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

Upwardly Rotatal Tip
295
Fig. 8.13 Short upwardly rotated nose. (a) Analysis, (b) Level 2, (c) Level 3, (d) Level 4
Ti
110°
Ti
Ni
N
C’
C’
SN
SN
AC
a

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Analysis and Commentary
A 6’ 4” contractor complained that his nose was too turned up and everyone looked up his
nostrils (Fig. 8.14). This was his natural nose, no prior trauma. Based on photo analysis, the tip
angle needed to be derogated from 115° to 95° and the dorsum lengthened from 37 to 45 mm.
A septocolumellar graft was used to lengthen the nose and provide a strong support for the
heavy soft tissue envelope. A major radix/dorsal graft with DC beneath it elevated the root
of the nose. This balanced approach resulted in correction of this very difficult problem.
(Level 3.0) Everything was difficult and reminded me of a cleft lip nose where major septo-
columellar grafts are essential.
Operative Technique
1) Tip analysis showed a severe inward folding of a concave domal segment. Only a 3-mm
scroll was excised.
2) Keystone area smoothed (<0.5 mm) and minimal cartilaginous excision (1.5 mm).
3) Insertion of a 22 × 15 mm septocolumellar graft.
4) Addition of a 25 × 8 mm pennant graft for a dorsal lengthening of 15 mm along the dorsal
plane.
5) Advancement and suture fixation of the alar cartilages to pennant columellar strut.
6) Major radix/dorsal half-length graft with DC boost.
7) Combined nostril sill/alar wedge excisions.
Case Study:
Short Upwardly
Rotated Nose
Fig. 8.14 (a–l)

Case Study: Short Upwardly Rotated Nose
297
Fig. 8.14 (continued)

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Abnormal tip shapes present a major challenge for the rhinoplasty surgeon, both technically
and analytically (Fig. 8.15). Accurate definitions are impossible as the identical tip is consid-
ered by one surgeon to be bulbous, while another considers it boxy. These two sections will
attempt to distinguish these tips based upon their intrinsic anatomy, external valve support,
and surgical treatment.
Broad Tip. This is most easily distinguished on oblique view where the sheer volume of the
tip of the alar cartilages is apparent. Anatomically, the domal segment is flat and continues
into a broad convex lateral crura. Aesthetically, one is seeing the tip-defining points not at
the domes, but rather at lateral crura convexities. The critical surgical steps within the tip
suture technique are as follows: (1) decrease volume by cephalic lateral crura excision, (2)
increase domal definition with domal creation sutures, and (3) decrease crural convexities
with lateral crural mattress sutures. This approach is highly effective and represents a normal
extension of Level 1 tip surgery to Level 2 cases.
Ball Tip. This is most easily diagnosed on anterior view as the lateral border of the alar
cartilages gives the tip a circular or ball appearance.. Anatomically, the tip-defining points
are on the lateral crura near the scroll formation, and not at the domes. Many ball tips can
be sutured with LCCS being effective provided the lateal crus is malleable. If the alars are
quite rigid or overprojected, then an open structure tip graft with domal segment excision
is necessary. Once the columellar strut is sutured into place, the line of excision is marked
6–7 mm above the columellar breakpoint. There are three possible locations for the segmental
excision: vertical to reduce projection, central to reduce projection and width, and lateral to
primarily reduce width. Excising the domal segment eliminates the broadness of the lateral
crura, while the open structure tip graft creates new tip-defining points.
Bulbous Tip. This is evident on any view as the tip looks like a “blob” due in large part to
a very large thick skin envelope. There is no evidence of any underlying anatomy or any
aesthetic tip characteristics. The first step is to make sure that the patients understand their
anatomical limitations and accept a limited improvement. Surgically, the first step is to thin
the soft tissue envelope. Infracartilaginous incisions are made and the lobular skin is elevated
in the subdermal plane. Then, the skin envelope is elevated from the transcolumellar incision.
The entire intermediate fibrofatty layer is elevated off the underlying alar cartilages. Second,
a major structural columellar strut is inserted between the alars, which are advanced upward
under tension and fixed with #25 needles. Usually, two crural strut sutures are used – one
below and one above the columellar break point. The domes and lateral crura are modified as
necessary. Third, a full-length structure tip graft is inserted, usually in the projected position
with a supporting cap graft. One is doing everything to create “tip show” through thick skin.
Often, a 7Fr drain will be inserted to shrink wrap the skin around the new tip.
Broad, Ball, and
Bulbous Tips

Broad, Ball, and Bulbous Tips
299
a
Fig. 8.15 (a) Broad, ball, bulbous tips, (b) broad, (c) ball, (d) bulbous

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Chapter 8  
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Analysis
An executive requested an aesthetic rhinoplasty, which would reduce her ball tip (Fig. 8.16).
She had no respiratory complaints. Her alar cartilages were quite rigid while her alar side
walls were quite weak. When asked to take a deep nasal inspiration, her external valves col-
lapsed. The alar cartilages were massive and no matter how much suturing could be done,
the tip would still look like a “ball.” Direct excisions removed the deformed domes and nar-
rowed the tip significantly. The concealer tip graft covered the suture repair and prevented
the show of any edges. The lateral crural strut grafts were sutured to the caudal border of
the lateral crura and then along true rim incisions to prevent external valve collapse. At one
year postop, the patient breaths well without nostrill collapse, but the vascular blush on her
columellar remains unchanged from pre operative status.
(Level 3.0) Domal excision and concurrent lateral crural strut grafts are demanding technical
maneuvers. A true form and function case.
Operative Technique
1) Open approach and septal exposure.
2) Dorsal reduction (bone: smooth, cartilage 2 mm), caudal septum 2.5 mm.
3) Septal body harvest.
4) Low to high osteotomies and spreader grafts.
5) Columellar strut Creation 6 mm rim strips.
6) Domal segment excisions 6 mm above columellar breakpoint (R 4.5 mm, L 6 mm). Repair
of excisions with 5-0 PDS (see Fig. 8.17c for intraop).
7) Diamond shape concealer tip graft of excised alar cartilage.
8) Lateral crura strut grafts (T 3) sutured into a marginal rim incisions.
Case Study:
Ball Tip
Fig. 8.16 (a–j)

Case Study: Ball Tip
301
Fig. 8.16 (continued)

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Chapter 8  
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These tips are characterized by a lack of support for the external valve due in large part to
a cephalic displacement of the lateral crura away from the nostril rim (Fig. 8.17). Cartilage
grafts are essential to provide nostril rim support.
Boxy Tip. This is most easily diagnosed on basilar view, where the basilar perimeter is square
and the nostril rim is concave rather than straight or convex. The alar cartilages can be highly
variable, ranging from splayed small alars to wide rigid ones requiring excision. Once the
tip surgery is completed, cartilage grafts are used to support the nostril rim. ­Although, alar
rim grafts (ARG) are simpler these cases most often require alar rim support grafts (ARS).
These grafts are ideally made of septal cartilage and measure 14 × 3 mm with a tapered
cephalic end. Due to severe weakness of the external valve, I will frequently make a true
rim incision 2 mm behind the nostril rim. The cephalic skin is undermined, but the nostril
rim is never unfurled. The dissection continues laterally into the alar base. The thick end
of the graft is inserted into the alar base pocket and then the graft is sutured at two points
along the alar rim. A final check is made of the cephalic end of the ARS to insure that it
is not overlapping the alar cartilages. Nostril splints will be used at night for 1–2 weeks to
maintain the desired shape.
Alar Malposition (AMP). These cases represent a triad of anatomical and aesthetic problems:
a parenthesis tip deformity, large abnormally shaped nostrils, and collapsible external valves.
Defining alar malposition is difficult and many surgeons simply say that they “recognize it
when they see it.” The problem is that in thick skin patients, AMP can be present without any
visible stigmata. Sheen defined AMP as “any displacement of the lateral cura from the usual
parallel alignment with the nostril rims … most often the caudal edge of the lateral curs is
parallel to the alar rim for half the length of the nostril.” In a series of 50 primary rhinoplas-
ties, I measured the distance of the lateral crura away from the midpoint of the nostril and
found that 7 mm appeared to be the critical distance. Often, this simple measurement is all
that is needed to suggest a diagnosis of AMP.
In severe cases, surgical treatment requires alar transposition plus lateral cural strut
grafts. On several occasions, I have sutured an AMP in situ and found no change in the aes-
thetic deformity once the skin was redraped. Elevating the alar off the underlying mucosa
is critical in making a permanent change in the tip deformity. The following surgical tip
sequence is recommended: (1) reduce the lateral crua to 6-mm wide rim strips, (2) elevate
the lateral crura off the underlying mucosa, (3) insert and suture the columellar strut, (4)
tip refinement with either tip sutures or a structured tip graft depending upon the degree of
overprojection, (5) attachment of lateral crural strut grafts, (6) temporary skin closure, (7)
alar base excisions as indicated, (8) definitive placement of the lateral cura strut grafts usually
along the rim (Type 3), and (9) closure and insertion of short temporary nostril sill splints.
The patient will use nostril sill splints for 2–3 weeks while taping at night. Tip overprojection
is quite real and domal excision plus a structured tip graft may be necessary. In thin skin pa-
tients, a “fascial blanket” will be used to cover the entire tip. One should never underestimate
the difficulty of these cases.
Boxy Tip and
Alar Malposition

