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

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Chapter 7  
Grafts
Currently, I use a columellar strut in virtually all my open rhinoplasties to provide intrinsic
columella shape, tip projection, and to counteract the contractual forces of the skin envelope.
I classify three types of strut grafts: columellar strut, extended strut, and septocolumellar
strut (Fig. 7.14).
Standard Columellar Strut. These struts measure approximately 20 mm in length and 2–3 mm
in width with the thicker portion located inferiorly (Fig. 7.14a). I rarely use an angled strut.
The strut is placed between the lateral crura with the inferior end short of the nasal spine.
The crura are then advanced upward and rotated medially 90° before being fixed to the strut
with a #25 needle just below the domes. A horizontal suture of 5–0 polydioxanone suture
(PDS) fixes the crura to the strut and is placed in the middle crura above the columellar
breakpoint. The superior portion of the strut can be cut to fit beneath the domes and the
inferior portion cut off, if there is too much fullness in the columellar labial angle.
Extended Columellar Strut. These grafts tend to be longer (30 mm) and shaped to influence
the columella labial angle. They measure 8–10 mm at their widest portion which is the junction
between the upper two third and the lower one third of the strut (Fig. 7.14b). After its insertion
between the crura, a distinct change should be seen at the columella labial angle. Again, the graft
is kept short of the anterior nasal spine (ANS) to avoid clicking. These grafts are frequently
used in ethnic noses and in the older patient with an acute columellar labial angle.
Septocolumellar Struts. Structural grafts are designed to provide support to the distal third
of the nose and thus represent a replacement/reinforcement of both the caudal septum and
the columella (Fig. 7.14c). In general, I insert large segments of osseocartilaginous septum
(30 mm high × 20 mm long) via a combined dorsal/tip split. The structure graft is fixed to the
septum at multiple points with 4–0 PDS. Then the crura are advanced upward on the strut,
fixed with a #25 needle, and then sutured with 5–0 PDS. The strut is contoured cephalically
to fit the supratip set off. The most common application is in Asian noses and lengthening
of the upwardly rotated tip. I called these septocolumellar grafts in the Atlas (Daniel 2002)
and Toriumi (1995) refers to them as septal extension grafts.
Problems. The most common problem is that the graft is too long and clicks across the ANS;
a situation easily corrected by direct excision of its inferior portion. Structural grafts are very
demanding and will be discussed in depth under upwardly and downwardly rotated tips.
Columellar
Struts

Columellar Struts
245
Fig. 7.14 (a) Types of columellar struts, (b) columellar strut 
(c) extended columellar strut graft 
(d) septo-
columellar strut grafts

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In primary cases, tip grafts can be divided into two materials and two shapes. The material
is either excised alar cartilage for add-on tip refinement grafts (TRG) or septal cartilage for
structural grafts.
Whenever possible, excised alar cartilage is used as it is quite pliable, easily shaped, and can
be layered. These grafts have minimal risk of showing through the skin in contrast to rigid
grafts of septal or conchal cartilages. There are 5 types:
1) Domal TRG. These grafts accentuate the dome defining points and are relatively small
(8x4mm). They are sutured over the domes covering the domal creation sutures. Single
or double layers are employed depending upon the desired definition.
2) Shield TRG. These are shield shape with a distinct dorsal edge to produce dome defining
points. The shoulder of the graft is sutured to the domal notch. A second “booster” graft
can be placed behind the shield to force the tip more caudal.
3) Diamond TRG. These grafts are diamond in shape and cover the entire tip diamond to
set the tip off from the rest of the tip lobule. They are sutured at each domal notch, the
columellar breakpoint, and the midline junction of the cephalic lateral crura.
4) Folded TRG. These grafts have the same shape as a long diamond, but are folded at their
widest point with the shorter end folded behind. The graft is projected 1-2mm above the
domes. Essentially, one is pushing the dome defining points caudally while achieving both
increased definition and projection.
5) Combination TRG. Any combination of these 4 grafts can be used to achieve a specific
goal. One variation is to insert multiple shields and diamonds to increase volume. Another
grouping is to add a domal graft first, then bend a diamond over it which accentuates the
tip diamond under thicker skin.
Structured Tip Graft. In contrast, septal cartilage is used for major tip changes. A tapered
golf-tee-shape graft is used with dimensions measuring 12–16 mm long, 8–10 mm wide at
the top tapering to 4 mm inferiorly, and 1–3 mm thick with greatest thickness superiorly.
The goal is to have the superior edge of the graft create the tip definition while the columel-
lar portion blends in with the crura. Prior to suturing the graft in place, two critical steps
have been completed: the crural strut has been inserted and the domes have been modified.
Before suturing the graft to the stable columella platform, a major decision must be made:
integrate the graft into the existing tip configuration or project the graft above the domes to
create definition through the skin (Fig. 7.16). The thinner the skin the more the graft must
integrate into the alar architecture and be highly beveled. The thicker the skin the more the
graft projects above the domes and the sharper the edges (Fig. 7.17). The graft is sutured in
place using 4–6 sutures of 5–0 PDS.
Tip Grafts
Tip Refinement
Grafts (TRG)

Tip Refinement Grafts (TRG)
247
Fig. 7.15 Add-on tip refinement grafts (TRG) 
Fig. 7.16 (a, b) Integrated tip graft 
Tip graft
b
a
Cap graft
Fig. 7.17 Projected tip graft 
Projected

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Chapter 7  
Grafts
Put simply, spreader grafts are a functional and aesthetic necessity (Fig. 7.18). Following
resection of the dorsal hump, the superior portion of the septum is converted from a broad
“T,” which distracts the upper lateral cartilages, to a narrow “I,” which allows the upper lateral
cartilages to collapse inward. Spreader grafts reestablish the broad “T” of the septum thereby
achieving two critical factors: (1) functionally, the internal nasal valve angle is opened and
(2) aesthetically, the dorsal lines are supported thereby avoiding a collapsed inverted-V
deformity.
Technique. The grafts are cut from the donor material using a #11 blade. Thickness varies
from the usual 1.5 mm up to 4 mm depending upon narrowness and asymmetry. The height
is 2–3 mm to facilitate suturing and the length is 15–25 mm depending on availability. A true
“pocket” as Sheen originally envisioned is not possible caudally in most cases but is very
desirable cephalically, especially under the bony vault. The grafts are inserted one at a time
making sure to have a smooth dorsum. They are held in place with two #25 needles placed
percutaneously through the skin. The needles pierce all five layers: the upper lateral cartilage,
then the spreader graft, the septum, spreader graft, and opposite upper lateral cartilage. The
caudal end is sutured first with 5–0 PDS often incorporating just the spreader grafts and the
septum (three layers), whereas the cephalic suture incorporates the upper lateral cartilages
as well (five layers). Suturing avoids accidental disruption or dorsal displacement.
Application. I tend to think of spreader grafts having different widths to correct dorsal asym-
metries. Different lengths are used for various purposes. The standard length is primarily
filling the cartilaginous open roof. After a high bony reduction, longer grafts are needed to
extend high into the bony open roof to maintain ideal dorsal width. For the upwardly rotated
tip, longer grafts can be placed more caudally in an “extended” position to brace a structured
columellar strut which allows the tip to be derotated.
Problems. To date, the benefits of spreader grafts have been extraordinary while the problems
have been few. The most worrisome is the 1% incidence of dorsal displacement, which cre-
ates a small bump in the keystone area that requires a revisional shaving down. Sometimes,
one can do this in the exam room with local anesthesia using a 16 needle. Without question,
the major problem with spreader grafts is surgical reluctance. Ultimately, this is one graft
where the answer is “just do it.” I have never regretted inserting spreader grafts, but I have
regretted not doing them.
Spreader Grafts

