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

Case Study: ­Secondary Septal Surgery
395
Fig. 11.9 (continued)

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Secondary ­Rhinoplasty: Decision Making
In secondary surgery, selection of the appropriate tip operation is guided by what is left of the
alar cartilages to work with, the degree of columellar support, and the thickness of the skin
envelope. Preoperatively, the surgeon and patient must answer two questions. (1) What do
we not like about the tip? (2) What type of tip do we want to achieve? If there is one guiding
principle, it is the need to provide structure to the tip and the entire nose. This section will
be discussed as a series of sequential intraoperative questions.
1) What will be the plane of dissection? In thin skin patients, I dissect in direct contact with
the cartilages and inject copious amounts of local anesthesia to facilitate the dissection.
In thick skin patients, I will dissect in the subdermal plane leaving as much subcutaneous
tissue and scar tissue on top of the alar cartilages as possible.
2) What is the status of the septum? The septum provides support to the nasal lobule and
influences the columellar. By exposing the septum, I will know four things: (1) What is the
degree of septal obstruction? (2) Can I safely reduce the cartilaginous dorsum? (3) How
much graft material can be harvested? (4) What needs to be done to the caudal septum?
3) What is the status of the alar cartilages? Once exposure is completed, one should take a
“time out” to analyze the alar cartilages remnants. Obviously, the range is from minimal to
total ­resection. Yet, the reality is that 75% of secondary tips can be sutured if one includes
the use of add-on grafts. The problem is at either extreme – a deficient 5% where there is
virtually no middle or lateral crura left and the excessive overprojected tip that the original
surgeon was too afraid to reduce. In between, an array of difficult tips exists where the lat-
eral crura are divided at the domes or mangled by excessive suturing. It is helpful to answer
the question – what was the original tip operation and what can I do to either complete the
primary operation or undo its consequences?
4) Will my original operative plan work? This is a critical question and one that must be
­answered honestly and realistically. One must remain flexible and ready to switch to an al-
ternative procedure. It is also time to consider prepping other donor sites for eventual graft
harvest. The most important question is – can I suture these alars or do I have to excise a
portion of them and insert a tip graft? Surprisingly, the lateral crura are often problematic
and one has to decide whether to reinforce, transpose, or recreate. In many cases, the alars
must be mobilized, which is achieved by release of scar tissue in-between the crura in the
columellar, between the domes and the septal angle, and then between the lateral crura
and the upper lateral cartilages. One must make a decision and decide on a specific tip
­operation. At this point, the rest of the secondary septorhinoplasty is done ranging from
dorsal profile to septoplasty to osteotomies, to spreader grafts. One then returns to the tip.
5) What type of columellar strut? The columellar strut is the foundation for the tip and is used
in all cases. These struts tend to be slightly larger and stronger than those used in prima-
ries as they need to resist contracture forces. It is not uncommon to use two strut sutures,
one above and one below the columellar breakpoint, to fix the alar remnants to the strut.
Frequently, an acute columellar labial angle is present and it can be corrected with a wider
strut or a plumping graft or both.
Decision
Making:
­Secondary Tip
Surgery

Decision Making: ­Secondary Tip Surgery
397
  6) Tip suturing in Secondaries versus Primaries? In 50% of cases, the original surgeon cre-
ated symmetrical rim strips and one just begins at this point and sutures the tip. Once
the scar tissue is released, the only variation is that the alars may be more rigid and the
sutures might need to be tied a bit tighter. Essentially, creation of the tip diamond is quite
comparable to a primary case. Once the ideal tip configuration is achieved, one needs to
redrape the skin and assess tip shape. Insertion of a single suture in the transcolumellar
incision may be required. Under thicker contracted skin, there will be greater need for tip
position sutures to achieve ideal projection as well as add-on grafts for definition. Thin
skin often dictates increased smoothing and perhaps a fascial graft.
  7) What can be done to the Domal Segment? The alternatives with the domal segment is
whether it can be shaped with sutures, repaired with sutures, or excised. If the original
surgery was done closed, then shaping the domal segment with sutures is the first choice.
Occasionally, a prior domal division would have been done, which can be repaired and
then covered with a concealer graft. If the tip is overprojected then direct excision of the
domes is done, the divided edges repaired, and an open structure tip graft inserted.
  8) What must be done to the Lateral Crura? An easy exam question is – what portion
of the tip is the most operated upon? The lateral crura is the obvious correct answer.
Ideally, the lateral crura would either be the correct width or underresected. Overresec-
tion or transection is a common finding. Both deformities require support using lateral
crura strut grafts. Alar rim structure grafts (ARS) are often sutured into the closure to
strengthen the rims with composite grafts used to lower the retracted rims. Lateral crura
transposition is ­reserved for correcting a persistent alar malposition.
  9) What is the role of add-on TRG grafts? Excised alar cartilage obtained from reducing the
lateral crura can be used as a concealer graft to cover infralobular bifidity or to add vol-
ume to the infralobule. Transverse grafts can cover suture repairs of the domal segments.
These grafts are often essential under thin skin. However, they are often ineffective in
secondary cases under thick skin in achieving definition or projection.
10) When do you go to a structure tip graft? A structure tip graft is done to create a new
tip following excision of deformed or overprojecting domes or even with when no
domes remain. They are also used to achieve projection under thick noncompliant skin
­envelopes.
11) What are the implications of an isolated tip graft? When the lateral crura have been
­excised completely, then an isolated tip graft, preferably of septal cartilage is sutured to a
major columellar strut inserted between the crural remnants. In these rare cases, major
ARS grafts or alar battens of concha can be sutured along the nostril rims and create an
attractive tip. In thin skin patients, true alar replacement grafts of conchal cartilage may
be necessary to avoid shrink wrapping of the skin envelope around the tip graft.

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Analysis
This 39-year-old patient had had two prior rhinoplasties (Fig. 11.10). The number of problems
with this nose was overwhelming, but it essentially came down to creation of a normal tip.
The skin was thick with a scar from a previous surgical tear. At 3 years post-op, the result far
exceeds both mine and the patient’s original expectations. The reason for this success was
the creation of a defined tip point (T). On the pre-op oblique photo, the distance from the
columellar breakpoint (C’) to tip (T) approaches 15 mm with the tip being poorly defined.
In the post-op oblique, we see T as a distinct entity crowning the nose. On anterior view, the
three leaf clover deformity is gone and the more balanced nose even reduces the visibility
of the patient’s facial asymmetry.
Operative Technique
1) Open approach. Alar analysis indicated prior domal division and “verticalization.”
2) Septal exposure. Prior SMR done with no cartilage available.
3) Prior dorsal graft exposed and removed. Dorsal reduction (bone: 1, cartilage: 3)
4) A 3.5 mm caudal septum excision.
5) Harvest of conchal cartilage. Insertion of conchal spreader grafts.
6) Columellar strut made from excised dorsal graft. Suture fixation to alar remnants.
7) Repair of prior domal division. Tips sutures: CS, DC, TP.
8) Conchal tip grafts: infralobular over laid by full-length graft.
9) Bilateral composite grafts to support nostril rims.
Case Study:
Secondary Tip
Fig. 11.10 (a–j)

Case Study: Secondary Tip
399
Fig. 11.10 (continued)

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Chapter 11  
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Analysis
A 52-year-old woman had had a rhinoplasty at age 17 and hated the result right away. A revi-
sion 1 year later did not improve it (Fig. 11.11). Her respiration was significantly impaired.
The vestibular and internal valves were collapsed. The nasal tip was extremely pointy with
a sharp bossa and the dorsum had a ski slope curvature. Intraoperatively, every secondary
rhinoplasty is a surprise, which requires flexibility. Reversing the Goldman tip and covering
the suture repair with a concealer graft were devised out of necessity. The lateral crural strut
grafts provided vestibular support. The paucity of donor graft material led to a rib harvest. As
seen at 4 years post-op and without any revisions, the dorsum looks natural with its “dorsal
lines” and has maintained its 4–5 mm of augmentation from day 1 without any absorption
of her DC-F graft (see DVD).
Operative Technique
  1) Septal assessment and prior partial SMR found.
  2) Open approach. Tip injected repeatedly to allow safe skin elevation.
  3) Tip “time out.” Analysis revealed a prior Goldman tip.
  4) Cartilaginous dorsal reduction (3 mm). Septal harvest.
  5) Columellar strut insertion. Repair of divided alars at the dome.
  6) Lateral crural strut grafts with T2 location into alar bases. ARG on L.
  7) Concealer graft to tip in the infralobular position.
  8) Harvest of cartilaginous portion of 5th rib. DC−F graft (1.0 cc) fabricated.
  9) Insertion of dorsal grafts (DC−F).
10) A 2 mm nostril sill excisions. Footplate grafts to columellar base.
Case Study:
Secondary
­Rhinoplasty
Fig. 11.11 (a–j)

