of CLA. Straight excisions of
the entire caudal septum effectively shorten the nose. Clinical retraction of the columella
limb is corrected by insertion of a long wide columellar strut graft (30 × 4), which extends
below the medial crura footplates. The graft pushes down both the columellar limb and the
CLA segment. One must avoid excessive length to prevent the graft from rocking across the
ANS. “Plumping grafts” of excised cartilage are placed in the CLA to fine tune and correct
the acute CLA.
Anterior Nasal Spine
The prominent ANS can be either shortened or its underlying bony webb deepened using
a double-action rongeur. Shortening reduces the prominence of the SN point while resec-
tion lets the upper lip inclination become negative. The retracted ANS can be an isolated
entity or part of a hypoplastic premaxilla which will often be expressed as an acute CLA.
In most cases, I correct the retro position of the SN point with a large columella strut graft
and additional small cartilage grafts placed subcutaneously in the columellar base beneath
the CLA (Fig. 5.8). Others have tried a pyriform graft of either preformed Proplast or rolled
GoreTex. The idea is to bring both the alar bases and the CLA forward. Unfortunately, I have
had to remove several alloplastic grafts for the following reasons: (1) visibility in thin patients
especially on smiling, (2) restricted movement of the upper lip, and (3) general dissatisfac-
tion. For this reason, I use 2–3 ccs of diced cartilage (DC) when peripyriform augmentation
is required, especially in the cocaine nose. In very asymmetric primary cases, I may build up
the hypoplastic maxilla with hypdroxyapatite granules, if sufficient cartilage is not available.
I do not recommend routine peripyriform grafts. Note: in many secondary cases, the caudal
septum has been overly resected and one must reestablish both the columellar segment and
the columellar inclination. In these cases, a large columellar strut can create the illusion of
significant tip rotation without direct tip surgery. It is important to understand the columellar
labial angle both as an isolated entity and as an integral part of rhinoplasty.
Columellar
Labial Angle
Columellar Labial Angle
165
Fig. 5.7 (a–f) Caudal septum/ANS resection
Fig. 5.8 (a, b) Grafting CLA
a
b
166
Chapter 5
Nasal Base
Analysis of the alar rim–nostril–columellar complex (ARNC) begins with drawing four
inclinations on lateral view: (1) tip angle, (2) tangent of alar rim, (3) nostril inclination, and
(4) columella inclination (Fig. 5.9). It is critical that the requisite tip angle and columellar
inclination be achieved before modifying the nostrils. The breakpoint of the alar rim is
marked as well as the proximal limb which should be twice the distal limb and the angle
of intersection should be approximately 45°. The nostril circumference is drawn, which
incorporates the alar rim cephallically and the posterior portion of the columellar caudally.
A line is drawn through the terminal points of the nostril and the resulting bisection classi-
fied as follows: (1) ideal with 2 mm on either side, (2) excesses greater than 2 mm indicating
a retracted alar, hanging columella or both, and (3) reductions of 1 mm or less denoting
a hanging alar or retracted columellar. Alar rim surgery can be divided into those for the
hanging or retracted alar rims.
Lowering the Alar Rim
Level 1. The easiest method for lowering the alar rim by 2 mm or blunting a notched alar
rim is the simple alar rim graft (ARG) (Fig. 5.10). A straight piece of cartilage measuring
10 × 2.5 mm is cut. A small transverse incision is made in the lateral vesitibule 3–4 mm behind
the rim and a subcutaneous pocket is dissected paralleling the rim. The graft should fit snugly
in the pocket and correct the visible deformity. The usual errors are a thick cephalic end
which can be visible in the soft tissue facet or create a bossa over the dome. Rigid support
can be achieved by suturing the graft into the alar rim as an ARS.
Level 2. For cases with 2–4 mm of alar rim retraction, I prefer to use a composite graft from
the cymba concha (Fig. 5.11). Several technical points: (1) mark the alar rim border and its
apex on the patient; (2) make the incision 2 mm behind the rim; (3) spread perpendicular
to the rim and never dissect toward the rim; (4) have equal amounts of cartilage and skin
in the graft; and (5) know that the graft works by filling the defect. The major problem has
been the three-dimensional challenge of getting rim descent without widening the nostril
horizontally or creating excess fullness cephalically.
Level 3. Any alar retraction greater than 5 mm is a severe problem and composite grafts in
the alar rim position tend to be inadequate. In severe cases with associated vestibular steosis,
I have used a large conchal cartilage graft (20 × 8 mm) placed in the vestibule.
