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

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Chapter 6  
Functional Factors
The functional problems in this area are deviations and deformities, which are treated by
resection, relocation, or replacement-the 3 Rs of caudal septal surgery.
Resection. The caudal septum is easily exposed through a unilateral transfixion incision.
A Joseph elevator is used to dissect directly onto ANS and outward onto either side. The
patient is warned that their upper lip elevation and smile may be weakened for 4–6 weeks
postoperatively. In minor deformities, the deviated caudal septum is limited to its distal ex-
tent. If aesthetically indicated, resection of 2–4 mm of caudal septum and judicious remodel-
ing of the ANS is sufficient. Careful evaluation of the aesthetic consequences of caudal septal
resection is essential – avoid upward rotation.
Relocation. The most effective method of correcting the deviated caudal septum is to free
it completely from its bony/fibrous attachments, bring it across the midline, and suture it to
the ANS (Fig. 6.6). This method works extremely well if one respects three factors: (1) the
caudal septum must be completely released and total mobilization achieved, (2) fixation to
the ANS must be rigid, and (3) the structural integrity of the caudal septum must not be
compromised by incisions or excisions. Exposure of the ANS needs to be complete to elimi-
nate the restraining influence of the contracted soft-tissue envelope. The visible deformity
is assessed for both cartilaginous and ANS deviations relative to the central incisor midline.
The cartilaginous caudal septum is freed from ANS through the joint area. Total mobiliza-
tion is achieved once the caudal septum can be brought to the contralateral side. Although
many surgeons recommend periosteal sutures, I prefer a drill hole through the ANS. Simple
mobilization without fixation is inadequate. The techniques that I favor are the following: (1)
the caudal septum is mobilized completely until it can be brought to the contralateral side, (2)
a drill hole is made through the ANS (if the ANS is resected, then a hole in the contralateral
pyriform edge is made), (3) a 4–0 PDS suture is placed from the non-deviated side through
the ANS, then through the septum, looped on itself, and then back through the septum, and
(4) the knot is then tied on the non-deviated side of the ANS. When completed, the caudal
septum must be rigidly fixed on top of the ANS on its non-deviated side.
Reinforcement/Replacement. When the structural integrity of the caudal septum is compro-
mised, then one must consider reinforcement or replacement. Overlapping or angled brace
grafts can be used to reinforce a weakened or slightly curved caudal septum. Obviously, this
graft insertion is most easily done through an open approach. One must consider the added
volume of grafts in the critical area. Certainly, reinforcement has the least risk and is the pro-
cedure of choice in primary cases. Replacement is often required in secondary and traumatic
cases especially when the structural integrity of the caudal septum has been compromised
by various incisions and excisions. In many ways, this is a “partial” total septoplasty.
Caudal Septum

Caudal Septum Relocations
195
Fig. 6.6 (a–e) Caudal septal relocation

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Chapter 6  
Functional Factors
Dorsal problems are either deviations or asymmetries with the solution often being
­straightening, bracing, or concealing. Solving these problems requires one to assign specific
causes to the various components of the entire osseocartilaginus vault and septum.
Level 1. Dorsal deviations are corrected via an open approach. The upper lateral cartilages
are released from the septum to allow adequate septal mobilization, and then asymmetrical
spreader grafts are inserted with the wider graft placed on the concave side. Differences in
width may range from 0.5 to 3.5 mm with asymmetries of the middle vault often requiring
onlay grafts over the upper lateral cartilages.
Level 2. These problems consist of linear or transverse deviations of the dorsal component
of the L-shaped strut (Fig. 6.7). Again, any dorsal reduction must be done first followed by
septal correction in the body and caudal septum. For transverse deviations or angulations, the
upper lateral cartilages are detached from the septum allowing evaluation of the location and
severity of the dorsal angulation (Fig. 6.7a). A spreader graft is placed on the concave side to
serve as a brace and maintain structural relationships (Fig. 6.7b). It is sutured to the septum
above and below the deviation. Then, the angulation in the septum is incised if possible and
excised only if necessary (Fig. 6.7c). With the dorsum now straight, a spreader graft is placed
on the previously deviated side and sutured as a five-layer “sandwich” incorporating upper
lateral cartilages, spreader grafts, and septum (Fig. 6.7d).
For linear deviations/angulations, which result in “dorsal curling,” total exposure on
both sides is critical. One must carefully analyze the point at which the upper septum begins
to curl and whether or not there is sufficient straight septum to fix a brace onto. If possible,
a higher (6 mm) spreader graft of minimal width (1 mm) is sutured to the lower straight
septum on the convex side extending longitudinally beyond the area of deviation. Then a
longitudinal v-incision is made on the concave side of the septum at the point of maximum
angulation. Next, the dorsal septum is sutured to the spreader graft and rigid support is pro-
vided. A similar spreader graft is placed on the opposite side as a brace across the cut.
Level 3. These cases require a “total septoplasty” and will be discussed in the next section.
Concealment/Camouflage. Although one can camouflage a deviated dorsum with crushed
cartilage or a solid dorsal graft, they are rarely effective in the long term. The crushed cartilage
will often melt away over time while the solid graft becomes visible as the skin shrink wraps
around it. However, the greater problem is that although the dorsum may appear straighter
the nose itself remains visibly deviated and the patient dissatisfied. Thus, one falls into a
trap of doing a simpler procedure, which is ineffective rather than the more aggressive but
more effective one.
Dorsal Septum

Dorsal Septum
197
Fig. 6.7 (a–h) Dorsal straightening

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Chapter 6  
Functional Factors
At first glance, complete removal of the cartilaginous septum with reinsertion of an L-shaped
strut seems excessive and fraught with risk. Yet, the long-term results are excellent and the
complications are few. Both Gubisch (2006) and Jugo (1995) have summarized their 20-year
experience with total septoplasty in stunning step-by-step publications. The L-shaped strut
replacement graft is a direct replica of the dorsal/caudal septum that is always preserved
during a septorhinoplasty.
Operative Technique. The following operation is used for severe panseptal deformities
(Figs. 6.8 and 6.9).
Step #1 Exposure. A top-down approach allows septal exposure while leaving the membra-
nous septum intact. Extramucosal tunnels are completed and the upper lateral cartilages are
detached from the dorsal septum. A top-down dissection is done beginning on the concave
side to expose the body of the septum followed by a posterior-to-anterior elevation along the
vomerine junction and across the caudal septum. The entire caudal septum–ANS complex
must be exposed and any ANS deformity treated. If exposure is inadequate, I do not hesitate
to add a “tip split” caudally. In sever cases, bilateral transfixion incisions can be done, which
permits a “tip flip” for total access.
Step #2 Excision. Once the septum is completely exposed, I reassess the deformity and opera-
tive plan. Assuming total replacement is indicated, the point of deviation along the dorsal
cartilaginous septum is defined, and then a vertical cut 10 mm in height is made just above
the deviation point. Then, the cut is extended cephalically paralleling the dorsum back to
the ethmoid plate. I then release the inferior septum from the ANS back along the premaxil-
lary and vomerine grooves as far posterior as possible. Last, the separation extends upward
from the vomer along the ethmoid plate juncture to the cephalic cut. The entire cartilaginous
septum is removed.
Step #3 Shaping the Graft. The cartilage is then placed on a towel and its outline traced. In
many cases, a pattern can be cut from this diagram; but with the dorsal component elongated
for overlap. Then, the specimen is evaluated and a straight L-shaped replacement graft is
designed using the previously drawn pattern.
Step #4 Graft Reinsertion. Reinsertion consists of the following steps: (1) the strut is placed
in position and assessed, (2) the graft is placed on the side opposite to the preoperative dorsal
deviation, (3) the graft overlaps dorsally with the cephalic septal cartilage stump and is held
in place with #25 percutaneous needles, (4) fixation to the ANS is done with a 4–0 PDS placed
through a drill hole in the ANS and the caudal septum positioned on the side opposite to
the preoperative deviation, (5) the graft is sutured to the dorsal septum at two points with
4–0 PDS, (6) a contralateral spreader graft is usually added followed by “sandwich sutures’
incorporating the upper laterals and graft, and (7) Doyle splints lubricated with polysporin
ointment are sutured into place and left for 10 days.
Total
­Septoplasty

Total ­Septoplasty
199
Fig. 6.8 Double shift of septum
Fig. 6.9 (a–d) Total septoplasty