Case Study: Secondary ­Rhinoplasty
401
Fig. 11.11 (continued)

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Chapter 11  
Secondary ­Rhinoplasty: Decision Making
In secondary cases, nostril distortions can be a visible stigmata of a prior rhinoplasty
and their correction is obligatory, not optional. Equally, the types of procedures required
are technically demanding and often require excision and replacement of scarred tissues.
Analysis of secondary base deformities can be very complicated (Fig. 11.12a). The following
questions must be answered.
Will the usual techniques work? Nostril base surgery is surprisingly common in secondary
surgery because the vast majority of surgeons are not comfortable with nostril excisions
and are not as compulsive in their execution as they should be. They tend to find a reason
not to do the excision rather than maximizing the result at the primary surgery. Essentially,
nostril sill, alar wedge, and combined excisions are utilized whenever there was an error of
omission at the time of the original surgery. Obviously, nasal base changes secondary to a
rhinoplasty can also occur creating the need for excisions. Also, one must carefully inspect
the nose for prior excisions and take them into account when designing future excisions.
A frequent occurrence is to design a combined excision following a prior nostril sill excision.
The sill scar is opened, but continued into a new alar wedge excision. The closure will correct
the retracted scar in the nostril sill from the prior surgery as well as reduce alar flare.
What about the nostril rims? The most common sequela is a “visual break” or notch in the
nostril rim, which can give a “three leaf clover” appearance to the tip. Suturing ARS grafts
along the nostril rims is highly effective at restoring support to the rims. In secondary cases,
an ARS is superior to an ARG. It is important to realize that septum is two to four times
as thick as alar cartilages. Thus, the ARS grafts must be shaped and thinned before being
sutured into the rim incision. ARG grafts placed in pockets are used for intraoperative weak-
ness rather than correcting contracted secondary problems.
What to do about the retracted nostril rim? When the nostril rim deformity extends beyond
weakness or notches to a truly retracted nostril rim with significant visibility into the nose,
then the solution is a composite graft from the concha. One needs to differentiate between
the “retracted nostril” and the “retracted nose/retracted nostril.” The distinction is very
important.
Retracted Nostril Rim. Composite conchal grafts are effective for lowering isolated nostril
retraction (Fig. 11.12b). Infraoperatively, the surgeon will reinforce or transpose the alar
cartilages which stabilizes and correctly localizes the alar cartilages. It is at this point that
the true deficiency of the nostril defect becomes apparent and the composite graft must be
used to fill the defect.
Retracted Nose. When the entire nose is involved, then lengthening of the nose and pull-
ing down the nostril rims is indicated (Fig. 11.12c). If there is heavy scarring between the
lateral crura and upper lateral cartilages, it may be necessary to incise the area and insert a
composite graft to force the alars downward. Once the alars are lowered maximally, then the
persistent nostril retraction is treated with either ARS or composite grafts.
Decision
Making: Base
and Nostrils

Decision Making: Base and Nostrils
403
Fig. 11.12 Secondary nasal base surgery, (a) analysis and planning for the case study that follows,
(b) composite strip graft, (c) ­internal valve area composite graft
b
c
Composite
Skin

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Chapter 11  
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Analysis
A 26-year-old sought improvement in the nasal appearance following two prior open rhino-
plasties (Fig. 11.13). She did not like her droopy columellar or the crookedness on anterior
view. The nostril rim retraction and long infralobule on oblique view made me suspicious
that she had had extensive “midline” sutures, which had pulled the alar rims upward. This
case illustrates why I consider multiple midline sutures between the alar cartilages to be a ter-
rible technique for most surgeons. Secondary correction required transection of the sutures
and the restrictive scar tissue. Composite grafts are often necessary to lower the nostril rims.
These are “sliver” grafts that are sutured first to the caudal rim, then contoured in place, and
sutured cephalically. Nostril splints are worn at night for at least 2 weeks.
Operative Technique
1) Fascial harvest followed by septal exposure, no prior septal surgery.
2) Open approach with exposure of extensively sutured tip and prior domal division.
3) Dorsal smoothing, then 3 mm excision of caudal septum and ANS contouring.
4) Septal harvest. Insertion of asymmetric spreader grafts (R: 2.5 mm, L: 1 mm).
5) Removal of all prior tip sutures and mobilization of alar cartilages.
6) Insertion of columellar strut and repair of domal divisions. Isolated tip graft.
7) Insertion of a laterally draping dorsal graft of fascia plus a fascial ball at the tip.
8) Closure of all incisions. Nostril sill excisions (R: 2 mm, L: 2.5 mm).
9) Sliver composite grafts sutured into nostril rims.
Case Study:
Secondary Base
and Nostril
Fig. 11.13 (a–j)

Case Study: Secondary Base and Nostril
405
Fig. 11.13 (continued)

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Secondary ­Rhinoplasty: Decision Making
Aiach O. Atlas of Rhinoplasty. St. Louis, MO: Quality Medical Publishing, 1996 (2nd ed. in
press)
Boccieri A, Marco C. Septal considerations in revision rhinoplasty. Facial Plast Surg Clin 14:
357, 2006
Constantian MB. Distant effect of dorsal and tip grafting in rhinoplasty. Plast Reconstr Surg
90(3): 405, 1992
Daniel RK. (ed) Aesthetic Plastic Surgery: Rhinoplasty. Boston, MA: Little, Brown, 1993
Daniel RK. Rhinoplasty: An Atlas of Surgical Techniques. Berlin: Springer-Verlag, 2002
Daniel RK. Tip refinement grafts: the designer dorsum. Aesth Surg J 29: 528, 2009
DeRosa J, Toriumi DM. Role of septal extension grafts in tip contouring. In: Gunter JP,
Rohrich RJ, Adams WP (eds) Dallas Rhinoplasty, 2nd ed. St. Louis, MO: Quality Medical
Publishing, 2007
Fry HJH, Interlocked stresses in human septal cartilage. Br J Plast Surg 19: 276, 1966
Gibson T, Davis WB. The distortion of autogenous cartilage grafts; its cause and prevention.
Br J Plast Surg 10: 257, 1958
Gruber RP. Lengthening the short nose. Plast Reconstr Surg 91: 1252, 1993
Gunter JP, Clark CP, Friedman RM. Internal stabilization of autogenous rib cartilage grafts
in rhinoplasty: A barrier to cartilage warping. Plast Reconstr Surg 100: 161, 1997
Gunter JP, Rohrich RJ, Adams WP (eds). Dallas Rhinoplasty: Nasal Surgery by the Masters,
2nd ed. St. Louis, MO: Quality Medical Publishing, 2007
Johnson CM Jr., Toriumi DM. Open Structure Rhinoplasty. Philadelphia, PA: W.B. Saunders,
1990. Additional information in Johnson CM, Wyatt CT. A Case Approach to Open Struc-
ture Rhinoplasty, 2nd ed. New York: Elsevier, 2006
Juri J, Juri C, Grilli DA, et al Correction of the secondary nasal tip and of alar and /or colu-
mellar collapse. Plast Reconstr Surg 82: 160, 1988
Kridel RWH, Soliermanzadeh P. Tip grafts in revision rhinoplasty. Facial Plast Surg 14: 331,
2006
Maring VP, Landecker A, Gunter JP. Harvesting rib cartilage grafts for secondary rhinoplasty.
In: Gunter JP, Rohrich RJ, Adams WP (eds) Dallas Rhinoplasty, 2nd ed. St. Louis, MO:
Quality Medical Publishing, 2007, 705
Menick FJ. Anatomic reconstruction of the nasal tip cartilages in secondary and reconstruc-
tive rhinoplasty. Plast Reconstr Surg 104: 2187, 1999
Meyer R. Secondary Rhinoplasty. Berlin: Springer, 2002
Millard DR. The alar cinch in the flat, flaring nose. Plast Reconstr Surg 40: 669, 1980
Sheen JH. Secondary rhinoplasty. Plast Reconstr Surg 56: 137, 1975
Sheen, JH. Secondary rhinoplasty surgery. In: Millard DR Jr (ed) Symposium on Corrective
Rhinoplasty. St. Louis, MO: Mosby, 1976
Sheen JH, Sheen AP. Aesthetic Rhinoplasty, 2nd ed. St. Louis, MO: Mosby, 1987
Suzuki S, Muneuchi G, Kawai K, et al Correction of atrophic nasal ala by sandwiching an
auricular cartilage graft between para-alar and nasal floor retrogressive flaps. Ann Plast
Surg 51; 513, 2003
Tardy ME. Rhinoplasty: The Art and the Science. Philadelphia, PA: W.B. Saunders, 1997
Toriumi DM. Structural approach to rhinoplasty. Facial Plast Surg Clin North Am 13: 93, 2005
Reading List

