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

Fillers for the Nose (Dr. Miles Graivier)
345
used and serial correction performed. Scarred and thin skin areas are more susceptible to vas-
cular compromise. Small volume injections of 0.1 ml per scarred area will allow gradual skin
expansion. Injections can be repeated at 4–6 week intervals until full correction is achieved.
Even with serial injections, it may not be possible to fully correct all defects. Radiesse is
injected beneath the dermis, but just above the periosteum or perichondrium. The needle is
placed in the desired plane and then injected in multiple fine threads as the needle is slowly
withdrawn. The material is fanned out throughout the area in multiple threads. After deposi-
tion, manual molding is done for contouring. Injection into too superficial a level, especially
the dermis, should be avoided. There is higher resistance in the nasal skin which is less likely
to stretch than other areas of the face. Additionally, injection into nasal skin pores will result
in extrusion of material out of the pore. Visible filler and nodules can occur, but blanching,
indicative of vascular capillary occlusion, is more likely.
Specific Areas
1. Dorsum/Lateral Sidewalls. To correct the nasal dorsum or sidewalls, the areas are marked
with the patient sitting up. After topical or local anesthetic has been administered, multiple
fine threads of Radiesse are injected in a fanning pattern, beginning inferiorly and advanc-
ing toward the top of the nose. Cross-hatching of the filaments with layering will increase
projection and elevation of the area. Injection into the dermis is avoided.
2. Nasal Tip Contouring. Radiesse can be used to improve the nasal tip and supratip shape. In
patients with thin skin and visible tip grafts, CH is injected between the grafts and the der-
mis. Of importance, nasal tip elevation and projection can be achieved by infra-tip lobular
and columellar augmentation. Vertical threads of material are injected into the ­upper half
of the columella, the tip anterior to the middle crus, and a small amount into the supratip
area. The total volume required is rarely more than 1 ml of Radiesse. In noses with asym-
metric lower lateral cartilages, the tip can be balanced and made more symmetrical.
3. Columella. This type of defect may be difficult to correct due to rigid scar tissue and the
lack of a bony base to project against. Stretching the scarred area with local anesthesia
prior to filler injection may help. Small volumes are injected, rarely more than 0.1 cc at one
time and this can be repeated monthly if necessary for full correction.
Fig. 9.18 (a, b) Radiesse injections for secondary rhinoplasty

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Chapter 9  
Advanced Primary Rhinoplasty
Posttreatment Care and Adverse Effects
No special postinjection care is required. Cool compresses and nonsteroidal antiinflamma-
tory medication suffice. The patient may have minor swelling or redness for 1–2 days which
is usually transient. Other reactions may include pain, discoloration, and tenderness at the
injection site. Too superficial an injection may show deposition in the skin which could be
removed with dermabrasion or laser abrasion. If nodularity or too much product is placed,
then conservative steroid injection (0.1 ml of Kenalog 10) is injected into the nodule. This
can be repeated in 4 weeks if necessary. If an HA has been used, hyaluronidase would be
used instead of a steroid to shrink the product. If conservative therapy fails, then excision
may be necessary.
As with any filler injected into the nose, vascular compromise is a potential risk. If
blanching occurs, vigorous digital massage to disperse the material and open the capillar-
ies is indicated. After several minutes of massage, if capillary refill is still diminished, then
­application of nitropaste, heat, oral vasodilators, and even hyperbaric oxygen therapy is indi-
cated. If a HA had been used, injection of a hyaluronidase would also be indicated.
Patient Satisfaction
Most patients who come in with complaints of nasal asymmetry, depressions, contour irregu-
larities, or postrhinoplasty appearance are very pleased to be offered a nonsurgical correction
with fillers. The minimal recovery time, minimal swelling, and minimal cost compared to
surgery is very appealing to most patients. Satisfaction level is very high as the patient has
input into how his or her nose looks immediately. The patient is encouraged to return in 4–6
weeks for evaluation and further fill if necessary.
In summary, Radiesse has demonstrated its value as a nonsurgical method of correcting
localized, discrete, nonfunctional cosmetic defects of the nose. Since it provides 1:1 correc-
tion and can be molded immediately, the results are visible immediately.

Fillers for the Nose (Dr. Miles Graivier)
347
Fillers: Final Thoughts
I am impressed with what can be done with fillers injected into the nose – but, I think the
cases have to be carefully selected. There will be patients with nasal deformities which can
be corrected with fillers temporarily. As seen in Fig. 9.17, this patient had a superb result,
but the filler was gone completely by 3 years. As seen in Fig. 9.18, this patient had an almost
miraculous correction with Radiesse of a very difficult secondary deformity. It is essentially
an augmentation solution and not a structural correction. What are the differences? First,
there would be minimal improvement in her nasal respiration. Second, there has been no
improvement in the nose job look of the tip due to alar rim collapse resulting in a pinched
tip. However, as the Radiesse disappears what will the patient do? Accept a gradual decline
or seek surgery for a definitive correction? How would a surgeon deal with this type of com-
bined nasal deformity? How to judge the final skin envelope or the requirement for structural
replacement? How effective would the removal be? How much damage was done to the skin
envelope at the time of injection and how much filler was placed inadvertently in the dermis?
Few surgeons want to talk about real complications following filler injection. As shown in
Fig. 9.19, fillers can produce real damage to the skin envelope, especially in secondary cases.
This case is an example of the inevitable sequence of a wonderful result with a Restalyne
injection followed by the patient’s desire to get a more longer lasting result with Radiesse
much to everyone’s regret. If I had two admonitions, they would be: (1) never be the first to
try something new – better to let the pioneers figure out what works and what does not, (2)
start with Restalyne and only go to Radiesse when you have lots of experience.
Note: with the exception of the patients in this section on fillers, none of the patients in this
text have had fillers injected into their nose to enhance their result. This may be the last
rhinoplasty text that will ever be “filler-free.”
Fig. 9.19 Radiesse injections – complication

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Advanced Primary Rhinoplasty
Becker H. Nasal augmentation with calcium hydroxyapatite in a carrier-based gel. Plast
­Reconstr Surg 121: 2142, 2008
Bizrah MB. Rhinoplasty for Middle Eastern patients. Facial Plast Surg Clin N Am 10: 381, 2002
Byrd HS, Salomon J, Flood J. Correction of the crooked nose. Plast Reconstr Surg 102: 2146,
1998
Constantian MB. An alternate strategy for reducing the large nasal base. Plast Reconstr Surg
83: 41, 1989
Daniel RK. Surgical techniques for bulky, boxy, and ball tips. In: Operative Techniques in
Plastic and Reconstructive Surgery. Philadelphia: WB Saunders, 2001a
Daniel RK. Rhinoplasty: Large nostril/small tip disproportion. Plast Reconstr Surg 107: 1874,
2001b
Daniel RK. Hispanic rhinoplasty in the United states with emphasis on the Mexican Ameri-
can nose. Plast Reconstr Surg. 112: 224, 2003a
Daniel RK. Asian Rhinoplasty (Video). Alexandria,VA: American Academy of Facial Plastic
and Reconstructive Surgery, 2003b
Daniel RK. Middle Eastern update Plast Reconstr Surg 124: 1630, 2009
Dayan SH, Bassichis BA. Facial dermal fillers; selection of appropriate products and tech-
niques. Aesthet Surg J 28: 335, 2008
Jansen DA, Graivier MH. Evaluation of a calcium hydroxyapatite-based implant (Radiesse)
for facial soft-tissue augmentation. Plast Reconstr Surg 118: 22, 2006
Flowers RS. Surgical correction of the East Asian nose. In: Daniel RK (ed) Aesthetic Plastic
Surgery: Rhinoplasty. Boston: Little, Brown, 1993
Gruber RP, Friedman GD. Suture algorithm for the broad or bulbous nose. Plast Reconstr
Surg 110: 1752, 2002
Guyuron B, Ghavami A, Wishnek SM. Components of the short nostril. Plast Reconstr Surg
116: 1517, 2005
Hamra ST. Repositioning the lateral alar crus. Plast Reconstr Surg 92: 1244, 1993
Matory WE Ethnic Considerations in Facial Aesthetic Surgery. Philadelphia: Lippincott-­
Raven, 1998
McCullough EG, Fedok FC. The lateral crural turnover graft: correction of the concave lateral
crus. Laryngoscope 103: 463, 1993
Neu BR. Suture correction of a nasal tip cartilage concavities. Plast Reconstr Surg 98: 971,
1996
Nishimura Y, and Kumoi T. External septorhinoplasty in the cleft lip nose. Ann Plast Surg
26: 526, 1991
Ortiz-Monestaerio F, Olmedo A, Iscoy LO. Rhinoplasty in the Mestizo nose. Clin Plast Surg
4: 89, 1977
Porter JP, Toriumi DM Surgical management of the crooked nose. Aesth Plast Surg 26: 1, 2002
Romo T III, Sclafani AP, Falk AN, et al A graduated approach to the repair of nasal septal
perforations. Plast Reconstr Surg. 103: 66, 1999
Roofe SB, Murakami CS. Treatment of the posttraumatic and postrhinoplasty crooked nose.
Facial Plast Surg Clin North Am 14: 279, 2006
Rorhrich RJ. External approach to Black rhinoplasty. In: Daniel RK (ed) Aesthetic Plastic
Surgery: Rhinoplasty. Boston: Little, Brown, 1993
Rorhrich RJ, Ghavami A. The Middle Eastern nose. In: Gunter JP, Rohrich RJ, Adams WP (eds)
Dallas Rhinoplasty: Nasal Surgery by the Masters. QMP, 757–772, 2007
Rorhrich RJ, Gunter JP, Deuber MA, et al The deviated nose: optimizing results using a
simplified classification and algorithmic approach. Plast Reconstr Surg 110: 1509, 2002
Sclafani AP, Romo T, Barnett JG, Barnett CR. Adjustment of subtle postoperative nasal ­defects:
Managing the “near-miss” rhinoplasty. Facial Plast Surg. 19: 349, 2003
Toriumi DM. Structural approach in rhinoplasty. Facial Plast Surg Clin North Am 13: 93, 2005
Toriumi DM, and Ries WR. Innovative surgical management of the crooked nose. Facial
Plast Clin 1: 63, 1993
Reading List

