Nâng Mũi Thẩm Mỹ Nâng Cao: Nghệ Thuật, Khoa Học Và Các Kỹ Thuật Lâm Sàng Mới

656
J. Guerrerosantos
extracting little by little the liquid formed then
placing a splint with constant pressure for
12 days, and an antibiotic is prescribed.
Conclusions
The use of the cartilage graft either fragmented
or without breaking into fragments covered
with fascia is an excellent alternative in the
augmentation rhinoplasty.
References
1. Stark RB, Frileck SP (1969) Conchal cartilage grafts in
augmentation rhinoplasty and orbital and orbital fl oor
fracture. Plast Reconstr Surg 43(6):591–596
2. Ortiz-Monasterio F, Olmedo A, Oscoy LO (1981) The
use of cartilage graft in primary aesthetic rhinoplasty.
Plast Reconstr Surg 67(5):597–605
3. Sheen JH (1987) Conchal cartilage for dorsal grafts.
In: Sheen JH, Sheen AP (eds) Aesthetic rhinoplasty.
Mosby, St. Louis, p 428
4. Gunter JP (1990) Augmentation rhinoplasty: dorsal
onlay grafting using shaped autogenous septal carti-
lage. Plast Reconstr Surg 86(1):39–45
5. Guerrerosantos J (1984) Temporoparietal free fascia
grafts in rhinoplasty. Plast Reconstr Surg 74(4):
465–475
6. Erol OO (2000) The Turkish delight: a pliable graft for
rhinoplasty. Plast Reconstr Surg 105(6):2229–2241
7. Guerrerosantos J, Trabanino C, Guerrerosantos F
(2006) Multifragmented cartilage wrapped with fascia
in augmentation rhinoplasty. Plast Reconstr Surg
117(3):804–812
8. Daniel RK (2006) The role of diced cartilage grafts in
rhinoplasty. Aesthet Surg J 26(2):209–213
9. Daniel RK (2008) Diced cartilage grafts in rhinoplasty
surgery: current techniques and applications. Plast
Reconstr Surg 122(6):1883–1891

657
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_41, © Springer-Verlag Berlin Heidelberg 2013
41
41.1
Introduction
Columellar reconstruction poses an operative
challenge, as both aesthetic and functional
rami fi cations need to be addressed. The colu-
mella, along with the medial crura of the lower
lateral cartilage, provides support to the nose and
overlying soft tissue envelope, projection to the
tip, and serves as an important aesthetic unit of
the face [ 1 ] . Moreover, it plays a pivotal role in
maintaining airway dynamics by opening the
nasal valve.
Columellar defects leading to tip collapse can
be the result of trauma, infection, malignancy,
iatrogenic cause, or congenital deformity [ 1 ] .
Traumatic dislocation of the anterior septum and/
or nasal spine, fracture of the anterior septum, or
septal hematoma with subsequent resorption of
the septal cartilage may cause the columella to
retract and the anterior third of the nose to drop [ 2 ] .
The columella may also collapse following oper-
ative nasal septum interventions in which the
anterior strut (L-strut) is not preserved and when
the anterior septum is missing or too narrow to
support the tip. In addition, a short columella
may present as part of bilateral cleft lip [ 3 ] or,
more rarely, as an isolated congenital deformity.
An innovative technique for columellar recon-
struction via the sublabial approach is presented.
41.2
Operative Indications
The operative technique presented herein is
indicated in patients with columellar deforma-
tion and/or tip collapse from diverse etiologies
(trauma, post-surgery, infection, malignancy, or
congenital deformity). Patients with antecedent
trauma to the anterior septum (septal fracture
or septal hematoma with subsequent resorp-
tion of the septal cartilage), prior septal surgery
in which L-strut is not preserved with resultant
septal collapse, infection (leprosy, leishmania-
sis, nasal abscesses), malignancy (involving the
columella/anterior septum necessitating surgical
excision), or congenital defects (e.g., bilateral
cleft lip deformity or isolated congenital absence
of columella) might present with collapsed tip
and bene fi t from columellar reconstruction via
the sublabial approach. The technique might be
performed as a prophylactic measure in patients
presenting with poor tip support or when the ante-
rior septum is severely deformed. The technique
Sublabial Approach for Columellar
Reconstruction in Corrective
Rhinoplasty
Sarit Cohen and J. Shem Tov
S. Cohen , M.D. ()
Department of Plastic and Aesthetic Surgery ,
Private Clinic , 8 Remba St ,
Ramat Gan 52486 , Israel
e-mail: sariti@zahav.net.il
J. S. Tov , M.D.
Department of Otolaryngology , Rabin Medical Center ,
Beilinson Campus , Petah Tiqwa , Israel
Sackler Faculty of Medicine ,
Tel Aviv University , Tel Aviv , Israel

658
S. Cohen and J.S. Tov
might also be indicated in cases of revisionary
rhinoplasty wherein a virgin operative fi eld is
undoubtedly superior, in cases of previous sep-
tal operations especially when septal perforation
is present. The technique is not indicated where
there is soft tissue de fi ciency or scar contracture
formation in the columella.
41.3
Operative Technique
The ideal donor site is the nasal septum since the
graft needs to be suf fi ciently long and thick to
push the nasal tip anteriorly and superiorly. When
the septum is unsuitable (e.g., was removed in a
previous operation or is calci fi ed or twisted),
conchal or rib cartilage may be used. If conchal
cartilage is chosen, its inherent curves should be
straightened by scoring or folding it into two,
with the inner concave surfaces facing each
other.
A graft measuring 5 mm wide × 20–25 mm
long × 2 mm thick is carved with carefully curved
edges. After the graft is harvested, the columellar
area and gingivolabial sulcus are anesthetized
with local anesthesia (lidocaine 2% and epineph-
rine solution, 1:100,000). An inverted V-shaped
incision is made in the midline of the labial
mucosa, with each shank measuring 1 cm in
length, beginning 3–4 mm above the gingiva;
care should be taken to avoid the frenulum
(Fig. 41.1 ). The incision is continued cephalad
toward the nasal spine with sectioning of the ori-
gin of the depressor septi nasi muscles. Blunt dis-
section with Metzenbaum scissors is then
performed superiorly into the columella between
the medial crura of the lower lateral cartilage and
the membranous septum (Fig. 41.2 ). The dissec-
tion should be wide enough to encompass the
graft and long enough to reach the nasal spine,
inferiorly, and the tip of the nose, between the
domes, superiorly. This creates a sublabial tunnel
through which the graft strut is introduced
(Fig. 41.3 ). Graft bulging above the level of the
domes should be avoided. The graft strut is fi xed
using a straight needle and an absorbable suture.
A trans fi xion suture is placed to support the graft
at the anterior septum.
An additional crescent-shaped graft is then
carved from the harvested cartilage and intro-
duced transorally, through the tunnel created, so
that it embraces the base of the fi xed graft and
secures it in position. The graft is fi xed to the
periosteum of the maxilla or to the nasal spine;
this is aimed to prevent the fi xed graft from
migrating anteriorly and into the upper lip. The
muscles are sutured meticulously, and then the
oral mucosa is secured with absorbable sutures
(Vicryl 4-0). The donor site is carefully sutured
and dressed. If septal cartilage is harvested, nasal
packing is necessary to prevent septal hematoma.
Rhinoplasty, if elected, is performed in the fi nal
stage of the operation.
Fig. 41.1 An inverted V-shaped incision is made in the
upper gingivobuccal sulcus avoiding the frenulum

659
41 Sublabial Approach for Columellar Reconstruction in Corrective Rhinoplasty
Fig. 41.2 A tunnel is created by blunt dissection with
Metzenbaum scissors up to the columella between the
medial crura of the lower lateral cartilages and the mem-
branous septum
Fig. 41.3 A conchal cartilage graft is inserted via the
tunnel created

660
S. Cohen and J.S. Tov
Case 1
A 38-year-old man had a past history that included
respiratory dif fi culties necessitating mandibular
advancement at age 15 and submucosal resection
6 years before admission. His complaints, however,
did not resolve. He presented with a droopy tip, colu-
mellar retraction, and nostril fl aring (Fig. 41.4 ). The
authors performed columellar reconstruction with
conchal graft via the sublabial approach as well as
conservative hump removal via an intercartilaginous
incision. No further operations were performed.
a
b
Fig. 41.4 ( a ) Preoperative patient. ( b ) Postoperative 24 months after sublabial columellar reconstruction