D uring the past decade, a new sophisticated level of nasal surgery has emerged – ­aesthetic
reconstructive rhinoplasty. It has its origins from two sources. The first is the incredible aes-
thetic results achieved in nasal reconstruction by Burget (1994) and Menick (1999). These
advances are to nasal reconstruction what Tessier’s contribution was to facial reconstruction.
The second is the dramatic improvement in the results of secondary rhinoplasty beginning
with the balanced approach of Sheen and then followed by the correction of the nasal foun-
dation using the open approach. The critical factors are the insertion of structure and the
goal of achieving true aesthetic natural results rather than mere “improvement.” However,
these advances have not come without an equally dramatic increase in requisite surgical
skills including the use of rib grafts. One only has to think of the three Cs – clefts, cocaine,
and catastrophes to realize the difficulty of both the problems and the corrections. In many
cases, the solution will be the new concept of “composite reconstruction” in which a deep
structural foundation layer is inserted first and then overlaid with an aesthetic contour
layer (Daniel 2007). The advantage of this technique is that one can maximize the reward
while minimizing the risk. For the experienced surgeon seeking the greatest challenges in
rhinoplasty surgery, these cases represent an extension of techniques perfected in secondary
rhinoplasty rather than a completely new operation with a prolonged learning curve. Yet a
word of caution is necessary. These are neither hopeless cases nor can a beginning surgeon
justify doing them because the expected improvement is minimal. These patients have suf-
fered a great deal in their lives and deserve the best possible result.
Introduction
Aesthetic
­Reconstructive
­Rhinoplasty12

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Aesthetic ­Reconstructive ­Rhinoplasty
The best way to understand the interrelationship between secondary rhinoplasty and aes-
thetic reconstructive rhinoplasty is to appreciate their evolution. Perhaps my own personal
perspective with this progression may be more interesting than a dry recanting of dates
and papers. As a first year plastic surgery resident, I was entitled to do all the secondary
rhinoplasties while the chief resident got to do the primaries. The reason was simple – the
results for secondary rhinoplasty at that time were so bad that it did not make any differ-
ence whether it was the most junior surgeon on the service or the chief of the department
who did them. In fact, it was common place for established rhinoplasty surgeons to turn down
secondary patients by saying dismissingly –“if you didn’t come to me for your primary, why
should I do your secondary?” All of this would be changed by one surgeon.
Sheen. In 1978, Jack Sheen published Aesthetic Rhinoplasty which changed rhinoplasty sur-
gery forever. For the first time, aesthetic analysis and goals were clearly defined. Requisite
techniques were illustrated and the results were shown in spectacular photographs taken
before and after the surgery. If the impact on primary surgery was evolutionary, the effect
on secondary rhinoplasty was revolutionary. Suddenly, excellence in rhinoplasty surgery was
measured by the surgeon’s ability to achieve superb aesthetic results in complex secondary
cases.
Prior to Sheen, secondary surgery consisted of repeated excisional techniques which
led to crucified tips in thin-skin patients and persistent polybeaks of scar tissue in thick
skin patients. By taking a balanced approach and using strategic grafts, Sheen was able to
achieve remarkable improvement in both form and function. At its essence, his technique
relied on numerous grafts placed in small pockets, which stretched the skin sleeve to produce
a beautiful functional nose. Yet, the technique proved difficult for those with less experience
and the reliance on numerous grafts increased the risk of error. Also, the inherent principal
of cosmetic concealment rather than structural correction paved the way for the next major
breakthrough.
The Open Approach. The open approach for rhinoplasty surgery began in the 1920s, but it
only became popular in the 1970s and 1980s due to the efforts of Goodman (1973). Although
initially done for primaries and cleft noses, it would have its greatest initial effect on sec-
ondary rhinoplasty. After the skin was elevated, one had a direct view of the alar cartilages
allowing analysis, utilization, fewer grafts, and new surgical techniques. Bidirectional access
to the septum, as well as straightening of the most deviated dorsum, was possible. Yet, the
greatest advance would be the ability to achieve a structural and functional foundation for
the nose, something almost impossible with the closed approach. One only has to think of
the ease of total septoplasty or the role of columellar struts via an open ­approach to ap-
preciate the differences. As surgeons began to use more grafts and become more aggressive
in rhinoplasty surgery, a new problem emerged – where to obtain graft material when the
septum and concha were used up?
Rib Grafts. Previously, I have reviewed the role of rib grafts in total nasal reconstruction and
for dorsal grafts in rhinoplasty surgery (Daniel 1994, 2004). Essentially, ribs replaced iliac
crest grafts because the latter would break with trauma and they replaced cranial bone grafts
because the bone got absorbed. The other advantage of costal cartilage is that it provides a
Overview

Overview
409
large amount of cartilage for the numerous grafts used in modern secondary rhinoplasty
surgery. Thus, it has become a reality that one cannot do secondary rhinoplasty without rib
grafts, either planned preoperatively or out of necessity intraoperatively.
Reconstructive Approaches. During the past decade, aesthetic reconstructive rhinoplasty
has emerged as an “ultra specialized” type of nasal surgery combining the tenets of nasal
reconstruction and cosmetic rhinoplasty. Three “schools” of aesthetic reconstructive rhino-
plasty have emerged. Although each technique produces spectacular results in the hands of
their originator, the technical challenges can be significant when done by those with less
experience.
Structuralists. The fundamental concept is that a dorsal graft of solid costal cartilage can
be kept from warping by the insertion of a K-wire and the tip supported by a major columel-
lar strut fixed to the anterior nasal spine (ANS) with a K-wire. In its full expression, the alar
remnants are replaced with the columellar strut expanded to provide both tip support and
domal shape. The challenges with this method include the following: (1) shaping the dorsal
graft is technically demanding and reliant on a foreign body for success, (2) the margin for
error is minimal as the grafts provide an “all or none” correction of structure and aesthetics,
and (3) revision or secondary correction can be extremely demanding.
Grafters. Sheen was the original “grafter” as he often inserted 10–12 grafts in a nose, but
these were done via the closed approach to expand the skin sleeve. With the advent of the
open approach, grafts were sutured into place and used for structure. Recently, a new genera-
tion of grafters has emerged using the open approach and placing 16–18 grafts per nose from
the plentiful rib donor site. Extended spreader and septal extension grafts of rib are placed
first, then a dorsal onlay graft followed by more grafts added layer after layer. As with Sheen’s
cases, these patients photograph well. However, the result is truly a rigid ­“reconstructed nose”
which female patients may find to be too big, too wide, and too masculine. Reoperation to
achieve the aesthetic nose that the patient wanted in the first place is a technical challenge and
often necessitates another rib graft procedure.
Aesthetists. Every patient who had a primary cosmetic rhinoplasty wants a more attrac-
tive nose. They become a secondary case because they did not achieve their original goal.
Thus, the aesthetist’s objective is to provide first a deep structural foundation that is then
overlaid with an aesthetic shape that achieve’s the patient’s original objective. Composite
reconstruction is used to construct the deep foundation layer that provides the support origi-
nally given by the L-shaped septal strut. Next, the aesthetic layer, consisting of a columellar
strut and a tip procedure, are done. Tip sutures are the first choice with tip grafts a frequent
necessity. Then a dorsal contour layer of diced cartilage in fascia is inserted. Any revision is
quite minor and involves revisional techniques rather than a formal reconstruction. Of the
three schools, it is the closest to being an extension of secondary rhinoplasty and the most
easily mastered with the least risk and the easiest to revise.