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Chapter 6  
Functional Factors
The nostril valve is composed of those structures that form and project into the nostril aper-
ture. The three most common causes of nostril valve collapse in primary cases are caudal
septal deviation, alar rim collapse, and nostril narrowing (Fig. 6.10a–c).
Caudal Septal Deviation. As previously discussed, the critical steps for correcting a caudal
septal deviation are the following: (1) bilateral submucosal exposure and release of restrict-
ing mucosa, (2) analysis of the deformity and structural integrity of caudal septum/ANS, (3)
selection of appropriate technique with repositioning being the first choice, (4) complete mo-
bilization of caudal septum, and (5) suture fixation through the ANS in a corrected ­position.
Alar Rim Collapse. Instability of the alar rim with dynamic collapse may be either isolated
or combined. Certain alar cartilage configurations contribute to lateral collapse including
boxy and parenthesis tips with their strong cartilages medially and weak alar lobules later-
ally. In Level 1 cases, alar rim grafts (ARG) of septal cartilage will correct the problem. The
grafts measure 3 mm in width, 8–14 mm in length, and are tapered in all dimensions. A small
transverse incision is made in the vestibule behind the alar rim and then the recipient pocket
is dissected parallel to the rim with blunt tip scissors. The tapered end of the graft is inserted
first to provide minimal volume near the dome while the blunt end is hidden within the alar
base. In Level 2 cases, alar rim support grafts (ARS) are sutured into true marginal rim inci-
sions. In Level 3 cases, larger grafts of conchal cartilage or even bony septum are inserted.
These grafts extend from the alar base and parallel the entire alar rim. In aesthetic cases, it
is critical that the graft should not be so wide that it blunts the alar crease separating the
alar base from the lobule.
Narrow Nostrils/Wide Columella. Although narrow nostrils may be multifactorial, the wide
columellar base is a common causal factor. It is most often produced by divergent footplates
of the medial crura and excess intervening soft tissue. A frequent form is the “comma nos-
tril.” The technique I currently favor is excision of the intervening soft tissue and suturing
the divergent footplates (Fig. 6.10e, f). The technique is as follows: (1) incise the mucosa just
above the cephalic border of the footplates, (2) dissect subcutaneously transverse across the
columellar base, (3) deliver the intervening muscle (depressor nasalis), (4) resect the muscle
using a cautery, (5) place a vertical mattress suture of 5–0 Prolene (yes a permanent suture)
between the footplates, and (6) tighten gradually and maintain a sloped columellar base. One
can also add columellar shaping sutures of 4–0 clears PDS. Widening nostrils in primary cases
is both rare and difficult. ARS grafts are the best solution. I am not an advocate of nostril
shaping excisions as the scarring is often significant.
Nostril Valve

Nostril Valve
201
Fig. 6.10 (a–c) Nostril valve  
(e, f) narrowing the columellar base

202
Chapter 6  
Functional Factors
The importance of the nasal vestibule and its role in respiration is well recognized. The
classic paper of Cottle (1955) states clearly that the vestibule is an effective series of resistor
baffles that slows down the air currents and directs them upward for warming and moisten-
ing. However, surgical correction of vestibular valve deformities is only now being extrapo-
lated from secondary to primary cases. Anatomically, the vestibule sits between two narrow
­apertures – the nostril and os internum (Fig. 6.11). Although a variety of septal problems
can impinge, most clinical cases consist of either lateral alar collapse or vestibular webbing
with the latter in secondary cases.
Lateral Alar Collapse. There are essentially two types of lateral àlar collapse: the flaccid alar
rim as seen in the parenthesis tip and the collapsed lateral crura–accessory cartilage junc-
tion. The lateral cartilage junction serves as the major baffle of the vestibule and it can be
obstructive. It is important to distinguish the etiology, since a cartilage graft for support is the
first choice with excision of the cartilage junction done only when indicated. For combined
deformities, I use the following techniques: (1) the area of depression is marked on the skin
and then its caudal border transferred internally, (2) the mucosa is injected and the incision
made, (3) the mucosa is elevated off of the lateral crura–accessory cartilage junction, (4) a
subcutaneous dissection is done, (5) the cartilage junction and any scar tissue is excised,
(6) the recipient pocket is dissected down to the pyriform aperture, (7) a reciprocal split of
the conchal bowl graft will provide sufficient material for both sides, (8) the wider portion
overlaps the pyriform edge while the superior portion is tapered as it nears the alar cartilage,
(9) the incision is closed with 5–0 plain catgut and the edge of the graft is incorporated into
the suture, (10) a “sandwich splint” of silactic sheeting is placed on either side to decrease
the dead space and to force the graft outward, and (11) the splints are removed after 3–5
days to avoid skin damage.
Vestibular Webbing. Traditionally, vestibular webbing was attributed to composite shorten-
ing of the upper lateral cartilages. Based on secondary cases, I feel the etiology is more com-
plex and may well be related to contracture and scarring of undermined mucosa. Treatment
of vestibular webs is difficult. I vary the operation depending upon the type and extent of
the web. Minor webs tend to be thin and are corrected with three-dimensional Z-plasties
similar to those used in lengthening a contracted thumb-index web space. Moderate webs
tend to be thicker and the web is turned into a medially based flap and the mucosa is el-
evated from the lateral side wall toward the septum. The mucosal flap will allow restoration
of the vestibular atrium and the lateral wall can be closed primarily or a thin mucosal graft
applied. For major stenosis, a composite graft harvested from the anterior conchal bowl is
inserted through an open approach.
Vestibular Valve

Vestibular Valve
203
Fig. 6.11 (a–f) Vestibular valve anatomy

204
Chapter 6  
Functional Factors
In primary patients, the most common causes of internal valve problems are septal ­deviation,
narrowing of the internal valve angle, turbinate hypertrophy, and lateral wall collapse
(Fig. 6.12). Since septal and turbinate surgery are discussed separately, emphasis will be on
the other two problems. Clinically, one can diagnose internal valve obstruction by retracting
the cheek outward, which should open up the internal valve (positive Cottle test). Intranasal
inspection before and after decongestant sprays is critical to determine the specific site of
the obstruction.
Internal Valve Collapse (Primary). Arbitrarily, one may discuss “compromise” of the internal
valve angle in which the angle is obstructed due to any of its three components: mucosal
abnormalities, dorsal septal deviations, or upper lateral cartilage collapse. In most primary
cosmetic cases, the etiology is collapse of the upper lateral cartilage against the septum over a
vertical distance of several millimeters resulting in marked narrowing of the angle. Although
initially asymptomatic, hump reduction followed by lateral osteotomies and shortening of
the nose may well tip the balance from asymptomatic to symptomatic nasal obstruction.
Preventive treatment with spreader grafts is the solution and should be an integral part of
most cosmetic cases. Although discussed elsewhere, the important points in using spreader
grafts are as follows: (1)septal cartilage or components of the excised hump are fashioned
into “matchstick size” grafts whose width is determined by both functional and asymmetric
aesthetic needs, (2) the caudal end does not extend into the angle, but rather forces the upper
lateral cartilage outward, and (3) the grafts are sutured into place.
Internal Valve Narrowing (Secondary). In some secondary cases, marked narrowing of the
valve is encountered and has the potential for multifactorial etiologies: surgically induced
mucosal scarring deficiencies, untreated dorsal septal deviations, and upper lateral cartilage
collapse. Obviously, one must correct the cause whether isolated or combined. Sheen evolved
the spreader graft as an effective method of restoring the internal valve angle. Although many
consider it to be a restoration of normal architecture, it is really a distraction outward of
the upper lateral cartilage away from the septum and a lowering/blunting of the mucosal
apex which results in a wider valve angle. In cases with an over-resected dorsum, placement
of a large dorsal graft will distract the upper lateral cartilages and markedly improve the
restoration.
Internal Valve

Internal Valve
205
Fig. 6.12 (a–d) Internal valve

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Chapter 6  
Functional Factors
The concept of a bony valve evolved during examination of secondary rhinoplasty patients
and was then confirmed in primary posttraumatic noses. In secondary rhinoplasty patients,
excessive verticalization of the lateral bony wall can occur especially after medial osteotomies.
In primary cases, the usual cause is trauma where the lateral wall is compressed against the
septum. It is only by mobilizing the bone outward that one can open the airway.
Diagnosis. During the intranasal examination, one can see that the internal valve is blocked
by a verticalization of the upper lateral cartilage. However, when the upper lateral cartilage is
elevated, it is obvious that the airway is still blocked by the lateral bony wall. The etiology is
primarily medial movement and increased verticality of the bony lateral wall; both of which
compromise and narrow the nasal passageway. The importance of this diagnosis is that one
cannot correct the problem with just spreader grafts.
Surgical Treatment. To correct the problem, one must mobilize the bony lateral wall outward
to alleviate the narrowing. To achieve total mobilization of the bony wall, one often has to
do medial oblique, transverse, and low-to-low osteotomies. Once the osteotomies are com-
pleted, a Boise elevator is then placed in the nose and the lateral wall moved outward and
angulated. With concurrent external finger palpation, the surgeon can feel the bone being
brought upward and outward. Stabilization in the desired position requires major spreader
grafts extending high into the bony vault to force the wall outward. Doyle splints with the
dorsal flange cut off permit the tube portion to be put high in the airway and provide out-
ward distraction for 2–3 weeks.
In sever cases of instability, it may be necessary to place a pair of parallel drill holes in
each nasal bone. The spreader grafts are then brought high into the bony vault and fixed with
a #25 needle through the most cephalic holes. The distal portion of the spreader grafts are su-
tured to the ULCs or a strut. Then, a 4–0 PDS suture is placed through the caudal holes in the
nasal bones and tied in an overlapping fashion. Then the upper needle is removed and a second
suture is placed through the cephalic holes. These two sutures will stabilize the bony pyramid.
Bony Valve
a