661
41 Sublabial Approach for Columellar Reconstruction in Corrective Rhinoplasty
Case 2
A 45-year-old man underwent septoplasty
1½ years before presentation. His chief complaint
was nasal obstruction. Examination revealed col-
umellar retraction, absent caudal septum and
anterior nasal spine, and an obstructed internal
nasal valve. Preoperative oblique and worm views
are shown (Fig. 41.5 ). Postoperative results at
15 months after conchal graft insertion via the
sublabial approach are shown in Fig. 41.5 . No
further operations were performed.
a
b
Fig. 41.5 ( a ) Preoperative patient. ( b ) Postoperative 15 months after insertion of conchal graft

662
S. Cohen and J.S. Tov
Case 3
A 38-year-old man underwent submucosal resec-
tion 5 years before presentation. During operation,
the anterior part of the septum was not preserved.
Subsequently, the patient presented with a droopy
tip (Fig. 41.6a ). Postoperative results at 12 months
after conchal graft insertion via the sublabial
approach and conservative hump removal via inter-
cartilaginous incision are shown in Fig. 41.6b .
a
b
Fig. 41.6 ( a ) Preoperative patient. ( b ) Twelve months postoperative following conchal cartilage insertion and conser-
vative hump removal

663
41 Sublabial Approach for Columellar Reconstruction in Corrective Rhinoplasty
41.4
Complications
One patient developed an infection 1 week post-
operatively and was successfully treated with
percutaneous drainage and systemic antibiotics.
This patient had had 3 previous operative inter-
ventions (rhinoplasty and two septal operations).
Due to marked fi brosis in the columellar region,
we could not determine whether or not the graft
was absorbed.
In fi ve patients (0.42%), absorption of the car-
tilaginous grafts was diagnosed following recur-
rent tip collapse and negative fi ndings on
palpation. In these cases, auricular grafts were
reharvested, folded into two, and secured with
meticulous suturing. Of these patients, one was a
heavy smoker and presented with tip collapse. A
conchal graft was introduced and was subse-
quently resorbed due to impaired perfusion.
Following hyperbaric oxygen therapy, additional
surgery using rib graft was partially successful.
In another patient, postoperative septal hema-
toma, which was drained twice, was a possible
cause for graft absorption.
Graft extrusion through the sublabial incision
was diagnosed in two cases (0.17%). In one of
these cases, the graft source was rib cartilage.
Upon reoperation, the grafts were shortened,
placed back into the tunnel, and carefully fi xed to
prevent migration. A crescent-shaped graft was
then introduced to secure the fi xed graft into posi-
tion. The fi nal outcome was satisfactory in both
cases. It should be emphasized that 4 patients
( n = 4) presenting with postoperative complica-
tions were among the fi rst ten reported in our pre-
vious publication of the technique [ 4 ] . To avoid
the relatively high postoperative complications,
the operative technique was subsequently
modi fi ed. This included 3 major changes: (1)
Precise control on pocket dimensions and borders –
recipients’ pocket width dimensions should be
adequate to encompass the graft comfortably, but
not so liberal as to hinder support and projection.
Likewise, pocket tightness is strongly discour-
aged so as to avoid possible graft fracture and
absorption. Pocket dissection should be limited
up to the level of the domes between the medial
crura to avoid graft visibility, thereby maximiz-
ing the aesthetic result. (2) Meticulous graft
fi xation with a straight needle and absorbable
suture. Additionally, a trans fi xion suture is placed
to support the graft at the anterior septum. (3)
The addition of a crescent-shaped graft to
embrace the base of the fi xed graft and secure it
in position. These modi fi cations yielded proper
fi xation and graft maintenance. Following tech-
nique modi fi cations, a marked decrease in the
graft-related complications was documented. In
the subsequent 107 patients reported in this series,
no graft extrusion was encountered, and graft-
related complications were virtually eliminated.
41.5
Discussion
Among the nasal aesthetic subunits, the colu-
mella is the most dif fi cult to reconstruct [ 5 ] . The
aesthetically pleasing nasal-columellar relation-
ship has been extensively investigated [ 6– 10 ] ,
and a thorough review is beyond the scope of this
article. For practical purposes, we will discuss
points that are speci fi cally relevant to the preser-
vation of a harmonic nasal-columellar relation-
ship during reconstruction.
Given the central location of the columella
along the midface, its aesthetic and structural
contribution to the nasal tip and lobule, and its
pivotal role in maintaining airway dynamics by
opening the nasal valve, proper reconstruction is
absolutely fundamental.
The ideal tip projection is calculated as the
distance from the stomion to the menton multi-
plied by a factor of 0.67 [ 6 ] . A basal view of the
columella and the outline of the nasal base should
form an equilateral triangle. When viewed from
the front, lobular portion of the nose should lie in
a 1:2 ratio with the columella [ 7 ] . An alar-colu-
mellar curvature indicates a hanging columella,
whereas a straight line indicates a retracted colu-
mella. Tip rotation is determined by the nasola-
bial angle: a straight line passing through the
most anterior and posterior edges of the nostrils
and the angle it makes with the plumb line. This
angle ranges between 100° and 105° in women,
and between 95° and 100° in men [ 7 ] .

664
S. Cohen and J.S. Tov
Tip support using grafts was popularized by
Sheen [ 11 ] , who suggested the use of a shield-
shaped graft placed in a subcutaneous pocket
within the tip lobule. This design is still often used
today. Another common design is the umbrella
graft proposed by Peck [ 12 ] , which consists of a
horizontal component that overlies the domes and
a vertical component placed between the medial
crura. The anatomic tip graft, fi rst designed by
Rohrich [ 13 ] , and later by Gruber and Grover
[ 14 ] , mimics the surface anatomy of the infratip
lobule and covers the area between the middle
crura (lower part) and the areas between the domes
(upper part). Graft augmentation of the nasal tip is
technically dif fi cult to master [ 15 ] , and problems
with graft visibility, graft migration, and malposi-
tion continue to challenge surgeons [ 13– 16 ] .
Tip augmentation is performed via endonasal
approach or open rhinoplasty. Complete anatomic
exposure and direct binocular view of the nasal
framework afforded by the open approach make
open rhinoplasty particularly advantageous in tip
procedures [ 17 ] . Precise manipulation in situ, car-
tilage sculpturing, and suture fi xation of grafts/ fl ap
suturing facilitate rigid architectural support. It
should be borne in mind, however, that open
access is associated with other liabilities, namely,
transcolumellar scarring, prolonged operating
time, and greater postoperative edema and fi brosis
when compared to the endonasal approach.
Though open rhinoplasty is considered the pre-
eminent access route in tip procedures, propo-
nents of the endonasal approach argue that by
separating columellar skin from the medial crura,
one loses an important component of tip stability
and projection. In endonasal surgery, pocket dis-
section is limited, and the need for graft fi xation is
minimized [ 18 ] . Regardless of the approach cho-
sen, surgeons must be cognizant of the fact that,
as stated by Constantian, “rhinoplasty is made
easier not necessarily by a larger incision but
rather by an accurate analysis of the surgical prob-
lem and adherence to a strategy that re fl ects the
real biological processes at work” [ 18 ] .
The technique presented herein is an ana-
tomic, minimally invasive approach for columel-
lar reconstruction using septal grafts introduced
via the sublabial approach. In this manner, the
columella is properly positioned anatomically,
with appropriate shape and length, and appro-
priate tip de fi nition and projection are achieved.
Furthermore, the external valve is braced against
collapse, the lining of the vestibule is supported,
and lobular shape is maintained, thus ful fi lling
both aesthetic and functional goals of the sur-
gery. In the author’s previous publication of the
technique [ 4 ] , there was a report on 32 patients
undergoing the sublabial approach for columel-
lar reconstruction. Several graft-related com-
plications were encountered and included graft
absorption in 2/32 patients (6.25%) and graft
extrusion in 2/32 patients (6.25%). These graft-
related complications were mostly recorded at
the beginning of our learning curve. Based on our
experience and upon technique modi fi cation, the
rate of postoperative complications was remark-
ably reduced, graft absorption was encountered
in 5/117 patients (0.42%), and graft extrusion was
recorded in 2/117 patients (0.17%). The percent-
age of patients in whom columellar reconstruc-
tion was performed following previous septal
surgery or rhinoplasty in the previous publication
[ 4 ] compared to this study was 10/32 patients
(31.25%) vs. 24/117 patients (20.5%), respec-
tively. The percentage of patients reporting ante-
cedent trauma in the previous report compared
to the series presented herein, [5/32 patients
(15.625%) vs. 16/117 patients (13.67%)], was
relatively the same with no statistically signi fi cant
difference. Based on our experience, precise con-
trol on pocket dimensions, proper graft fi xation,
and avoidance of graft visibility are strongly rec-
ommended to minimize graft-related complica-
tions and facilitate gratifying aesthetic results.
The procedure is easy to perform, can be rap-
idly mastered, and is time saving. With an experi-
enced hand, the surgery takes between 30 and
40 min to perform if septal cartilage graft is har-
vested and between 40 and 50 min if conchal car-
tilage is harvested. Compared to our experience
with traditional corrective open rhinoplasty tech-
niques, columellar reconstruction via the subla-
bial approach is an anatomic, minimally invasive
technique with a shorter operating time. The
resultant inconspicuous scar is cosmetically supe-
rior to the visible scar created by open rhinoplasty.