Boxy Tip and Alar Malposition
303
a
b
Fig. 8.17 (b) Treatment of Alar malposition using Alar transposition plus LCSG T3 
Fig. 8.17 (a) Normal anatomy, Alar malposition, and over lap.
Fig. 8.17 (c) Intraop photos of Alar transposition plus LCSG T3

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Analysis
A 31-year old woman presented with a most unusual and severe triad of nasal tip deformi-
ties (Fig. 8.18). The tip was overprojected with a boxy configuration and alar malposition.
Further complicating the challenge was her significant long face syndrome. Obviously, she
should have had a LeForte II and mandibular advancement, but she was not interested. She
did agree to a large chin implant. The basilar view of this patient confirmed the severity of
the boxy deformity and nostril rim weakness. Since alar transposition and lateral crural strut
grafts were planned, the normal open approach was altered. True rim incisions were made
rather than the conventional infracartilaginous incisions. Undermining of the lateral crura
allowed the tip to be fundamentally changed. This was a very aggressive tip operation for a
very severe tip deformity, which produced a profound change in the nostril shape.
(Level 3.0) Perhaps the most difficult primary tip imaginable – consisting of an aesthetic
deformity, overprojection, alar malposition, and external valve collapse.
Operative Techniques
1) Confirmation of pre-op alar malposition (10/19).
2) Open exposure using true rim incisions rather than infracartilaginous incisions.
3) Dorsal reduction (bone: 1 mm, cartilage: 5 mm). No caudal septal or ANS excision.
4) Septal harvest. Low to high osteotomies.
5) Creation of rim strips 6 mm in width. Release and transposition of the lateral crura.
6) Insertion of crural strut. Domal excision to drop projection 5 mm. Repair of excision.
7) Open structure tip graft of septal cartilage.
8) Suturing of lateral crural strut graft to lateral crura.
9) Out fracture of turbinates.
Case Study: Alar
­Malposition
Fig. 8.18 (a–j)

Case Study: Alar ­Malposition
305
Fig. 8.18 (continued)

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Primary Rhinoplasty: Decision Making
Byrd HS, Hobar PC. Rhinoplasty: a practical guide for surgical planning. Plast Reconstr Surg
91: 642, 1993
Byrd HS, Andochick S, Copit S, Walton KG. Septal extension grafts: a method of controlling
tip projection shape. Plast Reconstr Surg 100: 999, 1997
Cole P. Nasal and oral airflow resistors. Arch Otolaryngol Head Neck Surg 1: 18, 1992
Constantian M. The boxy nasal tip, the ball tip, and alar cartilage malposition: variations on
a theme – a study in 200 consecutive primary and secondary rhinoplasty patients. Plast
Reconstr Surg 116: 268, 2005
Constantian MB. Functional effects of alar cartilage malposition. Ann Plast Surg 30: 487,
1993a
Constantian MB. Experience with a three-point method for rhinoplasty. Ann Plast Surg 30:
1, 1993b
Constantinides M, Adamson PA, Cole P. The long-term effects of open cosmetic septorhino-
plasty on nasal air flow. Arch Otolaryngol Head Neck 122: 41, 1996
Daniel RK. Rhinoplasty: Creating an aesthetic tip. Plast Reconstr Surg 80: 775, 1987
Daniel RK. Anatomy and aesthetics of the nasal tip. Plast Reconstr Surg 89: 216, 1992
Daniel RK. Analysis and the nasal tip. In: Daniel RK (ed) Aesthetic Plastic Surgery: Rhino-
plasty. Boston, MA: Little, Brown, 1993
Daniel RK. Rhinoplasty: nostril/tip disproportion. Plast Reconstr Surg 107: 1874, 2001
Foda HM. Management of the droop tip: a comparison of three alar cartilage – modifying
techniques. Plast Reconstr Surg. 112: 1408, 2003
Gorney M. Patient selection rhinoplasty: practical guidelines. In: Daniel RK (ed) Aesthetic
Plastic Surgery: Rhinoplasty. Boston, MA: Little, Brown, 1993
Gunter JP, Rohrich RJ. Lengthening the aesthetically short nose. Plast Reconstr Surg 83: 794,
1989
Gruber RP, Friedman GD. Suture algorithm for the broad or bulbous nose. Plast Reconstr
Surg 110: 1752, 2002
Guyuron B. Precision rhinoplasty. Part 1: The role of life-size photographs and soft tissue
cephalometric analysis. Plast Reconstr Surg 81: 489, 1988
Johnson CM, Toriumi DM. Open Structure Rhinoplasty. Philadelphia, PA: W.B. Saunders,
1990
Peck GC. Techniques in Aesthetic Rhinoplasty, 2nd ed. Philadelphia, PA: JB Lippincott, 1990
Rees TD, La Trenta OS. Aesthetic Plastic Surgery, 2nd ed. Philadelphia, PA: W.B. Saunders,
1994
Rorhrich RJ, Adams WP Jr. The boxy nasal tip: classification and management based on alar
cartilage suturing techniques. Plast Reconstr Surg 107: 1849, 2001
Sheen JH. Spreader graft revisited. Perspect Plast Surg 3: 155, 1989
Sheen JH, Sheen AP. Aesthetic Rhinoplasty, 2nd ed. St. Louis, MO: Mosby, 1987
Tardy ME. Rhinoplasty: The Art and the Science. Philadelphia, PA: W.B. Saunders, 1997
Tebbetts JB. Shaping and positioning the nasal tip without structural disruption: a new sys-
tematic approach. Plast Reconstr Surg 94: 61, 1994
Toriumi DM. Structural approach to primary rhinoplasty. Aesthetic Surg J 22: 72, 2002
Reading List

What constitutes a difficult rhinoplasty? Traditionally, the answer is whatever ­rhinoplasty
you are doing at that moment, or any operation that pushes you beyond your comfort zone.
Objectively, I think the major differences between Level 2 and 3 cases are the following: (1)
severity of deformity, (2) complexity of operative technique, and (3) requirement for intraop-
erative flexibility. Essentially, these cases mandate that something be done to all parts of the
nose. One must modify and integrate the entire nose rather than simply lower the profile or
refine the tip. The operative plan is often complex consisting of a myriad number of grafts,
infrequently performed techniques, and asymmetric design. Intraoperative findings may
require one to make major changes in the original plan. How does one progress from Level
2 to Level 3 cases? For many surgeons, it is the challenge of ethnic rhinoplasties which can
have a spectrum of deformities that range from Level 2 to Level 3. Also, one will on occasion
realize intraoperatively that the problems are greater than anticipated thereby increasing the
grade from Level 2 to Level 3. When first entering practice, 33% of your rhinoplasty consults
may appear to be Level 3 cases. As your gain experience and your comfort zone expands,
the percentage of Level 3 cases will decrease. Ultimately, you will enjoy the challenge and
the technical demands of these cases.
Introduction
Advanced
Primary
Rhinoplasty9