Bony Valve
207
Fig. (a) Etiology of bony valve obstruction, (b, c) bony valve blockage (d, e) mobilizing bony wall with outward fixation using
spreader grafts, (f, g) preop and postop CT-Scan with opening of the bony valve

208
Chapter 6  
Functional Factors
The inferior turbinate is a dynamic structure, which diverts nasal air flow and provides
primary resistance (Fig. 6.13a). The head of the inferior turbinate is quite large (14 mm
in height), extremely dynamic, and located in the critical internal valve area. The inferior
turbinate is closest to the septum in its midportion before diverging away from the septum
posteriorly. Examination of the nose with anterior rhinoscopy should focus on the size, shape,
and color of the turbinates as well as the nasal mucosa and mucus. Next, the nose is vasocon-
stricted (Afrin) and anesthetized (tetracaine) with topical sprays. After several minutes, the
patient is asked if the obstruction is improved. Complete relief indicates mucosal congestion,
whereas partial improvement focuses attention on anatomical causes. On reexamination,
failure of the turbinate to shrink most often indicates bony hypertrophy.
Indications. Ultimately, inferior turbinectomy is done in three groups of aesthetic patients:
(1) unilateral compensatory hypertrophy associated with septal deviation, (2) chronic bilat-
eral hypertrophy, and (3) preventative resection.
Technique. In most cases, I perform a partial anterior inferior turbinectomy (hereinafter:
turbinectomy) near the end of the procedure as it minimizes any disruptive bleeding and
allows immediate insertion of splints as required (Fig. 6.13b). The exceptions are cases of
massive bony hypertrophy where access to the septum and airway mandates early excision.
The disadvantage of performing turbinectomy after lateral osteotomies is the intraturbinate
swelling that occurs after the lateral osteotomies. The preoperative plan is checked against
the intraoperative finding and a final decision is made as to how the anterior middle and
posterior portions will be treated. If the posterior obstruction is due to simple medial dis-
placement of the inferior turbinate, then a lateral outfracture is done. The advantage of do-
ing the outfracture at this point is that it allows confirmation of the diagnosis and permits
subsequent alternative treatment if necessary.
Then the head of the turbinate is injected with 1–2 cc of local anesthesia. As modified
from Mabry (1988), an incision is made in the head of the turbinate and the mucosa is elevated
over a distance of 2 cm. Then using a modified Greunwald forceps, the hypertrophic glandular
and bony tissue is excised submucosally. If the posterior portion is hypertrophied, then the
prongs of the Elmed bipolar coagulator are inserted through the incision. Coagulation occurs
between the two needle electrodes thereby reducing its size. Anteriorly, the redundant mu-
cosa is excised from the lateral portion, which allows creation of a smaller “neoturbinate.” The
mucosa is then closed with one to two 5–0 plain catgut sutures. In all cases, an internal splint
is used although three variations exist: (1) silastic sheet without side tubes for turbinectomy
alone, (2) silastic sheet with side tubes for turbinectomy and concomitant septal correction,
and (3) silastic sheet with gelfoam for extensive turbinectomy and in most males. The splints
are removed after 7 days.
Problems
The three most common postoperative problems are bleeding, synechiae, and long-term
failure. Bleeding after turbinectomy is a reality with ranges from 2% to 14% of patients but
5–6% is an accepted norm. It is tempting to speculate that the incidence of bleeding is related
Turbinates

Turbinates
209
to the amount of excision especially in the highly vascular posterior region. Since I do not
perform an extensive posterior resection, I was able to avoid a postoperative bleeding for
almost 8 years. Subsequently, I had three in the last 6 months; two of which occurred when
I did not use gelfoam in extensive resections and the other was patient medication induced.
Immediate control was achieved in the office by removing the silastic splint and inserting an
expansible splint (RhinoRocket) plus anxiety reduction with chlorpromazine. Reoperation
or posterior packing was not necessary. The rate of synechiae formation ranges from 4%
to 22% with reoperation occasionally required. This problem is easily avoided by the use of
intranasal splints, which are left in for 7 days.
a
b
Fig. 6.13 (a) Turbinate anatomy, (b) submucosal resection

210
Chapter 6  
Functional Factors
The functional result of a rhinoplasty is as important as the aesthetic result, a fact easily
confirmed in dealing with secondary patients.
Nasal History. Nasal obstruction is a term, which is frequently used, but rarely defined. Nasal
obstruction can be considered an alteration of normal function, which correlates with an
increase in nasal resistance. The diagnosis is made by history and rhinoscopic examination.
Question regarding onset, duration, frequency, exacerbating, and remitting factors, as well
as the character and frequency of rhinorrhea are important in distinguishing allergic from
anatomical nasal obstruction. Equally, one must pay careful attention to medications, envi-
ronmental factors, as well as previous trauma or surgery. The most common symptoms are
nasal stuffiness, postnasal drip, and recurrent bilateral sinusitis.
Nasal Exam. The patient is examined in the sitting position. I have the following instru-
ments available: (1) a standardized examination sheet, (2) a fiber optic headlight, (3) Afrin
and xylocaine sprays, (4) a nasal speculum and alar rim retractor, (5) cotton tip applicators,
and (6) an endoscope. The external nose is examined in resting and deep inspiration for
deviation, deformities, and dynamic collapse, as well as scars and skin conditions. A two-
staged internal examination is done on both sides before and after vasoconstriction (Fig.
6.14). It is important to examine the nostril/vestibule and internal valve angle using an alar
rim retractor rather than a speculum to avoid distortion of the structures. The valve angle
is inspected during normal and deep inspiration. The turbinates are assessed for size, color,
and surface changes. The septum is evaluated for deviations, displacements, and impactions.
The mucosal lining is observed as well as the mucous. The findings are recorded and then
the nose is sprayed with a decongestant. One is trying to eliminate the effect of mucosal
congestion, which should reveal underlying fixed anatomical deformities. The internal exam
is repeated and the operative plan for the internal nose is recorded.
Operative Planning. Most body deviations of the septum are corrected during the septal har-
vest. Caudal septal deviations are relocated away from the deviated side and routinely fixed
to the ANS using a suture through a drill hole. Spreader grafts are the definitive treatment
for internal valve collapse while preventing an inverted-V deformity. In general, I prefer out-
fracturing of the inferior turbinates and reserve resection for cases of 3 + fixed hypertrophy
or compensatory hypertrophy. In severe septal deviations, I have not been impressed with
how quickly a compensatory hypertrophy resolves and feel that definitive turbinate reduction
concomitant with septoplasty is warranted.
Decision
Making
Level 1

Decision Making Level 1
211
Fig. 6.14 (a–c) Intranasal exam
a
b
c
Septum
Cartilaginous
Grade I-V
Body
Caudal
Dorsum
Bony Deformity
Turbinates
R
L
Grade I-IV
Anterior
  Mucosa
  Bone
Posterior
  Mucosa
  Bone
Valves
R
L
Nostril
Vestibular
Internal
  Angle
  Area
Bony

212
Chapter 6  
Functional Factors
Analysis
A 32-year-old woman presented with a history of marked nasal obstruction worse on the
left than the right. There was no history of nasal trauma. Aesthetically, the patient wanted
refinement of her existing nose rather than a significant change. Functionally, this case
required all four of the basic techniques in Level 1 surgery. The caudal septum had to be
relocated L to R and fixed to the ANS. The severe body deviation was resected and truly
measured 14 mm across. The internal valves were opened with spreader grafts, which were
asymmetric for aesthetic reasons. The markedly hypertrophic right inferior turbinate was
partially resected including the bony hypertrophy. At 14 months post-op, her respiration is
markedly improved (Fig. 6.15).
Operative Technique
  1) Open approach
  2) Incremental dorsal reduction (bone 0.5, cartilage 1.0)
  3) A 5 mm caudal septal resection
  4) Bidirectional septal exposure via transfixion incision and dorsum
  5) Resection of quadrilateral cartilage and some vomerine bone
  6) Caudal septal relocation L to R with suture fixation to ANS
  7) Unilatreral L low-to-high osteotomy, no R osteotomy
  8) Asymmetric spreader grafts (R 2.0, L 3.5)
  9) Crural strut and tip sutures: CS, DC, DE, and TP
10) Partial resection of R inferior turbinate including bone
Case Study:
Septal Devia­
tion
Fig. 6.15 (a–j)