665
41 Sublabial Approach for Columellar Reconstruction in Corrective Rhinoplasty
Moreover, the sublabial access route makes it pos-
sible for the surgeon to section the origin of the
depressor septi nasi muscles. The anatomical and
clinical importance of this muscle in rhinoplasty
has been anatomically and clinically studied by
Rohrich et al. [ 19 ] . They report an enhancement
of the tip-lip relationship, relative upper lip length-
ening, provision of relative fullness to the upper
lip, maintenance of tip rotation/projection with
animation, and sensory/motor preservation of the
upper lip. Several other authors have advocated
the need to section the depressor septi nasi muscle
in order to improve the nasolabial angle and
enhance tip projection [ 20– 22 ] .
In recognition with the previously alluded pur-
ported advantages of sublabial approach for colu-
mellar lengthening, we began to perform the
technique prophylactically especially in cases pre-
senting with poor tip support and severe anterior
septum deformity. Under such circumstances, the
technique is indicated as a preventive measure. In
cases of previous septal operations or when septal
perforation is present, the sublabial approach for
columellar reconstruction is the procedure of
choice – mainly because there is no need for an
additional septal incision which might enlarge the
perforation or otherwise create a perforation which
did not exist prior to the procedure. It may also be
preferably indicated in cases of revisionary rhino-
plasty, when previous scar tissue makes dissection
and manipulation dif fi cult and limits reexpansion
and reshaping of the covering skin.
References
1. Bilkay U, Tokat C, Ozek C, Erdem O, Cagdas A
(2004) Reconstruction of congenital absent columella.
J Craniofac Surg 15(1):60–63
2. Perkins SW, Dayan SH (2002) Management of nasal
trauma. Aesthetic Plast Surg 26(Suppl 1):S3
3. Cronin TD, Upton J (1978) Lengthening of the short
columella associated with bilateral cleft lip. Ann Plast
Surg 1(1):75–95
4. Cohen S, Ad-El D, Yaniv E, Billig A, Tov JS (2009)
Sublabial approach for columellar reconstruction in
corrective rhinoplasty. J Plast Reconstr Aesthet Surg
62(11):1446–1452
5. Margulis A, Bauer BS, Han H, Patel PK (2003)
Reconstruction of the columellar in a pediatric patient.
Plast Reconstr Surg 112(7):1948–1949
6. Byrd HS, Hobar PC (1993) Rhinoplasty. Selected reading
in plastic surgery. Plast Reconstr Surg 91(4):642–654
7. Rohrich RJ, Muzaffar AR (2000) Primary rhinoplasty.
In: Achauer BM, Eriksson E, Guyuron B, Coleman JJ
III, Russel RC, Vander Kolk CA (eds) Plastic surgery
indication, operations and outcomes, 1st edn. Mosby,
St. Louis, pp 2631–2671
8. Sheen JH (1987) Esthetic rhinoplasty, vols I and II,
2nd ed. Mosby, St. Louis
9. Gunter JP (1995) Facial analysis for the rhinoplasty
patient. In: The tenth dallas rhinoplasty symposium,
Dallas, 1995, pp 17–28
10. Gunter JP (1993) The importance of alar-columellar
relationship in rhinoplasty. In: The tenth dallas rhino-
plasty symposium, Dallas, 1993, pp 37–46
11. Sheen JH (1993) Tip graft: a 20-year retrospective.
Plast Reconstr Surg 91(1):48–63
12. Peck GC (1983) The onlay tip graft for nasal tip pro-
jection. Plast Reconstr Surg 71(1):27–39
13. Rohrich RJ (1998) An 18-year experience with the
umbrella graft in rhinoplasty (discussion). Plast
Reconstr Surg 102(6):2166–2168
14. Gruber RP, Grover S (1999) The anatomic tip graft for nasal
augmentation. Plast Reconstr Surg 103(6):1744–17453
15. Constantian MB (1999) The anatomic tip graft for
nasal augmentation (techniques in cosmetic surgery).
Plast Reconstr Surg 103(6):1754–1758
16. Menick FJ (1999) Anatomic reconstruction of the nasal
tip cartilages in secondary reconstructive rhinoplasty
(cosmetic). Plast Reconstr Surg 104(7):2187–2198
17. Rohrich RD, Muzaffar AR (2006) Primary rhino-
plasty. In: Mathes SJ (ed) Plastic surgery, 2nd edn.
WB Saunders, Philadelphia, pp 427–471
18. Constantian MB (2006) Closed rhinoplasty: current
technique, theory, and applications. In: Mathes SJ (ed)
Plastic surgery, 2nd edn. WB Saunders, Philadelphia,
pp 517–572
19. Rohrich RJ, Huynh B, Muzaffar AR, Adams WP Jr,
Robinson JB Jr (2000) Importance of the depressor septi
nasi muscle in rhinoplasty: anatomic study and clinical
application. Plast Reconstr Surg 105(1):376–383
20. Cachay-Velasquez H (1992) Rhinoplasty and facial
expression. Ann Plast Surg 28(5):427–433
21. Lawson W, Reino AJ (1995) Reduction columelloplasty.
A new method in the management of the nasal base.
Arch Otolaryngol Head Neck Surg 121(10):1086–1088
22. Cetinkale O, Tulunay S (1998) Augmentation of the col-
umella-labial angle to prevent the “smiling deformity” in
rhinoplasty. Aesthetic Plast Surg 22(2):106–110

667
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_42, © Springer-Verlag Berlin Heidelberg 2013
42
42.1
Introduction
The caudal septal extension graft (CSEG) was
popularized by Toriumi and others for use in aes-
thetic rhinoplasty as a secure means to indepen-
dently control tip projection, rotation, and nasal
length. CSEGs are cartilage grafts placed at the
caudal margin of the nasal septum (Fig. 42.1 ).
They function to improve nasal tip position or
columella shape through modi fi cation of either
the anterior septal and/or posterior septal angle
position. These grafts are differentiated from tra-
ditional free- fl oating columellar strut grafts in
that they are securely fi xed to the caudal margin
of the septum. Using this septal attachment as a
de fi ning element for these grafts, it appears that
the fi rst caudal septal extension graft description
was actually termed a columellar strut and was
described as a maneuver in cleft rhinoplasty that
consisted of an end-to-end augmentation of the
caudal septum [ 1 ] . Later, this technique included
overlapping the graft with the caudal margin of
the nasal septum and was described as a columel-
lar control strut [ 2 ] .
Caudal Septal Extension Grafts
Lynn L. Chiu-Collins , Alexis D. Furze ,
and Brian J. F. Wong
L. L. Chiu-Collins , M.D.
Division of Facial Plastic Surgery, The Department of
Otolaryngology – Head and Neck Surgery-5386 ,
The University of California Irvine ,
19182 Jamboree Road , Irvine, CA 92617 , USA
e-mail: lynnchiu.md@gmail.com
A. D. Furze , M.D.
2552 Walnut Ave. #130 , Tustin , CA 92780 , USA
e-mail: alexis.furze@gmail.com
B. J. F. Wong , M.D., Ph.D. ()
Facial Plastic Surgery, The Beckman Laser Institute
and Medical Clinic, The University of California Irvine ,
1002 Health Sciences Road East , Irvine , CA 92617 , USA
Division of Facial Plastic Surgery,
The Department of Otolaryngology – Head and Neck
Surgery -5386 , The University of California Irvine ,
19182 Jamboree Road , Irvine , CA 92617 , USA
e-mail: bjwong@uci.edu
Fig. 42.1 Caudal septal extension graft (CSEG) is placed
at the caudal margin of the septum either in overlapping or
end-to-end con fi guration