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Chapter 9  
Advanced Primary Rhinoplasty
In contrast to posttraumatic cases, the asymmetric nose is often developmental in origin and
thus the component parts are anatomically dissimilar (Fig. 9.1). These observations must be
pointed out to the patient preoperatively using a mirror and emphasizing that only a “limited
improvement” is realistic. Equally, a careful internal exam must be done as septal deviation
and internal valve collapse are common.
Localized. Although slight discrepancies may be present in the bony and alar bases, the most
obvious asymmetry is usually in the dorsal lines and tip. The dissimilarity may begin at the
junctional “bumps” of the osseocartilaginous vault, be accentuated along the dorsum, com-
pounded by a concavity/convexity contrast of the two upper lateral cartilages, and further
highlighted by juxtaposition of a concave upper lateral cartilage and a convex lateral crura.
For minor and moderate deformities, asymmetric spreader grafts are often a judicious solu-
tion coupled with the usual dorsal reduction and cephalic lateral crura resection.
Generalized. Approximately 25% of my cosmetic rhinoplasty patients have some degree
of Asymmetric Developmental Deviated Nose (ADDN). I coined this term to distinguish
­developmental from posttraumatic deviations. In these cases, there is no history of significant
nasal trauma. Virtually the entire face and nose have significant differences: usually a vertical
and angular side of the nose while the face has a stronger/wider side versus a weaker/longer
side. The most common combination is an angular wider nasal half on the short wide facial
side and a vertical narrow nasal half on the long narrow facial side. If these discrepancies
are pointed out preoperatively with the patient holding a mirror, there will be far fewer
complaints postoperatively.
As regards the asymmetric nose, any underlying septal deviation is corrected first.
­Individual operative steps are modified to adjust for the asymmetries: (1) quantitative differ-
ences in resection, (2) unilateral steps, and (3) opposite procedures. For example, quantitative
differences would be a combined alar base resection in which a 2.5 mm resection was done
on one side and 3.5 mm on the other. A unilateral maneuver would be an onlay graft over the
upper lateral cartilage on the concave side with nothing done contralaterally. An opposite
procedure is rarely performed, but an example would be an out-fracture on the concave side
and an in-fracture on the convex side.
Major tip asymmetries are very difficult and one begins from the crural strut insertion
upward. Again, sutures followed by concealer tip grafts are the first choice. Frequently, lateral
crural strut grafts will be placed beneath concave or distorted lateral crura. In worst case
scenarios, it is necessary to excise the domes and insert an open structure tip graft.
Asymmetric
Nose and Tip

Asymmetric Nose and Tip
309
Fig. 9.1 (a) Asymmetric nose, (b) asymmetric nose/asymmetric face, (c) asymmetric developmental deviated nose (ADDN)

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Chapter 9  
Advanced Primary Rhinoplasty
Analysis
A 28-year old requested correction of her deviated nose and nasal obstruction. There was
no previous trauma (Fig. 9.2). A diagnosis of severe asymmetric developmental deviated
nose (ADDN) was made with its severity noted by the deviated philtral columns. The ana-
tomical obstruction included septal deviation to the left with blockage of the internal valve
plus turbinate hypertrophy. Aesthetically, she simply wanted the nose straighter, her dorsum
lower, and a slight reduction in tip volume. A closed approach was planned. The unplanned
conversion from closed to open was an intraoperative necessity to deal with a septal disjunc-
tion. Sandwiching the septum between spreader grafts and upper lateral cartilages provided
rigid support and prevented postoperative saddling. At 1 and 7 years post-op, the patient has
retained both nasal support and normal respiration.
Operative Techniques
1) Closed approach with volume tip reduction
2) Septal exposure with creation of extramucosal tunnels
3) Incremental dorsal reduction (bone: 2 mm, cartilage: 4 mm)
4) Caudal septal shortening (5 mm). Septal harvest. Caudal septal relocation L to R
5) Attempt to straighten bony septal deviation results in disjunction between the bony and
cartilaginous septum
6) Conversion to an open approach
7) Stabilization of septum with spreader grafts and five-layer suture fixation
8) Low-to-high osteotomies
9) L 2.5 mm nostril sill excision. Alar rim graft (ARG) on left
10) Bilateral partial inferior turbinectomy including bone on L
Case Study:
Asymmetric
Deviated Nose
Fig. 9.2 (a–k) ADDN nose, (a) preop, (b) 1 year postop, (c) 7 years postop

Case Study: Asymmetric Deviated Nose
311
Fig. 9.2 (continuned)

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Chapter 9  
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The posttraumatic deviated nose is exceedingly complex. One must be skilled with both
complex septal surgery and multiple techniques for modifying the osseocartilaginous vault.
A detailed history is obtained of the accident, age at injury, initial surgical treatment, and
any follow-up procedures, as well as current problems. In general, I classify them externally
into three types: straight line, C-shape, and S-shape. I do not hesitate to get CT-scan of the
nose to help sort out the residual deformity of the nose.
Straight Line. These deviations are often related to underlying septal deviation culminating
in caudal septum/anterior nasal spine (ANS) displacements to one side (Fig. 9.3a–d). They
are the epitome of Cottle’s dictum that “as the septum goes, so goes the nose.” Essentially,
standard techniques with emphasis on caudal septum relocation should yield a good result.
These cases are very similar to ADDN.
C-Shape. The C-shape nose requires separate analysis of both the bony and cartilaginous
vaults as well as the septum. Essentially, one must decide on the types of osteotomies and
how severe the cartilaginous deformity is. If any reduction is planned, it is done prior to the
septal work. It is important to detach the upper lateral cartilages and then individually adjust
each upper lateral. Once the profile line is set, then the definitive septal work is performed.
Lateral osteotomies are done as indicated. Osteotomies may facilitate outward repositioning
of the inwardly displaced side. Often, the laterally deviated side will rise above the profile line
and require additional lowering. The cartilaginous vault is then corrected beginning with
straightening and reinforcement of the L-shape septal strut with asymmetric spreader grafts.
S-Shape. The S-shape nose is a step up in complexity with the bony vault on one side, the
cartilaginous vault pushed to the opposite side, and then caudal septum crossing back to
the opposite side; hence a double cross of the midline (Fig. 9.3e–h). Certain variations from
the C-shape nose must be considered. First, the septal problems can be extraordinarily
challenging and a total septoplasty is often warranted. The bony vault may well require
asymmetrical rasping; more on the long angulated side, less on the short vertical side. Asym-
metrical osteotomies are often necessary with two low-to-low osteotomies to shorten the long
angulated side and a double-level out-fracture to correct the fixed concave lateral wall in the
cartilaginous vault. Following removal of the total septum, an L-shape septal replacement
graft is inserted. The reinserted L-shape graft is stabilized by the appropriate application of
spreader grafts for the dorsal component and fixation to the ANS for correct alignment of
the caudal component. A columellar strut will support the alars above the dorsal line and
provide the desired tip projection. I do no advocate supporting the alars on the L-shape
replacement graft.
Posttraumatic
Nose

Posttraumatic Nose
313
Fig. 9.3 (a-d) Deviated nose, straight line deviation
Fig. 9.3 (e-h) Deviated nose, S-shape deviation