Case Study: Septal Deviation
213
Fig. 6.15 (continued)

214
Chapter 6  
Functional Factors
These cases require a greater degree of sophistication, which is based on the building blocks
from Level 1 surgery.
Advanced Septal Surgery. Straightening most dorsal deviations requires relocating the cau-
dal septum first and then insertion of asymmetric spreader grafts. In more complex cases,
a portion of the dorsal L-shaped strut will need to be resected (Fig. 6.16a). The three-step
approach requires the following: (1)insertion of a single spreader graft on the concave side,
(2) controlled excision of the deviated portion of dorsal septum, and (3) insertion of the
second spreader graft with rigid five-layer fixation. The critical step is to get the septal strut
stabilized before resecting any of the dorsal limb of the L-shaped strut. In the most severe
posttraumatic and congenital ADDN cases, total septoplasty is warranted (Fig. 6.16b). The
entire cartilaginous septum is removed, an L-shaped strut is created, followed by reinser-
tion with fixation to the ANS and dorsum. The caudal fixation is similar to a caudal septal
relocation and the dorsal portion is a five-layer sandwich similar to that of repairing a dorsal
disjunction.
Valvular Surgery. One must become comfortable with both alar rim grafts (ARG) and alar
rim support grafts (ARS). These are essentially the same grafts, but the former is placed in
a subcutaneous pocket following the alar rim, whereas the latter is sutured along the nostril
rim via a separate rim incision. The choice of grafts is simple – an ARG is done unless the
deformity is so severe that an ARS is required. Also, if the ARG does not work, then remove
it, make a true rim incision and sew it in along the nostril border as an ARS. One of the more
complex questions is the role of lateral crura strut grafts and the way in which they compare
to alar batten grafts? I tend to think of the lateral crural strut grafts as a very precise graft
designed to provide support to the lateral crura. As will be discussed in Chapter 8, there are
three variations of alar extenders depending upon the orientation of the graft’s distal end.
One is restoring the tripod leg and providing support to the external valve. These thin grafts
(4–5 mm wide) are sutured to the undersurface of the lateral crura medially. The lateral
portion is inserted into one of three locations: pyriform, alar base, or nostril rim depending
upon indication. In contrast, most alar batten grafts are quite large (15–20 × 8–12) and are
used to support the entire lateral lobule.
Turbinates. The first choice for reducing turbinate obstruction is to out-fracture the
­turbinates. Turbinate resection is reserved for massively enlarged turbinates or those with
compensatory hypertrophy.
Decision Making
Level 2

Decision Making Level 2
215
a
b
Fig. 6.16 (a) Dorsal straightening, (b) total septoplasty

216
Chapter 6  
Functional Factors
Analysis
A 31-year-old woman presented with a history of nasal trauma at age 15 (Fig. 6.17). Intra-
nasally, the caudal septum was deviated to the right while the body was deviated to the left.
Since the external pyramid was also deviated, a total septoplasty with double shift reposition
was planned. Based on my experience, any septal procedure short of a total septoplasty would
not correct this degree of deviation. Removal of the septum eliminates the constricting septal
and mucosal forces allowing a straight L-shaped strut to be configured and reinserted. Note:
the septal replacement graft is a true septal replacement and not a septal extender graft. It
is the addition of a columellar strut that gives the tip support and allows it to rise above the
septum thereby avoiding a flat wide tip.
Operative Technique
  1) Open approach with detachment of the upper lateral cartilages.
  2) A right transfixion incision. Bidirectional septal exposure.
  3) Incremental dorsal reduction (bone: smooth, cartilage 1.5 mm).
  4) Caudal septum shortened 3 mm, but 7 mm at its most prominent.
  5) Total septal excision leaving a 10 mm long dorsal component.
  6) Immediate drawing of caudal septum, then 90° turn, and cut L-shaped replacement plus
columellar and bilateral spreader grafts.
  7) Transverse and low-to-low osteotomies, plus a double level on L.
  8) Septal replacement graft inserted as a “double shift”: caudal to left, dorsal to the right.
Braced with spreader grafts.
  9) Insertion of a columellar strut plus tip sutures (CS, DC, ID, TP).
10) Nostril sill excisions (R:2, L:3.5). Doyle splints for 12 days.
Case Study:
Total
­Septoplasty
Fig. 6.17 (a–l)

Case Study: Total ­Septoplasty
217
Fig. 6.17 (continued)

218
Chapter 6  
Functional Factors
These cases are exceedingly complex due to the absence of significant portions of the septum
and loss of septal support. The valvular areas are often heavily scarred and stenotic. These
cases are not for the faint of heart.
Septal Support Surgery. In these cases, the primary goal is to restore septal support. In certain
posttraumatic and unoperated cleft lip noses, the septal cartilage may be present but struc-
tural support is absent. The option is either a restoration of cartilage vault support or a total
septoplasty plus a columellar strut using the remaining cartilage (Fig. 6.18). In these cases,
an extended columellar strut is inserted as well as extended spreader grafts. The spreader
grafts are fixed to the cartilage vault cephalically and then the caudal end is angled up onto
the columellar strut to recreate the dorsal line. Suture fixation is followed by advancing the
alar cartilages onto to the strut to provide tip support.
When septum is not available, rib cartilage is necessary. Conchal cartilage is not suf-
ficiently strong to support the cartilage vault, especially when the mucosa is contracted. In
these cases, a true replacement of the L-shaped septal strut is done using spreader grafts for
the dorsal limb and a septal strut for the caudal limb. A “step-off” fixation is favored to mini-
mize bulk in the valve angle rather than a tongue-in-grove technique. A separate columellar
strut is necessary to support the tip above the dorsal limb (Fig 6.18).
Valvular Reconstruction Surgery. The majority of these cases have constricted alar rims or
severely scarred mucosal lining in either the vestibule or internal valve angle (Fig. 6.19). Com-
posite grafts are the only method of restoring both lining and support. Composite conchal
grafts are harvested. In most cases, the cartilage is shaved because concha is 2–3 mm thick
compared to <1 mm for alar cartilage. For alar rim deformities, a true rim incision is made
and the contracted area expanded in a longitudinal direction. The composite graft is sutured
along the rim border. The graft is then tailored to fit the defect and sutured cephalically. In
cases of vestibular stenosis, the scar is excised while shifting as much mucosa medially as
possible. The composite graft is often modified by excising cartilage from one half of the
graft. The composite portion is placed laterally, while the skin portion restores the attic and
septal mucosa defect. Stenosis of the internal valve area requires excision of the scarred area
with total replacement. A large composite graft (20 × 10 mm) is harvested from the conchal
bowl. Cartilage is excised from half of the graft and retained. The skin portion is sutured
into the mucosal defect on the septum and the composite portion is sutured into the defect
between the upper lateral and the alar cartilages.
Decision Making
Level 3

Decision Making Level 3
219
Fig. 6.18 (a–d) Septal replacement
Fig. 6.19 Vestibular stenosis

220
Chapter 6  
Functional Factors
Analysis
A 21-year-old student presented with a posttraumatic nasal deformity following an accidental
blow to the nose (Fig. 6.20). She noted a significant flattening of the nose and rounding of
the nasal tip and nostrils during the first 6 months. She had a positive septal collapse test.
She was nasally obstructed due to septal deviation and intranasal polyps. Since the patient’s
septum was intact prior to the trauma, sufficient septum was expected, but the patient
did give consent for a rib graft. Septal support and nasal appearance were restored using
interlocked extended spreader grafts and a structural columellar strut. The angulation of
the grafts restored the aesthetic dorsal profile line while the rigid fixation to the columellar
strut provided septal support.
Operative Technique
1) Exposure and evaluation of the septum via a transfixion incision.
2) Open approach and reduction of alar cartilages to 6 mm strips.
3) Excision of septal body to correct obstruction and provide graft material.
4) Transverse and low-to-low osteotomies.
5) Separation of ULC for insertion of extended spreader grafts.
6) Insertion of a structural columellar graft.
7) Fixation of spreader grafts to columellar strut on an angled basis to restore dorsal profile
line.
8) Fixation of alars to columellar strut, with CS .
9) Tip shaping with DC, DE.
Case Study:
Septal Support
­Surgery
Fig. 6.20 (a–j)

Case Study: Septal Support ­Surgery
221
Fig. 6.20 (continued)