Elevation of the Alar Rim. Elevating the hanging alar rim is of limited effectiveness as only
2–3 mm can be achieved at the maximum. An ellipse is drawn 3 mm above the alar rim and
centered at the desired point of maximum elevation. The width is twice the desired elevation.
This pattern is then transferred to the vestibular lining and a full thickness ellipse of soft
tissue is excised. The wound is closed with 5–0 plain catgut which should elevate the alar rim.
A more aggressive method is direct excision along the alar rim which I do not recommend
as the scarring is unpredictable.
The Alar Rim–
Nostril–
Columellar
Complex
Alar Rim–Nostril–Columellar Complex
167
Fig. 5.9 (a–d) Alar rim–nostril–columellar complex analysis
T
AR
N
C
2/3
1/3
x
x
x = 2 mm
45°
105°
A
B
C
D
Fig. 5.11 Composite grafts
Fig. 5.10 Nostril analysis
Retracted alar rim
Hanging columella
Combination
168
Chapter 5
Nasal Base
Many surgeons tell patients that the inherent size and shape of the nostrils cannot be changed
– nothing could be further from surgical reality. Both the size and shape of the nostrils can
be altered significantly, but it requires Level 2 and Level 3 techniques.
Changing Nostril Size. Large nostrils are similar to “stretchy doughnuts.” The aperture is
affected by the convexity and projection of the cartilaginous vault as well as the downward
rotation of the caudal septum. These extrinsic forces must be eliminated before true nostril
size can be determined (Fig. 5.12a–c). The combination of dorsal reduction and caudal sep-
tal resection plus the appropriate nostril base excision, usually a combined nostril sill/alar
wedge, will adequately reduce 90% of large nostrils. In the truly massive alar nostril (1–2%
of my cases), it is necessary to either excise a portion of the lateral crural segment or do a
domal excision plus open structure tip graft to reduce the nostrils. Note: increasing nostril
size is a nightmare and virtually never required in primary aesthetic cases. This subject will
be dealt with under cleft and secondary rhinoplasties later in the text.
Nostril/Tip Disproportion. Many patients complain of large nostrils and an under project-
ing poorly defined tip. On lateral analysis, it is a small tip which is accentuating normal or
large nostrils (Fig. 5.13a–c). One must increase intrinsic tip projection to achieve balance in
the ideal 2:1 nostril to tip ratio. The most common method is to suture the middle crura to
a columellar strut followed by tip suturing. Add-on grafts are used to increase infralobular
tip volume and domal definition.
Changing Nostril Shape. Virtually nothing has been written about changing intrinsic nostril
shape. After using a large number of ARS grafts, I realize how dramatically nostril shape
could be altered. However, it requires careful analysis, surgical skill, and checking of the
most minute details (Fig. 5.14a–c). The boxy tip with its weak alar rims is the most com-
mon deformity requiring a change in nostril shape. The steps are as follows: (1) eliminate
the deforming forces of the dorsum and caudal septum, (2) achieve the desired tip which
may involve domal excision or even alar transposition, (3) reduce the nostril base with the
appropriate excision technique, and (4) control nostril shape with an ARS graft. The key is
to suture an ARS graft into a true marginal rim incision. For the ARS graft, the steps are as
follows: (1) make a true rim incision 2 mm back from the rim extending into the alar base,
(2)undermine cephalically, never caudally into the nostril rim, (3) one should see a distinct
change in nostril shape with release of the mucosa, (4) the ARS graft must be shaped meticu-
lously – a length of 10–14 mm with a width of 2–3 mm but tapered medially and thinned to
1–2 mm, (5) the graft is inserted along the marginal incision and sutured at its central point
with 4–0 plain sutures, and (6) the medial portion must not overlap the domal segment or
a visible “bossa” will appear postoperatively.
Changing
Nostril Size
and Shape
Changing Nostril Size and Shape
169
Fig. 5.12 (a–c) Changing nostril size
Fig. 5.14 (a–c) Changing nostril shape
Fig. 5.13 (a–c) Correcting nostril: tip disproportion
170
Chapter 5
Nasal Base
Operative Planning. The truth is that in the majority of Level 1 cases, there is no surgery
indicated for the nasal base. The exceptions are those patients who complain of wide nostrils
or have a significant caudal septum deviation that influences the columellar. When first start-
ing out, the surgeon should be forced into doing a particular operative step, either by patient
request (nostrils too wide) or presenting deformity (crooked columellar). Intraoperatively, a
base excision might become necessary if a major dorsal reduction is done which results in
a secondary widening of the base. In contrast, alar rim grafts following tip suturing may be
necessary to minimize loss of alar rim support. To correctly analyze the problem, the surgeon
should answer the following questions.