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Chapter 9  
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Analysis
This patient had a severe nasal deformity following trauma in early childhood with ­possible
extension onto the left maxilla (Fig. 9.4). The nasal obstruction was quite sever. The septum
was collapsed longitudinally wiping out all support from the caudal septum. The destruction
of the septum precluded doing a total septoplasty and left a rib graft as the only method of
obtaining structural graft material. The extended spreaders and septal strut restored support
to the nose. The columellar strut and multiple tip grafts allowed the tip to project above the
dorsum which was reconstructed with DC-F. The double-level osteotomies narrowed the
nose effectively.
Operative Techniques
  1) Septal exposure with confirmation of extensive destruction.
  2) Harvest of cartilaginous portions of the eighth and ninth ribs.
  3) Open approach with bidirectional approach to the septum. The entire cartilaginous sep-
tum was excised leaving a 15 mm long by 10 mm high dorsal portion.
  4) Transverse and double-level osteotomies.
  5) ANS exposed via a gingival incision and a drill hole placed.
  6) Foundation layer inserted: septal strut fixed to ANS, extended spreader grafts fixed to
bony vault, and a “step off” fixation between spreaders and septal strut.
  7) Columellar strut insertion and suture fixation. Tip grafts: shield and cap.
  8) DC-F graft (0.6) to the dorsum.
  9) Major alar batten grafts to alar rim.
10) DC (4.0 cc) grafts to peripyriform and L maxilla.
Case Study:
Posttraumatic
Nose
Fig. 9.4 (a–m)

Case Study: Posttraumatic Nose
315
Fig. 9.4 (continued)

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Chapter 9  
Advanced Primary Rhinoplasty
Dorsal/Base Disproportion
In analyzing cases with disproportions, it is important to realize that either component can
be in excess while the other is either normal or deficient (Fig. 9.5). The fundamental treat-
ment principle is Sheen’s adage of “reduce where the structure is excessive, and augment
where it is deficient.” Although used within the context of secondary supratip deformities,
this balanced approach is ideal for primary cases where the base is large and the dorsum is
normal or hypoplastic. Although relatively rare in Caucasian primaries, it is the fundamental
deformity in many ethnic rhinoplasties. Sequentially, one reduces the base as much as pos-
sible and then augments the dorsum until the ideal profile is achieved. One does not hide
behind the concept of an “irreducible skin sleeve,” but rather maximizes lobular reduction
and tip definition with structure followed by aggressive alar base reduction. Once the base
has been maximally reduced then dorsal augmentation is done to achieve the final result.
Thinning the Skin Envelope. The lobule is ballooned with local anesthesia and undermined
via infracartilaginous incisions. Then the open approach is completed and the excess soft
tissue excised off the alar cartilages. The undersurface of the skin is never directly defatted
as it risks skin loss or scarring.
Structured Columellar and Tip Graft. Using the harvested septal cartilage, large columellar
strut, tip, and alar rim structure grafts (ARS) are carved. In these cases, the columellar labial
angle is often acute with a retracted columellar. Therefore, the columellar strut is shaped to
have a 6–8 mm width which will push down the columellar angle. The alars are advanced
high onto the strut and sutured at two points. A full-length structured tip graft is sutured
to the alars, often in a projected position with a supporting cap graft.
Alar Base Reduction and ARS. One of the major components of a large base is excess inter­
alar width and flare. If one fails to reduce the base, the nose will always look large. The best
method of reduction is a combined nostril sill/alar wedge resection often with the nostril
sill component being 2–3 mm, but the alar wedge component being 3–5 mm. In severe cases,
the nostril sill component will be deepithelialized and used to cinch the alar base to the
ANS. Since many of these cases have “occult alar malposition,” ARS grafts are essential and
often planned for from the beginning by using a true rim incision rather than the more
common infracartilaginous incision. The location of this “rim incision” is where the ARS
will be sutured at the time of closure. Nostril splints, followed by taping, are done every
night for several weeks.
Dorsal Reduction and Augmentation. Frequently, one has to reduce the convexity of the
cartilaginous vault while augmenting the bony dorsum. One often has to excise 1–2.5 mm of
the cartilaginous vault in order to achieve a straight dorsum. Subsequently, a straight dorsal
profile line becomes the goal and a wide range of dorsal grafts are considered – radix, radix/
half-dorsum, or full-length dorsum. These “construct” grafts are fabricated to fill the specific
deficit. They are made from fascia and diced cartilage (DC-F). Isolated radix grafts are usu-
ally DC+F, whereas longer grafts are DC-F.

Case Study: Posttraumatic Nose
317
Fig. 9.5 Dorsal/base disproportion, (a–d) surgical techniques, (e–g) analysis for following case study (Fig 9.6)

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Chapter 9  
Advanced Primary Rhinoplasty
Analysis
This was a very complex nose in which the tip was quite broad and the alar bases even more
disproportionate (Fig. 9.6). Her surface measurements were as follows: EN 32, AC 27, AL 38,
and AL smiling 43. There was an astounding +11 between AC and AL. The basilar view was
even more discouraging and emphasized the severe asymmetry that was present. This case
is a classic example of shrinking the base as much as possible and then building up the
dorsum. The first step was to narrow the tip significantly and fortunately the alar cartilages
responded to suturing. Next, the radix and dorsum were built up using a DC-F graft. The
tapered dorsal graft was cephalically oriented. Aggressive base excisions were done which
further compelled placement of ARS grafts. Unfortunately, I was correct when I told the
patient preoperatively that the nostril asymmetry could be made better but not eliminated.
Operative Technique
  1) Fascial harvest. Exposure of the septum through a transfixion incision
  2) Open approach and creation of 6 mm rim strips
  3) Dorsal exposure with rhinion found to be concave. Reduction: bone: 0 mm, cartilage:
<1 mm
  4) Harvest of septal cartilage. Relocation of caudal septum R to L
  5) No osteotomies nor spreader grafts
  6) Insertion of columellar strut. Tip sutures: CS, DC, ID, DE
  7) Insertion of a radix fascia graft, then a cephalically tapered dorsal graft (DC-F: 0.3)
  8) Harvest of a retroauricular dermis graft inserted transversely below “allergic line”
  9) Closure followed by bilateral combined sill/base resections (R: 3/3, L: 3/3)
10) Insertion of alar rim support grafts
Case Study:
Dorsal/Base
­Disproportion
Fig. 9.6 (a–j)

Case Study: Dorsal/Base ­Disproportion
319
Fig. 9.6 (continuned)

320
Chapter 9  
Advanced Primary Rhinoplasty
The author has extensive experience with Hispanic rhinoplasty and summarized his approach
in prior publications (Daniel 2003). Due to the diversity of both their presenting problems
and requisite surgical techniques, this group is a microcosm of the Level 1–3 concept. Rather
than classify by country of origin, Hispanic noses are best divided into four types based on
the presenting deformity which somewhat follows the level of technical difficulty (Fig. 9.7).
Type I: Castilian. These patients are quite similar to the average adolescent nose and require
the “Big 3” – reduce the profile, narrow the bony width, and refine the tip. A functional
­reduction rhinoplasty is done. The radix is not grafted. The dorsum is incrementally reduced
1–3 mm. Lateral osteotomies are done. A tip suture will provide the requisite refinement and
definition.
Type II: Mexican-American. These cases are challenging as regards analysis and operative
planning. They appear to have a convex dorsum whose reduction would solve the problem.
Alas, it is a “pseudohump” which is accentuated by a hypoplastic radix and an under-projecting
tip. A finesse rhinoplasty is required in which the radix area is grafted with DC+F while the
tip is projected with tip sutures over a columellar strut. If additional volume is required, add-
on grafts of excised alar are inserted. The intervening dorsum may or may not be reduced
depending upon its intrinsic excesses. All three types of base reductions may be required.
Type III: Mestizo. The fundamental problem is thick skin with poor tip definition and an
extremely wide base. Often this lobular problem is complicated by a dorsal/base dispropor-
tion. The solution is an open structure strut and tip graft. The critical first step is thinning the
skin of the nasal lobule. After judicious injection of local anesthesia in the lobule, ­bilateral
infracartilaginous incisions are made and the skin elevated in the subdermal plane. Then
the transcolumellar incision is made and the nose opened. The fibrofatty SMAS tissue is
excised off the underlying cartilages. The dorsum is smoothed. The alar cartilages are re-
duced to 6 mm rim strips. The septal cartilage is harvested through a top-down exposure.
A major structural columellar strut and tip graft are carved from the septal cartilage. The
excised alar is diced for a probable DC+F graft for the radix. The strut is inserted and the
alars advanced onto the strut, often requiring two strut sutures. The shield-shape tip graft
is sutured to the tip at the domal notches and a cap graft may be required depending upon
the degree of projection. Appropriate osteotomies are done. Frequently, large 3/3 combined
nostril sill/alar wedge excisions are necessary which in turn obligate insertion of alar rim
support grafts (ARS).
Type IV: Creole. These cases are similar to the African-American or Black nose with tremen-
dous interalar width (>45 mm) mandating aggressive narrowing, an exceedingly flat dorsum
which requires augmentation, and an under-projecting tip demanding an open structure tip
graft. The necessity for a full-length dorsal augmentation differentiates these cases from the
Type III Mestizo. These cases are treated similar to the Black rhinoplasty patient discussed
later in this chapter.
Hispanic
­Rhinoplasty