222
Chapter 6  
Functional Factors
Septal Disjunction. When the dorsal septum is divided or broken at the bony–cartilaginous
junction the result is an unstable nose. One can encounter this problem for the first time in
dealing with a twisted posttraumatic nose. The dorsum is reduced, the septum is exposed,
and pressure is put on the cephalic bony septum to straighten it. Suddenly, the septum breaks
at the bony–cartilaginous junction and one sees the cartilaginous septum slowly fall into the
pyriform aperture – that is, a septal disjunction (Fig. 6.21). One should not panic. Rather, just
assumes that a 10 mm L-shaped strut is present, but broken. If the body of the septum was
previously harvested, then one fashions bilateral spreader grafts from the septum. Otherwise
conchal cartilage is obtained. The goal will be to realign the strut components and brace them
on either side with spreader grafts. Then two five-layer sutures are used to brace the septal
division with the upper laterals in effect providing support for the strut. As seen in Fig. 6.21,
I had harvested the septal body for spreader grafts in a very deviated nose and mobilized the
caudal septum for relocation. Then I put pressure on the bony septum and heard a crack. As
the L-shaped strut dropped into the pyriform aperture, I overcame my “photo phobia” and
took a very rare picture – the patient’s L-shaped strut on the backtable prior to reinsertion
plus the previously resected septal body. As seen in the postoperative result, the nose was
definitely straight and I was greatly relieved.
Mucosal Tears. Inevitably, one will make a significant mucosal tear, usually at the convex
bony–cartilaginous vomerine junction or over a pointed septal spur. For small anterior
tears, direct suture through the nostril is not difficult if one uses a small M-1 (#742) needle
with 4–0 plain catgut. As the tears become larger and more posterior, I find the repair much
simpler if I have used an open approach and can repair it from the top on the “septal side”
rather than going through the nostril. However, when the tear is quite posterior and one
must tie the suture deep in the dark, then I use Drumheller’s “lasso technique”(Fig. 6.22).
It consists of the following steps: (1) use the M-1 needle, (2) take the end of the suture and
tie a surgeon’s knot around the end of the suction tip (Fig. 6.22), (3) slip the suture off the
suction tip leaving the circular “lasso,” (4) using a bayonet needle holder, insert the needle
across the cephalicend of the mucosal tear, (5) bring the needle out of the nostril and pass
it thru the “lasso” (Fig. 6.21b), (6) place tension on the suture pulling the lasso into the nose
snugging it down, and (7) continue sewing until the tear is closed and a knot can be tied
anteriorly near the nostril aperture. The beauty of the lasso technique is its simplicity and
avoidance of tearing the mucosa as one attempts to tie a knot deep in the nose.
Technical
­Misadventures

Technical ­Misadventures
223
Fig. 6.21 (a) preop (b) 1 year postop, (c) septal disjunction (left) and septal harvest (right), (d) reinsertion
Fig. 6.22 (a, b) Repair of mucosal tears 
a
b

224
Chapter 6  
Functional Factors
Adamson P, Smith O, Cole P. The effect of cosmetic rhinoplasty on nasal patency. ­Laryngoscope
100: 357, 1990
Bridger OP. Physiology of the nasal valve. Arch Otolaryngol 92: 54, 1970
Cole P. Nasal and oral airflow resistors. Site, function, and assessment. Arch Otolaryngol
Head Neck Surg 118: 790, 1992
Constantian MB. The incompetent external nasal valve: pathophysiology and treatment in
primary and secondary rhinoplasty. Plast Reconstr Surg 93: 919, 1994
Constantinides MS, Adamson PA, Cole P. The long-term effects of open cosmetic septorhi-
noplasty on nasal air flow. Arch Otolaryngol Head Neck Surg 122: 41, 1996
Cottle MH. The structure and function of the nasal vestibule. Arch Otolaryngol 62: 173, 1955
Cottle MH, Loring RM, Fischer GO, Gaynon IE. The “maxilla-premaxilla” approach to exten-
sive nasal septum surgery. Arch Otolaryngol 68: 301, 1958
Daniel RK, Regnault P. Aesthetic Plastic Surgery: Rhinoplasty. Boston, MA: Little, Brown, 1993
Goldman JL. (ed). The Principles and Practice of Rhinology. New York: Wiley, 1987
Grymer LF, Hilberg O, Elbrond O, Pedersen OF. Acoustic rhinometry: evaluation of the nasal
cavity with septal deviations, before and after septoplasty. Laryngoscope 99: 1 180, 1989
Gubisch, W. Twenty-five years experience with extracorporeal septoplasty. Facial Plast Surg
22: 230, 2006 (Note: entire Journal issue is devoted to septal surgery)
Gubisch W, Constantinescu HL. Refinements in extracoporeal septoplasty. Plast Reconstr
Surg 104: 1131, 1999
Guyruron, B, Uzzo, CD, Scull H. A practical classification of septonasal deviation and effective
guide to septal surgery. Plast Reconstr Surg 104: 2202, 1999
Haight JS, Cole P. The site and function of the nasal valve. Laryngoscope 93: 49, 1983
Haraldsson PO, Nordemar H, Anggard A. Long-term results after septal surgery submucous
resection versus septoplasty. ORL J Otorhinolaryngol Relat Spec 49: 218, 1987
Jackson LE, Koch RJ. Controversies in the management of inferior turbinate hypertrophy:
a comprehensive review. Plast Recosntr Surg 103: 300, 1999
Jost O. Post-traumatic nasal deformities. In: Regnault P, Daniel RK (eds) Aesthetic Plastic
Surgery. Boston, MA: Little, Brown, 1984
Jugo SB. Total septal reconstruction through decortication (external) approach in children.
Arch Otolaryngol Head Neck Surg 1113: 173–178, 1987
Jugo SB. Surgical Atlas of External Rhinoplasty. Edinburgh: Churchill, Livingstone, 1995
Kern EB, Wang TD. Nasal valve surgery. In: Daniel RK (ed) Aesthetic Plastic Surgery: Rhino-
plasty. Boston, MA: Little, Brown, 1993
Lawson W, Reino AJ. Correcting functional problems. Facial Plast Surg 2: 501, 1994
Mabry RL. Inferior turbinoplasty: patient selection, technique, and long-term consequences.
Otolaryngol Head Neck Surg 98: 60, 1988
McCaffrey TV, Kern EB. Clinical evaluation of nasal obstruction. A study of 1,000 patients.
Arch Otolaryngol 105: 542, 1979
Mosher, JP. The premaxillary wings and deviations of the septum. Laryngoscope 17: 840, 1907
Pallanch JF, McCaffrey TV, Kern EB. Normal nasal resistance. Otolaryngol Head Neck Surg
93: 778, 1985
Pastornek NJ, Becker DG. Treating the caudal septal deflection, Arch Facial Plast Surg 2: 217,
2000
Pollock RA, Rohrich RJ. Inferior turbinate surgery: an adjunct to successful treatment of
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RA, Rohrich, RJ. Inferior turbinectomy surgery; an adjunct to success Plast Reconstr Surg
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ment. ORL J Otorhinolaryngol Relat Spec 49: 314, 1987
Reading List

After inserting several thousand grafts during rhinoplasty surgery, I have come to ten
conclusions. First, grafts must be an integral part of analysis and operative planning, not an
intraoperative necessity. For example, the decision to do a radix graft will influence the amount
of dorsal reduction. Second, one must be adept at using all types of donor materials and not
be dependent on just one. Although septum is usually sufficient in primary cases, it is often
insufficient in complex secondaries thereby making rib grafts essential. Third, one should be
able to harvest a graft quickly. If it is difficult to take a graft, then one will often rationalize
why it is not needed. Four, graft shaping and recipient bed preparation are of equal importance.
Five, the less done to a graft the better it is. I am dubious of the long-term survival of crushed
and even bruised cartilage grafts. Six, fixation of the graft most often requires sutures during
an open approach, as one does not have the tight pockets of the closed approach. Seven, anti-
biotic coverage is important including an intravenous dose during the operation and 5 days
postoperatively. Eight, alloplasts may be a shortcut for the surgeon, but it increases the risk of
failure for the patient. Nine, autogenous grafts rarely extrude, can withstand infection, and
have definitely stood the test of time. One only needs to contrast the efficacy of autogenous
cartilage versus the inevitable absorption of cadaver cartilage. Ten, grafts have dramatically
improved the quality of our rhinoplasty results, allowing for a more natural functional primary
result, and a heretofore unobtainable nonoperative look in secondary cases.
Introduction
Grafts7