Base. Do I need to narrow the base of the nose? One should look on anterior and basilar
views to determine alar flare and alar width as compared to intercanthal width. One can either
do this on photos or by measurements with a caliper directly on the patient (my preferred
method). How much nostril sill do I see on anterior view or with the head slightly back?
Will a simple nostril sill excision solve the problem or is the alar flare so severe that I need
to do a wedge resection? A nostril sill excision has less risk of a visible scar, but does little
for alar flare. Always choose the simplest procedure.
Columellar/Caudal Septum. Is the nose too long? Is the tip rotated downward? Is the upper
lip crowded? Is the columellar deviated because of a caudal septal deflection? In addition to
direct inspection, one must answer these questions by palpating the columellar and caudal
septum as well as observing their changes on maximum smiling. The most common defor-
mity is that the nose is too long and the tip is somewhat downwardly rotated. Both problems
are minimized by excising 2–3 mm off the upper two thirds of the caudal septum. The ANS is
rarely excised unless the upper lip is very crowded. One must correct caudal septal deviations
both for functional and aesthetic reasons. A columellar strut between the alars can reduce
the impact of a deviated caudal septum.
Nostril Rim. Is the alar rim retracted on anterior view or weak on basilar view? After sutur-
ing the tip, did the alar rims loose support? In the vast majority of primary cosmetic rhino-
plasties, the alar rim is rarely a problem preoperatively. However, tip suturing can cause a
subtle change in alar rim contour requiring alar rim grafts to restore rim contour. These are
important grafts and if in doubt, insert them.
P R I N C I P L E S
Surface measurements with a caliper allow direct comparison of EN-EN, AL-AL, and AC-
AC. It insures a complete pre-op analysis.
Base modification is a critical step in the operative plan, not an optional ancillary minor
detail.
Meticulous closure of the excision is essential, especially eversion of the nostril sill.
Decision
Making Level 1
Nostril Sill Excisions
171
Analysis
Pre-op, the patient has a long downwardly rotated nose and a convex profile. The nostrils
are quite visible on all views, but especially the oblique, which would only be accentuated
postoperatively. For this reason, 2 mm nostril sill excisions were done on both sides. Note
how much smaller the nostrils look on the post-op oblique view. There were no ARG or ARS
grafts – just bilateral nostril sill excisions (Fig. 5.15).
Nostril Sill
Excisions
Fig. 5.15 (a–d)
172
Chapter 5
Nasal Base
This patient presented with the complaint of a large nose crowned by a bulbous tip. The skin
envelope was relatively thick. At surgery, her cartilaginous dorsum was reduced 5 mm and tip
projection dropped using bilateral transfixion incisions. The tip went from an over-projecting
narrow isosceles triangle to a wider equilateral triangle. Alar wedge excisions, 4 mm wide,
were an intraoperative necessity which is a fairly rare occurrence (Fig. 5.16).
Alar Wedge
Excisions
Fig. 5.16 (a–d)
Base Excisions
173
Analysis
Pre-op, the patient’s surface measurements were as follows: EN 28, AC 30, and AL 35. The
alar flare (AL) was +7 mm relative to the intercanthal distance (EN) thus leading to the com-
bined nostril sill/alar base excision (R & L: 2.5/2.5). Post-op on basilar view, the nasal base is
significantly narrower while the nostrils are smaller. The nostril sills no longer hang down
below the alar rims on anterior view. There were no osteotomies (Fig. 5.17).
Combined
Sill/Wedge
Excisions
Fig. 5.17 (a–d)
174
Chapter 5
Nasal Base
In the majority of Level 2 cases, the problems are both aesthetic and functional with correction
a necessity rather than an option (Fig. 5.18). One has to be prepared to deal effectively with
both a wider range and greater severity of problems. A classic example is the combination
of a boxy tip and a deviated caudal septum. One wants to reduce the rigid alar tip cartilages,
but the flimsy nostril rims are already weakened. On deep inspiration, the external valve
collapses on the side of the caudal septal deviation.