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Composite reconstruction is a two component technique (Daniel 2006, 2007). First, the deep
foundation layer restores the structural support previously provided by the L-shaped septum
using spreader grafts and a true septal strut. Second, an overlying aesthetic layer is added to
achieve tip refinement using a columellar strut with alar advancement or tip graft followed by
dorsal contour using a DC-F graft. In most cases, autogenous rib is required as the quantity
of cartilage required exceeds available septal material while the rigidity of cartilage necessary
precludes conchal cartilage. A two-layer reconstruction maximizes aesthetic finesse while
minimizing the vagaries and warping of rib reconstructions.
Operative Technique: Step by Step
First and foremost, these are incredibly difficult cases as they are often an aggregate of a
difficult primary followed by a failed secondary rhinoplasty. Frequently, septal support is
absent or compromised with perforations which are too common.
Step #1. Preoperative preparation and planning must be thorough. I try to obtain the previ-
ous operative reports. CT-scans can be essential for assessing the bony vault. Photographic
analysis and planning are extremely valuable for deciding what is both ideal and realistic.
Writing out a step-by-step operative plan forces you to decide in advance what to do.
Step #2. When a rib graft is planned, I harvest the rib first. Although a single rib graft might
be sufficient, I routinely harvest the cartilaginous portion of the ninth and the eighth rib.
The ninth rib is harvested supraperichondrially in a retrograde direction. The eighth rib is
stripped of its anterior perichondrium and then the cartilage is removed subperichondrially.
The wound is partially closed as any extra cartilage will be banked in the donor site.
Step #3. An open approach is used to expose the tip and dorsum. The dissection plane is
dictated by the skin sleeve – deep if thin, superficial if thick. Frequently, a “tip split” approach
provides direct access to the septum and ANS. Surprisingly, removal of tip grafts can reveal
symmetrical rim strips which can eventually be sutured, thus reducing the need for grafts.
At this point, a time out is taken to reassess the operative plan.
Step #4. If one has a clear idea of the grafts that will be needed, then they are carved at this
point in the operation. Usually, the columellar strut is obtained from the curved tip of the
ninth rib. A straight septal strut (20 ×10 × 3 mm) is then cut. The lateral shavings to narrow
the strut make ideal alar battens. Since I do not use a solid dorsal graft, it is only spreader
grafts that can warp. The spreader grafts are cut from solid cartilages (30 × 3 × 3). The
grafts are placed in saline and allowed to sit for 30 min. Excised pieces will be diced by the
circulating nurse and placed into tuberculin syringes.
Step #5. Persistent deformities of the osseocartilaginous vault and septum are corrected
prior to beginning the reconstruction. Dorsal modification, including reduction, is done
and any septal deviations are corrected. Osteotomies are performed and they must often
be asymmetric.
Composite
Reconstruction

Composite Reconstruction
411
Fig. 12.1 (a–n) Composite reconstruction. (a) Loss of septal support (b) Foundation layer 
(c) Spreader grafts, septal
strut, columellar strut 
(d) diced cartilage for dorsal augmentation 
(e, f) septal strut to ANS

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Step #6. The next step is the deep foundation layer which is a replication of the L-shape septal
strut. The spreader grafts replace the dorsal component and a true septal strut replaces the
vertical component. I expose the ANS through a gingival incision and drill a hole through the
ANS. If the ANS has been resected, then I use a burr to make a central groove in the midline
and then drill holes through the pyriform lip on either side. I pass a 4–0 polydioxanone
suture (PDS) suture through the drill hole and leave it.
Step #7. I insert the spreader grafts high underneath the bony vault. It is important to assess
the width and avoid making the nose too wide. Once satisfied, the grafts are held in place
with #25 needles and then multiple five-layer sutures of 4–0 PDS are inserted. On occasion, it
may be necessary to place drill holes through the bony vault to fix the spreader grafts. Next,
the alar cartilages are separated from top down and the precut septal strut is passed from
the dorsum down to the ANS. The septal strut is either split vertically in its lower 10 mm to
straddle the ANS or placed in a groove. Once the septal strut is seated, then the preplaced
4–0 PDS is used to fix the strut rigidly to the ANS. It is important to realize that this is a
septal strut and not a sepal extension graft designed to influence the columellar – they are
not the same!
Step #8. The classic tongue-in-groove overlap of spreader grafts on either side of a strut is
not used because it is too bulky and can block the internal valve angle. Rather, a “step-off”
configurations is used. One spreader graft is kept long as an overlap brace and the other is
cut shorter to act as a midline abutment against the strut. They are sutured together with 4–0
PDS. At this point, one has a rigid L-shaped septal replacement which becomes the founda-
tion for the nose.
Step #9. The aesthetic layer is comprised of the tip support and the dorsal contour. A stan-
dard columellar strut (25 × 3) is inserted between the alar cartilages. As usual, the alars are
advanced upward, fixed with a #25 needle, and sutured with 5–0 PDS. Frequently, the alars
might have been damaged and there will be a need for either add-on or structure tip grafts.
Essentially, these maneuvers are the ones done in secondary cases.
Step #10. Once the tip is finalized then a custom “made to measure” DC-F dorsal graft is
constructed on the back table. Variations in length, width, and thickness can be controlled.
The graft is guided into place with cephalic percutaneous sutures and then sutured at the
septal angle.
Step #11. Frequently, the peripyriform area is contracted and will require support using diced
cartilage. Pockets are made beneath each alar base and onto the maxilla via the gingival inci-
sion. The DC is packed into the pockets and the incision closed with 4–0 chromic.
Step #12. Fascial grafts and rib perichondrium are often used in thin-skin patients. Perichon-
drium should not be used indiscriminately throughout the nose as it diminishes definition.
It is useful for padding, whereas fascia is preferred for filling.

Composite Reconstruction
413
Fig. 12.1 Spreader graft fixation to (g) cartilage vault or (h) bony vault, (i, j) septal strut to spreader graft fixa-
tion using a step-off (k, I) Insertion of a columellar strut to support the tip 
(m, n) dorsal augmentation
with a DC-F graft

414
Chapter 12  
Aesthetic ­Reconstructive ­Rhinoplasty
Analysis
A 32-year-old woman was totally obstructed despite two prior septorhinoplasties including
an open procedure (Fig 12.2). The CT-scan showed severe septal deviation plus severe bony
vault deformity/angulation. She also had a septal perforation and no structural support. Rib
graft reconstruction was the only option.
Operative Technique: Step By Step
  1) CT-scan revealed severe bony and septal deviation.
  2) Harvest of the Ninth and Eighth Ribs.
  3) Exposure at subdermal level. Alar cartilages intact.
  4) Spreader, septal, and columellar grafts cut. Rest of cartilage diced.
  5) Deformed septal remnants removed, leaving no septal support. Medial oblique and trans-
verse osteotomies done.
  6) Spreaders fixed to bony vault with sutures thru drilled holes.
  7) Septal strut fixed to ANS with split straddle and suture.
  8) Step-off fixation of septal strut to spreader grafts.
  9) Columellar strut and tip sutures: CS, DC, ID.
10) Uniform 3 mm thick DC-F graft (0.5 cc) inserted to dorsum.
11) Nostril sill excision (R 2.5, L 3.0)
Note: There is a critical difference between a septal strut to restore stability and a columellar
strut that projects the tip above the dorsal line (Fig. 12.2b).
Case Study:
­Composite
Reconstruction
Fig. 12.2 (a–l)

Case Study: Composite Reconstruction
415
Fig. 12.2 (continued)

416
Chapter 12  
Aesthetic ­Reconstructive ­Rhinoplasty
Analysis
This 50-year-old patient had undergone a single rhinoplasty as a teenager. She finally decided
that it was time to get rid of her “Miss Piggy nose job look” (Fig. 12.3). Due to the prior
excessive excision and need for structure, rib cartilage was essential. The tip would need to
be forced downward and the dorsum augmented. Fortunately, the nasal lining was not con-
stricted thus allowing mobilization, downward rotation, and fixation on a septocolumellar
strut. Dorsal augmentation using a DC-F graft provided a capstone to the midvault which
had been widened by the spreader grafts. Despite the very thin skin, the DC-F graft has not
shown in the patient at 5 years post-op.
Operative Technique
1) Harvest of the ninth rib cartilage. Fascia harvest.
2) Open approach with exposure of a prior “universal” tip.
3) Exposure and excision of septal body.
4) Insertion of 3 mm wide extended spreader grafts.
5) Insertion of a “tomahawk” septocolumellar graft pushing the tip downward 8 mm.
6) Repair of the alar domal divisions then covered by a concealer tip graft.
7) Dorsal augmentation with a DC-F graft (1.0 cc).
8) Nostril sill excisions followed by insertion of alar rim structure graft (ARS) grafts.
Case Study:
Over-Resected
Nose
Fig. 12.3 (a–j)

Case Study: Over-Resected Nose
417
Fig. 12.3 (continued)