Can secondary rhinoplasty be taught? Three inescapable facts say no: (1) the highly vari-
able normal nasal anatomy is often destroyed by the earlier surgery and distorted by scar
contracture, (2) operative plans must be changed radically when intraoperative findings dif-
fer markedly from preoperative expectations, and (3) the diversity of cases makes learning
surgical cause and effect difficult. Ultimately, secondary rhinoplasty must be based on the
fundamental principles of primary rhinoplasty. One simply cannot provide a formula for
dealing with the complexities of secondary rhinoplasty. Just as there is a progression from
medical school through residency to fellowship, most surgeons should progress from primary
rhinoplasty through their own revisions to secondary rhinoplasty over a 3–5-year period.
Note: a secondary rhinoplasty is defined as a case where the primary rhinoplasty was per-
formed by another surgeon; a revision is when you reoperate on your own primary case.
In this chapter, I have emphasized how secondary rhinoplasty differs from primary
cases and the advanced surgical techniques that are required. In Chapter 11, I have
­reviewed the decision-making process and how one selects the appropriate technique.
I cannot overemphasize it enough – there are no Level 1 or 2 secondary cases. One must
be a competent rhinoplasty surgeon with significant experience in primary cases before
taking on secondary cases. The surgeon must be comfortable harvesting and using rib
grafts as many patients will not have sufficient septal cartilage available and concha is not
structurally adequate. As detailed in Chapter 12, aesthetic reconstructive rhinoplasty has
emerged as a separate entity. These latter cases are extraordinarily complex and require
even greater surgical skills than secondary rhinoplasty.
Introduction
Secondary
­Rhinoplasty:
­Surgical
Techniques10

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Chapter 10  
Secondary ­Rhinoplasty: ­Surgical Techniques
What makes secondary rhinoplasty so hard? While writing this book, I tried to devise a pre-
operative “score sheet” for determining the degree of difficulty for secondary cases. Certain
factors were obvious – number of prior operations, number of different surgeons, availability
of septum, skin thickness, etc. I was becoming convinced that a female patient with an ear-
lier single closed rhinoplasty with a palpable septum would be an easy secondary case. Of
course, I then operated on such a patient only to discover that her entire alar cartilages had
been excised from the footplates upward thus forcing a total tip reconstruction. The critical
issue is that you have no idea of what was done or is available in a secondary case until you
open them up. Thus, all secondary rhinoplasties are complex and you must be prepared for
any eventuality (Fig. 10.1).
Completing the Primary. From the surgeon’s perspective, these are the easiest of secondaries.
The patient often complains that the tip does not have enough definition, the bridge looks
pinched, the nostrils are too big, and they do not breathe well. If the primary was done closed,
then one usually has symmetrical rim strips to work with and a tip suture technique can
be done via the open approach. A columellar strut and spreader grafts are often necessary.
Eliminating the Negatives. Many of these patients have a higher degree of nasal complex­
ity and have frequently had a revision by the original surgeon. It is important for the new
surgeon to take a “fresh look” while the patient must be able to articulate what they want
changed. Most of my patients feel that their nose is still too big and not sufficiently feminine.
Often they consider the nose to be a smaller version of the original and not a significant
improvement. Technically, one has to be prepared for virtually any problem.
Converting from Operative Look to Natural Nose. Often, these patients feel that their nose
looks “done” due to an over-resected bridge, an upwardly rotated tip, retracted nostril, or a
tip bossa. The challenge is to create a solid foundation for the nose and improve respiration.
Numerous grafts ranging from septal to fascia to concha to composite and even unanticipated
rib grafts will be required. Tip surgery can range from tip suture to tip reconstruction, one
simply does not know until the nose is opened. All of these cases are done open as one has
the option of utilizing the various cartilage remnants and direct observation permits a wide
range of techniques. Unfortunately, skin coverage is often a consideration and fascial grafts
are used liberally in thin-skin patients. One must be comfortable with dorsal augmentation
and the various types of diced cartilage grafts. Nostril retraction or vestibular valve scarring
can be so severe that composite conchal grafts have to be utilized. There are no short cuts
in managing these cases.
Aesthetic Reconstructive Rhinoplasty. By definition, these are the most difficult of secondar-
ies and require numerous grafts often including rib grafts. The goal is to achieve a natural
attractive nose without any indication of prior surgery. One is doing an “aesthetic reconstruc-
tive rhinoplasty” to salvage the nose. These cases will be discussed in depth in Chapter 12.
Overview

Overview
351
Fig. 10.1 Range of secondary cases, (a) completing the primary, (b) eliminating the negatives,
(c) surgical to natural look, (d) aesthetic reconstructive rhinoplasty

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Chapter 10  
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Analysis
A 22-year-old girl had a rhinoplasty 2 years earlier and hated the result (Fig 10.2). She
especially disliked her minimally improved wide bulbous tip and pinched bridge. She had
had multiple consultations on the “nose circuit” and been told that she needed a major rib
reconstruction. Yet, her goal was still the same small cute nose that had led her to have a
rhinoplasty in the first place. I advised her that the donor site progression would be septum
to concha to rib. Fortunately, septum proved sufficient and her nose was made more refined
and the tip smaller. Her final result is more the “naturally cute nose” that primary patients
seek and not a “reconstructed nose” that complex secondary cases often have to accept.
Operative Technique
  1) Harvest of temporal fascia. Transfixion incision with confirmation of intact septum.
  2) Open exposure revealed alar rim strips following prior transcartilaginous excision.
  3) Cartilaginous dorsum lowered 1.5 mm. Bony dorsum smoothed with a rasp.
  4) Septoplasty – harvest of the septal body. Caudal septum relocation R to L.
  5) Insertion of bilateral spreader grafts.
  6) Alar transposition.
  7) Insertion of columellar strut plus tip suturing: CS, DC, ID, DE, TP. Add-on graft of excised
alar cartilage.
  8) Lateral crural strut grafts sutured to lateral crura.
  9) Insertion of “fascial blanket” over the dorsum and tip.
10) Lateral crural strut grafts placed into the alar bases (T2), not on nostril margin (T3).
Case Study:
Secondary
­Rhinoplasty
Fig. 10.2 (a–l)

Case Study: Secondary ­Rhinoplasty
353
Fig. 10.2 (continued)

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Chapter 10  
Secondary ­Rhinoplasty: ­Surgical Techniques
Why do patients seek secondary rhinoplasty? I believe they do so for three reasons: (1)
there is an obvious visible and/or functional problem; (2) the result is poor because a good
operation was done on the wrong anatomy; or (3) it is not what the patient wanted or had in
mind. The result is a patient who is disappointed or unhappy, but rarely litigious. In general,
the first part of the consultation for a secondary rhinoplasty patient is quite similar to that
of a primary case. I hand the patient a mirror and ask them to show me what three things
they do not like about their nose. Often, the patient will want to give me an operation-by-
operation account of how the nose got that way complete with sequential photographs and
op reports. I explain that I will want to look at that information later, but first “tell me what
you don’t like about your nose and, more importantly, what do you want.” I am trying to
get the patient to commit to a specific set of aesthetic objectives. Then I examine the nose
thoroughly and decide whether the tissues and my expertise will allow me to achieve their
goal. I do not impose my aesthetic objectives nor hide behind tissue limitations. Either, I
can achieve what the patient wants, or it is not worth doing the surgery. Concurrently, I am
evaluating the patient’s personality and psychological stability. Eventually, I ask myself two
critical questions: Is this patient a good surgical candidate psychologically and would I have
done this patient’s primary rhinoplasty? If the answer to either question is no, then I will
not operate on the patient under any condition. I continue to turn down 25% of secondary
patients for psychological reasons. The two most common factors are patient instability and
obsessiveness. Many patients, males in particular, become fixated on their noses and pursue
every small imperfection.
Without question, the best method of measuring the patient’s concern for their defor-
mity is Gorney’s diagram (Fig. 10.3). I frequently sketch this diagram in the patient’s chart.
If I decide not to operate on the patient, then I tell them that the risk/reward ratio is not in
their favor and explain why in technical details. If the patient continues to push, then I will
show the patient my diagram of deformity versus concern. If the patient still pushes, then
I conclude by saying “I simply do not have the skills to solve your problem.” That usually
works. On a more cheerful note, secondary rhinoplasty is often easier than primary because
the patient is more realistic and more willing to accept improvement rather than perfection.
Consultation
Fig. 10.3 The Gorney Diagram. Plotting the
­patient’s objective concern about the defor-
mity against the surgeon’s objective assess-
ment of the deformity. The worst candidate
has minimal ­deformity but maximum concern
(upper left corner), while the best candidate has
major ­deformity with little concern (lower right
corner). Anyone who falls above the line should
be ­reevaluated at a second consultation