Base. A combined nostril sill/alar wedge resection is necessary when a major reduction in the
base width is planned. Asymmetry is common and asymmetrical excisions of each compo-
nent are often required. I mark the nostril sill component first in the standard fashion. Then
the lower alar wedge incision is placed in the alar crease. The amount of excision varies from
the usual 2–3.5 mm to the exceptional 6–7 mm in Black patients. The nostril sill component
is incised first using parallel vertical cuts. Then the alar wedge component is incised from
lateral to medial, with tapering on the upper border into the nostril sill. Closure of the nos-
tril sill with an everting horizontal mattress suture of 4–0 plain catgut is critical to avoid an
inverted scar (Q sign). Due to the alar rim notching that follows major excisions, ARS grafts
are inserted after the alar base excision in most cases.
Columellar/Caudal Septum. The columellar is frequently deviated due to a caudal septal
deflection. The septum must be relocated to, and fixed in, the midline. Simple positioning
without rigid fixation is insufficient. Thus, the septum is fixed to the ANS in the correct
position. Next, a columellar strut is placed between the alar cartilages. The tip cartilages are
appropriately modified and supported on the columellar strut.
Nostril Rim. Support of the nostril rim becomes critical in these cases and a simple alar rim
graft (ARG) is rarely adequate. Rather, one must use alar rim support grafts (ARS) where the
graft is sutured into a true marginal rim incision. The rim incision is made rather than the
infracartilaginous incision to allow the graft to support the rim. Then a tapered 12 × 2.5 mm
piece of septal cartilage is sutured into the rim incision. These grafts offer both rim support
and the ability to change nostril shape significantly. The suturing is first at the midpoint
and then laterally. The medial extent of the graft must be carefully checked to avoid overlap
above the dome which can result in a bossa or distortion of the soft tissue facets. When in
doubt, a shorter graft is better.
P R I N C I P L E S
One must straighten the foundation first (caudal septum), then reduce asymmetry in the
columellar using a strut, and then the tip.
Any major combined nostril sill/alar wedge resection will require either an ARG or ARS
graft.
Decision
Making Level 2
Decision Making Level 2
175
Fig. 5.18 (a) Pre-op base, (b) septal deviation, (c) post-caudal sepal relocation, (d) columellar strut insertion,
(e) closure, (f) ARG (R), ARS (L), (g) pre-op/deep inspiration, (h) post-op/deep inspiration
176
Chapter 5
Nasal Base
Analysis
A 41-year-old male presented with a history of severe nasal obstruction, but no prior nasal
trauma (Fig. 5.19). Literally, everything that could cause nasal obstruction was present includ-
ing the following: (1) caudal septal deviation to the left, (2) alar rim weakness with collapse on
deep inspiration, (3) a severe S-shape deviation of the septal body, and (4) midvault narrow-
ing. The latter would be treated by detaching the upper laterals, inserting spreader grafts, and
no osteotomies. As shown on the previous page, straightening the caudal septum improved
the columellar while the nostrils were supported with an ARG on the right and an ARS on
the left. Aesthetically, the patient wanted a nose that was more compatible with his life style.
Operative Technique
1) Exposure of alar cartilages and dorsum
2) Septal exposure through right transfixion incision
3) Detachment of upper laterals for bidirectional septal access
4) Inferior tunnel for bony septal exposure
5) Major septoplasty, but maintaining a 12 mm L-shape strut
6) Caudal septal relocation L to R with suture fixation
7) Columellar strut plus tip sutures: CS, DC, ID, LCC × 2
8) ARG on R, ARS on L
9) Out fracture of turbinates
10) No lateral osteotomies, no nostril sill excisions
Case Study:
Base Collapse
Fig. 5.19 (a–j)
Case Study: Base Collapse
177
Fig. 5.19 (continued)
178
Chapter 5
Nasal Base
These cases often demand both creativity and surgical humility. In primary cases, the
progression is from unusual nostrils to ethnic challenges to cleft lip asymmetries. The critical
requirement is to combine base excisions with rigid alar rim support using either cartilage
or composite grafts. Nostril retainer splints are used at night for 2-3 weeks (Fig.5.20).
Composite Grafts. Although frequently used in secondary and cleft lip rhinoplasty, I rarely
use composite grafts in primary cases (<3%). These unusual cases involve significant isolated
alar rim retraction where the caudal septum cannot be excised. ARG or ARS grafts would not
solve the problem because true hypoplasia of the lateral crura is present. The solution is to
fill the defect with both cartilage support and skin lining. These grafts are custom tailored
to the defect and are usually “composite strips” (12 × 2–3 mm) in contrast to the 4–6 mm
wide composite grafts required in cleft or secondary cases. It is important to shave down the
cartilage surface until it has the thickness and pliability of alar cartilages.