668
L.L. Chiu-Collins et al.
The term “caudal septal extension” was initially
used to describe a maneuver performed in subtotal
septectomy and reconstruction. In the description
of this procedure, the reconstructed L-strut was
designed with additional dorsal length, which
allowed the strut to sit further caudally than the
position of the native caudal septal margin. The
medial crura were then sutured to the new caudal
margin, in fl uencing nasal tip position and stability,
as well as the shape of the columella via a tongue-
in-groove approach [ 3 ] . Later, it was described
that patients with a retracted columella could also
bene fi t from caudal septal lengthening. Similar to
the earlier descriptions of caudal septal extension
grafting, the medial crura were also secured to the
extension graft for improved stability of the tip and
columella [ 4 ] . These methods recapitulate the
“tongue-in-groove” method while offering addi-
tional structural advantages. Pure “tongue-in-
groove” approaches that simply secure medial
crura to the caudal septum are powerful methods
to stabilize the nasal tip, but must be exercised
with caution as overrotation is a common outcome
if the patient has inadequate native caudal septum;
therein lies the utility of the CSEG.
42.2
Advantages and
Disadvantages
In open structure rhinoplasty, CSEGs are being
more widely used, replacing traditional columellar
strut graft techniques. CSEGs have several advan-
tages over this classic approach. Traditional colu-
mellar struts are free fl oating and limited in the
degree of projection that can be achieved. Columellar
struts rely upon the use of shield- and cap-type
grafts to increase projection or require a lengthy
graft that is either resting on or sutured to the nasal
spine. In contrast, CSEG’s allow the surgeon to use
the native domes to de fi ne the tip by securing the tip
complex to an extended portion of the septum.
CSEGs can be used to alter nasal length, pro-
jection, supratip break, tip rotation, columella
shape, infratip lobule position, and nasolabial
angle, all independent of each other [ 5, 6 ] . The
surgeon has the freedom to adjust a structural
feature as an isolated element. The graft size and
shape are then customized to achieve the speci fi c
goals of the surgeon and patient.
A limitation of the CSEG method is nasal tip
stiffness and decreased compliance in compari-
son to traditional fl oating columellar strut meth-
ods. The patient must be informed of this prior to
surgery. There is a technical learning curve when
using this method, as all of the aforementioned
features of the nasal tip on lateral view change
and surgery requires intraoperative analysis and
reanalysis to ensure an appropriate outcome. This
approach may require the repeated placement
and replacement of the CSEG along with attach-
ment and reattachment of the medial crura to
assess outcomes. Intraoperative analysis is imper-
ative—if the CSEG is not carefully planned, there
is risk of excessive columellar show or blunting
of the columella with absence of the “double
break” curvature. Depending upon the speci fi c
application and need for projection and counter-
rotation, inadequate cartilage may necessitate the
use of conchal or costal cartilage.
42.3
Indications and
Contraindications
In open structure rhinoplasty, a CSEG should be
considered in cases where signi fi cant changes in
nasal tip projection are needed, particularly where
length must be increased while rotation is pre-
served. This is a particularly powerful technique
in patients with severe nasal tip ptosis or in platyr-
rhine noses such those encountered in Latin or
Asian patients. In cases of signi fi cant caudal
septal cartilage excess, the more straightforward
tongue-in-groove approach can be used. CSEGs
are also valuable in circumstances where postop-
erative loss of projection may occur due to con-
traction and wound healing such as in revision
rhinoplasty operations.
The role of the CSEG in a patient with cephali-
cally oriented lower lateral cartilage should be dis-
cussed here. In these patients, if the CSEG is used
to lengthen the dorsum or counterrotate the nose,
there is a risk of creating weakness in the soft tri-
angle region and a potential “parenthesis sign”
deformity. Alternatively, if rotation or reduction of

669
42 Caudal Septal Extension Grafts
nasal length is required, then CSEGs or the tongue-
in-groove technique will result in improvement of
the lower lateral cartilage cephalic orientation.
Finally, the external valve must be evaluated as
part of the rhinoplasty process if a CSEG is antici-
pated for use. CSEGs, when overlapping the native
septum, may signi fi cantly reduce the area of the
nasal aperture at the external nasal valve, and this
would also be a contraindication to use.
42.4
General Surgical Technique
The basic surgical technique of CSEG placement
remains the same regardless of the effect desired.
The cartilage can be harvested from the nasal
septum (ideal), the conchal bowl, or costal mar-
gin. Use of conchal cartilage must be exercised
with caution as these grafts may be curved or
lack adequate mechanical stability in many
cases. The graft will typically be shaped and
sized prior to implantation, but then precisely
modi fi ed in situ. Classically, caudal septal exten-
sion grafting is performed during open rhino-
plasty after separating the nasal domes from one
another, dividing intervening soft tissue and
exposing the septal cartilage by elevating the
mucoperichondrial fl aps on either side down to
the posterior septal angle. If necessary, wider
exposure of the nasal septum can be achieved by
separating the upper lateral cartilages from the
dorsal septum.
The graft is most often partially overlapped
with the caudal margin of the nasal septum and
sutured into place with multiple mattress sutures
in a manner that allows the caudal margin of the
graft to lie in the midline (Fig. 42.2 ) [ 4, 6 ] . In
most applications, the graft is overlapped with
the native caudal septum and held in position
using 25- or 27-gauge hypodermic needles
before suturing into place (Fig. 42.3 ). Suture
selection remains controversial, though the
senior author uses either absorbable or perma-
nent sutures depending on the degree of load
a
b
Fig. 42.2 Grafts are secured in ( a ) an overlapping fash-
ion with multiple sutures to counter gravity and fl exure
or ( b ) an end-to-end fashion secured either with small
buttress grafts or extended spreaders. Suture material can
be absorbable or permanent depending upon long-term
forces acting on the graft

670
L.L. Chiu-Collins et al.
bearing anticipated. In either case, at least three
sutures are used to secure the graft in position.
The CSEG is particularly valuable in cases where
the native caudal septum is deviated off the mid-
line; in this situation, the graft is positioned to
correct this deformity. In cases where this over-
lap creates a caudal deviation at the tip or colu-
mella, the cephalic portion of the graft can be
trimmed or the graft itself can be placed in an
end-to-end con fi guration with the caudal septum
with thin splinting grafts or extended spreader
grafts placed to reinforce the extension graft on
its lateral aspects (Fig. 42.2 ) [ 6 ] . PDS plates can
be used as well, but these are discussed elsewhere
in this volume. Of note, when securing the CSEG
to the septum in an overlapping manner, atten-
tion must be paid to the external valve, as graft
placement may potentially narrow the nasal aper-
ture in this area. Likewise, when the graft
signi fi cantly projects the nose, the downward
forces on the tip generated after closure of the
skin soft tissue envelope may lead to buckling or
torsional deformation of the graft and caudal
septum. In these circumstances, one should con-
sider securing both the graft and the posterior
septal angle to the nasal spine and using a CSEG
that extends to the spine as well.
Once the CSEG is in place, the medial crura
are sutured to the caudal margin of the graft in a
tongue-in-groove fashion in order to stabilize the
tip and control its position along with the degree
of columellar show and infratip lobule shape
(Fig. 42.3 ) [ 7, 8 ] . Alternatively, the medial crura
may be suspended from the caudal end of the
graft, in an end-to-end manner, using fi gure-of-
eight sutures as well, though this is less com-
monly performed and the fi xation less secure and
may be prone to “cheese wiring” if the tip is
excessively mechanically loaded. Once the
medial crura are secured to the CSEG, domal
geometry is reestablished using conventional
suture techniques. When executed properly, tip
and shields grafts are not required as the native
domal cartilages are sutured to create an aestheti-
cally contoured tip. Modi fi cation of lower lateral
cartilage shape is performed as in conventional
rhinoplasty.
The size and shape of the CSEG, as well as
the position in which the medial crura are
attached to the graft will determine the desired
effect on nasal shape. This grafting technique
can be used to increase nasal tip projection, rota-
tion, or counterrotation. It can also be used to
lengthen the nose, increase or decrease columel-
lar show, and control the shape and curvature of
the columella and infratip lobule, or simply to
add stability to the nasal tip. Figure 42.4 is a
montage that illustrates four common CSEG
designs that (a) project and lengthen the nose
without rotation, (b) rotate and lengthen with
counter rotation, (c) purely rotate the nose and
stabilize the tip, and (d) create a stable shape for
the infratip lobule while lengthening and rotating
the nose. These graft designs will be discussed in
detail below.
a
b
Fig. 42.3 ( a ) CSEG stabilized with 25-g hypodermic
needles. Use of a large graft creates signi fi cant projection
as well as control of the columella shape. ( b ) The medial
crura are secured to the CSEG, and dome sutures recon-
struct the tip