Operative ­Planning
355
For the experienced surgeon, analysis is probably more important in secondary cases for
three reasons: (1) the range of variables is not within “normal” limits but rather includes
the abnormal, (2) deficiencies are juxtaposed to excesses with few ideals, and (3) one often
has to create a desired look rather than eliminate the excesses. One uses the same sequence
learned in primary rhinoplasty: (1) detail history followed by external and internal nasal
exam, (2) regional exam including radix, dorsum, tip, base, and skin, (3) repeat internal exam
of septum, turbinates, and four valves following decongestants, (4) initial operative plan, (5)
photographic analysis, and (6) complete reassessment at the pre-op visit.
Initial Examination. For major secondaries, the key questions are what is wrong with this
nose, why does it look “done,” and what do I need to do to make it look more natural. One
is constantly asking which surgical maneuvers will be necessary and how to reconcile the
operative plan with the available tissues. Functional assessment is critical as you inherit
these limitations once you operate. Distinguishing between true anatomical obstruction and
mucosal disease is important. Also, one must be constantly determining the risk/reward ratio
both for the patient and for your self.
Examination and Analysis. The skin envelope is a much more limiting factor in secondary
cases than in primary cases. The surgeon must evaluate its thickness, size, compliance, com-
position, and prior surgical compromise including scars, furrows, and steroidal changes. The
three critical dorsal factors are height, straightness, and integration. From the lateral view,
dorsal height and inclination relative to the tip and radix influence the nasal ­appearance.
Surprisingly, the most common problem is excess height of the cartilaginous vault which is
relatively easy to correct. From the anterior view, dorsal deviation is obvious to the patient
and is usually due to persistent septal deviation. Osteotomies are often necessary to correct
asymmetries and narrow the nose. As regards the tip, one has to add distortion, ­deformity,
and deficiency to the usual concerns of definition, width, and projection. Essentially, one
evaluates the available structures and the need for grafts, and tries to determine what can
be achieved. Patients rarely make specific complaints about the base, although they are quick
to note columellar crookedness, nostril asymmetry, and excess alar width. Often, one can
classify these problems as to preexisting anatomical asymmetry, errors of omission (excess
alar width, caudal septal deviation), or errors of commission (retracted columella, notched
alar rims). On anterior view, it is often the combination of the “seagull-in-flight” and interalar
width which denotes problems. Overall examination of the base requires assessment in static
and dynamic poses as well as palpation.
Many surgeons are reluctant to do photographic analysis as they feel it diminishes their artis-
tic reputation – what nonsense. The following summary will be sufficient for most readers
with more in depth elsewhere (Daniel, 1993). The three steps are: (1) analyze the deformity,
(2) superimpose the ideal, and (3) evaluate alternative operative plans before finally selecting
the optimal one to fit the individual patient. How is it done? Usually, I use a simplified set of
angles and lines drawn on a lateral view.
Operative
­Planning
Photographic
Analysis

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Secondary ­Rhinoplasty: ­Surgical Techniques
Reference Points. The three key components are: three points (nasion, tip, subnasle), three
angles (nasofacial, tip, columella inclination), and three lengths (radix height, dorsum, tip
projection). Mark the following points: nasion (N), tip (T), subnasale (SN) and alar crease
(AC). Draw the following reference lines: (1) Frankfort horizontal, and (2) a vertical line
through the alar crease. Draw and measure the following angles: nasofacial, tip, and columella
inclination. Measure the following lengths: radix projection (C-N), dorsal length (N-T), and
tip projection (AC-T). Once the references are drawn then the ideal is superimposed.
Superimpose the Ideal. Every artist from Leonardo to Wyeth has used grids and canons to
define facial relationships. Nasal length is related to midfacial height. A red pencil is used
to draw the ideal which in turn defines the patient’s deformity. The nasion (N) is the deep-
est point in the nasofrontal angle. Its level is between eyelashes and alar crease, while its
height is 0.28 × midfacial height (MFH). Alternatively, N should be 4–6 mm posterior to the
glabellar. The tip (T) is the most projecting point on the lobule as seen on lateral view. The
subnasale (SN) is the deepest point in the columella labial angle uniting the columella and
the upper lip. The nasofacial angle (NFA) is the intersection between a vertical reference
line through the nasion and a straight line drawn from the nasion to the tip (N-T measures
dorsal length) with the ideal being 34° for females and 36° for males. The tip angle (TA) is
the intersection between a vertical reference line through the alar crease and a straight line
from alar crease to tip (AC-T measures tip projection) with the ideal 105° for females and
100° for males. The columella inclination (CIA) is measured between the vertical reference
line through the alar crease and a line tangent to the columella with identical ideal values to
the tip angle. This inclination has replaced the classic columella labial angle and nasolabial
angle in importance. The dorsal length (N-T) is measured from nasion to tip transecting
any intervening hump with the ideal being N-Ti = 0.67 × MFH. The tip projection (AC-T)
is measured from a vertical reference line through the alar crease to the tip with the ideal
being AC-Ti = 0.67 N-Ti. The nasion height (C-N) is measured from a vertical reference line
tangent to the cornea out to the ideal being C-Ni = 0.28 × N-Ti, (see Table 2.3, p50).
Operative Alternatives. In most cases, the discrepancy between actual and ideal is quite
obvious. However, surgical reality may require acceptance of more limited changes and that
is where alternative surgical solutions are best utilized. For example, a major radix augmen-
tation may not be acceptable to the patient and one must determine the impact it will have
on planning both dorsal reduction and tip projection. Equally, an obtuse columella labial
angle may be soft tissue in origin precluding caudal septal resection. It is this opportunity
to evaluate different operative treatments that is of great value.

Operative Planning
357
Obviously, Operative Plan #1 is made by integrating the patient’s desires and the surgeon’s
opinion (Fig. 10.4). Once the examination is completed, one should have a good idea as to the
goals, the requisite approach, the necessary changes to each of the four areas, the available
graft material, and the functional factors. Photographs, as well as surface measurements, are
taken. Then the in-depth study is done working through the progression of actual to ideal
to realistic changes finally reaching Operative Plan #2. At the next office visit, I examine
the patient asking myself these questions – what is wrong with the nose, what needs to be
corrected, and what is possible? I am essentially setting an overall goal (Operative Plan #3)
before going through the final step-by-step planning. I ask the patient for input and review
any photographs that the patient may have brought. Then, I do yet another internal exam to
confirm the functional requirements and check it against the initial evaluation. Each region
of the nose is assessed again and one arrives at Operative Plan #4 which will be taken to the
operating room. One must consider this as only a plan – one that can change dramatically
depending on the actual tissues available. In secondary rhinoplasty, the conversion from
“operative plan” to “operation” is often a painful lesson in surgical reality.
Operative
Planning
Fig. 10.4 (a–c) Secondary analysis

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Chapter 10  
Secondary ­Rhinoplasty: ­Surgical Techniques
The skin envelope is a major factor in secondary rhinoplasty and determines not only the
dissection plane, but often the type of tip surgery.
Thick Skin. The thick-skin envelope has always been considered a major limiting factor for
achieving both tip definition and the desired profile line. One must distinguish three char-
acteristics for the skin sleeve: thickness, size, and compliance. The fundamental concept is
that, rather than fearing skin contracture, one uses it to reveal the strong structured tip and
dorsum which are created during a secondary surgery.
When the supratip area is heavily scarred, I tend to dissect in the subcutaneous subder-
mal plane rather than in intimate contact with the alar cartilages (Fig. 10.5). The advantage
is that it allows me to excise or sculpt the supratip scar while setting the correct thickness
of the skin envelope. In most cases, one can resect the soft tissue on top of the alar cartilage
without resorting to debulking the undersurface of the skin envelope – a maneuver that risks
thinning, distortion, and even slough of the tip skin. In severe cases with minimal alar rem-
nants, the supratip scar is sculpted and a tip graft is sutured directly to the scar tissue. In most
cases, the nasal skin is widely undermined over the cartilaginous vault which allows the skin
to redrape laterally, avoiding the bunched supratip which occurs with a closed approach. One
can even undermine onto the anterior surface of each maxilla for extremely wide undermin-
ing. In severe cases, I will insert a 7Fr drain under the skin envelope to evacuate blood and to
suction the skin down to the underlying aesthetic structures for 3–5 days.
Thin Skin. Although thick skin receives greater discussion, it is really scarred thin skin that
strikes fear in the heart of the secondary rhinoplasty surgeon. The reason is quite simple:
every imperfection shows, nothing is hidden. The basic progression is plane of dissection
followed by padding. In thin-skin patients, it is critical to dissect in intimate contact with
the underlying cartilage (Fig. 10.6). One should see white glistening cartilage if possible.
The dissection must be done slowly and meticulously to avoid any skin perforation. I do not
hesitate to inject repeatedly with local anesthesia to foster hydrodissection. If a significant
skin perforation occurs, close it carefully with skin sutures to get the best possible repair.
Do not pretend that it did not happen and allow it to heal secondarily with a terrible scar.
Frequently, one will want additional soft tissue padding and deep temporal fascia is the
material of choice, in either single or double layer. For the dorsum, the fascia is folded, sutured
along its free edge, and placed underneath the dorsal skin using percutaneous sutures in the
radix and direct suturing caudally. When the tip is extremely thin, then a “fascial blanket”
is placed beneath the dorsum and over the entire tip lobule. In certain very scarred tips, a
­dermis graft is sutured over the tip or in areas where a previous skin slough has occurred.
Skin Envelope

Skin Envelope
359
Fig. 10.6 (a–d) Thin skin: Fascial graft coverage­ 
Fig. 10.5 (a–d) Thick skin: (a, b) defatting and (c, d) redraping