226
Chapter 7  
Grafts
Allure of Alloplasts
The instant availability, absence of donor site morbidity requirements, adaptability, spec-
tacular early results, as well as reduced cost and minimal surgical skills make alloplasts
highly desirable. Yet their problems with infection, extrusion, displacement, mobility, and
long-term failure are critical disadvantages. Three factors must be assessed: biocompatability
of material, surgical application, and long-term result. Most alloplasts are quickly embraced
only to be rejected once problems appear. Beekhuis (1974) championed Supramid mesh as
a “miracle of modern chemistry” and an ideal material for nasal dorsal augmentation. Early
problems were attributed to either technical error or poor patient selection. A decade later,
surgeons reported disappearance of the material and biopsies showed its degradation. The
second challenge is patient selection. In contrast to the favorable primary Asian nose, most
surgeons need a dorsal graft for their secondary cases with a nonfavorable recipient bed.
Thus, the implant is placed in a “subdermal” scarred nonvascular bed rather than a “subcu-
taneous” pocket. The third factor involves early versus long-term results. One of the more
intriguing transformations in results is in the use of cadaver cartilage. Schuller et al. (1977)
reported a complication rate of 5.5% early, 2% late, and partial absorption of 1.4% at 3-year
follow-up. Subsequently, Welling et al. (1988) reviewed 42 of Shuller’s original 107 patients
and found that 100% of the grafts were absorbed when in place longer than 10 years. What
is the rhinoplasty surgeon to do – alloplasts, yes or no? Based on 70 years of nasal surgery,
alloplasts in the nose do not have a good track record, especially on the dorsum and in
secondary cases. Therefore, I personally have decided to use only autogenous tissue in the
nose. For this patient, the eyes convey the early happiness of an alloplastic dorsal implant
and the misery that followed its failure 6 months later (Fig. 7.1).
Fig. 7.1 (a) early result, (b) infected alloplast graft 6 months later

Introduction
227
Fillers: ­Fantastic or Fantasy?
Most experienced rhinoplasty surgeons do not use allografts for one simple reason – they
have seen too many disasters from Porex, silicone, Goretex, etc. Currently, we are faced with
a new challenge – injectable fillers. As with previous promises of simple spectacular solu-
tions to complex deformities, one should evaluate the consequences, both immediate and
long term.
Advantages. The ability to correct localized depressions and blend in prominences is the
most attractive aspect of fillers. If valid, it would mollify patients and possibly reduce revi-
sions. The idea of major augmentation with fillers would help secondary patients with limited
economic resources.
Disadvantages. I see the “filler influence” creating major problems for rhinoplasty patients
and surgeons. For the patients, it will be a combination of false promises, competency, and
results. Many patients want to believe that a “lunchtime rhinoplasty” is possible, but do they
really understand that it is transitory? How can a nonsurgeon really understand what an
“open roof” is in a secondary rhinoplasty patient? How exactly can the filler be placed below
the dermis, but above the mucosa? For most injectors, it is a technical impossibility. I have
personally seen the complications of skin slough and fungating infection following Radiesse
injections in secondary cases. Just how long will the patient be happy, especially as the
improvement fades? Will the injector then be under pressure to go up the ladder of per-
manency – Restalyne, Radiesse, Articol, or Silicone? For the rhinoplasty surgeon, there will
be challenges throughout the perioperative period. Pre-op, many nonsurgeons and less-
experienced surgeons will balloon out a deformed secondary nose in hopes of satisfying
the patient. The result is a nose that is now a double disaster and may require a two-stage
approach – Op #1 to remove the filler, Op #2 to reconstruct the nose. Intra-op, surgeons who
are also injectors will see their commitment to operative perfection challenged and perhaps
compromised. A little voice will be whispering: “Oh, I can smooth that area out later with a
little filler, I don’t really need to remove that graft or take a fascia graft.” Short cuts are hard
to resist. What do I suggest? I remain skeptical of fillers and do not use them. However, I
remain seduced by their simplicity and hope that others will prove me wrong. For that reason,
I have included a section on fillers written by experts in the section on revisions in Chapter 9.
Note: none of the patients in this text has had fillers put in their nose to enhance their result.
This may be the last rhinoplasty text that will ever be “filler-free.”

228
Chapter 7  
Grafts
Analysis. Each area of the nose is carefully analyzed as regards preservation, reduction, or
augmentation. Reduction of an area may require compensatory grafting, with spreader grafts
being the most common example. Even a 1.5 mm vertical height reduction of the cartilage
vault can obligate spreader grafts in order to avoid an inwardly pinched middle vault exter-
nally and a collapsed valve internally.
Operative Sequence. Questions arise concerning when to harvest the graft material. Most
commonly, I obtain fascial grafts at the start of the operation to give additional time for nasal
vasoconstriction During an operation, there is often a temptation to rationalize that a fascia
graft is not needed; a hesitation that is easily overcome if the graft is already harvested. When
rib grafts are required, I tend to harvest the rib prior to nasal surgery. Septal cartilage is
always harvested after the dorsal change is completed. There is too great a risk of damaging
the integrity of the L-shape strut to harvest the septum first. I wait to harvest conchal car-
tilage until the definitive requirements are obvious. All materials are placed in a large basin
of saline with antibiotics. Based on my craniofacial experience, I do not change gloves and
instruments in facial surgery. Graft preparation is done on the back table using a silicone
carving board, grids, calipers, and marking pens. In complex cases, graft material is often at
a premium and careful design is important. Once all of the grafts have been prepared, they
are inserted in the usual sequence: spreader, columella, tip, radix, dorsum, and alar rim.
Problems. Virtually anything can go wrong with an operative plan and one must be capable
of using a large number of graft materials, especially in secondary cases. One must be pre-
pared to add additional grafts as required. Yet at the same time avoid excesses which will
become more apparent as postoperative edema subsides. There is tremendous temptation
to accept intraoperative illusions. A common example is crushed cartilage placed on the
dorsum to cover minor irregularities. Crushed grafts look great in the operating room, but
unpredictable absorption occurs and irregularities return. It is better to use solid structured
grafts and fuss with them until they are perfect. I have had very few problems; especially
regarding infection (two cases, both resolved without loss of the graft or compromising the
result). Nor have I seen significant absorption (virtually unknown). The principal problem
has been visibility. Virtually every cartilage graft in the radix becomes visible over time and
that is why I switched to fascia. Tip grafts can be too projecting or create a full infralobule.
Often, these problems are part of the “learning curve” and revisions will be necessary. Overall,
grafts have dramatically improved both my aesthetic and functional results, especially with
difficult cases.
Overview

Recent Advances
229
Based on experience with complex secondary cases, there have been three major advances
in grafting over the last 10 years, including greater use of fascia, diced cartilage grafts, and
rib grafts.
Fascia. I use fascia exclusively for routine radix grafts and to enclose diced cartilage grafts.
In addition, fascia is the key to managing the thin-skin nose. Single or double layer fascia
grafts are placed over the dorsum in primary cases. In complex secondary cases, I use a
“fascial blanket” to completely reline the entire skin envelope.
Diced Cartilage. Diced cartilage alone or wrapped in fascia has revolutionized dorsal grafting.
Diced cartilage grafts are enormously flexible in their dimensions, efficient in their use of
available cartilage, and survive long term. They have totally replaced solid septal or conchal
cartilage for dorsal grafting in my practice.
Rib Cartilage. As the number of graft depleted noses has increased, rib grafts have provided
a much needed solution. Rib cartilage is used for virtually every graft design possible, from
dorsum to tip to alar batten. As experience with rib grafts has increased, the use of conchal
grafts has decreased markedly and cranial bone is virtually never used. I utilize two different
types of rib grafts – cartilage or osseocartilaginous. The most common is a cartilage-only
harvest from either subcostal (9th, 8th ribs) or inframammary (5-7th ribs) approach. Most
offen a simple subcostal incision is made and the cartilaginous portion of the ninth rib is
harvested extra perichondrially in a retrograde direction from floating tip to bony junc-
tion. If additional cartilage is needed then the eighth rib is removed increasing operative
time 20–30 min. Osseocartilaginous grafts are reserved for the cocaine nose or paranasal
trauma cases.
Clinical reality is that I do a graft in virtually every case, both primary and secondary. The
following case study, illustrates the role of grafts, both for functional and aesthetic reasons.
The patient had an occult alar malposition which was expressed by nostril collapse on deep
inspiration. Aesthetically, the profile had to be grafted using a “balanced approach” with
fascia graft to the radix and true “tip creation” with multiple add-on grafts. Functionally,
alar transposition with lateral crural strut grafts was done to support the external valves
while spreader grafts opened the internal valves. Could this case have been done without
any grafts? I cannot conceive of a “no graft” approach.
Recent
Advances
Why Grafts
Are Essential
and Must Be
Mastered