Hispanic ­Rhinoplasty
321
Fig. 9.7 (a–f) Hispanic rhinoplasty
Type I: Castilian
Key step: functional reduction
  1.  Dorsal reduction
(bone: 2 mm, cartilage: 4 mm)
  2.  Tip suture
  3.  Relocation caudal septum
Type II: Mexican-American
Key step: finesse
  1.  Limited dorsal reduction
(bone: 0 mm, cartilage: 0.5 mm)
  2.  Increase tip projection
  3.  DC-F graft (0.2 cc) to radix/upper dorsum
Type III: Mestizo
Key step: balanced approach
  1.  Soft tissue defatting
  2.  Open structure tip graft
  3.  Dorsal reduction (1 mm)
  4.  Radix graft
  5.  Combined nostril sill/alar wedge resection

322
Chapter 9  
Advanced Primary Rhinoplasty
Analysis
A 26-year old of Mexican descent complained of a wide heavy tip with downward drooping
on anterior view (Fig. 9.8). Technically, I considered the preexisting inverted-V deformity
and hypoplastic upper dorsum a more serious issue. Nostril-tip disproportion can be cor-
rected largely through lengthening the infralobule on the columellar strut. The bony width
would be narrowed with osteotomies. The dorsum would be integrated by augmenting the
bony area. A DC+F graft consisting of 0.2 cc of diced cartilage was placed beneath the dorsal
component of the fascial graft and then molded to fill the defect. The risk of a solid half-
length dorsal graft showing at the rhinion is notorious. The harmonious integration of the
dorsum as seen on the postop photo confirms the operative plan.
Operative Techniques
1. Harvest of fascia and septal exposure
2. Minimum soft tissue defatting and 6 mm rim strip creation
3. Incremental dorsal reduction: bone: <0.5 mm, cartilage: 2 mm
4. Low-to-high osteotomies
5. Crural strut insertion and tip sutures: CS, DC, ID, DE
6. Ball and apron fascia graft with DC 0.2 below in upper dorsum
Case Study:
Hispanic
­Rhinoplasty
Fig. 9.8 (a–j)

Case Study: Hispanic ­Rhinoplasty
323
Fig. 9.8 (continued)

324
Chapter 9  
Advanced Primary Rhinoplasty
Approximately 20% of the author’s practice is of Middle Eastern descent, especially Persian
patients. These patients provide an interesting challenge of reconciling operative goals with
anatomical reality. In the United States, their goal has gone from a “surgically cute” to “natu-
ral” to now “naturally cute” noses. Whenever possible, these patients want their nose to look
unoperated (natural), but they expect the dorsum to be slightly curved, the tip rotated and
well defined (cute). Obviously, the challenge increases in direct proportion to skin thickness
and weakness of the alar cartilages. The author has seen a wide diversity in all the anatomical
components including the alar cartilages (Daniel 2009).
Level 1. Approximately one third of the patients have thin skin with a downwardly rotated
tip and a beaky aquiline profile (Fig. 9.9a, b). An open approach is highly effective in shifting
the tip defining point from the level of the columellar breakpoint to a true 105°The dorsum
is lowered incrementally, usually with emphasis on the cartilaginous component, and the
upper caudal septum resected for rotation. Tip suturing is done with domal creation sutures
at the domal notch and then narrowing of the tip with the interdomal suture. A tip position
suture rotates and projects the tip for the desired super tip break.
Level 2. The majority of these patients have a wide nose with a bony hump and a broad
dependent tip with no definition (Fig. 9.9c, d). The dorsum is lowered incrementally which
requires extensive rasping. A comparable amount of cartilaginous dorsum may be resected.
Caudal septum and ANS are often removed to shorten the nose. The osteotomies are often
medial oblique and low-to-low. Tip suture is done with significant amount of add-on grafts
in both the infralobule and across the domes to create tip definition through the moderately
thick skin. Alar base modification most often consists of extended nostril sill excision with
alar rim grafts (ARC) for shaping the nostrils.
Level 3. These cases are highlighted by an exceptionally thick skin sleeve, wide nasal bones,
and a broad tip with no definition (Fig. 9.9e, f). The skin sleeve is often thinned and is done
by raising the entire skin envelop in the subdermal plane followed by resection of the inter-
vening SMAS tissue, from tip to radix, and from one lateral wall to the other. Two 7 FR drains
are inserted to drain the nose at the end of the case and to promote “shrink wrapping” of the
skin around the underlying framework. Any and all combinations of osteotomies are con-
sidered, but maximum narrowing is often necessary. The tip is almost always reconstructed
with open structure columellar strut and tip grafts. Aggressive combined nostril sills/alar
wedges obligate alar rim support grafts (ARS). Even with this approach, the noses will merely
look “better,” not great. The patient must be prepared for this outcome.
Middle Eastern
Rhinoplasty

Middle Eastern Rhinoplasty
325
Level 1
Key steps
  1.  Dorsal reduction
(bone: 1.5 mm, cartilage: 4 mm)
  2.  Caudal septum: 4 mm
  3.  Tip sutures: CS, DC, ID, TP
  4.  Asymmetric osteotomies
Level 2
Key steps
  1.  Defatting lobule
  2.  Dorsal reduction
(bone: 2.5 mm, cartilage: 6 mm)
  3.  Low-to-low osteotomies
  4.  Tip suture and add-on grafts
  5.  Alar wedge excision and ARG
Level 3
Key steps
  1.  Defatting skin envelope
  2.  Dorsal reduction
(bone: 2 mm, cartilage: 4 mm)
  3.  Six osteotomies
  4.  Open structure tip graft
  5.  Alar wedge excision and ARG
Fig. 9.9 (a–f) Middle Eastern rhinoplasty

326
Chapter 9  
Advanced Primary Rhinoplasty
Analysis and Commentary
An 18-year-old girl of Persian descent requested a rhinoplasty which would produce a major
change in her nose (Fig. 9.10). She wanted a more feminine nose that would be as cute as
possible. Obviously, I stressed that her skin envelope was thick and its contractility unpredict-
able. In order to insure clarity of her desire, the patient was given a lateral profile to draw
the profiles she wanted. One year after surgery, the patient wanted further narrowing of her
bony vault and it was done. The original low-to-low osteotomies narrowed her bony width,
but did not change the intrinsic convexity of the bones themselves which was done with
double-level osteotomies at the time of revision. The patient is shown at 2.5 years post-op.
Operative Technique
1. Open approach and reduction of alars to 6 mm rim strips
2. Incremental dorsal reduction extending high (bone: 2.5 mm, cartilage 6 mm)
3. Septal harvest and spreader grafts
4. Transverse and low-to-low osteotomies
5. Crural strut and tip sutures: CS, DC, ID, TP, CSp
6. Double-layer domal onlay graft of excised alar to increase definition
7. Alar wedge resection (3.5 mm) and alar rim grafts (ARG)
Note: at 1 year the patient wanted her bones narrowed further and this was done using
double-level osteotomies.
Case Study:
Middle Eastern
Fig. 9.10 (a–j)