360
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For the vast majority of complex secondaries, an open approach is the only reasonable
method. (Table 10.1). If a prior open approach was done, then the preexisting transcolumellar
incision is used, otherwise the inverted-V at the midcolumellar point is preferred. Reopen-
ing a prior open rhinoplasty is not a major concern (Daniel, 1995). A bigger problem is skin
damage from either steroid injections or too superficial a dissection. The standard infracar-
tilaginous incision is used irrespective of prior incisions. The nasal lobule is injected heavily
with local anesthesia to facilitate dissection. The skin is elevated from the incision upward
using three point traction with extreme care over the domal points. Careful dissection in
intimate contact over the lateral crura is done except in thick-skin patients. The dissection
continues up over the dorsum with liberal addition of local anesthesia as necessary.
The septum is exposed through a complete unilateral transfixion incision, with addition
of the opposite transfixion as necessary. In most cases, the caudal septum can be exposed
“cleanly” and then continue into the dorsum under direct vision. The classic “top down” dis-
section from the dorsum can be extremely difficult in secondary cases due to scarring from
the prior dorsal resection. Using the available “bidirectional approach,” the entire septum is
exposed. One then determines where and how severely deviated is the septum, how much
septum remains for graft material, and how much can the dorsum be safely reduced.
Septal Considerations
1) During injection of local anesthesia, one can assess the resistance and probe for prior
septal resections. An endoscope can be of value to document prior septal perforations.
2) It is important to assess the status of the septum prior to dorsal reduction. If the previous
surgeon left a 7–8 mm L-shape strut and one is planning to reduce the cartilaginous vault
by 3–4 mm, then the risk of septal collapse is very real.
3) The dissection plane may change dramatically as one goes from easy elevation caudally
into scarred areas, especially if prior morselization was done. Equally, one can encounter
areas of septal overlap with fused layers of perichondrium.
4) In areas of prior resection, one must separate the two mucosal leaflets without tearing
them apart. On occasion, there will be a scar layer or even a pseudocartilaginous regrowth
of the septum.
5) Harvesting cartilage after prior resections is most often successful in the lower vomerine
area as well as superiorly under the dorsal strut near the perpendicular plate (Fig. 10.7).
6) Obviously, one must be able to correct every primary septal deformity which was not
treated previously. Also, one may encounter complete disruptions in both the caudal and
dorsal portions of the L-shape strut, but often without the advantage of usable septal
grafts. Ultimately, the surgeon must be able to fashion both a columella strut and a dorsal
graft from either conchal or rib cartilage!
Open Approach
and Septal
Exposure

Open Approach and Septal Exposure
361
Incisions
Prior open
Old transcolumellar
New infracartilaginous
Thin
Hydrodissection
Skin
Dissect on cartilages
Thick
Subdermal dissection via
­infracartilaginous
Transcolumellar dissection upward
Resect scar tissue on top of alars
Tip analysis
What is the status of each alar cartilage?
How much cartilage is resected, incised, or
damaged?
What was the original tip operation?
Will my operative plan work?
Table 10.1 Open approach to secondary rhinoplasty in 100 consecutive cases 
Fig. 10.7 (a, b) Secondary septal harvest when prior SMR was done

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Secondary tip surgery ranges widely from simple to complex. In about 15% of cases, the
intrinsic tip was considered ideal and changes were mere enhancement. Once these cases
are eliminated, secondary tip surgery becomes extremely difficult.
Analysis. In contrast to primary cases which begin with the shape of the alar cartilage, most
difficult secondary cases start from the base upward and the skin downward before finishing
with the alar cartilages. A good example is a dependent tip following previous surgery. The
problem is a combination of prior caudal septal resection, division of the domal segment,
and a thick-skin envelope. The solution is often a major columella strut to support the alar
cartilages, a rigid tip graft to show through the thick skin, and a columellar sutures for rota-
tion. The alar cartilages and “intrinsic tip” are relegated to a supporting roll. Once the nose
is opened, the critical step is to reconcile the operative plan with the exposed anatomical
realities. Major changes in the operative plan are often necessary.
Resection/Repositioning. The classic resection technique is essentially a “volume reduction”
by excising either alar cartilage or scar tissue to setoff the intrinsic tip. The line is drawn on
the tip, transferred with the mucosal marker, and then resected via an intracartilaginous inci-
sion. An interesting variation is done via the open approach where one resects the redundant
tissue and may even shape the underlying “scar ball” into a defined tip.
Tip Sutures. The ability to suture the alar remnants (45%) plus the use of add-on grafts (25%)
means that 70% of the secondary tips can be done with essentially a primary rhinoplasty
technique (Fig. 10.8a). Obviously, the ability to suture implies that a volume reduction or
other excisional method was used primarily. Divided domes can be repaired and shaped with
sutures, Domal “knuckles” or bossa are excised and sutured in a “gothic arch” formation.
Then a shield shape or transverse add-on graft is added which has two benefits: conceals
the repaired division of the crura while creating a distinct tip.
Structural Tip Grafts. Structural tip grafts are extraordinarily variable in composition
(septum, concha, or rib), edge shape (round, sharp), and position (projected, integrated)
(Fig. 10.8b). The indications ranged from wanting additional definition beneath a thick-skin
envelope to concealment of deformed domes.
Total Tip Replacement. In certain cases, the domes have been excised and one has to do a
total tip replacements usually consisting of an isolated tip grafts with alar support grafts
(Fig. 10.8c). In contrast to primary surgery where the difficulty is executing a specific tech-
nique, the surgeon is now forced into a corner by the remaining anatomy. Choices are di-
minished, alternatives are few, but the goal remains the same – an attractive unoperated tip
appearance.
Tip Analysis

Tip Techniques
363
a
b
Fig. 10.8 Secondary tip surgery (a) secondary tip: add-on grafts (b) secondary tip: structured tip graft (c) secondary tip:
isolated tip graft 
c

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When planning secondary surgery of the dorsum, one must add straightening, smoothing,
and camouflage of the dorsum, to the primary choices of reduction, augmentation, or balance.
Frequently, analysis is more complex in secondary cases as none of the cardinal landmarks
is ideal and setting each one creates interrelated challenges. Equally, the skin envelope over
the dorsum becomes a critical issue, usually revealing thinness over the rhinion or a non-
compliant thickness in the supratip area. Further complicating the issue is the number of
previous osteotomies with their variable locations and effectiveness. In addition, the prior
use of both autogenous grafts and allografts can produce some very difficult intraoperative
surprises. The lack of adequate septal material can cause a major problem in dorsal grafting.
Fortunately, most cases require dorsal refinement and appropriate osteotomies with dorsal
grafting an infrequent necessity.
Secondary Osseocartilaginous Vault Surgery. Based on a review of 100 secondary rhino-
plasties, there have been significant changes in the last 8 years (Table 10.2). Excluded from
this group are the aesthetic reconstructive rhinoplasties which require rib grafts as well as
ethnic noses. The radix area was grafted in 6% of the cases, either as a pure fascia graft or
a ball-and-apron fascial graft. The overall approach to the dorsum was reduction (75%),
augmentation (21%), and minimal changes (4%). Reduction was divided equally between
cartilage-only and combined bone and cartilage. Osteotomies consisted of low-to-high (42%),
low-to-low (21%), asymmetric (12%), microoseotomies (6%), double level (3%), and none
(16%). Spreader grafts were used quite frequently with bilateral (45%), unilateral (39%), and
none (16%). Augmentation was either DC−F or DC+F. Importantly, the choice of augmenta-
tion indicated that neither lateral osteotomies nor spreader grafts would be required. Perhaps
the most startling change has been the use of fascia. Fascia was used in 81% of the cases in
the following ways: dorsal fascia dorsal graft (36%), DC+F (15%), DC−F (6%), and a fascial
blanket (24%) interposed between nasal structure and overying skin.
Dorsal Refinement. Many secondary dorsums are a triad of reduction, correction of asym-
metries, and spreader grafts (Fig. 10.9). Generalized reduction was done with a rasp for the
bony vault and a #11 blade for cartilage vault. The majority of these reductions were in the
1–3 mm range with emphasis on smoothing irregularities. An interesting observation is that
a “cartilaginous dorsum only” reduction was done in 42% of the reduction cases. This find-
ing indicates that the bony reduction was done correctly at the initial operation. The critical
finding was the use of fascia to pad a thin-skin envelope in 65% of cases. Dorsal fascial grafts
could be a isolated dorsal graft or extended over the tip as a “fascial blanket” or combined
with a radix graft as a “ball-and-apron graft.” When the dorsum was not touched, it obvi-
ously indicated that the original surgeon had achieved the ideal dorsal line and the goal was
to modify the tip and correct nostril deformities.
Dorsal
­Modification

Dorsal ­Modification
365
Radix
Nothing
Augmentation
Reduction
93%
6%
1%
Dorsum
Nothing
Augmentation
Reduction
4%
21%
75%
Reduction
Bone and cartilage
Cartilage only
58%
42%
Dorsal grafts
Fascial blanket
Fascia dorsal
DC−F
DC+F
24%
36%
6%
15%
Osteotomies
Low-to-high
Low-to-low
Asymmetric
Microosteotomies
Double level
None
42%
21%
12%
6%
3%
16%
Spreader grafts
Bilateral
Unilateral
None
45%
39%
16%
Table 10.2 Secondary osseocartilaginous vault surgery in 100 consecutive cases
Fig. 10.9 (a–d) Dorsal modification