Spreader Grafts
249
Fig. 7.18 (a–d) Spreader grafts 
a
b
c
d

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Chapter 7  
Grafts
Radix Grafts
Early in my practice I went through the usual progression of radix grafts – crushed septum
then excised alar and finally fascia with a dramatic decline in revision rate from 20% to 5% to
virtually 0%. Currently, I use fascia in all my radix grafts, but do it in three configurations.
Radix Graft: Fascia (F). A sheet of deep temporal fascia is harvested, bunched into a ball,
and sutured together with a 4–0 plain catgut suture (Fig. 7.19a, d, g). The recipient pocket is
elevated, the attached needle is brought out at the nasion, and the fascial ball pulled into the
pocket. A steristrip tape is placed across the bridge keeping the fascia in the radix pocket.
Radix Area Graft: Diced Cartilage and Fascia (DC+F). When the entire radix area must be
augmented, I use a two-step method: (1) a small fascia graft is slipped into the pocket with
a percutaneous suture, (2) a small amount of diced cartilage (0.1–0.3 cc) is placed against
the bone (Fig. 7.19b, e, h). The cartilage will fuse to the bone while the fascia will provide a
soft contour and avoid any visibility of the graft.
Radix/Upper Dorsum: Diced Cartilage in Fascia (DC-F). As the length of the defect extends
below the nasion and down to the rhinion, a diced cartilage in fascia (DC-F) graft is cre-
ated. The fascia is penned to a silastic block, filled with diced cartilage (0.3–0.5 cc), and
then the fascial edges are sutured together with 4–0 plain catgut. This cartilage filled “bean
bag” is slipped into the recipient pocket using a percutaneous suture on the cephalic end
(Fig. 7.19c, f, i). The caudal end is sutured to the cartilaginous dorsum.
Problems. There have been virtually no problems with fascia grafts in the radix. In contrast
to solid septal grafts which are designed to extend the dorsal lines cephalically, fascial grafts
are only filling the radix area and moving the nasion outward from the corneal plane. As
the “area deficiency” increases, greater fill is required and hence the diced cartilage grafts.
Unless the diced cartilage is covered with fascia, it will be palpable and may become visible
long term. Historically, a half-length dorsal graft was the greatest nightmare of all grafts as they
always showed under the thin skin of the rhinion. However, diced cartilage in fascia grafts has
solved the challenge. It is always wise to be conservative in how much diced cartilage to put
in under the tight skin of the radix. If revision is necessary, bevel it in situ with a #15 blade.

Spreader Grafts
251
Fig. 7.19 (a-c) Radix graft – fascia 
(d-f) Radix area graft – DC+F 
(g-i) Radix/upper dorsum –
DC-F

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Chapter 7  
Grafts
Dorsal Grafts: The Designer Dorsum
During the last 8 years, the greatest advance in nasal grafting is dorsal augmentation. Solid
dorsal grafts are rarely used due to their inherent risks of visibility, sharp edges, or warping.
Three types of grafts are used to correct dorsal deficiencies. Fascia is used to pad the dorsal
skin envelope and augment minimally the dorsum (0.5–1.5 mm). Diced cartilage in fascia
(DC-F) is used for virtually all dorsal augmentations in the 1–8 mm range. It is inserted
either by itself or as the aesthetic layer of a composite reconstruction. Osseocartilaginous
rib grafts (OC) are reserved for contracted cocaine noses where structural support is critical.
A brief description of the latter technique will be given next with additional discussion in
the section on The Cocaine Nose.
Osseocartilaginous Grafts (OC). Once the OC graft is harvested, it is shaped using #11 blade
for the cartilage portion and a power drill burr for the bony portion (Fig. 7.20). The graft
is repeatedly placed into the recipient bed and the skin redraped until the ideal shape is
achieved. In most cases, the graft is a 60:40 composition of bone to cartilage. The graft is then
inserted and tightly held on the sides while two percutaneous K-wires are drilled through
the graft down to the nasal bones with the wires removed at 7–10 days. The basilar part of
the columellar strut is fixed to the ANS. Then a tongue-in-groove technique is used to join
the strut to the cartilaginous portion of the dorsal graft. Follow-up MRI scans indicate that
both bony fusion and survival occurs. Warping is rarely a problem in osseocartilaginous
grafts. Malalignment is the major concern.
Fascia (F). I use fascia as a dorsal graft whenever the dorsal skin is thin or minor augmenta-
tion of less than 1.5 mm is needed (Fig. 7.21). The fascia is pinned on a silastic block, trimmed
to an 8 mm width, and then fixed with 4–0 plain catgut on straight needles (SC-1) at the
cephalic end. The needles are passed through the skin at the nasion level and guided into
the pocket and then the caudal end is sutured to the cartilaginous vault. When a double layer
is required, the fascia is folded, fixed at either end, and closed with a running suture along
its open edge. Insertion and fixation is similar to a single layer graft. Note: the double layer
fascia graft is essentially the same technique that is used for the “container” of a DC-F graft.
Diced Cartilage in Fascia (DC-F). Diced cartilage has revolutionized dorsal grafting. The
basic concept is to dice cartilage into small bits (<0.5 mm) which can be put into a fascial
sleeve that is slipped into the dorsal defect. The technique will be described in detail fol-
lowed by an in-depth analysis of experienced gained from over 300 DC-F grafts done in the
past 7 years. Once again, the DVDs are of inestimable value in showing the actual technique.

Dorsal Grafts
253
Fig. 7.20 (a–d) Osseocartilaginous dorsal graft 
Fig. 7.21 (a–c) Fascial dorsal graft

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Chapter 7  
Grafts
Step #1: Fascial Harvest. The largest possible sheet of deep temporal fascia is harvested. The
resection extends superiorly to the periosteal junction, anteriorly to the deep temporal fascial
split, then inferiorly toward the concha, and posteriorly as far back as possible.
Step #2: Dicing the Cartilage. Cartilage is diced into <0.5 mm bits using excised cartilage
(dorsum, alar), septum, concha, or rib. In general, the circulating nurse puts on sterile gloves
and dices the cartilage into <0.5 mm squares while the surgeon continues to operate. It is
important to cut the cartilage with two #11 blades without traumatizing the cartilage – do
not morselize or crush it. A 1.0 cc tuberculin syringe is filled with diced cartilage. The plunger
is inserted and the cartilage is compressed maximally. The cartilage should be diced so fine
that it can pass through the hub – the spurt test. Since the cartilage is so finely diced, the hub
does not have to be cut off the syringe with a #10 blade.
Step #3: Constructing the Fascial Sleeve. Measurements of the dorsal defect allow an exact
DC-F construct to be made on the back table and inserted into the defect. The fascia is pinned
on a silastic block and folded into an 8–10 mm wide × 20–35 mm long sleeve. The cephalic
end is sutured at its corners using two sutures of 4–0 plain on SC-1 needles. Then the free
edge is trimmed and the free edge sutured partially closed with a locking suture of 4–0 plain.
Note: this is similar to a double layer dorsal fascia graft.
Step #4: Filling the Construct. The syringe is slipped into the open side of the sleeve and
filled to the desired thickness. The critical step is to achieve very specific dimensions: thick-
ness (1–8 mm), length (10–40 mm) and shape (tapered or uniform). It is done by using the
nondominant hand to mold the DC as it is slowly injected into the sleeve with the dominant
hand. Alternatively, one can use an elevator to “stuff” the sleeve, but one wants a solid shape.
The length of the dorsal graft is trimmed to the exact length required. It is important to mold
the graft to the exact dimensions on the back table and not over-graft the nose.
Step #5: Inserting the Graft. The percutaneous sutures are inserted at the nasion level and
the shaped graft slipped into the recipient bed. In most cases, the graft has been made quite
accurate and thus minimal molding in-situ is done. If I am concerned about the shape, I do
not hesitate to remove the graft and modify it on the back table. If necessary, diced cartilage
can be expressed out of the fascial sleeve. The graft is then closed and fixed to the cartilage
vault with a 4–0 plain suture (Fig. 7.22).