Cartilage Grafts. A decade ago, the choice of cartilage grafts for the alar rim was simple – an
alar batten graft. These large grafts provided support, but often obscured the alar crease or
altered symmetry. ARG and ARS grafts work well for the nostril rim, but are probably insuf-
ficient for most major external valve collapses. Thus, the lateral crural strut graft has become
the graft of choice because its size and position can be tailored to fit the problem (Fig. 5.21).
As discussed in Chapter 7, the three positions for the lateral crural strut graft are pyriform
(Type I), alar base (Type II), and nostril rim (Type III). The critical factor is that the graft is
placed beneath and sutured to the lateral crura which in turn can be in its normal position
or transposed. Simplistically, transposition of the lateral crura is a tip decision, whereas the
position of the lateral crural strut graft is a functional decision. The Type I pyriform loca-
tion supports the alar crease, the Type II alar base location supports the vestibule, and the
Type III nostril rim location supports and reshapes the nostril. Lateral crural strut grafts are
ideally made from rigid septal or rib cartilage and are highly tapered. This complex subject
is discussed extensively in Chapters 7 and 8.
P R I N C I P L E S
Composite “strip” grafts are effective in lowering the alar rims in primary rhinoplasty
cases.
Lateral crural strut grafts have replaced alar batten grafts in the majority of primary
cases.
Lateral crural strut grafts provide support, but should never be visible. Hiding the graft
beneath the lateral crura is essential.
A true marginal rim incision is used when the Type III lateral crural strut graft is placed
into and sutured along the nostril rim.
Decision
Making Level 3
Decision Making Level 3
179
Fig. 5.21 (a–f) Lateral crural strut grafts
Fig. 5.20 (a–d) Composite grafts and the use of nostril splints
180
Chapter 5
Nasal Base
Analysis
A 28 year old who works in the beauty industry requested a rhinoplasty (Fig. 5.22). Her
three complaints were the following: “(1) beaky on profile, (2) nostrils too big, and (3) tip
plunges.” I agreed with her diagnosis. In addition, there was a significant large nostril/small
tip disproportion. Technically, the major problem would be the preexisting retracted alars
which would require composite grafts, especially if a major tip change was accomplished.
Since analysis of the intrinsic tip was virtually impossible until the deforming extrinsic
forces were removed, it was elected to use a “closed/open” approach. The composite grafts
lowered the alar rim and provided support for the nostril contour. The result is shown at 2
years post-op.
Operative Technique Highlights
1) Intercartilaginous and transfixion incisions plus septal exposure.
2) Dorsal reduction (bone 0.5 mm, cartilage 2.0 mm).
3) Caudal septal (4 mm) and ANS resection followed by septal harvest.
4) Open approach. Minimal “scroll only” cephalic resection.
5) Low-to-high osteotomies. Insertion of spreader grafts.
6) Insertion of crural strut plus tip sutures: CS, DC, DE, TP.
7) Combined nostril sill/alar base excision R: 2.5/1.5, L: 3.5/2.0.
8) Composite conchal grafts to each nostril rim.
Note: patient had a chin implant (small) and submental liposution.
Case Study: Alar
Retraction
Fig. 5.22 (a–j)
Case Study: Alar Retraction
181
Fig. 5.22 (continued)
182
Chapter 5
Nasal Base
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Reading List
As a plastic surgeon specializing in rhinoplasty, I deal with two patient populations: the
cosmetic patient who wants a more attractive nose with the preservation of what they perceive
to be normal respiration, and the secondary patient whose nasal function is often impaired.
These problems are usually due to fixed anatomical deformities, which require surgical solutions
rather than the more common form of nasal obstruction due to vasomotor rhinitis requiring
medical management. This chapter provides a foundation for the younger surgeon to analyze,
diagnose, and manage the rhinoplasty patient. The goal is to preserve normal respiratory
function, recognize those who would be compromised by surgery, and treat those with fixed
anatomical deformities. During the last decade, two radical changes have occurred in septo-
rhinoplasty surgery as regards functional surgery. First, septal surgery has become far simpler
and consists of four areas: body resection, caudal septal relocation, dorsal straightening, and
total septoplasty. In contrast, a greater emphasis on valvular surgery requires attention to the
external and internal valves. Second, the primary cause of post-rhinoplasty nasal obstruction
has evolved from inadequate septal surgery (1980s)through untreated turbinate hypertrophy
(1990s) to collapse of the nasal valves (2000). Currently, I am convinced that the major cause of
post-rhinoplasty nasal obstruction is a failure to adequately diagnose and treat a preoperative
problem. Careful preoperative history, examination, and planning for the functional portion of
the internal nose are as important as the aesthetic improvement of the external nose. Compro-
mise of nasal respiration severely downgrades even the most beautiful result.