230
Chapter 7  
Grafts
Analysis
A 33-year-old health care worker requested a major difference in her nose including a straight
profile (Fig. 7.2). There were no respiratory complaints. However, the nostrils collapsed on
deep nasal inspiration. The small tip suggested an occult alar malpositon that was confirmed
at operation. It was emphasized that a “balanced approach” would be necessary to straighten
her profile: radix augmentation, dorsal reduction, and tip augmentation. Major rim support
would be necessary to prevent external valve collapse.
1) Harvest of deep temporal fascia and septal exposure
2) Open approach then dorsal reduction (bone: 0.5 mm, cartilage: 3 mm)
3) Upper caudal septal excision (1.5 mm) followed by septal harvest
4) Transverse and low-to-low osteotomies. Insertion of spreader grafts
5) Reduction of alar cartilages to 6 mm, undermining of lateral crura, then transection and
release of the lateral crura
6) Insertion of a columellar strut and tip sutures: CS, DC, and ID
7) Tip refinement grafts: folded infralobule and domal
8) Suture of lateral crural strut grafts to lateral crura
9) Insertion of a ball (radix) and apron (dorsum) fascia graft
10) Closure with suture of the lateral crural strut graft (LCSG) into the nostril rims
Number of grafts – five types with nine individual grafts.
Case Study:
Why Do Grafts?
Operative
­Technique
Fig. 7.2 (a–l)

Case Study: Why Do Grafts?
231
Fig. 7.2 (continued)

232
Chapter 7  
Grafts
Septal cartilage is the graft material of choice because of its survival, strength, shaping, and
availability. What are the disadvantages of septal cartilage? First, it must be harvested which
risks a septal perforation. Second, it must be shaped, placed, and secured correctly. Third,
it must survive long term. Technically, harvesting cartilage from a “normal” septum is far
easier than doing a septoplasty on an “abnormal” deviated septum or reentering the septum
during a secondary rhinoplasty (Fig. 7.3).
Technique. The septum is reinjected with local anesthesia (1% xylocaine with epinephrine
1:100,000) to produce hydrodissection. In general, the amount of cartilage to be resected is
determined by the types of grafts required while preserving at least a 10 mm L-shape strut
dorsally and caudally. Prior to the actual harvest, the following 3 things must be done: 1) the
definitive dorsum and caudal septum established, 2) the mucosa elevated bilaterally back to
the bony septum, and 3) the side with the septal spur identified which indicates the side with
the septal extension. At this point, the following 5 step septal harvest is done:
1) Dorsal incision 10mm below and parallel to the dorsal septum,
2) Caudal incision 10mm back and parallel to the caudal septum,
3) Posterior dissection of the septum out of the vomerine groove,
4) A downward “push” disarticulation of the cartilaginous septum from the bony perpen-
dicular plate of the ethmoid,
5 Careful mobilization of the cartilaginous tail of the septum which can be 10–15mm long.
At this point, the cartilaginous septum is completely disarticulated and easily removed.
Although many surgeons close the mucosal leaflets with 4–0 chromic sutures, I prefer to use
silastic nasal splints as they provide compression over a greater region and prevent synechiae
between the septum and the turbinates. Access incisions are closed in the standard fashion.
The goal is to remove septal cartilage only, not an osseocartilaginous piece of septum.
Problems. To date, there have been few problems with harvesting the septum. I am not aware
of septal collapse. There have not been any functional problems due to a flaccid septum or
chronic changes in mucosal integrity. I do warn all patients preoperatively that a 1–2% septal
perforation rate is to be expected especially in difficult secondary cases – fortunately, it is
an over estimation.
Septal ­Harvest

Septal ­Harvest
233
Fig. 7.4 (a) Bidirectional approach 
(b) transfixion approach
Fig. 7.3 Septal harvest

234
Chapter 7  
Grafts
Ear grafts can be classified into two broad categories: cartilage grafts and composite grafts
(skin and cartilage) (Fig. 7.5).
Technique. The ear is extensively prepped with Betadine to reduce bacterial count. I do not
change instruments or gloves and have not had any infections in several hundred ear grafts
during the past 15 years. A sheet of Xeroform gauze is cut into two pieces: a large three
fourth piece is used to make a mold of the conchal bowl and serve as an anterior bolster,
while the small one fourth piece is rolled up like a cigarette for a posterior bolster. The ear
is infiltrated anterior and posterior with a total of 5 cc of 1% xylocaine with epinephrine
1:100,000. The skin of the anterior conchal bowl should turn white and balloon away from
the cartilage under the force of the injection. With the ear retracted forward, a longitudinal
incision is made above the planned incision site of the cartilage. The posterior concha is
exposed. The cartilage is incised below the antihelical fold and the anterior skin is elevated.
Once the skin is completely elevated, the entire conchal bowl can be removed. Hemostasis
is repeated. Any sharp cartilage edges are rounded off. The incision is closed with a run-
ning locking 4–0 plain catgut suture. The tie-over bolster dressing is applied. Two 4–0 nylon
sutures are inserted starting from the conchal surface of the crural strut, passing through
the posterior surface of the ear below the suture line and then back through the ear above
the suture line. The rolled-up gauze is inserted in the posterior loop and pulled snug both
to cover the suture line and to serve as a bolster. The mold of gauze is then slipped into the
anterior conchal bowl and the two sutures tied. The ear is not drained and no other dressing
applied. The mold is removed at 1 week concurrent with nasal cast.
Problems. The patient must be informed of three expected occurrences: (1) pain, (2) scar, and
(3) possible change in ear position. The ear donor site always hurts more than the nose and
may be sensitive to cold for a year. The scar is generally insignificant when placed posteriorly
in contrast to the anterior scar which has a wide variation–do not use an anterior incision.
Asymmetry between the ears could occur, but it is rarely noticed. To date, there have been
no donor site infections, persistent neuromas, nor hematomas. It is better to use up one ear
before starting on the other. I have had retroauricular keloids in two Caucasian patients.
Conchal ­Harvest

Concha ­Harvest
235
Fig. 7.5 (a) Types of conchal grafts, (b–e) conchal cartilage harvest 
a
Reserve graft
Skin
Cartilage
Cymba
Cavum
Conchal cartilage

236
Chapter 7  
Grafts
Composite Conchal Grafts
Three applications of composite grafts are seen which often represent a progression in size
and difficulty: (1) alar rim lowering, (2) correction of vestibular stenosis, and (3) internal
valve stenosis. The usual sequence is to define the defect, harvest the graft, close the donor
site, and suture in the graft.
Technique. The most common donor site is the anterior surface of the ipsilateral cymba
concha (Fig. 7.6). Traction on the helical root and the antihelix will expose the hidden medial
extent of the cymba concha. The desired graft is then drawn most often with an elliptical
shape. Several factors must be considered. If the cartilage needs to be straight as for alar rim
then the upper border is placed lower towards the central strut, whereas if a curve is needed
for the vestibule then the border is moved as high as possible. Skin to cartilage ratio will also
influence location and method of closure. When large amounts of cartilage are required, the
cephalic incision is the same for both skin and cartilage while the lower border requires a
careful skin-only incision and then undermining of the skin downward toward the central
strut. The cartilage is then incised inferiorly. The posterior dissection is done above the
perichondrium. Hemostasis is meticulous and any sharp cartilage edges excised. Closure of
the donor site defect consists of the following: (1) wide skin undermining, (2) horizontal
mattress sutures of 4–0 plain catgut, which picks up centrally the underlying postauricular
soft tissue thus recreating the natural depression, and (3) 5–0 plain catgut sutures at either
end. No dressing is required. On occasion, the entire conchal bowl is harvested as a composite
graft and the defect filled with a full-thickness skin graft.
Reserve Composite Graft. A small (12 × 5 mm) composite graft can be harvested from the
anterior undersurface of the cephalic helical root when the concha bowl has been previously
used (Fig. 7.7). However, the donor site often requires a full-thickness skin graft to close the
defect.
Problems. Based on over 200 composite grafts in rhinoplasty patients, I have found com-
posite grafts to be extremely effective at correcting alar rim notching and lowering the alar
rim up to 4 mm. The disadvantages include its inherent greater thickness as compared to
alar cartilage and “graft show” especially if the incision is made too close to the alar rim or
the dissection is done downward toward the alar rim. Although the cartilage can be shaved,
a better solution for the thin-skinned patient is to use the undersurface of the helical rim.