DC-F Grafts
255
Fig. 7.22 (a) Diced cartilage in fascia (DC-F) 
, (b) dicing the cartilage 
(c) constructing the fascial sleeve 
(d) filling the sleeve to measure 
, and (e-h) inserting the graft 
a
b
c
d

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Chapter 7  
Grafts
Post-op Course. Once the nose is closed, the dorsum is gently taped with steristrips. When
the cast is removed at 6 days, the nose is inspected and gentle molding can be done to insure
a smooth dorsum. If required, the patient is seen every 2 days and the graft molded up to 14
days. The patient should not wear glasses for 6 weeks. If there is any asymmetry at 1 year,
it can be easily shaped by beveling with a #15 blade. When complex revisions are done, the
now solid graft is removed, shaped, and reinserted.
Diced Cartilage and Fascia (DC+F)
When highly tapered or localized grafts are required, then a DC+F graft is done. Essentially,
a standard fascial dorsal graft is inserted first, either single or double layer. Then diced
cartilage is placed beneath the fascia to achieve a very specific shape. Obviously, this step is
done immediately prior to closure to avoid any dispersal.
There are numerous advantages and very few disadvantages for DC-F grafts. The top ten
advantages are as follows: (1) These are autogenous grafts using viable cartilage with no risk
of rejection. (2) One can use any combination of excised, septal, conchal, or rib cartilage. In
contrast to solid grafts, one does not have to harvest the perfect, and rarely found, 35 × 8 mm
piece of septal cartilage nor fuse together two pieces of curvy conchal cartilage. (3) There
is neither a risk of warping nor a need for foreign material (K-wire). (4) The graft is easily
and quickly prepared with the circulating nurse or a junior assistant dicing the cartilage and
loading the syringe. (5) The shape is easily “customized” as regards thickness (1–8 mm), shape
(tapered or uniform), and length (Fig. 7.23). The ability to mold a graft with a specific shape
for a specific defect is extraordinary. (6) Molding of the graft is possible both intraop and
early post-op. (7) The graft can be easily revised using a percutaneous #16 needle to remove a
sharp edge, or a #15 blade to shave off any prominence. (8) Infection has not been a problem.
(9) Absorption has not been seen in over 300 cases with a maximum follow-up of 7 years.
(10) Over a period of months, the diced cartilage “solidifies.” The interspace between the
diced cartilage bits is filled with fibrous tissue within the fascial sleeve (Fig. 7.24a, b). When
removed the graft is quite solid and semirigid. Any pieces shaved off for shaping purposes
are sufficiently solid that they can be used even for tip grafts. Histological studies confirm
that the individual pieces of cartilage have survived and suggest that the fascia has become
a neoperichondrium (Fig. 7.24c, d).
Why Diced
­Cartilage
Grafts?

Diced ­Cartilage Grafts
257
Fig. 7.23 Range of augmentation and duration with DC-F grafts, (a) 2 mm, 2 years, (b) 4 mm, 6 years,
(c) 6 mm, 3 years
Fig. 7.24 (a–d) DC-F graft at 1 year: Rigidity, normal architecture and histology

258
Chapter 7  
Grafts
Alar Rim Graft and Alar Rim Support Graft
For patients with a retracted alar rim or a high potential for developing it, alar rim grafts
of septal cartilage are dramatically effective and technically simple. What is the difference
between alar rim grafts (ARG) and alar rim structure grafts (ARS)? Basically, it is the same
graft, but placed along the alar rim in two different ways. The ARG is inserted into a subcu-
taneous pocket while the ARS is sutured into a marginal rim incision along the full-length
of the nostril. In general, ARG grafts are used for minor weaknesses and slight retractions
of the alar rim. In contrast, ARS grafts are used for major retractions and to fundamentally
change the shape of the nostrils (Daniel 2002, 2004).
Technique (ARG). The grafts measure approximately 10–14 mm in length by 2–4 mm in
width with the thinnest end tapered significantly (Fig. 7.25). The contour of the alar rim is
marked, especially the high point of the alar rim notch which often corresponds to the alar
base/lobular junction. Then, a short intra nostril 4 mm incision is made at the level of the
alar base posterior and transverse to the alar rim. A subcutaneous pocket is dissected that
is parallel and 2–3 mm posterior to the alar rim. The graft is pushed into the pocket tapered
end first and then the incision is closed. There should be an immediate improvement in the
alar rim border. However, it is important to check the nostril shape from the basilar view
and to palpate for the graft near the domes. If there is any distortion, the graft is backed out,
shortened, and reinserted. One must balance lowering the alar rims, while avoiding distor-
tion of nostril shape.
Technique (ARS). The exact same graft can be sutured along the alar rim rather than placed
in a subcutaneous pocket (Fig. 7.26). In the majority of cases, a true rim incision is made
2 mm back from the alar rim beginning laterally and ending medially at the infracartilagi-
nous incision. A pocket is dissected posterior to the incision – one never unfurls the alar
rim. The graft is placed into the pocket. The incision is closed with 4–0 chromic but pick-
ing up the graft in each bite. It is essential to check the cephalic end of the graft and make
absolutely sure that it is not overriding the domes. Postoperative nostril splinting is done
for 2–3 weeks at night.
Problems. Most of the problems with alar rim grafts have been minor. If thick cartilage is
used, there is a tendency for it to show in the area of the soft-tissue facets. The primary
failure is expecting it to do too much. This type of graft is excellent for alar rim support
or lowering the rim 2 mm at the very most. Any more than 2 mm of lowering requires a
composite graft.

ARG and ARS Grafts
259
Fig. 7.25 (a–d) Alar rim graft (ARG) 
Fig. 7.26 (a–d) Alar rim support graft (ARS)

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Chapter 7  
Grafts
Lateral Crural Strut Grafts
These grafts were developed by Gunter (1997) to reshape, reposition, or reconstruct the
lateral crura while providing support for the external valve. Essentially these are straight
strong pieces of cartilage measuring 3–4 mm in width by 14–20 mm in length. Although used
in different ways, the medial portion of the graft is sutured to the undersurface of the alar
cartilage while the distal end is placed in a lateral pocket. I insert the lateral portion into
one of three locations: pyriform, alar base, or nostril rim depending upon indication (Fig.
7.27). Whenever possible, septal cartilage is used.
Technique: Shaping or Salvaging the Alar Cartilage. Deformed or mangled alar cartilages
can be straightened and shaped by placing a short lateral crural strut graft beneath them
and fixing the graft to the alar with several sutures of 5–0 PDS. This maneuver is particularly
helpful in severely concave lateral crura. These grafts tend to be uniform in thickness.
Extended Lateral Crural Strut. In primary cases, the lateral crural strut is added once the tip
suture surgery is completed. Essentially, the desired pocket is undermined in one of the three
positions: Type (1) underneath the accessory cartilages, Type (2) in the alar base, or Type (3)
along the nostril rim. These grafts are highly tapered and thin at the cephalic end to avoid
distorting the domal area while thick laterally. The graft is inserted into the pocket, shortened
laterally if necessary, and then sutured to the lateral crura at two points. One should avoid
placing the lateral strut graft underneath or cephalic to the alar groove as it will be visible.
Lateral Crural Strut and Alar Transposition. These are very complex cases where one wants
to make a fundamental change in tip shape and provide support to the external valve
(Fig. 7.28). Alar transposition implies dividing the lateral crura at its junction with the A-1
accessory cartilage, undermining the entire lateral cartilage up to the domal segment, and
then transposing it from a cephalic position to a more caudal position paralleling the nos-
tril rim. In these cases, I have found it important to transpose the alars prior to insertion of
the columellar strut. Once the alars are transposed the surgical sequence is as follows: (1)
columellar strut, (2) tip suturing with optional TRG grafts, (3) suturing the lateral crural
strut graft to the lateral crura, and (4) placing the lateral crural strut graft along the nostril
rim or into an alar base pocket. In certain secondary cases, additional composite grafts may
be required.
Problems. During the learning curve, the most common problems are distortion of the nos-
tril rim, graft visibility in the alar grove, and palpability. These grafts must “flow” with the
alar contour while providing support. Tapering of the medial end is critical. Mark the alar
groove prior to surgery and place the pyriform extension caudal to it whenever possible.
Warn patients in advance that they will be able to palpate the grafts.