671
42 Caudal Septal Extension Grafts
a
b
c
d
Fig. 42.4 CSEG designs that ( a ) Project and lengthen
the nose without rotation. ( b ) Project and lengthen with
counterrotation. ( c ) Purely rotate the nose and stabilize
the tip. ( d ) Create a stable shape for the infratip lobule
while lengthening, projecting, and counterrotating the
nose

672
L.L. Chiu-Collins et al.
42.5
Applications
42.5.1 Changing Nasal Tip Projection
In patients with a deprojected nasal tip, the medial
crura can be sutured along the nasal septum in a
more anterior position in order to further project
the tip, provided excess caudal septum exists
(simple tongue-in-groove technique). However,
this anatomy is relatively uncommon, particu-
larly in the revision rhinoplasty patient. If there is
a paucity of septal cartilage in either the anterior
or caudal dimensions, the septum can be extended
with a CSEG so that the medial crura can be
secured in a position that adequately projects the
nasal tip without causing columella retraction or
unwanted rotation of the tip (Fig. 42.4 ).
Figure 42.5 illustrates the use of a CSEG to
largely correct projection with little or no change
to tip rotation. This patient had three previous
rhinoplasty operations, and in addition to CSEG
placement, a gently morselized thin auricular car-
tilage graft was along the dorsum. Septal perfora-
tion repair was performed, and spreader grafts
were placed at the same time. Based on the shape
of the caudal septal extension graft and the posi-
tion of the medial crura attachment, nasal tip pro-
jection can be increased independently or in
conjunction with rotation or counterrotation of
the tip, lengthening or shortening the nose, or
increasing or decreasing columellar show. Sutures
are placed at discrete points of the overlap
between the medial crura and CSEG in order to
further control the appearance of the columella
on lateral view. The ability to place these multiple
sutures allows precise control over the extent of
columellar show and appearance of the infratip
lobule on lateral view. The CSEG can be modi fi ed
to increase fullness of the infratip lobule as well
(Fig. 42.4 ) and facilitate the creation of a soft
double break, rather than a straight line from sub-
nasale to tip.
In order to increase tip projection without
altering other aspects of the nasal tip (e.g., rota-
tion), a CSEG should be designed with its caudal
margin roughly parallel to that of the caudal sep-
tum and its cephalocaudal distance just wide
enough to extend past the cephalic margin of the
paired medial crura without passing their caudal
margin. One uses this graft to create a tongue-in-
groove approximation. The caudal margin of the
graft is fashioned to shape the columella on lat-
eral view. This graft is somewhat rectangular in
shape [ 6 ] . The amount of anterior extension of
the graft and the amount of anterior advancement
of the medial crura on to the graft will determine
the degree of the additional projection achieved.
The “new” anterior septal angle created by the
CSEG is the key surgical landmark, and it is
important to design the graft such that this point
is at or near the point where the desired nasal tip
will reside. Inadequate extension (position of the
“new” anterior septal angle) is common when
fi rst using this technique and is readily evident
upon attachment of the medial crura and dome
suturing. In this circumstance, the sutures need to
be removed and graft repositioned.
If deprojection alone is desired (without nasal
lengthening), CSEGs are seldom used. However,
if the caudal margin of the native septum does not
approximate the medial crura and the medial
crura need to be positioned further posterior to
achieve deprojection, then a CSEG may be nec-
essary. The graft design would be rectangular in
shape, similar to those used to increase projec-
tion, without signi fi cant anterior extension of the
graft.
42.5.2 Changing Nasal Tip Rotation
The caudal septal extension graft can be a power-
ful tool to control rotation of the nasal tip, while
independently controlling projection. Reliable
independent control of rotation and projection is
lacking in conventional columellar strut tech-
niques when combined with lateral crural steals
even with the use of shield and cap grafting.
Nasal tip rotation is largely assessed by the naso-
labial angle, and as such, changing this angle is
achieved by changing (1) the cephalocaudal
dimension of either the posterior columella—
moving the pedestal of the columella more toward
or away from the posterior septal angle—or (2)
the position of the nasal tip at the area of the
intermediate crura.

673
42 Caudal Septal Extension Grafts
a
b
c
d
Fig. 42.5 ( a ) Preoperative patient with three previous rhinoplasty operations. ( b ) Postoperative after CSEG to correct
projection with little or no change to tip rotation

674
L.L. Chiu-Collins et al.
Simply rotating the tip more cephalically will
shorten nasal length. Conversely, if the tip area is
counterrotated into a more caudal position, then
overall nasal length will be increased. The rela-
tive position of the subnasale can be controlled
with this technique as well (Fig. 42.4 ), as it may
be positioned more anteriorly or posteriorly,
depending upon the shape of the CSEG. It is
important to remember that if subnasale posi-
tion—the dimension at the columellar pedestal—
is changed, this will have an inverse effect on the
apparent length of the upper lip. Caudal septal
extension grafts can be designed to address these
speci fi c areas in the columella-tip complex that
will achieve the desired effect on tip rotation.
In order to increase tip rotation with a CSEG,
the graft must be fashioned in a manner in which
the graft tapers to become more cephalad at its
anterior aspect—in other words more triangular
with the apex pointing skyward (Fig. 42.4 ). This
can be achieved either by (1) designing the graft
to be wider in a cephalocaudal dimension at its
posterior aspect (near posterior septal angle)
and narrower as it approaches the nasal tip or
(2) simply controlling the degree of overlap
between the graft on the caudal septum so that
its anterior aspect is positioned more cephali-
cally than its posterior aspect (preferred by
senior author) [ 2 ] . The key point again is deter-
mining the locus of the new anterior septal angle
which is almost always more anterior and cau-
dal than one initially anticipates. It is more pru-
dent to create excess cartilage in the CSEG
which can be precisely trimmed when the
medial crura are attached and domal sutures
applied. In cases where the posterior columella
is positioned too far cephalically causing an
acute nasolabial angle, the extension graft can
be designed with excess posterior caudal exten-
sion in order to position the posterior columella
more inferior and increase the nasolabial angle
and tip rotation. Figure 42.6 illustrates the use
of a large CSEG that creates a much more pro-
jected and rotated nasal tip; no hump reduction
surgery was performed in this primary rhino-
plasty patient. The images of the CSEG for this
patient are in Fig. 42.3 [ 6 ] . When cartilage tis-
sue availability is inadequate for the creation of
a CSEG along the entire border of the native
caudal septum, plumping grafts can be placed
along the spine.
Counterrotation of the nasal tip is accom-
plished by designing grafts in a manner opposite
of those used to rotate the tip (Fig. 42.4 ); obvi-
ously, such grafts also lengthen and project the
nose at the tip area. As such, this calls for grafts
that are wider at their anterior aspect (i.e., near
new anterior septal angle) so that the medial crura
can be repositioned more caudally. If the nasola-
bial angle is overly obtuse, the medial crura may
need to be repositioned so their footplates lie
more cephalically. Typically, this can be done
with a tongue-in-groove maneuver by suturing
the medial crura to the caudal septum. If there is
a de fi ciency of caudal septum, however, an exten-
sion graft may be needed to allow fi xation of the
medial crura without causing columella retrac-
tion. In many cases, where the nasolabial angle is
obtuse, however, there is excess cartilage in the
area of the posterior septal angle, making a septal
extension graft unnecessary.
42.6
Lengthening the Nose
Lengthening the nose usually requires reposition-
ing the nasal tip in a more anterior and caudal
position. CSEGs are a powerful means to achieve
this. By moving the nasal tip in this manner, either
rotation or columella show will be affected. As
previously described, a CSEG with an anterior
aspect that is widened in a cephalocaudal dimen-
sion will lengthen the nose as the tip is counter-
rotated. This graft is useful in the short, overrotated
nose. If the degree of rotation is adequate and to
be preserved during nasal lengthening, then the
caudal extension graft will need to be rectangular
in shape to allow the entire medial crura to be
advanced antero-caudally and maintain the naso-
labial angle (Fig. 42.2 ), and sometimes must be of
considerable size (Fig. 42.4 ). Nasal lengthening
will entail stretching of the skin-soft tissue enve-
lope, and the cartilaginous nasal tip-CSEG-septal
complex will have to resist the forces of wound
healing, contraction, and native tissue elasticity.
This is particularly common and challenging in