418
Chapter 12  
Aesthetic ­Reconstructive ­Rhinoplasty
Septal saddle nose deformity results from a loss of the dorsal support normally provided by
the cartilaginous and/or bony vaults (Daniel 2006). The diagnosis is easily made by pressing
on the tip of the nose (Fig. 12.4). If the tip is easily compressed against the premaxilla, then
the test is positive for a lack of septal support. The most common history is initial nasal
trauma followed by a formal septorhinoplasty to improve function and appearance, not a
simple nasal fracture reduction. Thus, the need for strong septal reconstruction creates a
major challenge, often requiring rib grafts.
Identifying the Problem. Frequently, one has to expose the entire nose before defining the
problem and figuring out the deficits and the grafts required. The septal integrity is com-
promised, but is it from trauma, overzealous surgery, intrinsic weakness, or all of the above?
Rarely will there be sufficient rigid cartilage for reconstructing the nose. The tip cartilages
can be intact or previously excised, one does not know until the nose is opened.
Surgical Sequence. Once the operative plan is refined, then the grafts are harvested and
shaped (septum, fascia, rib, and possibly concha). Dorsal modification is done first, and
then followed by osteotomies which allow the lateral walls to be positioned correctly (in or
out).
Stabilizing the Septal Foundation. Septal reconstruction often requires extended spreader
grafts of rib sutured to a true septal strut using a step-off configuration (Fig. 12.5). The
septal strut is fixed to the ANS employing a gingival incision. The spreader grafts are placed
high up in the bony vault along the cartilaginous septum. If the cartilaginous vault is intact,
then the standard five-layer suture of 4–0 PDS will support the dorsum. If the cartilaginous
vault or septal cartilage is compromised, then one can penetrate the nasal bones, spreaders,
and septum (5 layer). One can sometimes suture within the open roof area by incorporating
just the spreader grafts and cartilaginous septum. The step-off suture of the spreaders to the
septal strut reduces the width of the grafts in the nasal valve area compared to a tongue-in-
groove technique.
Aesthetic Tip and Dorsum. Once the foundation layer is stabilized, then the tip is created.
These tips often require a major columellar strut to support the alar remnants as well as a
combination of tip grafts. Trying to support the tip and the septum with the same strut ­often
leads to a tip which blends into the dorsum and does not have sufficient supratip break. The
dorsum is often “designed” to achieve the ideal contour relative to the tip. Grafting is usually
either fascia to insure a smooth dorsum or a tapered DC-F graft Daniel (2009). These grafts
are “constructed” on the back table to fit the exact dimensions of the defect as regards length,
width, and thickness. They are guided into the defect using percutaneous sutures and then
sutured distally to the cartilaginous vault. Base and nostril work are done as necessary.
Septal Saddle
Nose

Septal Saddle Nose
419
Fig. 12.4 Septal saddle test (a) collapse preop, (b) Support postop
a
b
c
Fig. 12.5 Septal saddle. (a) Clinial pathology (b) surgical techniques

420
Chapter 12  
Aesthetic ­Reconstructive ­Rhinoplasty
Analysis
I did a primary rhinoplasty on this patient at age 22. It was done closed and there was no
septal surgery. She returned 4 years later with an obvious septal saddle collapse (Fig. 12.6).
I was devastated that this could have happened. However, intranasal exam revealed a 4 cm
septal perforation and the patient admitted to substance abuse. I used a “two strut” approach
to the problem – a septal strut to restore the L-shaped septal support and a columellar strut
to project the tip above the dorsal line. DC is often placed in the peripyriform area to over-
come contracture, see lateral views (Fig 12.6f, g).
Operative Technique
  1) Harvest of the cartilaginous portions of the ninth and eighth ribs.
  2) Open approach with tip split to expose a weakened collapsed septum.
  3) Low-to-high osteotomy on R side.
  4) A 20 × 10 mm septal strut was fixed in a groove to the ANS.
  5) Extended spreader grafts fixed to cartilage vault and then to the septal strut using a “step-
off” configuration.
  6) Columellar strut inserted with alar advancement onto strut.
  7) Domal onlay tip graft from rib cartilage with perichondrial cover.
  8) Fascial graft to dorsum for smoothing.
  9) Insertion of 4.0 cc of DC to peripyriform area.
10) Nostril sill excisions. Alar battens of split rib to alar rims.
Case Study:
Septal Saddle
Nose
Fig. 12.6 (a–j)

Case Study: Septal Saddle Nose
421
Fig. 12.6 (continued)

422
Chapter 12  
Aesthetic ­Reconstructive ­Rhinoplasty
Cocaine eats through the septum, erodes the nasal lining, penetrates the maxillary sinuses
and can even vaporize the upper lateral cartilages. The progression is from septal perforation
to loss of septal support to contracture of the mucosal lining and ultimately to compromise
of the skin envelope itself. Put simply, all cocaine noses are difficult. The range is from dorsal
collapse correctable with composite reconstruction to severe midvault collapse necessitat-
ing an osseocartilaginous dorsal graft, and eventually severe intranasal lining contracture
requiring intraoral mucosal flaps.
Surgical Correction. The timing of surgical correction requires that the patient be “clean”
of cocaine for at least a year. Structural support is critical when the lining is contracted. No
attempt is made to close the septal perforation.
1) Nasal Lining Release. The nasal lining can be released using the Meyer (2002) “sleeve”
technique where the lining is released high up under the bony vault and then dragged
downward leaving the donor area to heal by secondary intention. In severe cases, it may be
necessary to excise the heavily scarred mucosa in the upper lateral area to allow derotation
of the tip. All mucosal tears must be repaired until it is water tight to minimize infection.
2) Dorsal Support. I prefer an osseocartilaginous rib graft for the dorsum and a cartilage graft
for the columella strut (Fig. 12.7). The two are joined in a tongue-in-groove fashion to force
the tip downward. Since most cocaine patients have not had a prior rhinoplasty, the alar
cartilages can be advanced over the strut. Due to the contracted skin sleeve, one should
plan on a single strut and advance the tip above the dorsal line. Very thin tip grafts made
from rib are frequently utilized. Closure of the columellar incision can be difficult. It may
require V-Y techniques and even skin grafts on the internal incisions.
3) Nostril Support. Vestibular contracture and nostril collapse are two problems requiring
extensive grafting. Alar batten grafts extend into the alar base to provide support to the
contracted mucosa (Fig. 12.8). One combination used in a severe contracture (see Fig 12.9)
was the following: (1) a true lateral wall graft (20 mm high × 15 mm wide) along the caudal
border of the bony vault, (2) a composite graft (15 mm high × 8 mm wide) to release the
contracted vestibule, and (3) an alar batten graft (15 mm high × 10 mm wide) of thin rib
cartilage to support the nostril rim. Nostril splints are inserted deep into the nose, sutured,
and left for 3–4 weeks if possible.
4) Peripyriform Grafting. As the nasal lining contracts in the cocaine nose, the nasal base
sinks inward towards the pyriform aperture. Surgeons have recommended relining the
nose with nasolabial flaps. This procedure is unnecessary and creates irreparable facial
scarring – do not do it. One can easily move the nasal base forward by widely under-
mining the peripyriform area and maxilla followed by insertion of diced cartilage grafts
(3.0–5.0 cc).
Cocaine Nose

Cocaine Nose
423
a
b
c
d
e
Osteotome
High speed burr
Bony fixation
platform
Tip graft
Fig. 12.7 (a–e) osseocartilaginous reconstruction 
Fig. 12.8 (a–d) Nostril/alar base support

424
Chapter 12  
Aesthetic ­Reconstructive ­Rhinoplasty
Analysis
A 48-year-old woman presented with a history of cocaine abuse and had been “clean” for 5
years (Fig. 12.9). She felt that her nose was continuing to collapse and felt that surgery was
necessary because of total nasal airway obstruction. A 4–5 cm septal perforation was pres-
ent. Traction on the columellar indicated severe restraint. Due to the restricted nasal lining,
a total “mucosal sleeve advancement” was done. Once, mobilized, a deep foundation layer of
spreader grafts and a true septal strut provided support. The aesthetic contour was created
with alar advancement over the columellar strut and then aesthetic dorsal augmentation
with a DC-F graft. Support of nasal base was achieved with massive (15 × 9 mm) composite
grafts placed in the vestibules.
1) Harvest of the cartilage portion of the ninth and eighth rib.
2) Open approach with tip split exposing a collapsed caudal septum.
3) Total mobilization of mucosal lining including the upper lateral cartilage (ULC).
4) Spreader grafts fixed in a “step-off” fashion to septal strut.
5) Columellar strut inserted with alars advanced over it. Structured tip graft with perichon-
drial coverage.
6) Dorsal augmentation using a DC-F graft (0.3 cc).
7) Composite grafts to “vestibular release” defect.
8) Diced cartilage (1.0 cc) to each peripyriform area.
Case Study:
Cocaine Nose
Operative
­Technique
Fig. 12.9 (a–l)

Cocaine Nose
425
Fig. 12.9 (continued)