Case Study: Middle Eastern
327
Fig. 9.10 (continued)

328
Chapter 9  
Advanced Primary Rhinoplasty
As Asian patients become more sophisticated they are faced with a dilemma. They want
the nasal refinement provided by a silicone implant, but not the complications. Early in my
practice, I did over 75 silicone implants in Asian patients with a very experienced colleague.
After seeing the post-op results and dealing with the deviations and dissatisfaction, I swore
I would never do another silicone implant. For 15 years, I was faced with a conundrum – the
silicone implant provided a much better aesthetic result than autogenous tissue, but the com-
plications were unacceptable. Once I began doing diced cartilage grafts, I was able to obtain
excellent aesthetic results which even exceeded those of silicone because of their natural
appearance. In contrast to Hispanic and Middle Eastern noses with their wide anatomical
variations, Asian rhinoplasty is rather homogeneous Table 9.1 (Fig. 9.11a). One merely adds
or deletes certain steps depending upon the patient’s anatomy and requests. Despite the broad
variation of patients making up the Asian-American community from Cambodia to Korea
(think dorsal height), and the Philippines to Vietnam (think skin envelope), the following
operation gives excellent results, but does require attention to detail.
Operative Sequence
Graft Harvesting. At the beginning of the operation I harvest a large sheet of deep temporal
fascia through a 3 cm incision and conchal cartilage through a retroauricular incision. A
tip graft and alar rim support grafts are cut from the conchal bowl. The rest of the conchal
cartilage is given to the circulating nurse to dice.
Soft Tissue Defatting. In the majority of cases, the soft tissue envelope of the lobule is defatted
beginning with extensive infiltration of local anesthesia (Fig. 9.11b). The skin is elevated in
the subdermal plane via the infracartilaginous incisions. Then the transcolumellar incision
is made and the entire skin envelope elevated. The SMAS and adipose tissue is carefully ex-
cised from the underlying cartilage. Symmetrical 6 mm rim strips are created and the excess
flimsy alar cartilage is also diced.
Septal Harvest. Obtaining a large rigid piece of septal cartilage in an Asian patient is both
critical and technically demanding. In contrast to the normal septal harvest of cartilage only,
a large osseocartilaginous piece of septum is required (Fig. 9.11c). A combined top-down
and tip-split approach to the septum is used. A transfixion incision is avoided as the intact
membrous septum helps to centralize subsequent insertion of the septocolumellar strut. The
entire septum is exposed, especially posteriorly. Since the caudal septum will be reinforced, a
8–10 mm L-shape strut is maintained despite the flimsy septal cartilage which is common in
Asian patients. Once the initial cuts are made, a septal scissor is placed parallel to the dorsal
strut. The scissors cut across the osseocartilaginous junction. The vertical cut is extended
down to the vomer and the cartilage is mobilized. Again the septal scissors are inserted par-
allel to the vomer and then cut posteriorly across the osseocartilaginous junction. A large
piece of osseocartilaginous septum is removed using the septal grasper.
Septocolumellar Graft. The sepal graft is subdivided if possible into a massive 20 × 20 mm
piece for the septocolumellar graft, a full-length 15 × 8 mm tip graft, and two alar rim support
grafts. Frequently, the septocolumellar graft is composed of cartilage which will be placed
Asian
­Rhinoplasty

Asian ­Rhinoplasty
329
Step 1
Fascia and conchal cartilage harvest
Step 2
Soft tissue defatting of lobule
Step 3
Osseocartilaginous septal harvest
Step 4
Septocolumellar graft
Step 5
Open structure tip graft
Step 6
Dorsal graft of DC-F
Step 7
Osteotomies (optional)
Step 8
Alar base modification (optional)
Table 9.1 Asian rhinoplasty – an autogenous tissue operation
Fig. 9.11 (a) Asian rhinoplasty anatomy, (b) soft tissue defatting, (c) septal harvest
Wide dorsum
a
Poor tip
Low radix
Splayed
alar
Fibrofatty
tissue
Low dorsum
Flat tip
Acute CL angle
Short
columella
Wide alar
bases

330
Chapter 9  
Advanced Primary Rhinoplasty
at the top and bone which will rest against the ANS (Fig. 9.11d). Since a “tip split” was done
for septal exposure, insertion of the graft is relatively simple and the shaping is done in situ.
The graft is placed between the alar cartilages and extends 2–8 mm below the caudal septum
depending upon the degree of “columellar show” that one wants to obtain. Once satisfied, #25
needles are placed across the cartilaginous septum and the graft at two points. The caudal
border of the graft should rise 6–10 mm above and 6–10 mm caudal to the septal angle. This
rigid strut will produce the lengthening and projection that is required in the Asian nose.
Three sutures of 4-0 polydioxanone suture (PDS) are inserted at overlapped areas to fix the
strut to the caudal septum and dorsal septal cartilage. Final shaping will leave a columellar
component that is 5–6 mm in width and the excised cartilage can be used as a rigid tip graft
or diced. The final graft looks very much like a “tomahawk.”
Tip Graft. Ideally, the tip graft is a long tapered graft of rigid septal cartilage. It is placed in
a projecting position above the domes with a cap graft behind it for support (Fig. 9.11e). The
reality is that it may be half-length septum or conchal cartilage. The cap graft is essential to
maintain tip projection.
Dorsal Grafts. The dorsal graft is a DC-F graft, ranging from 0.7–1.0 cc of a tuberculin syringe
(Fig. 9.11g, h). Most Asians will require a dorsal graft of uniform thickness. Currently, I use
a separate fascia graft for the radix area and construct the dorsal graft on the back table.
These can be either a uniform or tapered construct depending upon the patient’s original
dorsal deficiency. It is important that the dorsal graft is not done until the maximum tip
projection has been obtained. The dorsal graft should not be excessively shortened to create
a strong supratip break.
Osteotomies (Optional). I do lateral osteotomies, if the nose is wide. Since the bones are not
very high, they are technically low-to-low although I use a curved osteotome. The goal is to
narrow the x-width of the bony vault. These are done as indicated despite the fact that the
nasal bones are relatively short and there is no open roof.
Alar Base Modifications and ARS/ARG (Usually). Two anatomical realities mandate caution
when doing alar wedge resections in Asian patients (Fig. 9.11i, j). First, alar malposition is
the “norm” not the exception in Asian patients. Second, the nostril axis ranges dramatically
from upward to transverse to even inverted. One of the goals is to change the shape (round
to oval) and the axis of the nostrils using alar rim support grafts (ARS). Further complicat-
ing the problem is that combined nostril sill excision/alar wedge resections further collapse
the alar rim and risk significant scarring. Preoperative discussion must emphasize the limi-
tations of narrowing nostril width, which most patients want, and the risk of scars, which
most patients do not expect. Whenever possible, I will do an “extended nostril sill” excision
with ARS. Essentially, an angulated nostril sill excision is done which tapers into the true
alar crease for 3–4 mm, but is not visible from the profile view.