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Secondary septal surgery is more difficult than primary surgery for three reasons: (1) the
structures are often distorted and scarred from previous manipulation, (2) prior resections
may have weakened the critical L-shape strut, and (3) the maximum amount of graft mate-
rial is needed. The actual indications for septal surgery are somewhat constant: correction of
anatomical obstruction and/or harvest of graft material, but with the additional possibility
of prior surgical failure and distortion. I did septal surgery in 85% of the secondary cases
with 33% of these done solely for harvesting graft material and 67% for the functional rea-
sons with concomitant harvest of graft material. Of tremendous importance, 75% of these
secondary cases had a prior septoplasty including some resection! Elevation of the mucosal
flaps ranged from simple to nightmarish. In addition, 18% or almost one out of five required
a total septoplasty to correct the septal deformity. Any thought that one can do secondary
rhinoplasty without managing difficult septums is completely naive. As always, one must
be prepared to deal with all types of septal deformities including the caudal septum, dorsal
deviations, and total septoplasty. Obviously, the prior errors of commission (excessive exci-
sion, destabilizing incisions, weakening morselizations) cannot be overestimated. Long-term
structural support must be restored.
Caudal Septum. Frequently, the caudal septum will have to be replaced or reinforced due to
prior incisions or excisions (Fig. 10.10a). Whenever possible, the replacement graft is sutured
into position prior to excising the deformed caudal septum. This allows an accurate replace-
ment without loss of support.
Dorsal Septal Deviation. As always, one straightens the septum first and then uses asym-
metric spreader grafts as required (Fig. 10.10b). Rarely, one will need to support the dorsum
with a unilateral spreader graft, then divide the dorsal portion of the L-shape strut, and splint
it again with a spreader graft on the other side.
Vestibular Valve. These problems are often subdivided into attic and lateral vestibular col-
lapse with careful assessment of mucosal and structural loss (Fig. 10.10c). Vestibular attic
webs are classified as thin, which can be treated with Z-plasties or thick, which require
composite grafts. In the lateral vestibule, one must answer three questions: (1) Is the lining
deficient thereby requiring a composite graft? (2) Does the lateral crura accessory cartilage
junction protrude into the airway, thereby necessitating resection?, and (3) How thin and
structurally weak is the lateral vestibule? Most often, it comes down to a simple question:
Do I have to replace lining with a composite graft or is a conchal cartilage graft sufficient
for support?
Secondary
Septoplasty and
Vestibular Valve

Secondary Septoplasty and Vestibular Valve
367
Fig. 10.10 (a) Caudal septal replacement 
(b) dorsal septal deviation (c) vestibular valve
scarring and collapses

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Osteotomies. I find that the majority of secondary cases require osteotomies despite the fact
that they were done during the primary rhinoplasty. The need for osteotomies is due to the
following: (1) excessive bony width, (2) asymmetries, and (3) bony deformities. Although the
usual problem is a wide asymmetric bony vault, standard paired low-to-high or low-to-low
osteotomies will usually solve most problems. It is tempting to speculate that the primary
osteotomies failed due to a lack of adequate mobilization. When an exceptionally wide
dorsum is encountered, then medial oblique, transverse, and low-to-low osteotomies are
used (Fig. 10.11a). Small bony asymmetries localized to the keystone area are treated with
microosteotomies (Fig. 10.11b). Convex lateral walls can be converted to straight by using
double-level osteotomies.
One of the major challenges in secondary cases is the nose with a pinched bony vault. To
solve this problem, I have devised a new operation in which the nasal bone is totally ­mobilized
and then stabilized in its normal location (Fig. 10.11c, d). Usually, a combination of medial
oblique and low-to-low osteotomies is done. Then using a Boyes elevator the lateral wall is
mobilized outward which both moves the wall laterally and converts a vertical wall to an
angled wall. Then extra-long spreader grafts are placed as high as possible to stabilize the
bone in an outward position. Doyle splints, with the flat superior portion cut off, are sutured
high in the airway. The splints force the lateral wall out and are removed at 2 weeks.
Spreader Grafts. I find that less than 5% of secondaries had prior spreader grafts
(Fig. 10.11e–h). This omission results in an internal valve that is collapsed and a midvault
which is either pinched or asymmetric. In secondary cases, it is essential first to complete
the dorsal modification followed by a septoplasty and septal harvest whenever the latter is
possible. Also, all osteotomies and mobilization of the lateral walls must be completed prior
to graft insertion. Asymmetric spreader grafts are used in almost all secondaries. Rigid septal
grafts are only essential when dorsal deviations must be excised and repaired. If graft material
is scarce, concha material makes excellent spreader grafts. In primary cases, spreader grafts
are directed at opening the internal valve and avoiding a pinched midvault. In secondary
cases, spreaders tend to be longer, wider, and inserted higher within the bony vault. These
grafts must overcome the deformity and contracture which has occurred following the
primary rhinoplasty. In a high percentage of cases, one is actually supporting and aligning
the lateral bony wall with these grafts. If the failure to use spreader grafts results in such an
obvious form and function liability why do surgeons continue not to use them in primary
cases? My conclusion is that most surgeons want to avoid any additional step they can and
rationalize that spreader grafts are really not necessary – what a false assumption.
Osteotomies
and Spreader
Grafts

Osteotomies and Spreader Grafts
369
Fig. 10.11 (a) Medial oblique osteotomies, (b) microosteotomies 
(c, d) correcting collapsed lateral bony wall,
(e–h) spreader grafts in secondary cases

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Tip surgery can vary enormously in secondary cases from literally nothing to total
­reconstruction. However, the biggest surprise of the last decade has been that 75% of the
tips can be sutured with or without add-on grafts. This approach has replaced solid or mul-
tilayer tip grafts as the technique of choice. Thus, secondary tip surgery is now closer to the
primary operation. Tip surgery will be discussed in the order of tip techniques actually used
in 100 secondary rhinoplasties (Table 10.3). It is important to note that this series does not
include aesthetic reconstructive rhinoplasty cases which often have the most complex tips
and require a higher percentage of open structure tip grafts and total tip reconstructions.
Columellar Strut
Columellar struts are an essential part of all secondary tip surgery – there are no exceptions
(Fig 10.12a). The alar cartilages are often highly scarred or distorted and often need to be
reinforced. Alternatively, they may be persistently over-projected requiring direct excision,
but with a strut insertion prior to destabilization. Whenever possible, septal cartilage is the
donor material of choice with optional inclusion of ethmoid bone. Rigidity and structural
support is essential. The second decision is the dimension of the graft, both length and shape.
Structured columellar struts are more frequently required with the struts being longer and
often wider near the base to push down the columellar labial angle. Insertion is comparable
to primary cases, but excessive length must be avoided to prevent rocking across the ante-
rior nasal spine (ANS). For short columellars, double-suture fixation above and below the
columellar breakpoint is a consideration. Once tip surgery is completed, columellar shaping
sutures using clear 4–0 polydioxanone suture (PDS) are often inserted to narrow the colu-
mellar and rotate it more cephalically.
Preparation of the Alar Cartilages
In contrast to primary cases with their pristine crura, the alar cartilages in secondary cases
are frequently distorted, incised, excised, and encased in scar tissue. Instead of the simple
step of creating symmetrical rim strips, preparation of the alars for suturing is much more
complex and requires numerous decisions.
Release of Scar Tissue
Significant scar tissue always occurs in secondary tips in the dead space (Fig 10.12b) between
the remaining alar rim strips and the caudal end of the upper lateral cartilages. Scar contrac-
ture is also present in the supratip area and extending downward between the domes and the
anterior septal angle. This scar tissue is released using sharp scissors and downward traction
on the alars. Next, the middle crura are separated. This amount of release is typical following
a closed primary procedure. What if the primary procedure was an open tip suture? I have
seen virtually every combination of sutures. Release of midline narrowing sutures is done
by dividing the columellar sutures and releasing any interdomal and lateral crural spanning
sutures. Domal creation sutures are removed, but only with limited effectiveness.
Tip Surgery

Tip Surgery
371
Open approach
100%
(Note: 5% done closed, but no tip surgery)
Columellar strut
100%
(Stronger, wider, longer)
Tip technique:
100%
  Sutures only
49%
  Sutures and add-on grafts
29%
  Open structure tip grafts
19%
  Isolated tip graft
3%
Fascial tip coverage
44%
Nostril rim:
61%
  ARG
5%
  ARS
28%
  LCS graft
20%
(Lateral transposition 10%)
  Composites
8%
Table 10.3 Secondary tip surgery in 100 consecutive cases
Fig. 10.12 (a) Columellar struts, (b) Release of scar tissue contracture in the tip
a
b

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Incisions, Divisions, and Bossa
Incisions of lateral crura and domes to weaken their convexity remain an integral part of closed
rhinoplasty despite their inevitable tendency to form bossa and distortions. The weaken lateral
crura will often require an underlying lateral crural strut to stabilize and reshape them. For some
reason, domal division remains popular for narrowing the wide tip among endonasal surgeons
despite its ineffectiveness, especially under thick or thin skin. Fortunately, these divisions can be
repaired after insertion of a columellar strut and the domal segments sutured. Sharp pointed
bossa or prominences are usually excised and the edges sutured with 5–0 PDS. Coverage with
a concealer grafts is frequently necessary to insure a smooth tip.
Tip Sutures
Suturing a secondary tip is somewhat similar to the techniques used in primary tips
(Fig. 10.13a–c). The first step is to release the scar contracture and then analyze the remain-
ing alar remnants. Symmetrical rim strips are created by appropriate excision of any excesses
or asymmetries. I delay any repair of previous transections or excision of deformed segments
until the columellar strut is in place. After columellar strut insertion, the domal creation
sutures are done. Usually, the cartilages remain sufficiently malleable, and one can create a
tight domal convexity with adjacent lateral crura concavity. An interdomal suture is inserted
to narrow tip width and to equilibrate domal height. The skin is redraped and the tip evalu-
ated. Frequently in secondary cases, it will be necessary to add a tip position suture to achieve
the desired supratip break. The addition of lateral crural convexity sutures is essential for
minimizing lateral convexities or excessive tip width.
Tip Sutures Plus Add-On TRG Grafts
Once tip suturing is completed, add-on TRG grafts are used liberally to increase definition
and projection (Fig. 10.13d–f). Excised lateral crura are the material of choice. Skin thickness
will dictate the number of layers while aesthetic goals will dictate graft placement. Single
infralobular concealer grafts are necessary under thin skin, whereas double-layer onlay
domal grafts are common under thicker skin.
Lateral Crural Deformities
Deformities of the lateral crura are very real in secondary cases. They may require either
excision, sutures, or grafts with transpositions an occasional necessity. Surprisingly, decisions
regarding the lateral crura are just as complex as the domes and the role of lateral crural
strut grafts cannot be over emphasized.
Structured Tip Grafts
In most secondary cases, a structured tip graft is not done for subtle changes of definition or
projection (Fig. 10.13g–i). Rather, the grafts are designed to show a distinct change in the tip
and to overcome a scarred or thick-skin envelope. A strong solid shield-shape tip graft is the
graft of choice. The tip graft is fixed in a higher position of projection with a cap graft behind it.
The first step is to prepare the alar cartilages for the structured tip graft. A ­combination of