Lateral Crural Strut Grafts
261
Fig. 7.27 (a–d) Lateral crural strut grafts (LCSG) 
Fig. 7.28 (a, b) Alar transposition and LCSG

262
Chapter 7  
Grafts
Composite Conchal Grafts
Composite grafts are used in three configurations which ­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.
Lowering Alar Rim. For lowering a retracted alar rim, an intranasal incision is made 2 mm
back from the alar rim and parallel to the notched rim. The wound is spread with tenotomy
scissors perpendicular to the rim. There is no attempt to “create” a pocket but rather to
spread against the caudal edge of the lateral crura and to force the unfurled alar rim down-
ward. Never undermine the alar rim itself as it distorts and thickens the rim. The graft is
tailored to fit the defect. It is important to shave down the cartilage surface of the composite
graft until it is thin like an alar cartilage. In most cases I suture the exteriorized graft to the
alar rim side first using three to four sutures of 5–0 plain catgut. I then advance the graft
intranasally into the defect. The cartilage is then adjusted in situ until the alar rim is forced
downward the desired distance.
Vestibular Stenosis. These problems are seen most commonly in secondary cases and will
be discussed extensively in Chapter 9. For Grade II obstructions of 15–40%, I have found a
medially based flap plus a composite graft to be a useful maneuver (Fig. 7.29). The following
technique is used: (1) the stenosis is incised from lateral to medial thereby creating a medially
based mucosal flap, (2) the scar tissue is cored out, (3) the mucosal flap is advanced upward
onto the septum, (4) the lateral wall is resurfaced with a composite conchal graft, and (5)
intranasal splints are sutured in place for 2 weeks followed by a nostril retainer splint worn
nightly for 2 months.
Internal Valve Collapse. Composite grafts are of definite value in treating the fixed collapsed
internal valve due to mucosal scarring (Fig. 7.30). The first step is to release the scarred mu-
cosa and spread the upper laterals outward cephalic to the valve. As diagramed, a composite
graft can be designed as skin-only over the septum, but with a structural strong cartilagi-
nous composite component laterally. It is essential to place the convex cartilage in the defect
between upper lateral and lower lateral cartilage. Usually, a large cartilaginous component is
required measuring 10 mm in width and 15 mm in length. The skin is sutured first with the
knots tied intranasally. The graft is sutured flush to the dorsal septum to avoid a prominence.
The width of the graft can force the retracted alar rim downward.

Composite Conchal Grafts
263
Fig. 7.29 Vestibular stenosis
Fig. 7.30 Internal valve collapse

264
Chapter 7  
Grafts
Certain grafts are utilized rarely or almost exclusively in secondary cases.
Lateral Wall Grafts. Grafts to the lateral wall are associated with asymmetric noses or large
dorsal grafts (Fig. 7.31a, b). To avoid visibility, the graft should be anatomically precise to
correct a specific problem and placed in a pocket with suture fixation. A lateral wall graft is
shaped like the upper lateral cartilage and then placed in a pocket directly over the upper
lateral cartilage (ULC). The dorsal edge is precisely aligned with the dorsum. Full-length
lateral wall grafts are not used as they tend to be visible.
Alar Spreader Grafts. This graft, which I refer to as an alar bar graft, was devised by Gunter
(1992) to provide support for the pinched tip as seen on basilar view (Fig. 7.31c, d). Although
conceptually simple, it is technically demanding. If lateral crura are 2 mm in width or more,
then the cartilage is undermined from the vestibular lining. A #25 needle is placed across
at the point of greatest collapse. The alar cartilages are slid along the needle until the de-
sired correction is achieved. Then a piece of septal cartilage, often measuring 14 × 4 mm, is
shortened to fit the desired length. The graft is sutured underneath the alar cartilages with
5–0 PDS. The graft must not be excessively long or nostril flare will occur. I have not found
triangular alar spreader grafts effective as they create excessive supratip fullness.
Dermal Grafts. I have found dermal grafts to be extremely valuable in restoring defects
resulting from loss of the dermis (Fig. 7.31e, f). The donor site is retroauricular for small
defects and suprapubic for large defects. It is important to excise subcutaneous fat and hair
bulbs from the under surface of the graft. For a heavily scarred tip, the entire lobule is un-
dermined and then packed with the dermis graft which can measure 9 × 2.5 cm. The donor
site scar will resemble a C-section scar in the supra pubic region. Smaller defects can have
a two-layer stacked graft cut slightly bigger than the defect and guided into position with
percutaneous sutures using SC-1 needles.
Banking and Harvesting. Any significant pieces of left over cartilage are banked beneath the
scalp (Fig. 7.31g, h). The location is the temporal region, if fascia was harvested or in the lower
retroauricular mastoid area. Any extra rib cartilage is placed in the sub costal rib donor site,
but not in the inframammary site. In the latter cases, small pieces of costal contilage can be
placed in the temporal region. I have harvested grafts up to 6 years post-insertion and all
grafts have retained their rigidity, shape, and volume. Histologically, the cells are viable and
stain for chondrocyte activity.
Specialized
Grafts

Specialized Grafts
265
Fig. 7.31 (a, b) Lateral wall graft, (c–d) alar spreader graft, (e, f) dermal grafts 
(g, h) banking/harvesting