Introduction
Functional
Factors6
184
Chapter 6
Functional Factors
Surgeons frequently want rhinoplasty to be simple. One of their favorite fantasies is that
cosmetic rhinoplasty does not really require correction of functional nasal obstruction.
They often ask the following questions. Can you do a rhinoplasty without fixing septal devia-
tions? No. Do you really need to do spreader grafts? Yes, and frequently for both functional
and aesthetic reasons. Can the operation be split into two parts with one surgeon doing the
functional part and another surgeon the cosmetic portion? No, it is an integrated operation.
I schedule all of my aesthetic cases as a “cosmetic septorhinoplasty with possible inferior
turbincetomy and multiple grafts,” which reflects the dual nature of the operation. Now that
the delusion of a pure cosmetic operation has been put to rest, we can talk about functional
factors that must be evaluated in every rhinoplasty.
Level 1. The surgeon should be able to deal with the following four functional factors: sep-
tal body deviation, caudal septal deviation, internal valve collapse, and inferior turbinate
hypertrophy (Fig. 6.1a, b). The surgical solutions are straightforward: resect septal body
deviations, relocate caudal septal deviations, insert spreader grafts to open the internal valve,
and partially resect hypertrophic inferior turbinates.
Level 2. Additional surgical sophistication is required to deal with severe deviations of the
septum due to either trauma or developmental causes. Caudal septal problems go beyond
dislocation to instability or collapse, which may require either reinforcement or replace-
ment using grafts of septal cartilage. Dorsal deviations are a reality and are corrected with
the following sequence: (1) place spreader grafts on the nondeviated side, which is sutured
above and below the deviation, (2) excise the deviated portion of the septum, and (3) place
a spreader graft on the deviated side with five-layer suture fixation (Fig. 6.1 c, d). Problems
in the external valve will require the use of alar rim grafts (ARG) or alar rim support grafts
(ARS) in the nostril valve and lateral crura strut grafts for the vestibular valve. Problems
can be found in the middle turbinate or synechiae between the turbinates and the adjacent
tissues.
Level 3. Whenever one deals with severe primary cases (clefts, cocaine, and posttraumatic
deformities) and virtually all secondary rhinoplasties, the surgeon must be prepared for a
major challenge. One will need to fix the unstable septum and even do a total septoplasty
(Fig. 6.1 e, f). These cases require a significant step-up in technical sophistication and I
consider these cases to be “nasal reconstruction of the internal nose.” In the septum a wide
range of prior destabilizing incisions and extensive resections can be present. One must be
prepared to establish septal support and to harvest grafts from alternative sites, including
rib grafts for stability. Valvular surgery can range from opening up constricted stenotic areas
with composite grafts to widening the bony valve. Turbinate surgery can be complicated by
scar fusion with the septum or an over abundance of polyps.
Overview
Overview
185
c
d
Fig. 6.1 (c,d) Dorsal septal deviation
Fig. 6.1 (a,b) Septal and valvular obstructions
Fig. 6.1 (e, f) Total septoplasty
186
Chapter 6
Functional Factors
Anatomy of the nasal airway is discussed in great detail in many textbooks. Rather than
repeating standard anatomical findings, I will present a few useful observations (Fig. 6.2a).
Septum. The septum is composed of the quadrilateral cartilage and five bones (premaxilla,
crest of maxillary bone, crest of palate bone, vomer, and perpendicular plate of ethmoid). The
size, thickness, and structural integrity of the quadrilateral cartilage varies enormously. I am
convinced that most saddling is caused by applying aggressive techniques to flimsy septal
cartilage. The interlacing perichondrial and periosteal fibers at the ANS and premaxillary
area preclude an easy dissection. Why is it so difficult to expose this area? The explanation
rests in the embryology of the septum. The vomer and perpendicular plate of ethmoid are
ossifications of the primordial cartilaginous septum, whereas the premaxilla is a distinct
separate bone that undergoes massive changes with growth. The premaxillary “wings” hide
the anterior palatine foramen. Aggressive dissection in this area can risk disruption of the
neurovascular bundles resulting in insensitive or even black teeth. The area just above the
junction of premaxilla with vomer is distinct for four reasons: (1) the quadrilateral cartilage is
thinnest here, (2) the caudal prolongation of cartilage begins here, (3) the organ of Jacobson
may occur, and (4) a significant growth center can exist. The lower 5 mm of septal cartilage
that runs in the premaxillary/vomerine groove is quite thick and may be out of the groove
on one side as a “deflection.” The septal cartilage has a “caudal prolongation” of 10–18 mm,
which separates the vomer and ethmoid bones. Bony deformities are often quite striking and
may take the shape of a triangular “spur.” Resection must be done with small sharp biting
forceps. Twisting the bone can result in catastrophic disruption of the entire perpendicular
plate extending into the cribriform plate. Although perichondrium is considered a single
sheet, its elevation confirms that it is composed of multiple compressed layers.