Tip Surgery
373
Fig. 10.13 (g) Persistant over projection of tip, (h) 6 mm domal segmant excision, (i) rigid structure tip graft 
Fig. 10.13 (a) Prior tip graft with thin skin, (b) alars sutured, (c) fascia coverage 
Fig. 10.13 (d) Prior delivery procedure, (e) alars sutured, (f) diamond shaped add-on TRG graft

374
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Secondary ­Rhinoplasty: ­Surgical Techniques
­excisions of fixed deformities and balancing sutures is necessary to produce the requisite
domal configuration. In some cases, the configuration of the domal segment becomes irrel-
evant as it serves as a hidden foundation for a tip graft that will create the intrinsic tip.
Major differences exist in all aspects of the tip graft: composition, shape, and placement.
In primary cases, the tip graft can always be made from septal cartilage, whereas in secondary
cases conchal or rib cartilage may be necessary. The dorsal domal edge varies with the skin
thickness: smooth round (thin skin), angled edges (normal), and sharp corners (thick skin).
The graft is tapered to fit within the divergence of the crura. Graft placement can vary from
integration to high projection depending upon the desired tip definition. As the graft rises
above the alar domes, a solid “backstop” or cap graft must be added.
Total Tip
All too frequently, one encounters cases where the domal segment has been excised or, even
worse, the entire alar cartilages excised beyond the footplates. Thus, total tip reconstruc-
tion becomes a necessity. Essentially, there are three possible methods of reconstruction:
isolated tip graft, lobular tip graft, and total alar replacement graft. Many of these concepts
are modifications of Juri’s (1993) surgical approach to the crucified tip.
Isolated Tip Graft
In secondary cases, the domes and lateral crura may be totally absent from prior excision.
Quite surprisingly, it is often not necessary to replace the lateral crura. In some cases, a
crural strut is placed in between the medial crura through a midline split (Fig. 10.14a). A
long rigid tapered tip graft is sutured to the stabilized columellar. After the tip is closed,
then the alar rims are supported often with ARS grafts or alar battens. Obviously, this “tent
pole” concept works best under thicker skin. In more unstable case, the entire lateral crura
need to be replaced.
Total Alar Replacement
If the patient has severe external valve collapse or alar rim retraction, then total lateral crura
replacement is indicated (Fig. 10.14b). The simplest method of reconstruction is to harvest
the entire conchal bowl. The cartilage is then transected diagonally on its long axis creating
two reciprocal grafts. The graft is not designed to be an anatomical replacement of a lateral
crura, but rather a graft that will go from the dome along the alar rim down into the substance
of the alar base. The purpose is to support the alar rim and the vestibule.
Bossas and Bumps
Many secondary patients complain of small bumps on their tip ranging from slight promi-
nences to sharp points. Most patients want a simple solution – the bossa shaved down. On rare
occasions it can be done. Unfortunately, the more common result is swapping one deformity
for another with the patient remaining disappointed – the bump is gone, but now that dome
is flattened in contrast to the opposite side. A formal secondary tip rhinoplasty via an open
approach is usually the right choice.

Tip Surgery
375
Fig. 10.14 (a) Isolated tip graft
a
Fig. 10.14 (b) total tip graft reconstruction
b

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Chapter 10  
Secondary ­Rhinoplasty: ­Surgical Techniques
Secondary base surgery can range from simple to complex and from isolated to combined.
The most common problem is the isolated alar base/nostril sill deformity which is compa-
rable to that of the primary nose. Yet it is the retracted nostril and the retracted nose that
require detail analysis and precise surgical correction.
Alar Base/Nostril Sill. The isolated alar base/nostril sill problem can be similar to a primary
case or quite challenging due to prior excisions. The best situation occurs when the requisite
excisions were not done at the original operation, the indications remain, and routine exci-
sions are done. Frequently, one encounters previous excisions done too timidly or the scars
misplaced. If possible, prior scars are incorporated into the planned excision, but with the
caveat to be conservative. When distortions are present it is best to incise the old scar, recre-
ate the defect, and reassess. Although, diagrams of composite grafts and transposition flaps
are shown for correcting nostril sill contracture, results are limited at best.
Retracted Nostril. Many secondary cases present with a “retracted look” due to a combined
alar rim/nostril/columella deformity (ARNC) (Fig. 10.15a). This triad consists of retracted
alar rims and allows one to look into the person’s nostril aperture which is accentuated by
the hanging columella. It is essential to analyze the four inclinations on lateral view (tip,
alar rim, nostril, columella) and assess the nostril by bisecting its aperture and assigning
the etiology to alar rim and/or columella. Of the three possibilities, the most common is a
combined deformity corrected by excision of the caudal septum, lowering of the alar rim by
either alar rim grafts or composite grafts, and appropriate alar base/nostril sill excisions.
The columellar deformity is due to excessive length of the caudal septum and/or intrinsic
deformity of the medial crura. It is critical to assess upper lip length and inclination before
excising caudal septum. In secondary cases, the nostril rim deformity implies rim retraction
which is treated progressively from alar rim graft (ARG) to alar rim structure graft (ARS),
and ultimately composite grafts. The tapered composite “strip” graft measuring 2–4 mm in
width and 8–10 mm in length is highly effective in lowering the rim.
Retracted Nose. These complex cases are often short upwardly rotated noses which were
over-resected followed by severe scar contracture (Fig. 10.15b). Essentially one must be able to
force the tip and columellar downward with a major septocolumellar graft. The critical deci-
sion is to decide whether the lobule should be downwardly rotated and lengthened or whether
the entire nose should be lengthened. The distinction is made at the SN point – ­rotation
downward versus lengthening. If SN is kept as is, then the tip can be rotated downward usu-
ally with a pennant graft. Stretching rather than contracture of the membranous septum is
crucial. When scar contracture is severe or SN needs to be lower, then a large septocolumellar
graft is placed between the alars to force down the tip followed by infralobular tip grafts.
Vestibular scarring often mandates major composite grafts to lengthen the nasal lining.
Nostrils and
Alar Base

Nostrils and Alar Base
377
a1
a2
Retracted alar rim
Hanging columella
T
Ti
C´
C´
C
Ti
C
Combination
Fig. 10.15 (a) Columellar/nostril relationship and deformities, (b1) lengthening with either a pennant
or a septocolumellar graft, (b2,3) lengthening with a pennant graft

378
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Constantian M. Four common anatomic variants that predispose to unfavorable rhinoplasty
results. Plast Reconstr Surg 105: 316, 2000
Constantian MB, Clardy RB. The relative importance of septal and nasal valvular surgery
in correcting airway obstruction in primary and secondary rhinoplasty. Plast Reconstr
Surg 98: 38, 1996
Daniel RK. Rhinoplasty: Creating an aesthetic tip. Plast Reconstr Surg 80: 775, 1987. Follow-
up: Daniel RK. Rhinoplasty: A simplified, three-stitch, open tip suture technique. Part I:
Primary rhinoplasty, Part II: Secondary rhinoplasty. Plast Reconstr Surg 103: 1491, 1999
Daniel RK (ed). Aesthetic Plastic Surgery: Rhinoplasty. Boston: Little, Brown, 1993
Daniel RK. Rhinoplasty and rib grafts: Evolving a flexible operative technique. Plast Reconstr
Surg 94: 597, 1994
Daniel RK. Secondary rhinoplasty following open rhinoplasty. Plast Reconstr Surg 96: 1539,
1995
Daniel RK. Rhinoplasty: Septal saddle nose deformity and composite reconstruction. Plast
Reconstr Surg 119: 1029, 2007
Daniel RK. Diced cartilage grafts in rhinoplasty surgery: current techniques and applica-
tions. Plast Reconstr Surg 122: 1883, 2008
DeRosa J, Watson D, Toriumi D. Structural grafting in secondary rhinoplasty. In Gunter JP,
Rohrich RJ, Adams WP (eds) Dallas Rhinoplasty: Nasal Surgery by the Masters. QMP,
719–740
Gunter JP. Secondary rhinoplasty: The open approach. In: Daniel RK (ed) Aesthetics Plastic
Surgery: Rhinoplasty. Boston: Little, Brown, 1993
Gunter, JP, Rohrich, RJ. The external approach for secondary rhinoplasty. Plast Reconstr Surg
80: 161, 1987
Gunter JP, Rohrich RJ, Friedman RM. Classification and correction of alar-columellar dis-
crepancies in rhinoplasty. Plast Reconstr Surg 97: 643, 1996
Juri J. Salvage techniques for secondary rhinoplasty. In: Daniel RK (ed) Aesthetic Plastic
Surgery: Rhinoplasty, Boston: Little, Brown, 1993
Kim DW, Toriumi DM. Nasal analysis for secondary rhinoplasty. Facial Plast Surg Clin North
Amer 11: 399, 2003
Kridel RW, Konior RJ. Controlled nasal tip rotation via the lateral crural overlay technique.
Arch Otolaryngol 117: 441, 1991
Meyer R. Secondary and Functional Rhinoplasty – The Difficult Nose. Orlando: Grune and
Stratton, 1988
Peck GC. Techniques in Aesthetic Rhinoplasty. (2nd ed.) Philadelphia: JB Lippincott, 1990
Rohrich RJ, Sheen JH. Secondary rhinoplasty. In: Grotting J (ed) Reoperative Plastic Surgery.
St. Louis: Quality Medical Publishing, 1994
Rohrich RJ, Sheen JH, Burget O. Secondary Rhinoplasty. St. Louis: Quality Medical Publish-
ing, 1995
Sheen JH. Achieving more nasal tip projection by the use of a small autogenous vomer or
septal cartilage graft. A preliminary report. Plast Reconstr Surg 56: 35, 1975
Sheen JH. A new look at supratip deformity. Ann Plast Surg 3: 498, 1979
Sheen JH, Sheen AP. Aesthetic Rhinoplasty (2nd ed.) St. Louis: Mosby, 1987
Sheen JH. Tip graft: A 20-year retrospective. Plast Reconstr Surg 91: 48, 1993a
Sheen JH. Balanced rhinoplasty. In: Daniel RK (ed) Aesthetic Plastic Surgery: Rhinoplasty.
Boston: Little, Brown, 1993b
Tabbal N. The alar sliding graft for correcting alar collapse and expanding the nasal tip.
Aesth Surg J 20: 244, 2000
Toriumi DM. New concepts in nasal tip contouring. Arch Facial Plast Surg 8: 156, 2006
Toriumi DM. Augmentation rhinoplasty with autologous cartilage grafting. In Park JL, ed.
Asian Facial Cosmetic Surgery, Philadelphia: Elsevier, 2007, pp. 229–252
Toriumi DM, Johnson CM. Open structure rhinoplasty: featured technical points and long-
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4: 413, 2000
Reading List