675
42 Caudal Septal Extension Grafts
a
b
c
d
Fig. 42.6 Aggressive use of CSEG. Primary rhinoplasty patient in whom a large CSEG was used to project and rotate
nasal tip; no hump reduction surgery was performed. ( a ) Preoperative. ( b ) Postoperative

676
L.L. Chiu-Collins et al.
revision rhinoplasty cases. In these circumstances,
the senior author advocates using (1) as large a
CSEG as possible, maximizing overlap with the
native septum; (2) a CSEG that extends to the
nasal spine; and (3) nonabsorbable sutures. A
caveat is that once the skin-soft tissue envelope
has been replaced, the downward forces acting
upon graft may lead to fl exure and buckling.
Hence, it is important to consider the three mea-
sures noted above as well as considering stouter
tissue such as costal cartilage.
The soft tissue envelope may ultimately limit
the extent of grafting that can be performed. If the
nose is to be lengthened or projected dramatically,
the skin and subcutaneous tissue may not stretch
enough to accommodate a large caudal septal
extension graft. In these cases, the surgeon may
be forced to settle for less length and projection
than what is ideal. In cases of chronically infected
or severely retracted skin and soft tissue, the
patient may even require soft tissue reconstruc-
tion to achieve the desired outcome. Because of
this, patients should be counseled with respect to
these potential limitations prior to surgery.
Figure 42.7 illustrates a secondary rhinoplasty
patient who had resection of the anterior septal
angle. The objective of surgery was to lengthen
the dorsum without altering signi fi cantly nasal tip
rotation. In this case, a columella strut would not
have achieved this objective and, potentially, its
placement would increase columellar show. A
CSEG was placed to position the nasal tip de fi ning
point as well as create a softer contour along the
infratip lobule. An extremely conservative carti-
laginous hump reduction was performed along
with spreader graft placement. The nasal tip was
created using dome suture techniques alone.
As with all CSEG applications, columellar
show and infratip lobule structure will change in
noses requiring this maneuver, so care must be
taken when attaching sutures between the medial
crura and the CSEG. It is extremely important to
perform rigorous intraoperative analyses of the
columellar pro fi le in these instances.
42.7
Summary of Advantages
CSEGs provide the rhinoplasty surgeon with inde-
pendent control of nasal tip projection and rota-
tion with very stable long-term results due to the
fi xation of the lower alar cartilage to the nasal sep-
tum. These grafts resist the downward pull created
by contraction of the skin-soft tissue envelope
over time. Unlike classic columellar strut methods
or lateral crural steal techniques, projection and
rotation can be controlled independent of one
another. Likewise, judicious selection of suture
points and graft design allows for establishment
of the ideal contour for the infratip lobule and
nasal labial angle. One powerful application is
that a retrused or de fi cient columella can easily be
corrected. Tip position is determined by where the
medial crura are attached to the CSEG using a
tongue-in-groove-type technique. Conventional
domal sutures are used to reestablish tip shape and
reduce the need for shield or cap grafts.

677
42 Caudal Septal Extension Grafts
a
b
c
d
Fig. 42.7 Subtle use of CSEG in secondary rhinoplasty
patient who had previous resection of the anterior septal
angle (performed elsewhere). The objective of surgery
was to lengthen the dorsum without altering signi fi cantly
nasal tip rotation. ( a ) Preoperative. ( b ) Postoperative

678
L.L. Chiu-Collins et al.
References
1. Dibbell DG (1976) A cartilaginous columellar strut in
cleft lip rhinoplasties. Br J Plast Surg 29(3):247–250
2. Tebbetts JB (1994) Shaping and positioning the nasal
tip without structural disruption: a new, systematic
approach. Plast Reconstr Surg 94(1):61–77
3. Toriumi DM (1994) Subtotal reconstruction of the
nasal septum: a preliminary report. Laryngoscope
104(7):906–913
4. Toriumi DM (1995) Caudal septal extension graft for
correction of the retracted columella. Oper Tech
Otolaryngol Head Neck Surg 6(4):311–318
5. Byrd HS, Andochick S, Copit S, Walton KG (1997)
Septal extension grafts: a method of controlling tip pro-
jection shape. Plast Reconstr Surg 100(4):999–1010
6. Toriumi DM (2006) New concepts in nasal tip contour-
ing. Arch Facial Plast Surg 8(3):156–185
7. Kridel RW, Scott BA, Foda HM (1999) The tongue-in-
groove technique in septorhinoplasty. A 10-year expe-
rience. Arch Facial Plast Surg 1(4):246–256; discussion
257–258
8. Toriumi DM (2005) Structure approach in rhinoplasty.
Facial Plast Surg Clin North Am 13(1):93–113

679
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_43, © Springer-Verlag Berlin Heidelberg 2013
43
43.1
Introduction
With the exception of the congenitally deviated
nose, as that associated with cleft lip, all the devi-
ated noses are traumatic in origin whether fol-
lowing external trauma or failed rhinoplastic
procedures.
Due to the intimate relationship of the bony
cartilaginous framework of the nose, the effects
of the fractured nasal bones may extend to involve
the nasal septum, the upper lateral cartilages, and
even the alar cartilages. For successful correction
of the deviated nose, all the anatomic components
involved in the deformity should be adequately
recognized and surgically realigned.
With the evolution of modern rhinoplasty,
many pioneer surgeons recognized that success-
ful correction of the deviated noses requires com-
bining septal and rhinoplastic surgery because
the mobilized external nasal pyramid usually
heals along the septal axis. Since then, the one-
stage septorhinoplasty became the standard line
of management for the deviated noses [ 1– 9 ] .
Apart from the cosmetic sequelae of the
deviated nose, most of these cases suffer of
variable degrees of nasal obstruction. However,
even in the absence of functional problems,
septal surgery may still be indicated to correct
minor septal deviations that may interfere with
the proper alignment of the external nasal pyra-
mid. In the current study, a graduated surgical
approach is presented for the correction of sep-
tal deviations associated with the externally
deviated nose.
43.2
Preoperative Evaluation
During the initial consultation, the patient has to
understand the complex nature of the crooked
nose deformity and the technical challenges and
limitations associated with its surgical repair and
that a perfectly straight nose may not be possible
to achieve in every case. Each patient should be
subjected to:
1. Full history taking, stressing on history of
nasal trauma, obstruction, and previous nasal
surgeries.
2. External facial evaluation to exclude any con-
genital malformations or facial asymmetries.
3. External nasal evaluation; the deviations are
classi fi ed according to the level of deformity
into bony, cartilaginous, or mixed. Additional
evaluation includes the type of nasal skin,
level of nasal dorsum, width of nasal bridge,
and any tip or nostril asymmetry.
Septal Surgery in the Crooked Nose
Hossam M. T. Foda
H. M. T. Foda , M.D.
Facial Plastic Surgery Division,
Otolaryngology Department ,
Alexandria Medical School ,
Alexandria , Egypt
P.O. Box 372 , Sidi Gaber, Alexandria , Egypt
e-mail: hfoda@dataxprs.com.eg