426
Chapter 12  
Aesthetic ­Reconstructive ­Rhinoplasty
Nasal implant extrusion is usually heralded by focal redness followed by ulceration and
exposure. If the infection decompresses internally, patients will try to ignore the problem. If
it erupts externally, surgery is sought immediately.
Staged Reconstruction. In most cases, the implant is removed intranasally and any external
skin wound allowed to heal by secondary intention. This approach is strongly recommended
for those cases with infected Porex implants due to mark tissue in growth and the difficulty
of removing all of the implant. I will insert a dermis graft to maintain some contour and
revitalize the damaged skin.
Early Reconstruction. The problem with delayed reconstruction is skin contracture and a
severe deformity for the patient (Fig. 12.10). One option is to remove the implant and place
the patient on appropriate antibiotics. Early reconstruction at 7–10 days in a clean wound
is done with limited risk. At that time, one has the option to proceed or delay depending
upon the degree of infection. The benefit to the patient is an early return to near normality.
Immediate Reconstruction. A high-risk option is to remove the implant and do immediate
reconstruction. It is considered only for those with silastic implants and willing to gamble
on complete loss of the reconstruction due to persistent infection (Fig. 12.11). Do not do
this operation in patients with infected Porex implants. Repeated consultations and detailed
informed consent are essential.
1) Open Approach. An open approach is used irrespective of the skin ulceration site. The ­implant,
including its capsule, is removed and the wound cultured again. The wound is profusely
­irrigated with antibacterial solution. The feasibility of the operative plan is reassessed.
2) Graft Harvest. The usual grafts are rib, fascia, and dermis with the latter necessary under
any skin ulceration.
3) Columellar and Tip. A major structural columellar strut is inserted and fixed to the ANS.
The alar cartilages are then advance upward on the strut and fixed at two points. A full-
length tip graft is placed in the projected position and cap grafts added.
4) Dorsum. A full-length DC-F graft is inserted with an optional radix graft of fascia to build
up the glabellar region. If possible, a new plane of insertion is developed between the nasal
SMAS and the dorsum.
5) Dermis Graft. If the tip skin is compromised or the grafts exposed, then a dermis graft with
minimal fat is inserted with the dermis side up beneath the ulceration. The ulceration is
allowed to heal by secondary intention. One can expect a tip defect to heal within 6 weeks.
The scar will be 50% smaller than the original defect and probably 75% smaller than an
excisional closure. A simple scar revision can be done at 6 months if requested.
Implant
­Disasters

Implant ­Disasters
427
Fig. 12.10 (a, b) Early reconstruction at 8 weeks with composite reconstruction and a dermis
graft 
Fig. 12.11 (a–d) Immediate reconstruction see Fig 12.12 for result

428
Chapter 12  
Aesthetic ­Reconstructive ­Rhinoplasty
Analysis
A 50-year old of Filipino descent presented with an infected nasal implant 23 years after its
insertion. The implant had been exposed for 2 months (Fig. 12.12). All cultures were negative.
The patient was given a choice of three options for reconstruction – staged, early, or immediate.
Given her work schedule, she opted for immediate reconstruction despite the significant risk
of infection. Due to the extensive damage to the tip skin, immediate closure was not planned.
At 9 months postop, the underlying dermis graft has allowed the skin to contract and avoid
a depressed tip scar (intraop photos Fig. 12.11). The patient was able to avoid a 6–12-month
period of abnormal appearance and the difficulty of fixing a contracted skin sleeve.
Operative Technique
1) Harvest of cartilaginous portions of the ninth and eighth ribs.
2) Removal of the implant and its capsule thru an open approach.
3) Profuse irrigation of the wound with antibiotic solution.
4) Insertion of a structural columellar strut fixed to ANS.
5) Simple advancement of the alar cartilages over the strut.
6) Dorsal augmentation with a DC-F graft (0.9 cc).
7) Coverage of the lobule with a dermis graft from suprapubic area.
8) No closure of the tip wound.
Case Study:
Infected Implant
Fig. 12.12 (a–j)

Case Study: Infected Implant
429
Fig. 12.12 (continued)

430
Chapter 12  
Aesthetic ­Reconstructive ­Rhinoplasty
Why is the unilateral cleft lip nasal deformity infinitely more difficult than the bilateral? The
answer is obvious – lack of symmetry. Even worse, our attempts at surgical construction
are in visible contrast to the normal nasal side. Our ultimate limitation remains the lack of
nostril symmetry on basilar view.
Anatomical Limitations. The unilateral cleft lip nose is truly a deformity of the entire cleft
side of the face. In the adolescent, the nasal deformity is related to initial severity, pubertal
growth, and prior surgical intervention (Fig. 12.13). Pathologically there are at least nine
problems: (1) affected dome is lower, (2) lateral crura is crimped, (3) lateral crura is tipped
caudally, (4) tip bifidity, (5) obtuse columella nostril angle, (6) depressed bony floor, (7)
horizontal nostril angle, (8) missing nostril sill, and (9) caudal septum deviated to normal
side. Increasingly, one must add the alterations, distortions, and scarring from prior surgery.
Surgical Technique. Due to the variability of deformities only a generalized outline of pos-
sible techniques is offered (Fig. 12.14).
1) Incision. Skin hook traction is placed at the nostril apices and a stair step incision lower
on the cleft side is drawn. An incision at the columella base is never used as it destroys the
normal sweep of the columella labial segment.
2) Exposure. The nasal skin is elevated and the septum exposed via a dorsal-tip split. The alar
cartilages are carefully analyzed. If dorsal reduction is indicated, it is done at this time.
3) Septum. Invariably, the septum is deviated in its midportion to the cleft side and caudally
to the normal side. Total septal excision and replacement is often necessary. Approximately
5–10 mm of cephalic dorsal cartilage is left for suture fixation. A large septo/columellar
“tomahawk” strut is carved with the caudal portion setting tip projection. A portion is
saved for a tip graft.
4) Tip Creation. The medal/middle crura are advanced on the septocolumellar strut. Often
it is necessary to release the lateral crura from any adherence to the accessory cartilages.
Domal creation sutures are inserted. A structured tip graft is added to achieve the desired
projection and definition. Frequently, the lateral crura on the cleft side remains distorted
requiring a major lateral strut graft and often a composite graft for the nostril rim.
5) Base/Nostrils. The nostril variables are truly infinite, and one must take into account size,
shape, axis, and position. The preoperative basilar view often shows the total nostril size the
same bilaterally, but the four subunits including the axis to be radically different. Equally,
one may find incredibly thick vestibular scars both in the lateral wall and floor which are
corrected by excision followed by major composite conchal grafts.
6) Nuances. Numerous small steps are considered including: a double-stacked “footplate
graft” to the columellar, hydorxyapetite granules beneath the alar base on the cleft side.
Nostril retainer splints are worn at night for 3 months to minimize nostril contracture.
Unilateral Cleft
Lip Nose

Unilateral Cleft Lip Nose
431
Fig. 12.13 Pathology of unilateral cleft lip nose
Fig. 12.14 (a–c) Surgical techniques

432
Chapter 12  
Aesthetic ­Reconstructive ­Rhinoplasty
Analysis
A 14-year old presented for repair of her unilateral left cleft lip nasal deformity (Fig. 12.15).
The septal body was severely deviated and totally blocked the left airway while the caudal
septum was deviated to the right. Correction required resection of fixed deformities and
structural support throughout the L-strut. Subtle maneuvers would not work. Due to her
normal skin thickness, add-on grafts were effective. Multiple attempts to adjust nostril size
were not effective. Alas, the nostril dilemma was nothing new. I always tell the patient the
following: “Our goal is to give you an attractive natural appearing noncleft nose. The contour
of the nose is more important than the nostrils.”
Operative Technique
1) Open approach via a staggered columellar incision. Alar cartilages normal.
2) Incremental dorsal reduction (bone: 0.5 mm, cartilage: 1.0 mm).
3) Septal exposure revealed severe deviation with need for a “temporary L-strut.”
4) Resection of septal body. Creation of a “tomahawk” septocolumellar graft.
5) Insertion of strut with fixation to ANS and dorsal septum. Resection of severely deviated
caudal septum. Addition of spreader grafts with five-layer dorsal fixation.
6) Transverse and low-to-low osteotomies.
7) Advancement of the alars onto the strut and then cap and shield add-on tip grafts.
8) Alar rim graft (ARG) on left. Composite graft and multiple cartilage grafts on right.
9) Partial inferior turbinectomy on left.
Case Study:
Unilateral Cleft
Nasal Deformity
Fig. 12.15 (a–j)

Case Study: Unilateral Cleft Nasal Deformity
433
Fig. 12.15 (continued)