I n a primary rhinoplasty, a great deal of decision making goes into the operative plan,
which is then executed with minimal changes in 90% of cases. When modifications are
required, it is usually a single step moved up or down the scale; i.e., a combined sill base
excision rather than a pure nostril sill excision. In contrast, the operative plan for a sec-
ondary case is complex and a challenge to figure out. Intraoperatively, the best conceived
plan serves merely as a guide, the execution of which requires constant decision making
and often radical changes to its fundamental components. An example of constant decision
making is elevating the skin envelope – a relatively straightforward step in a primary case,
but stressful in a scarred thin secondary case. A radical change in the operative plan can be
the creation of symmetrical rim strips. In a primary case, the surgeon knows that a 6 mm
alar rim strip is possible, only in rare cases will the lateral crura need to be relocated (alar
malposition) or flipped (severe concavity). No matter how much experience the surgeon
has, no one knows for sure what the alar cartilages will be like in a secondary case and the
same goes for the septum. Thus, every secondary rhinoplasty is a surprise, often bad, and
one must be prepared for significant intraoperative stress. The three requirements most es-
sential for doing secondary rhinoplasty are the following: (1) know exactly what the patient
dislikes about their nose and what they want, (2) do photographic analysis and write out an
operative plan, but stay flexible as major changes will be required, and (3) the more surgi-
cal techniques you have experience with the better. This chapter is an attempt to guide you
through the decision-making process of secondary rhinoplasty, which will hopefully teach
the reader to recognize the challenges ahead of time and deal with them intraoperatively.
Introduction
Secondary
­Rhinoplasty:
Decision
Making11

380
Chapter 11  
Secondary ­Rhinoplasty: Decision Making
In the majority of secondary cases, the skin envelope can be dealt with employing the
techniques learned in Level 3 primary cases – controlled defatting for thick skin and fascial
coverage for thin skin. The critical difference is that in primary cases failure to correct the
skin challenges merely downgrades the final result. In difficult secondary cases, the skin
envelope can lead to failure often with the final result looking like a smaller, more distorted
version of the pre-op nose, but on a very unhappy patient.
Thick Skin: Secondary
The two critical components are defatting of the skin envelope and providing strong struc-
tural support to the lobule. In these cases, maximal defatting of the lobular skin is done and
occasionally the entire skin envelope (Fig. 11.1). The lobule is injected with sufficient local
anesthesia to facilitate the dissection. The skin is elevated first in the subcutaneous plane
via the infracartilaginous incisions. Then, the transcolumellar incision is made and the skin
elevated toward the domes. Elevation is completed in the superficial plane, which leaves the
subcutaneous tissue on the underlying alar cartilages. One is not elevating the skin at the
cartilage level as done in primary cases. Next, subcutaneous and scar tissues are excised by
dissecting in contact with the cartilage. Intraoperative drains (#7 Fr) are used when extensive
resection is done, especially when muscle is resected in the radix area. Serial casting is done
for 2–3 weeks. It consists of replacing the acrylic cast at 1 week with a soft foam-lined cast,
which remains on for another week. Although skin envelope defatting is important, structural
support is essential. The columellar struts are long (25–35 mm) and rigid (septum or rib,
not concha). Solid structural tip grafts rather than add-on grafts are employed and placed
in the projected position. Frequently, isolated tip grafts are obligate necessities due to prior
weakening or resection of the lateral crura.
Thin Skin: Secondary
As previously shown, fascia is used in 60% of secondary cases either as an isolated dorsal
graft or as a fascial blanket to reline the entire nasal skin envelope (Fig. 11.2). Fascial grafts to
the dorsum can be either single or double layers. A double layer of fascia is used underneath
the thin dorsum to pad the skin and to prevent a “shrink rap” effect. If the skin on the tip
is also thin, then a continuous sheet of fascia for dorsal and tip coverage becomes a “fascial
blanket” for the entire undermined area. If a bossa has dangerously damaged the dermis, then
a specific ball of fascia is sewn directly over the domes. An “interpositional fascial graft” is
used in cases with severe steroidal damage or early reoperation to release skin folds created
by metallic splints. The skin is released and raised followed by insertion of the fascial graft
using numerous percutaneous guide sutures. In severe cases, one has to decide whether to
use dermis or fascia grafts. The answer seems to be dictated by loss of dermis. Small dermis
grafts are placed beneath depressed areas or sites of prior skin loss. Furrows are treated
by wide undermining and tailored dermis grafts fixed percutaneously beneath the furrow.
Certain cases will have such severely damaged or destroyed skin that an open approach is
precluded and a staged approach is favored. The first stage is to raise the skin and place a
dermis graft widely beneath the damaged area. One then waits 6–9 months before raising
the skin or resecting the small scarred area.
Decision
Making: Skin
Envelope

Decision Making: Skin Envelope
381
Fig. 11.1 (a, b) Thick skin (see following case study for result)
Fig. 11.2 (a–d) Thin skin. Result at one year following only insertion of a fascia graft

382
Chapter 11  
Secondary ­Rhinoplasty: Decision Making
Analysis
A 15-year-old presented for a secondary rhinoplasty 1 year after her primary. She felt that her
nose was still too wide and the tip too bulbous (Fig. 11.3). The skin envelope was extremely
thick and the tip indeed quite wide. Since her profile was acceptable, the osseocartilaginous
vault would be narrowed dorsally and at the base bony width without changing the profile.
At 1 year post-op, the patient was pleased with the result. The tip changes were achieved by
aggressive deffating of the skin envelope via a subcutaneous dissection followed by direct
excision against the alar cartilages not by direct thinning of the skin (intraops see Fig. 11.1).
At 15 years post-op, (Fig 11.3 right) the skin envelope shows relatively little change from 1
year post-op, thereby confirming that no dermal damage had occurred.
Operative Technique
1) Infracartilaginous incisions with subcutaneous dissection. Extensive defatting and exci-
sion of supratip scar tissue.
2) Septal harvest.
3) Dorsal width narrowing using 6-mm wide paramedian osteotomies.
4) Base bony width narrowing with transverse and low-to-low osteotomies.
5) Excision of redundant upper lateral cartilage and suture repair of dorsum.
6) Insertion of columellar strut with 7 mm width at SN point.
7) Crural strut suture followed by 4 mm domal segment excision.
8) Insertion of a rigid curved structure tip graft.
9) Wide skin undermining over nose and maxilla from nasal and intraoral incisions.
Case Study:
Thick Skin
Sleeve
Fig. 11.3 Defatting of secondary skin envelope: (a) preop (b) 1 year postop (c) 15 years postop

Case Study: Thick Skin Sleeve
383
Fig. 11.4 (d–l)

384
Chapter 11  
Secondary ­Rhinoplasty: Decision Making
Analysis
A 39-year-old woman had had a rhinoplasty at age 15. Eventually, she got tired of not being
able to breath and having a “nose job” look (Fig. 11.4). Her nostrils collapsed completely on
deep inspiration. The septum was deviated into the left airway. Aesthetically, she felt that
her nose was too pointy, too long, too done. Technically, the skin was paper thin with the
cartilages showing through. Bilateral asymmetric spreaders opened the internal valves while
the lateral crural strut graft supported the external valves. Resection of a 5 mm junctional
segment of lateral crura and A1 accessory cartilage was necessary to eliminate the deep
lateral depressions. The lateral crural strut graft provided support. A “fascial blanket” was
placed between the elevated skin and incorporated into the suture closure all the way down
to the transcolumellar incision.
Operative Techniques
  1) Septal exposure and confirmation of severe deviation into L airway.
  2) Open approach with visualization of previous bilateral domal division.
  3) Dorsal exposure. Bidirectional approach to septum. Cartilaginous dorsum smoothed.
  4) Septal body resection correcting deviation and providing graft material.
  5) Insertion of spreader grafts: R: 2 mm, L: 2.5 mm.
  6) Undermining of lateral crura with segmental excision of lateral crura – A1 junction.
  7) Suture of lateral crural strut graft toward the pyriform aperture (Type I).
  8) Insertion of a crural strut plus tip sutures (CS, plus domal division repair).
  9) Application of a “concealer graft” of excised alar cartilage to hide suture repair.
10) Insertion of a “fascial blanket” to cover all undermined areas, especially the lobule.
11) Note: no bony vault surgery or osteotomies.
Case Study:
Thin Skin
Fig. 11.4 (a–j)