680
H.M.T. Foda
4. Internal nasal evaluation including a thorough
evaluation of nasal septum, nasal valve areas,
turbinates, and nasal mucosa.
5. Photographic documentation of external nose
using the standard rhinoplasty views as well
as endoscopic photography of any intranasal
pathology.
Postoperative follow-up with periodic clinical
examination and photographic documentation is
mandatory to evaluate the aesthetic and func-
tional outcome of the performed procedure.
43.3
Surgical Technique
With the patient under general anesthesia, the
nasal septum and the external nose are in fi ltrated
with 1% xylocaine with 1/100,000 units of epi-
nephrine. Time is allowed for the vasoconstric-
tive effect of the in fi ltration solution to take
place after which a #15 blade is used to perform
a left hemitrans fi xion incision placed directly
on the caudal edge of the septal cartilage.
A Cottle elevator is used to undermine the left
septal fl ap, in a strict submucoperichondrial
plane while leaving the right fl ap adherent to
the septum. Using sharp dissection, the fl ap
elevation is continued down the maxillary crest
and the nasal fl oor. The septal cartilage is then
fully mobilized, starting along the fl oor by dis-
articulating it from the maxillary crest, as well
as posteriorly by removing a triangular piece of
cartilage at its junction with the bony septum.
The septal fl ap elevation is continued on both
sides of the bony septum, and Becker double-
action scissors is used to take down any bony
deviations of perpendicular plate of ethmoid
or vomerine spurs that may interfere with the
medialization of nasal bone after osteotomies.
In cases where the bony septum is found to be
exceptionally thick, secondary to compound
fractures with overlap of fractured segments, a
Caplan double-action scissors is used to excise
the thickened portions of the bony septum.
Any deviated parts of septal cartilage are care-
fully removed using a Cottle elevator taking care
to preserve the integrity of the contralateral fl ap.
Excisions are limited to the central part of the
cartilage making sure to preserve a minimum of
1 cm intact strut dorsally as well as caudally to
maintain the nasal dorsal and tip support.
Finally, the intact L-shaped strut of septal car-
tilage is allowed to swing back to the midline and
the areas of resected bone and cartilage are
reskeletonized using crushed septal cartilage.
The hemitrans fi xion incision is closed using
interrupted 5/0 plain gut sutures and the fl aps are
mattressed together using 4/0 chromic catgut, in
a running fashion, to stabilize the septal segments
and to eliminate any dead space thus preventing
hematoma formation and minimizing the need
for intranasal packing, which was limited to a
light pack made of Telfa sheets soaked in
Gentamycin cream.
43.3.1 Dorsal Septal Deviation
The external rhinoplasty approach provides an
excellent access for evaluation and correction of
dorsal septal deviations. The dorsal septal carti-
lage is exposed by separating it from the upper
lateral cartilages; this separation is done without
opening the underlying mucosa. To correct the
dorsal cartilaginous deviation, a graduated 4-step
approach is adopted; the fi rst step is to remove a
triangle of cartilage posteriorly at its junction
with the bony septum (Fig. 43.1 ); the apex of the
triangle should be at least 0.5 cm below the dor-
sal line to keep enough support to the cartilagi-
nous dorsum. The second step is to straighten the
deviated dorsal septal cartilage by performing a
series of vertical partial-thickness cartilaginous
incisions on the concave side of the septum
(Fig. 43.1 ). In some cases, where the cartilage is
found to be thick or duplicated, one or two of the
partial-thickness incisions are transformed into
full-thickness incisions in order to break the
spring action of the thickened cartilage.
The third step, after freeing and straightening
of the septal cartilage, is to splint the scored car-
tilage with a piece of fl at bone (5–6 mm by
2–2.5 cm) from the ethmoidal plate (Fig. 43.1 );
this splinting graft is sutured using 5/0 PDS
sutures in a horizontal mattress fashion. The
fourth step is to consider the need for spreader

681
43 Septal Surgery in the Crooked Nose
cartilage grafts [ 10 ] , which is based on the evalu-
ation of the relationship of the upper lateral carti-
lages to the septum. According to such assessment,
you may need to use a unilateral spreader graft on
the concave side or bilateral spreaders grafts of
different thickness in order to correct the middle
third asymmetry.
In cases where the upper lateral cartilage and
the nasal bone on the same side are both depressed,
an extended spreader graft [ 11 ] (Fig. 43.1 ) is used
with its upper end wedged between the septum
and the nasal bone after performing a medial
osteotomy. The upper end of the extended
spreader graft is beveled according to the amount
of nasal bone lateralization required.
43.3.2 Caudal Septal Deviation
Deviations of anterior part of the septal cartilage
may lead to de fl ection of caudal margin of the
septum from the midline and its prolapse into one
Fig. 43.1 Schematic diagram for the correction of dorsal
and caudal septal deviations. ( a ) The cartilaginous septum
showing dorsal and caudal deviations. ( b ) Freeing the sep-
tal cartilage cephalically, by removing a triangular piece
at its junction with the perpendicular plate of ethmoid,
and ventrally, by removing the prolapsed cartilage on the
side of the maxillary crest, the mobilized cartilage is then
brought to the midline and fi xed by suturing it to the ante-
rior nasal spine. ( c ) Straightening of the dorsally deviated
cartilage by a series of partial-thickness incisions fol-
lowed by splinting it by a bone graft. ( d ) Using a beveled
extended spreader graft that extends into the bony cut of
the medial osteotomy to lateralize the upper lateral carti-
lage and the nasal bone on the left side

682
H.M.T. Foda
of the nostrils resulting in asymmetry of the nasal
base. The fi rst step toward correction is the full
mobilization of the caudal septum by freeing it
both ventrally and cephalically. Ventrally, the
cartilage is found to be dislocated off the maxil-
lary crest; trimming of the overhanging part of
cartilage will decrease the vertical height of the
septum thus allowing its replacement into the
maxillary groove and fi xing it ventrally using a
fi gure-of-eight permanent suture [ 9 ] between the
cartilage and the anterior nasal spine (Fig. 43.1 ).
Cephalically, a vertical cut is performed to sepa-
rate the deviated caudal segment from the poste-
rior part of the septal cartilage. The cut is made
through the full thickness of the cartilage starting
at the maxillary crest, proceeding upward to stop,
at least 5 mm, short of the dorsal margin. In cases
with fractured nasal septum leading to sharp
angulation of the caudal segment, cephalic sepa-
ration is completed by performing a wedge exci-
sion of the fracture line. After suture fi xation of
caudal septum to the anterior nasal spine, it is not
uncommon for the dorsal part of the caudal sep-
tum, at anterior septal angle, to show some resid-
ual deviation which may lead to de fl ection of
nasal tip. This is corrected by scoring of the car-
tilage and splinting it with a piece of thin fl at
bone (4–5 mm by 1.5–2 cm) from the perpen-
dicular plate of ethmoid (Fig. 43.1 ). This bone is
sutured with 5/0 PDS mattress sutures after per-
forating it using a #11 blade, in a rotary fashion.
If bone thickness is over 1 mm, a drill with a fi ne
diamond fraise is used to thin out the bone graft
and drill in the suture holes.
Finally, after the dorsal and ventral fi xation is
completed, the free margin of the caudal septum,
which is now in the midline, is fi xed to the medial
crura in a tongue-in-groove fashion [ 12 ] .
In some complex caudal septal deviations, the
caudal septal cartilage is found to be severely devi-
ated and fractured with the fracture line extending
to its caudal edge; in such cases, the whole caudal
segment is excised and replaced by a caudal sep-
tum replacement graft [ 13 ] which is fi xed to the
medial crura by horizontal mattress sutures.
At completion of the procedure, the external
rhinoplasty incisions are closed in a routine fash-
ion followed by external taping and splinting
using an external metal nasal splint which is
removed after 1 week.
43.4
Results
On reviewing 1,000 patients presenting with
crooked noses, septal surgery was found neces-
sary in 92% of the patients to correct the external
nasal deviations as well as to improve the patients’
breathing. The cause of nasal deviation was
related to a de fi nite history of nasal trauma in
58%, to a previous nasal surgery in 18%, and the
remaining 24% of patients were not able to relate
their nasal deviation to any previous trauma or
surgery. Variable degrees of nasal obstruction
were present in 72% of the patients; this was
mainly due to deviated nasal septum (84%), nasal
valve problems (56%), inferior turbinate hyper-
trophy (17%), and septal perforations (6%).
As regards the outcome of the surgical proce-
dure, 90% of the patients were satis fi ed with their
aesthetic improvement, while functionally 76%
of the patients, with preoperative nasal obstruc-
tion, reported improved breathing. Revision sur-
gery, to correct minor degrees of residual
deviations, was required in 8% of cases.
43.5
Discussion
External trauma to the nose resulting in fractured
nasal bones usually affects the nasal septum leading
to fractures, deviations, or dislocations. However, in
the course of emergency treatment of the fractured
nose, the septal pathologies are usually neglected
which may result in incomplete correction or recur-
rence of the external nasal deviation.
Septal surgery was necessary in 92% of the
patients with deviated noses, not only to improve
breathing but also to achieve an aesthetically pleas-
ing straight nose. The commonest septal deviations,
to affect nasal symmetry, are those involving the
dorsal (Figs. 43.2 , 43.3 , and 43.4 ) and caudal parts
(Figs. 43.5 , 43.6 , and 43.7 ) of the cartilaginous sep-
tum. As compared to central septal deviations,
which can be safely excised, any excisions involv-
ing the dorsal or caudal segments will directly

683
43 Septal Surgery in the Crooked Nose
Fig. 43.2 ( Left ) Preoperative patient with severe dorsal
and caudal septal deviations. ( Right ) One year postopera-
tive after straightening the septum using a unilateral
spreader graft on the right side. Medial and lateral osteot-
omies were performed
Fig. 43.3 ( Left ) Preoperative patient with severe right
caudal septal deviation with a major shift of the anterior
septal angle and nasal tip from the midline. ( Right )
Eighteen months postoperative following correction of
the caudal deviation. No osteotomies were performed