Nasal Valves
Based on my experience of doing more than 2,000 secondary rhinoplasties, I now classify and
utilize a four-valve concept: (1) nostril, (2) vestibular, (3) internal, and (4) bony (Fig. 6.2b,c).
The nostril valve is composed of those structures, which form and project into the nostril
aperture, including the columella, caudal septum, crural footplates, soft-tissue alar rim, alar
lobule, and nostril sill. The vestibular valve sits between two narrow apertures (nostril and
internal valve) with the most common obstructions being lateral alar collapse or vestibular
webbing. The internal valve has two parts: the narrow slit-like internal valve angle and the
internal valve area. The bony valve is comprised of the lateral bony wall and the septum,
both the angle and the cross-sectional area can be distorted following rhinoplasty or trauma.
Anatomy
Anatomy
187
Upper
lateral
cartilage
Middle concha
Inferior concha
Premaxilla
Maillary crest
Palatine crest
Vomer
Ethmoid Plate
Quadrangular
cartilage
Superior concha
Alar
cartilage
a
b
c
Nostril Valve
Fig. 6.2 (a) Internal nasal anatomy, (b) external valve, (c) internal valve
188
Chapter 6
Functional Factors
Anesthesia. After prepping the internal nose with Betadine swabs, the subperichondrial
mucosal space is injected using 1% xylocaine with epinephrine 1:100,000. The goal is to
achieve a hydrostatic dissection, which will facilitate subsequent elevation of the septal
mucosa. Injections allow evaluation of mucosal quality and septal structure. Next, the
mucosal lining is vasoconstricted using topical agents. Most surgeons use either a solution
of 4% cocaine, local anesthesia, or Afrin. I find that two 18-in. strips of ½-in. gauze allows
more accurate packing with better contact. In complex secondary cases, an endoscopic evalu-
ation is often helpful.
Septal Exposure. Routinely, I use a full unilateral right transfixion incision combined with
dorsal access to expose the septum. The caudal septum is exposed by retraction of columel-
lar to the left side and then a full-length transfixion incision is made 2–3 mm back from the
caudal border. Using the angled Converse scissors, the mucosa is elevated and the subper
ichondrial space is entered. To insure a clean dissection, I routinely crosshatch the lining
with a #15 blade and then scrape through to the cartilage using a dental amalgam. Once the
perichondrium is elevated, the dissection continues posteriorly over the cartilage and onto
the ethmoid and vomer bones, In contrast to this uninterrupted passage, the dissection in-
feriorly is blocked at the junction of cartilage with premaxilla due to the joint fascia where
perichondrium and periosteum meet. Any attempt to pass inferiorly will result in tears of
the mucosa. For most cases, this degree of exposure via an “anterior tunnel” is sufficient.
However, in complex cases with significant deformities involving the premaxilla, it is neces-
sary to create an “inferior tunnel” for complete access to the premaxilla.
Access Alternatives. The classic septal access via the open approach was obtained through
a top-down dorsal split technique in which the upper lateral cartilages are detached from
the septum (Fig. 6.3 a, b). This dorsal split can be combined with a tip split separating the
alar cartilages in the tip/columella, which adds exposure of the caudal septum and permits
its correction (Fig. 6.3 c, d). However, the combination of a unilateral transfixion with the
dorsal split, dual exposure, is used most frequently; especially in secondary cases (Fig. 6.3e, f).
The elevator is passed from the transfixion incision up to the septal angle and into the gap
between septal angle and attachment of upper lateral cartilages. In secondary cases, this
subperichondrial dissection from the known (caudal septum) to the unknown (the dorsum
with its heavily scarred disrupted anatomical planes) is much easier than a top-down dis-
section. The tip flip method is a combination of the intercartilaginous incisions extended
into bilateral transfixion incisions plus the open approach with its transcolumellar and
infracartilaginous incisions (Fig. 6.3g, i). Once the soft-tissue elevation is completed, then
the entire tip lobule can be rotated downward onto the upper lip. One is starting directly at
the septum end on.