266
Chapter 7  
Grafts
Aiach G. Atlas of Rhinoplasty. St. Louis: Quality Medical Publishing, 1996
Anderson JR, Ries WR. Rhinoplasty: Emphasizing the External Approach. New York: Thieme-
Stratron, 1986
Baker TM, Courtis EH. Temporalis grafts in open secondary rhinopasty. Plast Reconstr Surg
93: 802, 1994
Becker H. Nasal augmentation with calcium hydroxyapatite in a carrier-based gel. Plast
­Reconstr Surg 121: 2142, 2008
Beekhuis GJ. Saddle nose deformity. Etiology, prevention and treatment: Augmentation Rhi-
noplasty with Polyamide. Laryngoscope 84: 2, 1974
Byrd HS, Andochick S, Copit S, Walton KG. Septal extension grafts: A method of control-
ling tip projection and shape. Plast Reconstr Surg 100: 999, 1997. Six year follow-up. Plast
Reconstr Surg. 112: 1929, 2003
Byrd SH, Meade RA, Gonyon DL. Using the autospreader flap in primary rhinoplasty. Plast
Reconstr Surg 119: 1897, 2007
Constantian MB. Indications and use of composite grafts in 100 consecutive secondary and
tertiary rhinoplasty patients; introduction of the axial orientation. Plast Reconstr Surg
110: 1116, 2002
Daniel RK (ed). Aesthetic Plastic Surgery: Rhinoplasty. Boston: Little, Brown, 1993
Daniel RK. An Atlas of Surgical Techniques. Berlin: Springer-Verlag, 2002
Daniel RK. Rhinoplasty and rib grafts: Evolving a flexible operative technique. Plast Reconstr
Surg 94: 597, 1994
Daniel RK. Discussion of ARS & ARS in Constantian MB. Plast Reconstr Surg 114: 1582, 2004
Daniel RK, Brenner KA. Saddle nose deformity: A new classification and treatment. Facial
Plast Surg Clinics 14: 301, 2006
Daniel RK. Rhinoplasty: Dorsal grafts and the designer dorsum. Plast Clin N. Amer vol 37,
November 2, 2010
Daniel RK. Rhinoplasty: Septal saddle nose deformity and composite reconstruction. Plast
Reconstr Surg 119: 1029, 2007
Daniel RK, Calvert JC. Diced cartilage in rhinoplasty surgery. Plast Reconstr Surg 113: 2156,
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Daniel RK. Diced cartilage grafts in rhinoplasty surgery: Current techniques and applica-
tions. Plast Reconstr Surg 122: 1883, 2008
Daniel RK, Velidedeoglu H, Demir Z, Sahin U, et al Discussion of block and surgical-wrapped
diced solvent-preserved costal cartilage homograft application for nasal augmentation.
Plast Recosntr Surg 115: 2081, 2005
Daniel RK. Tip refinement grafts the designer tip. Aesth Surg J. November, 2009
Dayan SH, Bassichis BA. Facial dermal fillers; selection of appropriate products and tech-
niques. Aesthet Surg J 28: 335,2008
Erdogan B, Tuncel A, Gokhan G, Deren O, Ayhan M. Augmentation rhinoplasty with dermal
graft and review of the literature. Plast Reconstr Surg 111: 2060, 2003
Flowers RS. Rhinoplasty in oriental patients: Repair of the East Asian nose. In: Daniel RK
(ed) Aesthetic Plastic Surgery: Rhinoplasty. Boston: Little, Brown, 1993
Guerrerosantos J. Temporoparietal free fascial grafts to the nose. Plast Reconstr Surg 76:
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Gruber RP, Park E, Newman J, et al The spreader flap in primary rhinoplasty. Plast Reconstr
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Gryskiewicz JM, Rohrich RI, Reagan BJ. The use of AlloDerm for the correction of nasal
contour deformities. Plast Reconstr Surg 107: 561, 2001
Gunter JP, Rohrich RJ. Correction of the pinched nasal tip with alar spreader grafts. Plast
Reconstr Surg 90: 821, 1992
Gunter JP. Secondary rhinoplasty: The open approach. In: Daniel RK (ed) Aesthetic Plastic
Surgery: Rhinoplasty. Boston: Little, Brown, 1993
Gunter JP, Friedman, RM. The lateral crural strut graft: Technique and clinical applications
in rhinoplasty. Plast Recosntr Surg 99: 943, 1997
Gunter JP, Yu YL. Secondary rhininoplasty: Using autologous cartilage.
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A398 (24 part video showing Dr. Gunter’s rib harvesting technique)
Gunter JP, Friedman RM, Hackney Fl. Correction of alar rim deformities: Lateral crural
strut grafts. In Gunter JP, Rohrich RJ, Adams WP. Dallas Rhinoplasty: Nasal Surgery by
the Masters. QMP, 757–772, 2007
Jackson IT, Yavuzer R. AlloDerm for dorsal nasal irregularities. Plast Reconstr Surg 108:
1827, 2001
Jansen DA, Graivier MH. Evaluation of a calcium hydroxyapatie-based implant (Radiesse)
for facial soft –tissue augmentation. Plast Reconstr Surg 118: 22, 2006
Johnson CM Jr., Toriumi DM. Open Structure Rhinoplasty. Philadelphia: Saunders, 1990
Juri J. Salvage techniques for secondary rhinoplasty. In: Daniel RK (ed) Aesthetic Plastic
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Kamer FM, McQuown SA. Revision rhinoplasty. Arch Otolaryngol Head Neck Surg 114: 257,
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Reconstr Surg 121: 1442, 2008
Miller TA. Temporalis fascia grafts for facial and nasal contour augmentation. Plast Reconstr
Surg 81: 524, 1988
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of 106 patients. Plast Reconstr Surg 94: 241, 1994
Ortiz-Monasterio F, Olmedo A, Oscoy LO. The use of cartilage grafts in primary aesthetic
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deformities in rhinoplasty. Plast Reconstr Surg 109: 2495, 2002
Schuller DE, Bardach J, Krause CJ. Irradiated homologous cosral cartilage for facial contour
restoration. Arch Otolaryngol 103: 12, 1977
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Sheen JH. Tip graft: A 20-year retrospective. Plast Reconstr Surg 91: 48, 1991
Sheen JH. Spreader graft: A method of reconstructing the roof of the middle nasal vault fol-
lowing rhinoplasty. Plast Recosntr Surg 73: 230, 1984
Sheen JH. The ideal dorsal graft: A continuing quest. Plast Reconstr Surg 102: 2490, 1998
Tardy ME. Rhinoplasty: The Art and the Science. Philadelphia: Saunders, 1997
Tebbetts JB. Shaping and positioning the nasal tip without structural disruption: A new
systematic approach. Plast Reconstr Surg 94: 61,1994
Toriumi DM, Josen J, Weinberger M, Tardy E. Use of alar batten grafts for correction of nasal
valve collapse. Arch Otolaryngol Head Neck Surg 123: 802, 1997
Toriumi DM. Caudal septal extension graft for correction of the retracted columellar. Op
Tech Otolaryngol Head Neck Surg 6: 311, 1995
Toriumi DM, Josen J, Weinberger M, et al Use of alar batten grafts for correction of nasal
valve collapse. Arch Otolaryngol Head Neck Surg 123: 802, 1997
Toriumi DM. Autgoenous grafts are worth the extra time. Arch Otolryngol Head Neck Surg
126: 562, 2000
Welling DB, Maues MD, Schuller DE, Bardach J. Irradiated homologous cartilage grafts: Long-
term results. Arch Otolaryngol Head Neck Surg 114: 291, 1988

At this point in the text, the surgeon should understand and feel comfortable with each
step in the basic rhinoplasty operation. The challenge now is how to progress from Level 1
cases to more complicated deformities, which require a broader array of surgical techniques.
What is a logical progression? Surprisingly, many Level 2 nasal deformities are simply
Level 1 cases, but with one component being markedly more difficult. For example, many
patients with underprojecting tips require a standard approach to the rest of the nose, but
sophisticated use of columellar struts and add-on grafts for the tip. Fortunately, the surgeon
can progress to Level 2 cases using the basic skills mastered in Level 1 cases. This chapter
will emphasize tip surgery because the reality of private practice is that “as the tip goes so
goes the rhinoplasty” for both patient and surgeon. In addition, the surgeon will learn how
to recognize Level 3 cases. Ultimately, each surgeon will develop their own grading system
for Level 1–3 cases, which will facilitate selection of cases and techniques resulting in an
expansion of their comfort zone.
Introduction
Primary
Rhinoplasty:
Decision
Making8

270
Chapter 8  
Primary Rhinoplasty: Decision Making
Tip definition is defined with difficulty, but it is essentially the visibility or distinctive set-off
of the dome defining point from the rest of the alar cartilage (Fig. 8.1). Its anatomical correlate
is more easily specified – the domal junction line between domal segment and lateral crura.
A convex domal segment juxtaposed to a concave lateral crura produces the most attractive
tip and is the configuration I try to achieve with the domal creation suture.
Decision Making. Tip definition is carefully assessed from all four views and the patient
is asked for their opinion. Tip projection and skin thickness are critical correlates. Thick
skin precludes subtle corrections, while thin skin makes any abnormality more visible. An
example of the latter is the patient with thin skin who does not like a visible bifidity in the
infralobule (a problem easily corrected with a concealer graft of excised alar cartilage). In
contrast, too little tip definition is a common complaint for most rhinoplasty patients and
will be discussed in depth.
Level 1. In minor deficiencies, the tip is “all right,” but lacks the distinctiveness to set it off
from the tip lobule on oblique view and the dorsal line on profile view. One can easily correct
these deficiencies with a tip suture technique. First, a columellar strut is inserted to insure
adequate support. The domal segment is pinched at the domal notch to determine where to
place the domal creation suture. These sutures are inserted bilaterally followed by an inter-
domal suture. The skin is redraped and a tip position suture is added if necessary.
Level 2. When tip suturing is insufficient, then the desired domal definition can be created
using add-on grafts (TRG) of excised alar cartilage. This is either shield shaped to fill the
infralobule thereby creating a tip line, or domal shaped to set-off the tip from the dorsal line.
These infralobular grafts are designed to fit within the sutured alars while rising above the
domal notches. The domal graft is made both short (8 mm) and narrow (4 mm), and then
sutured to the domes. It can be either a single or double layer. One is accentuating the domal
segments above the adjacent lateral crura.
Level 3. These deformities imply multiple factors including deformed or weak alar cartilages,
significant deficencies of projection, and a thick skin envelop. Many ethnic noses are typical
of this category. Even the most creative sutures will not show through the thick skin nor
provide the requisite projection. In these cases, a strong crural strut and structure tip graft
of septal cartilage are required. One has the option of either suturing or excising the domes
followed by a solid tip graft with sharp edges placed in a projecting position, and backed
by a cap graft. Excised alar cartilage is simply not rigid enough to show through the thick
skin. To avoid a hanging infralobule, any “narrowing sutures,” either interdomal or domal
equalization, must be removed before suturing the tip graft into position.
Tip Definition