434
Chapter 12  
Aesthetic ­Reconstructive ­Rhinoplasty
The pathology of bilateral cleft nasal deformity is different than the unilateral deformity
(Fig. 12.16). These cases are extremely difficult and require a wide variety of cartilage grafts.
Equally, the scarred restricting skin envelope and major functional problems increase the
demand for surgical expertise. One major difference from the literature is that I have not
found the short columella to be a limitation in the majority of bilateral cleft patient. Com-
posite grafts to the columella and banked forked flaps are not necessary.
Surgical Techniques. As in all cleft nasal deformities, structure is critical in providing sup-
port and achieving an aesthetic result (Fig. 12.16). Whenever possible, I use the standard
inverted-V and infracartilaginous incisions placed low on the columella, but never in the
columella labial angle. However, preexisting scars may force modifications.
Septal Surgery. In the majority of bilateral cases, the septum is deficient in its distal third, but
not severely deviated. The septum is approached through a “tip split” thereby preserving the
membranous septum integrity. This maneuver allows for more control of the septocolumellar
support graft. A major harvesting of the septal body is done. A septocolumellar graft linking
caudal septum and columella provides support and prevents secondary distortion. These
grafts are often massive (25 × 20 mm) which achieves both lengthening (10–15 mm) and
projection (5–8 mm). The graft is placed with percutaneous needles as a unilateral spreader
graft juxtaposed to the caudal septum. Suture fixation with 4–0 PDS is done first at the ANS
and then to the septum at multiple points. The turbinates may be markedly enlarged as the
flat broad tip confers a platyrrhine configuration. Judicious reduction is done as indicated.
Tip Creation. The alar cartilages are advanced upward on the septocolumellar graft ­using a
double-skin hook placed in the nostril apices. Strong traction will determine whether it is
necessary to undermine the collumelar base and mobilize additional skin out of the ­upper
lip. The alar cartilages are advanced on the strut beginning with the footplates, then the
collumella breakpoint, and ultimately the middle crura. Next, the alar cartilages are refined
with domal creation sutures and approximated over the top of the strut. In most cases, the
skin is so thick that a rigid tip graft is used to gain the desired tip definition.
Closure/Alar Bases. All of the incisions are closed and tension is rarely a problem due to the
prior upward advancement of the columella base. In virtually all bilateral cases, alar base
narrowing is a necessity and a combined nostril sill/alar wedge excision is the usual solution.
In asymmetric cases, it is important to do the more severe side first and to vary the amount
of excision. I reserve the alar cinch maneuver for those rare cases where the nostril size is
small or the sill is of limited width.
Bilateral Cleft
Lip Nose

Bilateral Cleft Lip Nose
435
Fig. 12.16 Pathology of the bilateral cleft lip nasal deformity
Fig. 12.17 (a–e) Surgical techniques

436
Chapter 12  
Aesthetic ­Reconstructive ­Rhinoplasty
Analysis
A 34-year-old patient had undergone numerous operations (>20) for his bilateral cleft lip
deformity including three on his nose (Fig. 12.18). The patient stated that he had “a blob” for
a nose and would be grateful for anything that could be done. The skin sleeve was incred-
ibly thick and noncompliant. At 2 years, the result was a significant improvement for a nose
that was a true deformity. The columellar strut and onlay tip grafts created a tent pole effect
which triangulated and supported the tip (intraop photos Fig. 12.17d, e). Serendipitously, a
drain was inserted into the nose to reduce blood accumulation following the radix reduc-
tion. As soon as the suction bulb was compressed, the entire nasal skin dramatically “shrink
wrapped” around the tip.
Operative Technique
1) Harvest of the cartilaginous portion of the ninth rib.
2) Open approach with skin elevation in a subdermal plane.
3) Excision of a 9 mm thick supratip scar ball.
4) Thick radix reduction (4 mm). Dorsal width measured 17 mm.
5) Dorsum narrowed from 17 to 7 mm using paramedian, transverse, and
low-to-low ­osteotomies.
6) Major columellar strut inserted.
7) Alar rim remnants excised and replacement with alar battens.
8) Double thickness domal onlay grafts from rib cartilage.
9) Nasal drain (7 Fr) inserted with shrink wrapping effect on skin.
Case Study:
Bilateral Cleft
Nasal Deformity
Fig. 12.18 (a–j)

Case Study: Bilateral Cleft Nasal Deformity
437
Fig. 12.18 (continued)

438
Chapter 12  
Aesthetic ­Reconstructive ­Rhinoplasty
I am frequently asked by visiting surgeons if I have always done just rhinoplasty surgery. I
tell them yes with a smile and say that it was my father who was a pioneer in reconstructive
microsurgery as well as a researcher into the blood supply of the skin, electrical burns, and
hand transplantation. My 30-year progression from reconstructive microsurgeon to rhino-
plasty surgeon seems to fade in the intense focus required to do that particular rhinoplasty
at that particular moment. After “experiencing” 5,000 rhinoplasties, what advice do I have
for the younger surgeons wanting to become a rhinoplasty surgeon?
Step #1. No one emerges from their residency or fellowships being very good at rhinoplasty
surgery. The requisite expertise is lacking. One does not have experience with a diverse
range of patients nor an understanding of surgical cause and effect. It is what you learn and
what your commitment is in your practice that will determine whether you become a good
rhinoplasty surgeon. The slate is clean, it is commitment that counts.
Step #2. If learning rhinoplasty surgery is so difficult, why bother? The answer is simple –
creativity and challenge for the surgeon, a profound life-changing event for the patient. There
is no other surgical procedure that will fascinate and challenge you throughout your entire
surgical career.
Step #3. Where to begin? The first step is to assess your core competence and confidence
in rhinoplasty. Your residency and fellowship training will have exposed you to certain
techniques. Plan to master these techniques first within the outline of the basic rhinoplasty
operation (Chapter 2). Defining Level 1 cases and operating within your comfort zone are
critical in the first year or two of practice. Your goal is to become comfortable with the entire
perioperative course of rhinoplasty surgery, from consultation through long-term follow-up.
Also, it establishes your reputation for competency in the community. Despite being cautious,
you will misjudged certain cases and end up doing a few Level 2 cases, thus inadvertently
expanding your comfort zone.
Step #4. Every rhinoplasty you do is a learning experience – so maximize it! Take photos of
every nose consult and do a three-step analysis. Write out an operative plan. If they come
back, they will be impressed with your preparation and you can check your initial assess-
ment. Refine your operative plan – record what changes are necessary intraop. Take tip
photos before closing. Write out your “three questions.” See the patient frequently post-op
and always look at your op diagram. Reread the Section of “Teaching Yourself Surgical Cause
and Effect” in Chapter 1.
Step #5. Read everything you can on rhinoplasty surgery. Attend as many meetings as pos-
sible, both local and international. You learn a lot not only from the lecturers, but also from
talking with other attendees. Do not hesitate to go to multispeciality or different specialty
meetings. I find DVDs are extraordinarily valuable for understanding the details of specific
techniques. If possible, find a course with cadaver dissections.
Step #6. Find a mentor or visit several surgeons who do a lot of rhinoplasties. The older and
more established the surgeon, the more likely they are to help you out. For 1 year, I spent every
The Practice of
Rhinoplasty:
A Summation

The Practice of Rhinoplasty: A Summation
439
Thursday morning in the operating room with Dr. Paule Regnault and then every Thursday
afternoon doing my own cases. The experience was incredible. Once a year, I go and spend
2–3 days in the OR with a colleague. I always learn an enormous amount.
Step #7. Identify your weaknesses and correct them. Due to my plastic surgery background,
I needed to strengthen my knowledge of managing nasal obstruction early in my practice.
I did the following: (1) took the 3-day Cottle Rhinology Course, (2) went to the Mayo Clinic
Rhinology Course and spent a clinical week with Dr. Eugene Kern, (3) operated with an
ENT colleague for 6 months, and (4) had a Resident spend a year developing a “localized
rhinomonometry” system.
Step #8. As you develop greater confidence, then expand your comfort zone to Level 2 cases
and eventually Level 3 cases. Be forewarned – you will have problems and unhappy patients.
What to do? Try and be objective. Will a revision make a difference? Should you arrange
a consultation for the patient with a colleague? Learn from your revisions. Early on, I was
as excited about one of my revisions as I was about a primary as I got to see what I did
wrong. ­Although I do not enjoy revisions, it is still fascinating to truly understand what
went wrong.
Step #9. Decision time. Realize that you will reach a point when you need to reassess your
commitment to rhinoplasty surgery and at what Level you wish to remain. If you have a
broad interest in your primary surgery specialty, you may wish to remain at Level 1 and
enjoy straightening crooked male noses and eliminating the bumps on cute teenage girls.
The surgery is fun and the stress limited. Some will want to take on the challenge of Level
2 cases consisting of more difficult primaries and ethnic rhinoplasties which will require
competency with a large number of grafts. Realistically, only about 10% of the surgeons will
enjoy doing Level 3 cases and infinitely difficult secondary rhinoplasties with their requisite
rib grafts. It is important to operate within your comfort zone. There is no need to give up
doing rhinoplasty just operate within your comfort zone.
Step #10. A rhinoplasty practice is a career journey, not a destination. I am convinced that
few surgeons would want or could deal with an exclusive rhinoplasty practice for more than
10 years. Although the majority of patients are appreciative and delighted with their result,
there is a minority whose unhappiness and anguish erodes one’s soul. As has been said “be
careful of what you wish for, you just might get it.” Yet, I still continue to suffer from “nose
lust” and the curiosity of how to correct challenging nasal deformities. I am both cursed and
blessed to have had this affliction for the last 25 years – it has been delightful.