Concha ­Harvest
237
Fig. 7.7 (a, b) Reserve composite graft
Fig. 7.6 (a–c) Standard composite graft

238
Chapter 7  
Grafts
Autogenous fascia is an extremely valuable grafting material for nasal surgery when soft
tissue padding is need as opposed to structural support. Deep temporal fascia is used exclu-
sively due to its thickness and long term survival. Superficial temporal fascia is too thin and
has little long term presence.
Technique. I routinely harvest a 5 × 5 cm piece of deep temporal fascia (DTF) through a 3.0
cm incision above the auricle (Fig. 7.8). Recently, I have converted from astraight line incision
to a posterior angled V-incision. A straight line is drawn coming up from the tragus and
the a posterior V with 1.5cm limbs is added. The hair is not shaved. The area is injected with
local anesthesia containing epinephrine. The incision passes downward to the subcutaneous
tissue which is spread transversely with the scissors. Haemostasis is checked at this point.
The superficial temporal fascia is penetrated and the loose areolar layer is found with the
gleaming white deep temporal fascia underneath. Then the scalp is retracted superiorly us-
ing two Ragnell retractors. The fascia will be incised as 4 arcs: 1) superiorly at the junction
of DTF and perichondrium, 2) anteriorly at its split to accommodate the deep temporal fat
pad, 3) inferiorly down to the top of the ear, and 4)posteriorly as far back as necessary. As
the DTF is incised, one sees the underlying red temporalis muscle. The scalp is then retracted
in each of the other three quadrants and the fascia incised. A large fascia graft is removed.
Haemostasis is repeated. The incision is closed with staples. No drains or dressings are used.
Antibiotic ointment is applied, and the patient is allowed to wash their hair on the second
postoperative day. Fascia is used in a wide variety of configurations. Virtually all radix grafts
are simple balls of fascia (Fig. 7-9). In thin skin patients, a full length dorsal graft of fascia
in a single layer is employed for primary cases and a double layer for secondary patients.
When both the radix and dorsum need extra padding, I use a “ball and apron” to fill the
radix and pad the dorsum. In other secondary patients, the entire nose will be relined using
a “fascia blanket” graft.
Problems. Donor site morbidity is more theoretical than real as the scar is extremely well-
hidden by the unshaved hair. Any postoperative hematoma that occurs can be expressed after
removing several staples and then a pressure dressing applied. There is no need to return
to the operating room.
Perichondrium. Rib perichondrium is interesting for soft-tissue padding. It is significantly
thicker than fascia and swells more. It is used concurrent with rib grafts to the nose and is
not harvested separately. Rectus fascia is also tempting, but it contracts and thickens mark-
edly which makes it of little value.
Fascia Harvest

Fascia Harvest
239
Fig. 7.8 (a–d) Harvesting fascia. (a) Approach 
(b-d) Endoscopic view 
Fig. 7.9 (a, b) Radix and radix/dorsal graft 
(c, d) dorsal graft

240
Chapter 7  
Grafts
The term, “rib grafts,” has a wide variety of meanings in rhinoplasty surgery. There are varia-
tions as regards donor site, composition, shaping and utilization [Daniel 1994]. Initially, rib
cartilage was required to fashion a dorsal graft, but the indications have expanded dramati-
cally. In complex secondaries, virtually every type of graft will be made from rib cartilage
including tip, alar rim, spreaders, pyriform. Traditionally, rib cartilage grafts were harvested
from the chondrosynschium of ribs 5-7 both for ear and nasal reconstruction (Fig. 7.10). In
contrast, rhinoplasty surgeons want straight segments of rib cartilage. I use either the sub-
costal (9th & 8th ribs) or inframmary (5th & 6th ribs) incision depending upon the patient’s
preference for the location of the scar.
Harvesting Costal Cartilage: Subcostal Approach. The 9th rib is the first “floating rib” and thus
a simple retrograde supraperichondrial dissection is possible (Fig. 7.11). The patient is placed
in the supine position with a small sand bag under the hip. The 9th rib tip is palpated and a
2.5cm incision is marked between the 8th and 9th rib extending laterally from the 9th rib tip.
The area is injected with 6cc of local anesthesia. The initial incision is carried down to the
fascia. Palpation is repeated to confirm the rib location and dissection continues through
the muscle and fascia til the distal 9th rib is fully exposed. Although it is possible to harvest
the entire cartilaginous portion through a 2.5cm incision in thin patients, the incision is usu-
ally extended to 3.5cm especially when the 8th rib will also be harvested. Once the rib tip is
revealed, it is grasped with forceps and then a retrograde supraperiosteal dissection is done
back to the bony junction using the cautery. A Doyen elevator is placed beneath the palpable
bony junction and a #15 blade is used to cut through the junction. Once the graft is removed,
then the wound is filled with saline and the anesthesiologist maximally expands the chest to
test for any pneumothorax. If additional cartilage is required, then a segment of the 8th rib is
harvested subperichondrially similar to harvesting the 5th and 6th rib. The wound is partially
closed in layers as extra cartilage can be banked for future use. The wound is not drained.
Harvesting Costal Cartilage: Inframmary Approach. It is important to mark the inframmary
fold, especially its medial extent, preoperatively with the patient sitting. If the patient has
breast implants, they must be warned that a rupture could occur. The standard incision is
3.5cm and is placed 1cm above the inframmmary fold which usually coincides with the 5th
costal interspace (Fig. 7.12). With experience, a 1.5cm keyhole incision can be used, but it
is very ­restrictive and is usually placed in the inframmary fold and obliqates excision of the
adherent 6th rib. The wound is infiltrated with 6ccs of local anesthesia. The incision is made
and then a cautery is used to dissect down to and through the rectus fascia. The muscles are
“split,” easily retracted and thereby left intact which minimizes postop pain. The 5th and 6th
ribs are easily exposed. In general, one prefers to harvest a segment of the 5th rib as it rarely
has a cartilage fusion to the 6th rib. In contrast, the 6th rib is fused on its caudal border to the
7th rib virtually 95% of the time which makes for a more tedious dissection. Next, one must
decide whether to split or excise the anterior perichondrium as a possible graft for padding
of the nasal skin envelope. The lateral perichondrium on either side is elevated using curved
elevators. A complete circumferential dissection is done beneath the cartilage at either end.
Once satisfied with the length of the graft, then the cartilage is divided at either end. A Doyen
elevator is placed beneath the rib and the cartilage cut partially with a #15 blade and the cut
completed with a Freer elevator. The graft is then dissected off the ­underlying ­perichondrium
Rib Harvest

Rib Harvest
241
Fig. 7.11 (a–b) Costal rib: Supraperichondrial harvest of 9th rib 
, and (c-d) Costal rib: Subperichondrial
harvest of 8th rib 
Fig. 7.10 (a–c) Costal cartilage harvest 
a
b
c

242
Chapter 7  
Grafts
from lateral to medial. Once the cartilage graft is removed, the wound is checked for a pneu-
mothorax. Each of the intercostal nerves is blocked with 0.5cc of 1% Marcaine. The closure
is multi layered, but no drain is required. How does the subcostal 8th harvest differ from
an inframammary 5th & 6th harvest? The critical difference is the reality of “ intermediary
cartilage fusion” between 6 and 7. These bridges have to be carefully divided. One can not
pass a Doyen rib stripper as it is a cartilage fusion not perichondrial attachments between
the adjacent ribs, thus making the dissection more tedious.
Harvesting – Osseocartilaginous. When structural dorsal grafts are required (cocaine nose),
I harvest an osseocartilaginous graft from the 9th rib (Fig. 7.12). The advantage is that there
is no need for K-wires as warping is not a problem. Survival occurs because bone is placed
over bone and cartilage over cartilage. The patient is turned into a right hemi-lateral posi-
tion and held in that position with an inflatable bean bag mold. The incision is centered at
the tip of the 10th rib and drawn in the intercostal space between the 9th and 10th ribs. The
donor area is injected with 8 cc of 1% xylocaine with epinephrine 1:100,000. A 3cm incision
is made and extended down through subcutaneous tissue to the muscle fascia using a blade
tip cutting cautery. Then, the external oblique muscle is divided over the 9th rib. One enters
an areolar space and the glistening rib is easily visualized. The osseocartilaginous junction is
exposed and marked. The periosteum is divided over the bony portion of the 9th rib, elevated
using a Cottle elevator, and then Doyen elevators. A minimum 4 cm of bone is taken and it is
wise to confirm this distance using a ruler. With the bony rib supported away from the pleura,
the rib is easily cut with two snips of a rongeuer. The cartilaginous portion is dissected free
supraperichondrially using the cautery. A standard test for pneumothorax is done.
Problems. There are very few problems associated with harvesting the rib except for the
expected scar. Pain is reduced with Marcaine intercostal blocks done prior to closure. Pneu-
mothorax is rarely a factor, but is treated as follows: (1) insertion of a small Robinson catheter
through the perforation, (2) closure of the surrounding muscle layer and then a purse string
suture of 2-0 vicryl around the tube, (3) maximum chest expansion by the anesthesiologist,
and (4) removal of the tube as the knot is tied. A postoperative chest x-ray is mandatory.