Tip Definition
271
a
Fig. 8.1 (a) Correcting inadequate tip definition, (b) Level 1, (c) Level 2, (d) Level 3

272
Chapter 8  
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Analysis
A 30-year-old student requested a significant change in her nose, especially the tip (Fig. 8.2).
She emphasized that she wanted a small refined tip while the surgeon emphasized tissue
limitations. The size and thickness of the skin envelope were discussed as was the width of
the nasal base. The goal was to achieve a maximum change in the tip and nasal base while
taking a balanced approach to the dorsum. Excision of a cephalically tapered segment of
the caudal septum improved tip rotation. The use of a columellar strut prevented tip droop
postoperatively. Placement of the shield-shape add-on graft insured tip definition and a
longer infralobule.
(Level: 2.0)
Operative Technique
  1) Small intraoral chin implant and fascial harvest
  2) Open approach and reduction of alar cartilages to 6 mm rim strips
  3) Incremental dorsal reduction (bone: 0.5 mm, cartilage: 1.5 mm)
  4) Upper caudal septal resection of 2.5 mm, followed by septal harvest
  5) Low to high osteotomies; insertion of fascial radix graft
  6) Crural strut and tip sutures: CS, DC, ID, DE
  7) Shield-shape add-on graft using excised cephalic lateral crura
  8) Bilateral spreader graft and out-fx of turbinates
  9) Combined nostil sill/alar base excision (R:1.5/2.0, L 3/3)
10) Alar rim support grafts sutured into marginal incisions
Case Study:
Tip Definition
Fig. 8.2 (a–j)

Case Study: Tip Definition
273
Fig. 8.2 (continued)

274
Chapter 8  
Primary Rhinoplasty: Decision Making
Tip width is generally accepted to be the distance between the dome defining points (Fig. 8.3).
For most primary noses, excessive narrowness is rarely an issue. I can only conceive of it being
present in association with a major concavity of the adjacent lateral crura or an abnormal
tip shape. Treatment would consist of correcting the entire structure of the lateral crura and
possibly adding a columellar strut to separate the domes. In contrast, excessive tip width is
a common complaint among primary rhinoplasty patients. Often, it is associated with poor
tip definition.
Decision Making. One must first analyze tip width as well as the related characteristics of
definition and projection. Anatomically, tip width is the distance between highly defined tip
points, which is accentuated by concave rather than convex lateral crura. I will often mark
tip width and show it to the patient pre-op. It is the combination of excessive tip width and
lack of definition that leads most patients to request tip surgery. Palpation is important in
determining the rigidity of the alar cartilages and how well it will respond to tip suturing.
Level 1. Aesthetically, the tip-defining points are too wide (6-10m) and yet definition is
reasonable. The usual method of reducing tip width is the interdomal suture with optional
addition of a domal equalization suture. At the cartilage level, it is important to leave the
domes 3–4 mm apart. This is one reason to be careful in using a single unifying transdomal
suture, which can create a “monopoint” tip. On rare occasions, the anatomical cause is the
width of the abutting middle crura. This rare problem is corrected by excising cephalic crura
medially behind the domes and onto the middle crura.
Level 2. Aesthetically, these deformities are a combination of excessive width and lack of
definition. Visually, one tends to see a tip width approaching (14-18 m) with poor defini-
tion. Anatomically, it is associated with a smooth domal segment and a convex lateral crura.
These cases are easily treated with tip sutures beginning with the strut, domal creation, and
interdomal sutures. Next, any lateral crural convexities are corrected using the lateral crural
convexity suture. The tip position suture insures a supratip break. Add-on grafts can be added
to further refine the tip (Daniel, 2009).
Level 3. Major tip deformities represent a shift in how we perceive tip width aesthetically.
Often, the true tip is present, but our eye concentrates on a more lateral “pseudotip” produced
by the retrograde curvature of the lateral border of a convex lateral crura (20-24m). Often
these problems are further complicated by rigid cartilages or over projection. Tip suturing
runs the risk of creating a smaller version of the original and therefore the solution may be
domal excision plus a structured tip graft.
Tip Width

Tip Width
275
Fig. 8.3 (a) The wide tip, (b) Level 1, (c) Level 2, (d) Level 3

276
Chapter 8  
Primary Rhinoplasty: Decision Making
Analysis
A 35-year-old woman felt that her nose was too wide and deviated (Fig. 8.4). It was ­emphasized
to her that she had a significant asymmetric developmental deviation as opposed to a deviated
septum. Surface measurements were the following: intercanthal width (29.5), alar flare (32),
and tip width (25). Her tip width was within 4.5 mm of her intercanthal width – a truly wide
tip especially on oblique view. The profile indicated the third major problem – a very low
radix and bony dorsum. The critical step was to achieve an absolute reduction in tip width
toward the ideal and then to augment the dorsum until the nose was balanced. Extensive tip
suturing was done and then an add-on shield graft was added to produce a refined tip. The
patient was warned – better not perfect, very limited improvements possible.
(Level 3.0) Everything about this nose was difficult and every area required surgery.
Operative Technique
1) After the open approach, the alars were reduced to 6-mm wide rim strips.
2) Fascia and septal cartilage was harvested. Caudal septum relocated R to L.
3) Bilateral low-to-high osteotomies.
4) A 2.5-mm spreader graft was inserted on the L side only.
5) A crural strut was inserted followed by tip sutures: CSx2, DC, DE, ID, TP.
6) LCCSx2 were used on each side to reduce tip width followed by add-on graft.
7) Glabellar graft of DC + F inserted and then a DC – F graft (0.8 cc) for the dorsum.
8) Bilateral combined nostril sill/alar wedge resection.
9) Alar rim support grafts.
Case Study:
Wide Tip
Fig. 8.4 (a–j)

Case Study: Wide Tip
277
Fig. 8.4 (continued)

278
Chapter 8  
Primary Rhinoplasty: Decision Making
Interestingly, patients perceive of the “wide nose” at multiple points besides the tip – bony
width, dorsal width, and alar base width (Fig. 8.5). Width is two of the three reasons why
most patients seek a rhinoplasty: (1) a wide poorly defined tip, (2) a wide osseocartilaginous
vault, and (3) a prominent profile.
Decision-Making. Essentially, one must decide on the best type of lateral osteotomy to narrow
base bony width and whether any dorsal modification other than reduction is necessary. The
most common problems include the following: x-point width beyond the intercanthal line,
intrinsic convexity of the lateral walls, an excessively wide bony vault, or the combination
of a wide nose and normal profile height. Frequently, the wide base will require combined
nostril sill and alar base excision with the appropriate alar rim support grafts.
Level 1. As base bony width increases (x-points), transverse and low-to-low osteotomies be-
come the right solution. The ability to rotate a straight osteotome against the lateral nasal wall
while forcing the osteotome against the maxilla will insure definitive narrowing. As dorsal
reductions exceed 6 mm, the resulting open roof often extends above the intercanthal level.
In these cases, spreader grafts must extend high into the bony vault to avoid an inverted-V
deformity.
Level 2. One will encounter noses with a wide bridge at the osseocartilaginous junction,
which can become even more visible following dorsal reduction. The most effective way of
insuring parallel dorsal lines is the medial oblique osteotomy. A curved osteotome is placed
in the open roof and driven at 45° outward and downward. It is usually combined with a
low-to-low osteotomy to insure narrowing of the entire complex. Another common deformity
is the nose whose width is accentuated by convex lateral walls. A straightforward solution
is the “double level” osteotomy. Essentially, one is breaking the lateral nasal wall at its mid
portion and converting it from convex to straight or even slightly concave. It consists of
the following sequence: (1) a perforated type osteotomy using a 2 mm osteotome along the
fusion line of the nasal bone and the frontal process of maxilla, (2) a standard transverse
osteotomy, and (3) a low-to-low osteotomy.
Level 3. The most interesting deformity is the wide nose with normal height on profile.
­Essentially, one must narrow the dorsum without changing the profile. This challenge is eas-
ily solved by doing a paramedian narrowing of the dorsum. The technique is as follows: (1)
the dorsum is exposed through an open approach and extramucosal tunnels are made, (2)
the midline is marked, (3) the ideal dorsal width is marked on the osseocartilaginous vault
(5–8 mm), (4) paramedian cuts are made on the dotted lines along the cartilaginous vault up
to the keystone area), (5) these cuts are extended through the bone using a straight guarded
osteotome, (6) lateral osteotomies are done usually consisting of transverse and low-to-low
osteotomies, (7) after the infractures, the excessive height of the upper lateral cartilages are
trimmed (often 3–6 mm), and (8) the upper lateral cartilages can be sutured adjacent to or
underneath the T-shaped septum.
The Wide Nose