440
Chapter 12  
Aesthetic ­Reconstructive ­Rhinoplasty
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Calvert JC, Brenner KB, DaCosta-Iyer M, Evans GRD, and Daniel RK. Histological analysis of
human diced cartilage grafts. Plast Reconstr Surg 118: 230, 2006
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Surg. 94: 597, 1994
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Plastic and Reconstructive Surgery, 2003
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diced solvent-preserved costal cartilage cartilage homograft application for nasal aug-
mentation. Plast Reconstr Surg 115: 2081, 2005
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Reading List

A
ADDN. See Asymmetric developmental
­deviated nose
Add-on grafts
principles, 130
technique, 130–131
Aesthetic reconstructive rhinoplasty
bilateral cleft lip nose
pathology, 434–435
septal surgery, 434
surgical techniques, 434–435
unilateral deformity, 434
bilateral cleft nasal deformity
analysis, 436–437
operative technique, 436
cocaine nose
analysis, 424–425
operative technique, 424
surgical correction, 422–423
composite reconstruction
analysis, 414
component technique, 410–411
operative technique, step, 410–415
spreader graft fixation, 413
implant disasters
early and immediate reconstruction,
426–427
staged reconstruction, 426
infected implant
analysis, 428–429
operative technique, 428
open approach, 408
overview 407–409
over-resected nose
analysis, 416–417
operative technique, 416
reconstructive approaches, 409
rib grafts, 408–409
septal saddle nose
aesthetic tip and dorsum, 418
analysis, 420–421
diagnosis, 418–419
operative technique, 420
problem, 418
septal foundation, stabilizing,
418–419
surgical sequence, 418
Sheen’s approach, 408
unilateral cleft lip nose
anatomical limitations, 430–431
nostril symmetry lack, 430
surgical technique, 430–431
unilateral cleft nasal deformity
analysis, 432–433
operative technique, 432
Aesthetics
radix and dorsum modification, 72–73
tip surgery techniques
Subject Index

442
Subject Index
extrinsic factors, 110–111
intrinsic factors, 108–109
Alar base modification
principles, 42
surgical techniques, 42–43
Alar cartilages preparation, tip surgery, 370
Alar flare (AL), 158
Alar malposition (AMP)
analysis, 304–305
anatomy, 303
definition, 302
operative techniques, 304
Alar rim
collapse, 200–201
principles, 132
procedure, 134–137
Alar rim graft (ARG), 156
Alar rim–nostril–columellar complex
(ARNC), 160, 166–167, 376
Alar rim support graft (ARS), 156, 166–167
Alar spreader grafts, 264–265
Alar wedge excision, 162–163, 172
Alloplastic dorsal implant, 226
Anatomical components, 158–159
Anesthesia
local anesthesia, 19
principles and precautions, 18
Anterior nasal spine (ANS), 156, 164–165
ARG. See Alar rim graft
ARNC. See Alar rim–nostril–columellar
complex
ARS. See Alar rim support graft (ARS)
Asian rhinoplasty
alar base modifications and ARS/ARG,
330, 331
analysis, 332, 333
autogenous tissue operation, 328–329
dorsal grafts, 330, 331
graft harvesting, 328
operative techniques, 332
osteotomies, 330
septal harvest, 328, 329
septocolumellar graft, 328, 330, 331
soft tissue defatting, 328, 329
tip graft, 330, 331
Asymmetric bony vault, 94–95
Asymmetric developmental deviated nose
(ADDN), 308, 310
Asymmetric nose and tip
analysis, 310–311
localized and generalized, 308–309
operative techniques, 310
Autogenous tissue operation, 328–329
B
Ball and boxy tip, 300–302
Ball tip modification, 60–61
Banking/harvesting, grafts, 265–266
Base and nostril
analysis, 404, 405
nasal base surgery, 403
operative techniques, 404
queries, 402
Basilar anatomy, 158–159
Bilateral cleft lip nose
pathology, 434–435
septal surgery, 434
surgical techniques, 434–435
unilateral deformity, 434
Bilateral cleft nasal deformity
analysis, 436–437
operative technique, 436
Black rhinoplasty
analysis
major, 337
moderate, 336
surgical techniques, 334, 335
Bony base realignment, 386, 387
Bony valve, 206–207
Bony vault reduction, dorsum, 78–79
Bossas and bumps, tip surgery, 374
Broad tip and bulbous tip, 298–299
C
Cadaver dissection, 192–193
Camouflaging and augmenting, bridge, 386
Cartilaginous vault reduction, dorsum,
78–79
Castilian noses, 320, 321
Catgut suture, fascia, 250–251
Caudal septal deviation, 200–201
Caudal septum, 156, 158, 164–165, 168–170,
174, 366, 367
principles, 28
relocations, 194–195
resection and relocation, 28–29
CLA. See Columellar labial angle
Classification
level 1, form and function, 5
level 3, major changes, 7
level 2, tip challenges, 6 (See also Tip
modification method)
operative complexity and surgical
techniques, 4
patient request and deformity, 4
Cleft lip rhinoplasty
bilateral cleft nasal deformity
analysis 434–435
case study 436–437
surgical techniques 434–435
unilateral cleft nasal deformity
analysis 430–431
case study 432–433
surgical techniques 430–431
Cocaine nose
analysis 422
case study 424–425
surgical techniques 423
Columellar
inclination, ARNC, 166–167
struts, 244–245, 334, 370, 371
and suture, 118–119

Subject Index
443
Composite reconstruction
operative technique 410–414
case studies 414–417
Columellar labial angle (CLA), 158, 160–161,
164–165
Combined sill
base excision, 162–163
wedge excisions, 162–163, 173
Complications
incidence and hemorrhage, 64
infection, 64–65
nasal obstruction and septal problems, 65
Composite conchal grafts
applications and problems, 236
internal valve collapse, 262–263
lowering alar rim, 262
technique, 236–237
vestibular stenosis, 262–263
Conchal harvest, 234–235
Consultation
analysis, 14
base and tip analysis, 15
nasal deformity and patient factors,
14
radix and dorsum, 15
Costal cartilage harvest, 240–241
Creole noses, 320, 321
Crural convexities
principles, 126
technique, 126–127
Cymba concha, 166–167
D
Decision making
alar malposition (AMP), 303
analysis, 304–305
definition, 302
operative techniques, 304
analysis, 400, 401
ball tip
analysis, 300–301
operative techniques, 300
base and nostril
analysis, 404, 405
nasal base surgery, 403
operative techniques, 404
queries, 402
boxy tip, 302
broad tip and bulbous tip,
298–299
camouflaging and augmenting,
bridge, 386
deviated nose, 386, 387
dorsal augmentation
analysis, 390–391
operative techniques, 390
dorsal deviation
analysis, 388, 389
operative techniques, 388
downward rotating long nose
analysis, 292–293
levels, 290–291
operative techniques, 292
operative techniques, 400
over projecting nose
analysis, 284–285
levels, 282–283
operative techniques, 284
realignment, bony base, 386, 387
secondary tip
analysis, 398, 399
operative techniques, 398
surgery, 396–397
septal surgery
analysis, 394, 395
operative techniques, 394
septum and valves, 293, 392
skin envelope, 380, 381
thick skin
analysis, 382, 383
operative techniques, 382
thin skin
analysis, 384, 385
operative techniques, 384
tip definition
analysis, 272–273
levels, 270–271
operative techniques, 272
tip width, 274–275
underprojecting nose
analysis, 288–289
levels, 286–287
operative techniques, 288
upward rotating short nose
analysis and commentary, 296–297
levels, 294–295
operative techniques, 296
wide nose/wide tip
analysis, 276–277, 280–281
levels, 278–279
operative techniques, 276, 280
Dermal grafts, 264–265
Diced cartilage in fascia (DC-F), steps,
252, 254–255
Domal equalization suture, 124–125
Dorsal augmentation
analysis, 390–391
operative techniques, 390
Dorsal/base disproportion
analysis, 318–319
operative techniques, 318
Sheen’s adage, 316–317
Dorsal deviation
analysis, 388, 389
operative techniques, 388
Dorsal grafts, 239, 330, 331
Dorsal septal deviation, 184–185
Dorsal straightening, 196–197
Dorsum/lateral sidewalls, 345
Dorsum modification
aesthetics, 72–73
anatomy, 70–71