Asian ­Rhinoplasty
331
Fig. 9.11 (d) septocolumellar graft, (e) tip graft, (g, h) dorsal augmentation (DC-F), (i, j) alar base excision

332
Chapter 9  
Advanced Primary Rhinoplasty
Analysis
A 32-year-old woman of Chinese descent requested a rhinoplasty (Fig. 9.12). She stated that
she did not want an implant as a couple of her friends had problems. The keys to the opera-
tion are creation of a more refined projected tip, dorsal augmentation, and narrowing of the
alar base. Rigid tip support is critical and thus the “tomahawk septocolumellar strut” was
devised. In most Asians, DC-F grafts obviate the need for rib while creating a very natural
dorsum – how often do you really need more than 8 mm of augmentation? Since alar mal-
position is “normal” in the Asian patient, ARS grafts are essential to support the rims and
change nostril orientation. At 6 years post-op, the patient has done well and there has been
no revisional surgery.
Operative Technique
1) Harvest of fascia and conchal cartilage
2) Open approach with soft tissue defatting of the lobule
3) Tip split with septal harvest of maximum osseocartilaginous tissue
4) Insertion of a columellar pennant graft with bilateral “brace” grafts (short spreaders)
5) Suture of alars over the columellar strut and then addition of a structured tip graft
6) Dorsal augmentation using the entire conchal for a DC-F graft (0.7 cc)
7) Combined nostril sill/alar base excision (2 mm)
Case Study:
Asian
­Rhinoplasty
Fig. 9.12 (a–l)

Case Study: Asian ­Rhinoplasty
333
Fig. 9.12 (continued)

334
Chapter 9  
Advanced Primary Rhinoplasty
Despite wide individual variations, the Black nose often comes down to a combination of
low dorsum, a bulbous under-projecting tip, and wide alar base plus a retruded columellar
labial angle. These cases are technically demanding and one must be willing to make the
major commitment required to achieve excellent results. All of the steps used in the Asian
nose are required in the Black nose, but to a greater degree (Fig. 9.13). The columellar must
be maximally lengthened by advancing the alars on the columellar strut and fixed at two
points rather than one. The dorsum may require a true “composite” reconstruction with solid
cartilage grafts below and DC-F on top when silicone is not used. The combined alar base/
nostril sill excisions may require a cinch component.
Note: The surgeon must be sensitive to the patient’s desires, their concern for ethnic identity
and preservation. Some patients will want minimal refinement, others moderate improve-
ment, and a few maximum change. One should review Matory’s (1998) excellant text on
Ethnic rhinoplasty.
Surgical Technique
Soft Tissue Defatting. The standard defatting of the lobule is done via the infracartilaginous
dissection followed by excision of the soft tissue on the alar surface via the open approach.
Columellar Strut. In most cases, a major columellar strut is inserted first and the medial/
middle crura advanced upward to effectively lengthen the columella. Two sutures are used.
With the strut in place, the columellar base is advanced upward from the lip and fixed with
a #25 needle at the level of the columellar breakpoint. A lower columellar strut suture is
inserted. Next, the needle is removed and the alars advanced as high as possible. Then a
second CS is placed above the columellar breakpoint.
Tip Graft. A tip graft of solid septal cartilage with sharp edges is placed in a projecting posi-
tion to achieve tip definition through the thick skin. Often a “backstop” graft of solid cartilage
is placed behind it to force the tip graft downward and to provide resistance similar to a
cap graft. When the entire infralobule is flat, then I add a shorter tip graft to the infralobule.
Dorsal Graft. Frequently a balanced approach is required with slight excision of the car-
tilaginous vault (<2 mm) followed by a full-length augmentations using a DC-F graft. In
severe cases, a thin (1–2 mm) full-length cartilage graft will be placed first and then a DC-F
contour graft on top. The solid graft provides support for the skin envelope and ameliorates
the visual separation that one can see between bony and cartilaginous vaults.
Nasal Base. Inevitably, the nasal base is extraordinarily wide in alar flare and nostril sill vis-
ibility. If the columellar strut is effective, then the nostrils are often shifted from round to
oval and the axis from transverse to 45°. In Black patients, I do not hesitate to do aggressive
combined sill/base excisions with 3/6 and 4/8 dimensions being common. One assumes that
Keloid scars will remain virtually unreported in the central facial triangle.
Black
­Rhinoplasty

Black ­Rhinoplasty
335
Fig. 9.13 (a) Soft tissue defeating, (b) tip graft, (c, d) combiner nostril sill, alar wedge rectron
Fig. 9.13 (e–h) A 35 year old wanted a major change in her nose

336
Chapter 9  
Advanced Primary Rhinoplasty
Analysis
An 18 year old student felt that her nose was too heavy and too unattractive (Fig. 9.14a-d).
She wanted a significant refinement, but within the limits of her ethnicity. The operative high-
lights were: 1) defatting of the soft tissue envelope, 2) a septocolumellar strut, 3) a structure
tip graft, 4) DC-F 0.8cc graft to the dorsum, and 5) a combined sill / wedge resection (3/4).
At one year the patient is pleased, but would have accepted even more refinement.
Black
­Rhinoplasty
(Moderate)
Fig. 9.14 (a–d)

Black ­Rhinoplasty (Major)
337
Fig. 9.14 (e–h)
Analysis
A 54 year old wanted to know what could be done to fix her flat, wide nose (Fig.9.14e-h).
The interalar width measeured 55mm while her nasal length (N-T) was 28mm. The even-
tual operative plan included a chin augmentation and submental liposuction plus a central
endoscopic forehead lift to move the Nasion higher. The nasal surgery consisted of the
following; 1) minimal defatting, 2) rib harvest, 3) columellar strut and structured tip graft,
4) a deep solid dorsal rib graft -6mm thick plus and overlay DC-F graft- 4mm thick, 5) alar
cinch excision 4/6, and bilateral composites to alar rims. Postoperatively, the patient stated
that she felt pretty for the first time in her life.
Black
­Rhinoplasty
(Major)

338
Chapter 9  
Advanced Primary Rhinoplasty
Surgeons do not enjoy revising their own cases as they often feel that it represents a failure
to achieve their original goal. I have learned to accept revisions and try to learn from them.
At the pre-op visit, I explain to patients that my revision rate is 5–7% by 3 years. I do not
charge a surgical fee for most revisions, but ask the patient to pay for OR supplies and/or
anesthesia. Why is my revision rate so high? First, I think that I tend to see more difficult
primary cases referred by other plastic surgeons and that in most cases I try for maximal
aesthetic improvement. Second, I do not try to avoid revisions nor make it difficult for the
patient. I would rather have a happy patient recommending me than a disappointed patient
disparaging me. Third, I am always curious to know what went wrong since I did my very
best at the initial operation. Remember: only you can teach yourself surgical cause and effect
and revisions certainly focus your attention. Two examples of what experience has taught me
are as follows. With radix grafts, crushed septum was always visible, so I switched to excised
alar which had 10% problems and then went to fascia which has a 0% visibility rate. With
spreader grafts, the difficulty was an occasional dorsal bump due to the cephalic end of the
graft pushing through the open roof. The solution was to suture the graft at two points using
an “overlap” suture cephalically.
In preparing this section, I personally reviewed 100 consecutive primary cosmetic rhino-
plasties with a mean follow-up of 18 months. What I found was quite surprising and ­extremely
useful. There were seven revisions which I would classify as follows: (1) one case was supratip
fullness following open rhinoplasty, (2) two cases were inadequate tip refinement following
closed rhinoplasty, (3) two were dorsal bumps, one from inadequate rasping of the bony vault
and the other probably part of a spreader graft, (4) two cases were “laughing struts” (the strut
clicked across the ANS only when the patient laughed spontaneously, not when they talked
or smiled). All in all, the revision rate was not bad and the degree of difficulty was neither
severe nor complicated to fix. The revisions were interesting. The open cases were revised
closed while the closed case was revised open. Excision of supratip scar tissue was easily done
through intra cartilaginous incisions. The closed tip required a crural strut plus suturing of
the previously created symmetrical rim strips (Fig. 9-15). The columellar struts were short-
ened through the bottom of the transfixion incision. On reflection, I think I could ­“divide” the
bottom of the strut using a #16 needle in the exam room. Dorsal smoothing was done with a
rasp via an inter cartilaginous incision. Why go through the trouble of pulling 100 charts and
analyzing each one? The reason is that one begins to “see” less than perfect aesthetic results.
Specifically, I found that I had not reduced the bony dorsum sufficiently in “high” dorsal
humps and probably over resected the caudal septum at its junction with the ANS in long
hanging noses. Although painful to see ones deficiencies and revisions, an annual review is a
crucial learning experience that I highly recommend.
Revision
­Rhinoplasty