The Wide Nose
279
Fig. 8.5 (a) The wide nose, (b) Level 1, (c) Level 2, (d) Level 3

280
Chapter 8  
Primary Rhinoplasty: Decision Making
Analysis
A 20-year-old student requested a rhinoplasty because of her wide tip and unattractive nose
(Fig. 8.6). Of course, she wanted a thin narrow nose with a delicate tip. Further complicating
the analysis was that her profile was essentially ideal and thus the nose needed to be nar-
rowed without changing the profile. Controlled narrowing of the dorsum was done using
paramedian osetotomies, which were marked 2.5 mm from the midline and represented a
reduction from 19 to 5 mm at the keystone. Once all six osteotomies were completed, the ULC
rose 3 mm above the dorsum and had to be excised. Tip sutures plus a two-layer infralobular
add-on graft was effective at narrowing and triangulating the tip. ARS grafts were used to
change the nostril shape from round to tapered.
(Level: 3.0) Every anatomical component of this nose was wide and amorphous. The analysis
was complex and the surgical techniques were demanding.
Operative Technique
1) Harvest of fascia and septum.
2) Open approach with excision of the “scroll junction” only.
3) Minimal smoothing of the keystone area with a rasp.
4) Paramedian dorsal ostotomies 2.5 mm from the midline. Transverse and low-to-low
­osteotomies.
5) Three millimeter excision of overlapping ULC and suture fixation ULC to septum.
6) Cural strut and tip sutures: CS, DC, ID, DE. Two-layer shield-shape add-on graft.
7) Insertion of fascial radix graft and alar rim support grafts.
Case Study:
Wide Nose/Wide
Tip
Fig. 8.6 (a–j)

Case Study: Wide Nose/Wide Tip
281
Fig. 8.6 (continued)

282
Chapter 8  
Primary Rhinoplasty: Decision Making
Decision Making. Assessing projection often comes down to two factors: tip projection and
the ideal dorsal profile line. Tip projection is defined as the distance from alar crease to tip
(Fig. 8.7). It is composed of both intrinsic alar components and extrinsic influences from
the osseocartilaginous vault. For those who enjoy photographic analysis, it is very easy to use
Byrd’s (1993) ratios of measuring midfacial height (MFH) and then using two thirds of its
value for ideal dorsal length (N-Ti) and two thirds of N-Ti for ideal tip projection (AC-Ti).
Two angles are drawn: the tip angle from the alar crease and the nasofacial angle from the
ideal nasion. Where the two lines intersect determines tip projection, dorsal length, and
ideal dorsal profile. In most cases, I place the greatest weight on tip projection and tip angle.
Level 1. These cases are often a “strong nose” where one wants to drop overall projection by
2–3 mm and the etiology is primarily extrinsic. Essentially, the tip is stretched outward on the
dorsum and caudal septum. Thus, incremental dorsal reduction achieves the ideal profile line
and drops both nasal and total tip projection. Additional subtle reductions in tip projection
can be achieved by bilateral transfixion incisions (a loss of an additional 1–1.5 mm).
Level 2. These cases represent a challenge as the amount of deprojection is greater (3–6 mm),
and the etiology is often combined. My goal is to eliminate the extrinsic forces (dorsum)
first, which defines the remaining intrinsic (tip) component. The dorsum/radix is lowered
appropriately until the ideal profile line is obtained. Then, the caudal septum/ANS is usually
resected. At this point, all of the external forces, which influence the tip have been eliminated
and one must reassess the operative plan. Can I drop tip projection using segmental exci-
sions of lateral crura or do I need to excise the domes? In Level 2 cases, I create the ideal tip
configuration with sutures and then reduce tip projection with segmental excision of the
lateral crura. Isolated excisions of middle crura are not done as they are extremely destabi-
lizing and fraught with complications.
Level 3. In these cases, the overprojection is quite great (>6 mm) and the intrinsic factors are
significant including deformities of the alar cartilages. In these cases, suture modification
is virtually impossible, and I prefer an open structure tip graft. The excess cephalic lateral
crura is excised and then a cural strut is inserted. Next, a point 6–7 mm above the columel-
lar breakpoint is marked. A transverse cut is made through the middle crura and the lateral
component is undermined submucosally. An appropriate domal segment is excised (4–8 mm),
which drops projection dramatically. The domal excision is closed with 5-0PDS. A tip graft
is fashioned and then sutured into place. This is a very flexible operative technique and has
worked well in cases requiring up to 12 mm of tip deprojection.
The Over
­Projecting Nose

The Over ­Projecting Nose
283
Fig. 8.7 (a–d) The over projecting tip. (a) analysis of tip projection, (b) Level 1, (c) Level 2, (d) Level 3
a
x - overprojection
x’ - underprojection
Ti
Ti
AC
AC
AC
C’
Total projection
Overprojection
Increased intrinsic
projection
x
x
x’

284
Chapter 8  
Primary Rhinoplasty: Decision Making
Analysis
This 5’ 7” patient wanted a significantly smaller nose. Lateral photographic analysis indicated
that a 10-mm tip deprojection would be necessary (Fig. 8.7d). Surgically, the choice is – Can the
tip be set back using lateral crural excision or do the domes need to be excised? This case was
done in sequential fashion. First, the extrinsic forces were eliminated by reducing the dorsum
and shortening the caudal septum (Fig 8.8 a, b). Second, careful alar analysis indicated that lateral
segment excision would not be adequate and thus a domal excision would be required (Fig 8.8 c).
Therefore, a direct 6 mm excision of the middle crura was done to drop projection. (Fig 8.8 d)
Third, tip creation was necessary using a shield-shape graft plus a cap graft. The overall tip
reduction approached 10 mm (Fig. 8.8).
(Level: 3.0) This was truly a functional reduction – eliminating the extrinsic forces first then
the intrinsic. The difficulty was the magnitude of the reductions.
Operative Technique
1) A closed-open approach. Dorsal reduction (bone 1.5, cartilage 7).
2) Caudal septal excision of 5 mm.
3) Open approach and reduction of alar cartilages to 6 mm.
4) Harvest of septal body. Low to high osteotomies.
5) Insertion of spreader grafts.
6) Insertion of columellar strut. A 6-mm middle crura excision 6 mm above the columellar
breakpoint.
7) Insertion of a shield-shape tip graft and cap graft.
8) Closure of all incisions and nostril sill excision.
9) A unilateral left ARG.
Case Study:
­Overprojecting
Tip
Fig. 8.8 (a–l) Extrinsic factors (a, b), intrinsic factors (c, d)

Case Study: ­Overprojecting Tip
285
Fig. 8.8 (continued)