Septal Surgery
Septal Exposure
189
Fig. 6.3 Septal exposure. (a, b) Dorsal split
(c, d) combined dorsal/tip split
(e, f) trans-
fixion
(g, h) tip flip
190
Chapter 6
Functional Factors
In prior decades, septal body surgery ranged from complex to fantasy. Each surgeon devised
a special operation, which was beautifully illustrated, but impossible for other surgeon to do.
Fortunately, everything changed with the adoption of cartilage grafts and the need for har-
vesting large portions of septum. The concept of leaving a 10-mm L-shaped strut for septal
support meant that there was essentially no difference between a septal harvest for acquir-
ing graft material and excision of a severely deviated septal body. Suddenly, the technical
complexity of parallel cuts and crosshatching became passé. The simplistic, but effective rule
has become “when in doubt take it out.” The obligatory corollary is to first assess the overall
rigidity of the septal cartilage and be conservative when the cartilage is flimsy. One should
take out only the necessary amount needed to correct the deflection or to obtain sufficient
graft material.
Cartilaginous Correction. Conceptually, the “surgical septal body” is that portion of the sep-
tum beneath and behind the critical 10-mm L-shaped strut. Once the definitive dorsum and
caudal septum have been established, one measures down and back 10 mm from the anterior
septal angle (Fig. 6.4a–d). At this point, the septum is incised with a #15 blade paralleling the
dorsum and staying 10 mm below the dorsum all the way back to the bony septum. Then the
vertical caudal component is extended downward to the vomerine groove using a #15 blade
parallel to the caudal septum while the mucosal leaflets are retracted with a nasal speculum.
It is not a vertical cut but rather is angled posteriorly to insure a caudal 1-cm strut at the level
of the caudal septum/ANS junction. Next, the inferior border of the cartilaginous septum is
freed up along the vomerine groove. Then, the dissection comes downward from the dorsal
cut, “popping through” the junction between cartilaginous septum and perpendicular plate
of ethmoid. Next, the dissection continues posterior to free the vomerine extension of the
cartilaginous septum. This extension overlaps the bony septum on one side, which is signaled
by the “spur side” of the posterior septum; i.e., most spurs are cartilage on the convex side
overlapped by bone. Thus, in a septoplasty one can dissect the cartilage in its entirety or plan
to excise the bony spurs with their overlapped cartilage. The harvested cartilage is placed in
a large basin of saline with antibiotics.
Bony Resection. With the mucosa elevated on both sides, it is possible to resect any fixed
bony deformities using a small Takahashi forceps (Fig. 6.4e, f). These “bony spurs” are
sharply “bitten off” with the forceps and not twisted out as the latter will risk disruption of
the cribiform plate resulting in a cerebrospinal fluid leak. Correction of the bony septum
should emphasize gentle relocation with limited resection. The exception to this rule is the
posttraumatic nose where bony resection is obligatory. I am not convinced that trying to
straighten the bony septum with a “speculum spread” is a good idea. It may work when the
septum is essentially intact, but it risks septal disruption when a septal harvest has been done.
Septal Body
Septal Body
191
Fig. 6.4 (a, b) Septal exposure
(c, d) cartilaginous resection
(e, f) bony resection
192
Chapter 6
Functional Factors
Routine bony deviations are resected using a small Takahashi forceps (Fig. 6.5 a, b). Whenever
possible, straight deflections are fractured back to the midline under direct vision using a
Cottle elevator. When the bony deviation involves the premaxillary area, then an “inferior
tunnel” must be made (Fig. 6.5 c, f). After reinjecting the nasal floor, one exposes the anterior
nasal spine and the pyriform aperture using a MacKenty elevator through the transfixion
incision. With the curved elevator, the vestibular lining overlying the premaxilla is raised
and then continued posteriorly along the nasal floor thereby creating the “inferior tunnel.”
As one sweeps up the premaxilla, the joint fascia between periosteum and perichondrium
is reached. This joint fascia is carefully divided in an anterior to posterior direction using a
#64 Beaver blade (Fig. 6.5b, g, h). Now the septum is totally exposed on one side. If exposure
of the opposite premaxilla is required, one can mobilize the cartilaginous septum out of the
vomerine groove followed by elevation of the periosteum in a top-down direction. The ability
to raise an inferior tunnel without shredding the mucosa is an important skill to master.
Bony Septum/
Premaxilla: The
Inferior Tunnel
a
b
Fig. 6.5 (a, b) Resection of bony deviation