Case Study: Minor Revision
339
Analysis and Commentary
This patient requested a rhinoplasty, but wanted it to be completely natural. Her primary con-
cern was the profile and not the tip (Fig. 9.15a, d). I did her rhinoplasty closed. After a year,
she returned and wanted the tip rotated upward a bit and refined more. An open tip suture
technique was done with the following sutures: CS, DC, ID, TP (Fig. 9.15c, f). For me personally,
it illustrates all of the advantages of open tip suturing – projection, definition, and tip position.
Case Study:
Minor Revision
Fig. 9.15 (a–f)

340
Chapter 9  
Advanced Primary Rhinoplasty
Without question, incorrect patient selection and excessive suturing can produce dif-
ficult problems including the “snarl tip” and the upwardly rotated tip. Again, the caveat must
be respected – do not tie every suture tight, rather tighten the suture until the desired effect
is achieved and then stop. An example is the domal creation suture under thin skin with the
resulting sharp point rather than a subtle curve. Yet the most dangerous suture is the tip
­position suture as it can excessively rotate the tip leading to a very unhappy patient. Although
I prefer to wait 1 year, this might be a situation where I would reoperate within a couple of
weeks. Excessive infralobular length can be caused by a “lateral steal” technique where the
domal creation suture is placed laterally on the crura rather than at the domal notch. One can
inadvertently add 4–6 mm to the infralobular length. Errors of omission are often a failure of
preoperative analysis and may include not doing osteotomies or nostril sill excisions.
Open tip graft techniques have revolutionized rhinoplasty, but not without a learn-
ing curve both for pioneers and followers. One of the first tendencies to avoid is excessive
narrowing of the columellar or domes when inserting the crural strut. If the crura are too
­approximated, then the tip graft will be stuck on the infralobule producing a hanging colu-
mella rather than an integrated tip. Also, the projecting tip graft must have a “cap graft” or
rigid backstop to resist the folding forces from scar tissue.
When do I do revisions? Usually not before 1 year. The single exception would be obvi-
ous displacement of a major dorsal or tip graft. I have reoperated at 10 days for a displaced
dorsal graft and was extremely glad that I did. Also, I have done a composite graft to a con-
tracted nostril apex at 6 weeks to appease a very demanding patient. Each revision must be of
aesthetic benefit to the patient, and hopefully become a learning experience for the surgeon.
Over the years, one should see a decrease in the complexity of one’s revisions and hope-
fully their frequency. Essentially, the indication should be confined to one area (tip, nos-
tril, etc.) or one major problem (asymmetry) rather than several. Rhinoplasty is not a static
­operation and with adoption of new techniques there will be a learning curve and new prob-
lems to revise. One word of caution – never suggest a revision to a patient, let them ask for it.
Revisions only make things “better,” never perfect.

Case Study: Major Revision
341
Analysis and Commentary
This is the worst result of one of my primary rhinoplasties that I have revised in the last 6
years. At the initial operation, I tried to do this closed, but switched to an open as I could not
control the tip cartilages (Fig. 9.16a, d). A columellar strut was inserted and tip sutures done:
CS, DC, and DE. At 1 year, the patient was satisfied. However, by 6 years the nasal asymmetry
was obvious, especially the tip collapse on right oblique view (Fig. 9.16b, e). A revision was
necessary (Fig. 9.16c, f) and consisted of the following:
1) Banked cartilage was removed from the L-temporal area as was temporal fascia.
2) The tip was reopened. The cephalic end of the L-spreader grafts was excised.
3) A “fascial blanket” was inserted under the elevated skin envelope.
4) DC was placed under the fascia in the supratip region.
5) Lateral crural strut grafts were sutured to the lateral crura and along the nostril rim.
Case Study:
Major Revision
Fig. 9.16 (a–f)

342
Chapter 9  
Advanced Primary Rhinoplasty
There is a long history of injecting fillers into the nose to regularize contours. Paraffin was
used extensively in the early 20th century and collagen in the 1980s. During the past decade,
the popularity of injecting fillers into the face and nose has expanded dramatically. Currently,
these materials include the following: (1) autogonous fat, (2) hyaluronic acid (HA) products
like Restylane and Juvederm, and (3) calcium-based products including calcium hydroxy-
apatite (CH), Radiesse. They can be used to straighten noses, hide the edges of tip grafts, fill
in bifid tips, and cover visible nasal bones (Fig. 9.17). The results of successful filling to the
nose can be impressive, making an indifferent result into an excellent one without the need
for complex secondary surgery.
Personal Preference
I prefer hyaluronic acid (HA) products because of their duration, reversibility, and expansile
qualities. Fat injections to the nose have never worked well for me other than in the radix.
Reinjections of fat are common and the material is too thick to put into confined spaces. CH
(Radiesse) is preferred by some for its perceived longer duration which in my experience
has not proved to be the case. In addition, errors of injection with CH cannot be reversed.
HA (Restalyne) fillers were first introduced for treatments of nasolabial folds and the
assumption was made that the duration would be 6–8 months. Further experience in nonmo-
bile parts of the face has shown that HA duration is decidedly site-specific. In lower lids and
brows it can exceed 3 years. When injected in the nose, duration is subsite-specific. It seems
to last longer in the tight tissues of the tip and alar bases than in the looser tissues of the
proximal dorsum and radix. I have seen durations of over 3 years in the tip and about a year
in the radix.
Injection Technique. First, the nose is marked. I find this to be the most interesting aspect of
the treatment. Careful study of the nose is necessary and usually shows a number of locations
where wisps of volume might improve the contour. Second, I anaesthetized the area using
lidocaine without epinephrine. The reason to avoid epinephrine is to allow assessment of any
sign of a vascular compromise as evidenced by blanching of the skin which will not be visible
in an already vasoconstricted area. Numbing creams tend to cause surface vasoconstriction
and thus are avoided. I usually apply an ice cube to the area to be injected for 5 seconds and
then inject a small amount of local, which is then enlarged as needed. Third, the filler is in-
jected. I inject tiny amounts of Restalyne with a 30 g needle usually on withdrawal. If product
is seen coming out of adjacent nasal pores, then the injection pressure needs to be reduced
and the needle should be shifted. Frequently, four or five injection sites may be necessary as
the product will not spread in a scarred tip. Surprisingly small amounts are needed in the
tip, usually 0.1–0.2 cc, and not much more in the dorsum.
Concerns. Though it may be tempting to power fill an indentation that will not elevate, the
chance of having problems is much greater. It is far safer to treat difficult scarred tips in
stages. If blanching occurs, it is massaged gently for a few minutes. If it persists, the area is
Nasal Fillers:
Restalyne
(Dr. Val Lambros1)
1  Dr. Val Lambros lambrosone@aol.com. Dr. Lambros has no financial conflict of interest and is not a paid
consultant for any product.

Nasal Fillers: Restalyne (Dr. Val Lambros)
343
treated with hyaluronidase to dissolve the HA. Hyaluronidase is generally derived from beef
and patients should be asked if they have allergies to beef products, or are highly allergic
to bee stings, which also contains hyaluronidase. Allergies are rare, and if there is any doubt
a skin test may be made on the arm of a few units. Hyaluronidase, traditionally comes in
a solution of 150 units/cc. If there is a vascular problem in a small area like the nasal tip,
then 20 units of hyaluronidase diluted in 1 cc of saline should remedy the situation. In addi-
tion, hyaluronidase will correct HA-induced contour deformities no matter when they were
placed. If a contour mistake is made with another class of filler such as Radiesse, it cannot
be reversed.
Postinjection Management
The patient is told to expect some localized swelling and the usual maneuvers are used to
minimize it. Bruising is usually not an issue. I see them within a few weeks of the injection. On
leaving the office, patients are generally happy as the swelling alone makes them look better.
HA products expand by about 30% as they hydrate and the contour will improve beyond
the first day. Most patients report that the nose is considerably improved for the first week
or so. Many of the patients I inject have been told that secondary surgery is not advisable
for their particular nose, and thus they are happy with whatever improvement is possible.
Fig. 9.17 Restalyne injection – no prior surgery. (a, d) Preinjection, (b, e) 7 months post, (c) 2 years
post injection