286
Chapter 8  
Primary Rhinoplasty: Decision Making
Decision Making. Inadequate tip projection is often a spectrum ranging from an attractive
tip with a slight deficiency to the more common problem of a wide depressed tip (Fig. 8.9).
The underprojecting tip is usually caused by weak splayed alar cartilages ensheathed in thick
skin. There is intrinsic weakness of the alar cartilages in contrast to the over projecting tip
where extrinsic forces often dominate. Therefore, the critical factor is to provide structure to
the alar cartilages and progress to rigid tip grafts as necessary. In the underprojecting nose,
the dorsum is rarely a factor except in the ethnic nose where dorsal augmentation with a
DC-F dorsal graft is the solution.
Level 1. The majority of these tips can be improved dramatically using a columellar strut and
tip suture technique. The strut should be sufficiently long (20 mm) to provide support. Once
the strut is in place, the alars are elevated and turned 90° before fixing with a #25 needle.
This maneuver insures lengthening of the infralobule. The crural strut suture stabilizes the
tip unit. The dorsal position suture often adds 2–3 mm of projection and creates the supratip
set-off, which accentuates projection. One can also add a septocolumellar suture through the
transfixion incision to get an additional 1 mm of height.
Level 2. When extensive suturing has been done or the alar cartilages are so hypoplastic to
preclude an attractive intrinsic tip, then “add-on” grafts are used to achieve the desired tip.
The important distinction is that these grafts add volume as well as refinement. The most
frequent grafts are composed of excised alar cartilage. The configuration is often either a
combination of a shield graft with a cap graft, or a “folded” tip graft. The goal is to fine-tune
the projection, definition, and volume of the intrinsic tip. The most dramatic application is
in patients with a large nostril/small tip disproportion.
Level 3. In major cases, one often has the worst of all worlds: an unattractive tip with flat
splayed alar cartilages ensheathed in thick skin. The solution requires structure using a
columellar strut and tip graft. Often, it is necessary to defat the skin envelope in a conserva-
tive manner. The columellar strut must be quite long (25 mm), wide at the columella labial
area (4–6 mm), and very rigid. The alars are stretched vertically on the strut and fixed at 1–2
points. Then, domal creation sutures are inserted. The tip graft is placed in position higher
than the domes. One can achieve an additional 2–3 mm of projection depending upon how
the tip graft is sutured to the middle crura. The shape of the graft and the sharpness of its
edges will be dictated by skin thickness. A cap graft is placed across the domes behind the
tip graft. A cap graft is mandatory to avoid backward curling of the tip graft and loss of
projection.
Underprojecting
Nose

The Underprojecting Tip
287
Fig. 8.9 The underprojecting nose. (a) Analysis of tip projection, (b) Level 1, (c) Level 2, (d) Level 3
a
x - overprojection
x’ - underprojection
Ti
Ti
AC
AC
AC
C’
Total projection
Underprojection
Decreased intrinsic
projection
x
x’
x’

288
Chapter 8  
Primary Rhinoplasty: Decision Making
Analysis
A 17-year-old student presented with a succinct complaint –“I hate my tip.” Since the dorsum
would be lowered minimally, it would be necessary to add volume and projection to the tip
(Fig. 8.10). The tip was wide, downwardly rotated, hypoplastic, and intrinsically underproject-
ing. The columellar strut provided projection and prevented drooping postoperatively. The
dorsal reduction was minimal and no spreader grafts were required. The interdomal suture
narrowed the tip. The double-layer add-on graft provided intrinsic projection, tip volume,
and domal definition. The triangulation of the tip is evident on basilar view. The power of
TRG grafts should not be under estimate (Daniel, 2009).
(Level: 2.0) A classic example of “how the tip goes, so goes the rhinoplasty.”
Operating Technique
1) Open approach with alar cartilage analysis.
2) Dorsal reduction (bony 0.2 mm, cartilage < 1.0 mm).
3) Harvest of septum and temporal fascia.
4) Low to high osteotomies. Insertion of radix fascial graft.
5) Insertion of crural strut and tip sutures: CS, DC, ID, DE.
6) Double layer domal add-on graft (6 × 3 mm).
7) ARS grafts to lower alar rims.
Case Study:
Under
Projecting Tip
Fig. 8.10 (a–j)

Case Study: Under Projecting Tip
289
Fig. 8.10 (continued)

290
Chapter 8  
Primary Rhinoplasty: Decision Making
Decision Making. Tips can be in downward rotation due to either extrinsic factors (extended
caudal septum/ANS) and/or intrinsic factors (a long lateral crura or a long middle crura) (Fig.
8.11). Although everyone recognizes a long nose, it can be extremely difficult to classify. The
first step in analyzing the long nose is to mark both the current nasion (N) and ideal nasion
(Ni). The three distal points are marked (T, C′, SN) and measured. Obviously, N-T is dorsal
length and the ideal N-Ti = .67xMFH. In general, N-SN is longer (5–6 mm) than N-T, whereas
N-C′ is about 2 mm shorter than N-SN. Whenever N-C′ is longer than N-SN, then a hanging
columella is present. The key factor is how “crowded” is the upper lip by the nose and will
shortening of the caudal septum result in a long upper lip?. Also, assessment in static and
smiling positions is required as well as palpation. Clinically, I classify downwardly rotated
tips based on their severity into dependent, plunging, and plunging “plus.”
Level 1. Most relatively long noses with downwardly rotated tips can be corrected by the
following sequence: (1) excision of excess cephalic lateral crura, (2) conservative resection
of caudal septum (3–4 mm) and occasionally the ANS, (3) tip suture including tip position
suture for rotation and projection. Judicious excision (2–3 mm) of caudal border of the upper
lateral cartilages can be considered.
Level 2. When suturing is not enough, then segmental excision of the lateral crura is added.
For upward rotation, a cephalically based triangle is excised approximately 10 mm from
the dome. The cephalic base is about 5 mm and tapered to the caudal rim either as a true
triangle or 1–4 mm to also drop projection. The edges are then brought together with 5-0
PDS. I think that sutures from lateral crura to upper lateral or septal cartilage are very risky
and not recommended.
Level 3. In certain cases, an open structure tip is the only solution including a domal segment
excision, which includes the intrinsic deformity of the alar cartilage. The excised edges are
repaired with 5-0 PDS and then an open structure tip graft is added.
Note: A relatively rare cause of the downwardly rotated tip in primary cases is caused by
retrusion of the lower caudal septum/ANS (see Fig. 8.12). It is indicated clinically by an acute
columella labial angle and a downward inclination of the columellar, especially in the older
patient. Careful examination including palpation is critical. Correction requires insertion
of a major columella strut to push down the columella as well as the SN point. The result is
conversion of the columellar labial angle from acute to smoothly tapered. One can also add
plumping grafts to the SN area.
Downward
Rotating Long
Nose

Downward Rotating Long Nose
291
Ti
Ti - 105°
T - 85°
Ti
Ni
a
N
C’
C’
SN
SN
AC
Fig. 8.11 (a) Long downwardly rotated nose, (b) Level 1, (c) Level 2, (d) Level 3

292
Chapter 8  
Primary Rhinoplasty: Decision Making
Analysis
A 55-year-old woman sought improvement in her appearance, especially her nose. Obviously,
the nose would need to be made smaller, but the real challenge would be the plunging tip
on profile (Fig. 8.12). This deformity is emphasized by the retracted columellar. One must
understand different concepts of the “long nose.” The surgical procedure effectively short-
ened the nose as measured at N-T, but lengthened it at N-SN. The tip angle was raised from
90° to 100° and the columellar labial angle was raised from an acute 80°. A “teeter totter”
approach was used – a major columellar strut pushing down the columellar labial segment
and a tip position suture rotating the tip upward. To further reduce the signs of aging, a
lower lid blepharoplasty and chin implant were done.
(Level 2.0) The analysis and operative planning were critical, while the actual surgery was
straight forward except for the essential 7 mm wide columellar strut.
Operative Technique
1) A medium chin implant and lower lid bleph were done. Fascia was harvested.
2) Open approach with reduction of alars to 6 mm rim strips.
3) Incremental dorsal reduction (bone: 1.5 mm, cartilage 7.5 mm).
4) A 1 mm upper caudal septal resection followed by septal harvest.
5) Low to high ostotomies followed by spreader graft insertion.
6) Insertion of a structured columellar strut measuring 7 mm at CLA.
7) Tip suturing: CS, DC, DE, DP.
8) Insertion of combined “ball & apron” radix/dorsum fascia graft (F).
9) Alar wedge excision of 3.5 mm and ARG grafts to nostril rims.
Case Study:
Downward
Rotation
Fig. 8.12 (a–j)

Case Study: Downward Rotation
293
Fig. 8.12 (continued)