Case Study: Thin Skin
385
Fig. 11.4 (continued)

386
Chapter 11  
Secondary ­Rhinoplasty: Decision Making
As previously noted, the secondary dorsum can be improved in many cases with the triad
of smoothing the bony dorsum using a rasp, reducing the cartilaginous dorsum, and cor-
recting the inverted V with spreader grafts. Many secondary noses remain wide and a high
percentage of low-to-low osteotomies are required. All of these steps are a part of routine
primary rhinoplasties and do not represent a greater degree of complexity. The most chal-
lenging issues are straightening the deviated asymmetric dorsum, augmenting the bridge,
and realigning the bony base.
The Deviated Nose. Correcting the deviated asymmetric nose begins with the septum – check
for deviations caudally and dorsally. Caudal deviations are obvious, but whether the dorsum
is intrinsically straight will only be revealed once the upper laterals are detached from the
dorsal septum. Asymmetric osteotomies are often done with all combinations possible. The
encountered problems can be due to errors of omission or commission, as well as intrinsic
bony asymmetries. Microosteotmies of the nasal bones just beneath the keystone area are of-
ten necessary. Once the osteotomies are completed, then dorsal deviations of the septal strut
are addressed by splinting the nondeviated side first, resecting the deviation, and placement
of a second spreader graft. Asymmetric spreader grafts are often essential (Fig. 11.5a–d).
Camouflaging and Augmenting the Bridge. Despite our best attempt at straightening the
bridge, the dorsum can remain asymmetric and camouflage is one solution. Obviously, every
effort is made to achieve true structural straightness before resorting to concealment. The
DC−F graft is the easiest way to restore a natural dorsal contour and to camouflage any persis-
tent deformity. One inserts a double-layer dorsal fascial graft and then places small amounts
of finely dice cartilage in the areas of deficiency. Another entity is the over-resected bridge,
which requires augmentation, either partial or full length. In these cases, one has to choose
between a DC−F or a DC+F graft. I prefer the DC+F graft for localized or highly tapered
augmentations. As the dorsal augmentation exceeds 2 mm and becomes less tapered, then
the DC−F graft becomes the choice. Essentially, the fascial container is the same as a double
level fascial graft, but now the diced cartilage is placed inside the sleeve rather than beneath it.
Realigning the Bony Base. A significant number of secondary cases have markedly differ-
ent bony bases on the two sides caused by prior osteotomies (Fig. 11.5e–h). Most frequently,
one lateral wall is outwardly displaced and the other is inwardly displaced. Low-to-low and
transverse ostetotomies are used on both sides. The outwardly displaced wall is mobilized
toward the midline often using the leverage of the osteotome against the maxilla to force
the wall inward. The inwardly displaced wall is mobilized outward often by placing a Bois
elevator in the nose and carrying the wall outward beyond the bony base. Careful palpation
will confirm a successful mobilization. It is then important to inset a full-length spreader
graft up into the open bony vault on the previously concave side to stabilize the bony wall
(see Fig. 10.11d, p. 369).
Decision
Making: Dorsal
Modification and
Osteotomies

Decision Making: Dorsal Modification and Osteotomies
387
Fig. 11.5 (a–d) The deviated secondary nose
Fig. 11.5 (e–h) The deviated secondary nose, realigning the bony base and opening the bony vault

388
Chapter 11  
Secondary ­Rhinoplasty: Decision Making
Analysis
A 27-year-old male presented with a history of nasal trauma plus a prior attempt to straighten
the nose including a septoplasty (Fig. 11.6). The internal exam indicated that the septum
was severely deviated to the left caudally, but to the right cephalically. There were numerous
synechiae plus enlarged inferior turbinates. The dorsal deviation was most apparent in the
“head down” position. The combination of prior trauma and nasal surgery is a recipe for
unpredictable difficulties. Once the septum was exposed, it became obvious that there had
been a partial resection and a totally displaced swinging door septoplasty. The options were
either to fabricate an L-shaped replacement graft or obtain a rib graft. Fortunately, it was
possible to achieve rigid support for the nose using a total septoplasty.
Operative Techniques
  1) Division of synechiae using a cautery.
  2) The septal mucosa was elevated, but extensive morselization made it challenging.
  3) Open approach with bidirectional septal exposure. Partial prior resection.
  4) Prior “swinging door” septoplasty created a “crossover” blockage of both airways.
  5) Asymmetric osteotomies. R: transverse and low to low. L: low to low.
  6) Lowering of cartilaginous dorsum 3 mm.
  7) Total septoplasty. Reinsertion of a two piece L-shaped strut.
  8) Columellar strut followed by advancement of alar cartilages over strut.
  9) Add-on grafts: transdomal insufficient then shield shape. ARG on R.
10) Bilateral partial inferior turbinectomy.
Case Study:
Secondary
Dorsal
Deviation
Fig. 11.6 (a–j)

Case Study: Secondary Dorsal Deviation
389
Fig. 11.6 (continued)

390
Chapter 11  
Secondary ­Rhinoplasty: Decision Making
Analysis
A 52-year-old woman had been unhappy with the result of her primary rhinoplasty for 30
years (Fig. 11.7). The intranasal exam revealed severe vestibular scarring (>66%) that would
require bilateral composite grafts. The septum was deviated into the left airway. Externally,
the nose was a classic bony saddle deformity due to over resection of the dorsum, probably
from using an osteotome for the hump reduction. The open approach revealed that there
were no alar cartilage remnants – nothing to work with and thus total tip reconstruction
became a priority. The tip graft was made from a “shave” of outer rib cartilage. Vestibular
stenosis was reduced by using bilateral composite grafts. At 4 years post-op, the patient has
done very well and the 6 mm dorsal augmentation has been maintained. The criticism that
DC−F grafts do not produce “dorsal lines” is visually invalid.
Operative Techniques
1) Harvest of cartilaginous portions of the 9th and 8th ribs. Fascial harvest.
2) Open approach revealed total resection of the alar cartilages, nothing was left.
3) Bidirectional exposure of septum due to heavy scarring. Septal harvest.
4) Splitting of the vestibules with recreation of massive vestibular mucosal defects.
5) Insertion of a “septal brace” to support the caudal septum.
6) Unilateral low-to-low osteotomy on the L.
7) Columelar strut insertion and then a shield tip graft of rib.
8) Composite graft harvest. Suturing of composite grafts into vestibular defects.
9) A DC−F graft (0.8 cc) placed in the dorsum to help spread the internal valves.
Case Study:
Dorsal
­Augmentation
Fig. 11.7 (a–j)

Case Study: Dorsal ­Augmentation
391
Fig. 11.7 (continued)

392
Chapter 11  
Secondary ­Rhinoplasty: Decision Making
Secondary septal surgery requires greater skill as to exposure and management of persistent
deviations and surgical sequelae. Elevation of the mucosal leaflets can be difficult as 75% of
my secondary cases have had prior septal surgery. Despite the original surgeon’s attempt at
fixing deviations, one often finds persistent caudal deviations and bony deflections. The great­-
est challenges are prior incisions that have destabilized the L-shaped strut. From a frequency
perspective, it is the internal valve that predominates in primary cases, whereas it is the
nostril and vestibular valves that pose the greatest technical challenge in secondary cases.
Secondary Septal Surgery. What makes the secondary septum difficult is destabilization
with loss of structure, and inadequate septal tissue for reconstruction thereby mandating
a rib graft (Fig. 11.8a–d). External and internal exams reveal persistent deviations plus a
void over the septal body and, most alarming, a lack of septal support for the tip. When one
confirms a lack of septal support and a probable prior septal resection, then permission for a
rib graft is essential. The operation begins with an open approach plus a transfixion incision,
which allows bidirectional septal exposure. The degree of septal compromise and available
graft material are readily obvious. If a rib graft is necessary, then it is harvested at this time
and the appropriate spreader grafts and struts are carved. The grafts are placed in saline to
allow any warping to occur. The nasal surgery is continued and the osteotomies are com-
pleted. Whatever portion of the septum remains deviated or structurally weakened is de-
finitively corrected. Then the spreader grafts and a septal strut are inserted to rebuild the
essential L-shaped strut.
Septal Perforations. The open approach allows easy mobilization of the mucosal lining and
direct suture of perforation edges together. Then a large disk of fascia is placed ­in-between
the mucosa and actually sutured at four corners to serve as a scaffold if the mucosa does not
heal properly. In general, I only close perforations of 2 cm or smaller.
Valvular Surgery in Secondary Rhinoplasty. Valvular problems are usually a result of surgical
commission (vestibular webs), or surgical omission (external valve) or both (internal valves)
(Fig. 11.8e–g). Whenever possible the solution is to provide structural support with restora-
tion of mucosal lining an occasional necessity. Spreader grafts are used 85% of the time with
the majority being asymmetric. The external valve is supported with the spectrum of ARG,
ARS, and lateral crural strut grafts. When in doubt, the scarred heavy tissues of secondary
cases make ARS grafts preferable to ARG. Due to its technical complexity, most surgeons want
to avoid treating vestibular stenosis if possible. The first step is to recreate the defect, but with
dissection of the lining from lateral to medial. This step allows the thicker composite portion
of the graft to be put laterally. Then the thinner skin portion is sutured to the septal defect
thereby avoiding any bulk in the narrow valve angle.
Decision Making:
Secondary
Septum and
Valves

Decision Making: Secondary Septum and Valves
393
Fig. 11.8 (a–d) Secondary septal surgery, (e–g) secondary valvular surgery