684
H.M.T. Foda
Fig. 43.4 ( Left ) Preoperative patient with a left caudal
dislocation causing tip de fl ection, nostril asymmetry, and
a hanging columella with vestibular deformity. ( Right )
Three years postoperative after correction of the caudal
dislocation, tongue-in-groove technique [ 12 ] , and trim-
ming of membranous septum on left side. Additional
maneuvers included hump reduction and osteotomies
affect the shape of the external nose due to weaken-
ing of dorsal and/or tip support. Mobilization and
straightening of the dorsal and caudal cartilaginous
septum may be technically dif fi cult to the extent
that some authors [ 14– 18 ] recommended radical
excision of the entire septal cartilage and its rein-
sertion, after correction of its deviation. However,
these techniques are associated with some prob-
lems in stabilizing the reinserted cartilage and in
realignment of the nasal dorsum.
It is strongly believed that if the cartilage can
be straightened outside the nose, it can also be
straightened in situ without compromising its
structural role in dorsal and tip support. This was
greatly facilitated by using the external rhino-
plasty approach [ 19– 21 ] which provides an excel-
lent exposure of the dorsal and caudal parts of the
nasal septum, allowing the most complex
corrective maneuvers to be conducted with ease
under direct vision [ 11, 22– 27 ] .

685
43 Septal Surgery in the Crooked Nose
Additionally, in revision cases [ 28 ] where
variable amounts of the bony cartilaginous sep-
tum have been previously excised, the external
approach provided a safe access to the nasal sep-
tum. In such cases, the whole septum is carefully
instrument palpated, to map-out the areas of pre-
viously excised bones and/or cartilage, before
attempting any septal fl ap elevation. In most
of our revision cases, previous septal excisions
were found to be limited to the central part of the
nasal septum; thus, no septal fl ap elevation was
performed centrally to avoid septal perforations,
but alternatively a ventral tunnel is performed by
elevating the mucoperiosteum of the vestibular
fl oor and maxillary crest to provide access to the
bony septum; meanwhile, the remaining dorsal
part of the septum was accessed through the rou-
tine external approach.
In the current technique, the fi rst step toward
correction of septal deviations associated with
the crooked nose was to fully mobilize the devi-
ated septal cartilage from all extrinsic deforming
Fig. 43.5 ( Left ) Preoperative patient with a severe
C-shaped dorsal septal deviation with prolapsed right nasal
bone and left caudal dislocation deforming the columellar
base. ( Right ) Two years postoperative after correcting the
caudal dislocation and the dorsal septal deviation using an
extended spreader graft on the right side to lateralize the
right nasal bone and upper lateral cartilage. Additional
maneuvers included osteotomies, lateral crural steal [ 6 ] ,
and a columellar strut to increase tip projection and
rotation

686
H.M.T. Foda
forces of the deviated nasal bones, upper and
lower lateral cartilages, as well as of the bony
septum [ 11, 29 ] . After freeing the septal carti-
lage, it was straightened by weakening it and
breaking its spring action, and fi nally fi xing it in
the midline. For fi xation, different methods were
suggested by many authors. Gunter and Rohrich
[ 30 ] used silicon intranasal extramucosal septal
splints; later, Ramirez and Pozner [ 31 ] described
using internal cartilage splints to avoid the dis-
comfort and possible complications associated
with the long-term use of the silicone septal
splints. Byrd et al. [ 32 ] depended on control
sutures and spreader extension grafts for fi xation,
while Guyuron et al. [ 33 ] used a combination of
extramucosal septal splints and spreader grafts.
In the current study, the bony splinting grafts
were found to be an excellent alternative for
fi xation, as the thin fl at bone of the ethmoidal
plate provides rigid, permanent, internal stenting
of the septal cartilage, thus allowing it to heal in
the corrected position, and prevents any cartilage
deformation by contracture forces of the healing
phase. The fi xation of the bony splinting grafts is
done 5 mms below and parallel to the dorsal
edge of the septal cartilage to allow restoring the
normal relationship between the upper lateral
cartilages and the dorsal septum. The second
advantage of the low fi xation of the splinting
grafts is in cases where spreader grafts are
needed, as that leaves an adequate space above
the splinting graft for the placement and fi xation
of the spreader graft. The regular spreader grafts
were helpful in cases needing lateralization of
the upper lateral cartilage (Figs. 43.3 and 43.5 );
meanwhile, an extended spreader graft was used
in cases that needed lateralization of both the
upper lateral cartilage and the nasal bones on the
same side (Figs. 43.2 and 43.4 ).
In the current study, 76% of the patients with
preoperative nasal obstruction reported an improve-
ment in breathing which was mainly due to the
Fig. 43.6 ( Left ) Preoperative patient with right-sided dorsal septal deviation. ( Right ) Postoperative following correc-
tion of the dorsal septal deviation and using a spreader graft on the left side. No osteotomies were performed

687
43 Septal Surgery in the Crooked Nose
Fig. 43.7 ( Left ) Preoperative patient with a right-sided
bony cartilaginous deviation. ( Right ) One year postopera-
tive after correcting the dorsal septal deviation and using an
extended spreader graft on the left side. Additional maneu-
vers included hump reduction, osteotomies, and tongue-in-
groove technique [ 12 ] to correct the hanging columella
straightening of the nasal septum and widening of
the nasal valve areas by using spreader grafts; other
functional procedures, which were performed less
commonly, included inferior turbinoplasty [ 24 ]
and septal perforation repair [ 22, 27 ] .
In 8% of the cases, revision surgery was nec-
essary; this was due to partial recurrence of cau-
dal septal deviation which happened in 20% of
our earlier cases in whom the ventral fi xation to
the maxillary crest was done using Vicryl sutures.
This incidence was later reduced to only 3% after
using 4/0 PDS sutures. Other causes of revision
were inadequate medialization of the nasal bones
on one side or presence of dorsal irregularities.
Despite the large number of surgical tech-
niques described, a stable long-term correction of
the severely deviated nose remains a dif fi cult
problem. It is our strong belief that the key for
reliable and stable outcome is to completely
mobilize and straighten the nasal septum without
compromising its pivotal role in supporting the
external nose.
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DOI 10.1007/978-3-642-28053-5_44, © Springer-Verlag Berlin Heidelberg 2013
44
44.1
Background
Correction of the residual nasal deformity remain-
ing after unilateral cleft lip and nasal reconstruc-
tion can be a formidable challenge. For more than
a century, surgeons have tested their intellectual
and technical skills against the seemingly unsolv-
able problem of de fi nitively correcting the mis-
shapen cleft nose in a reliable, reproducible, and
consistent manner. The sheer number of tech-
niques devised by others in attempts to rise
against the challenge [ 1 ] serves as a testament to
both the dif fi cultly of this task and the limitation
of our collective abilities to provide a dependable
surgical solution to this problem. Correction of
the residual cleft lip nasal deformity remains one
of the more dif fi cult reconstructive and aesthetic
challenges in rhinoplasty.
44.2
The Anatomy of the Cleft
Nasal Deformity
Critical to the surgical management of the residual
unilateral cleft lip nasal deformity is a thorough
understanding of the aberrant nasal anatomy as
well as the causal forces that lead to the nasal
deformity itself. For the purposes of this chapter,
the anatomy described will be that of the complete
unilateral cleft lip deformity, meaning a complete
cleft of the upper lip and primary palate.
The primary force leading to unilateral cleft lip
nasal deformity is displacement of the greater and
lesser segments of the alveolus. In the unaffected
patient, the alveolus of the upper jaw is intact and
a standard “U” shape is appreciable in the upper
jaw when viewed from below. In the affected
patient, the cleft (or separation) affects not only
the upper lip but also the alveolus directly behind
the upper lip and the fl oor of the nose. During fetal
and neonatal development, the greater (medial)
segment of the alveolus is rotated anteriorly and
laterally by the protruding movement of the
tongue. The lesser (lateral) segment, in contrast,
collapses posteriorly, as its normal point of stabil-
ity to the remainder of the alveolus has been inter-
rupted. As the alveolus of the upper jaw is the
foundation upon which the nose stands, displace-
ment of the alveolar segments leads to signi fi cant
twisting and perversion of the nasal form much
like pitching a tent on a terraced mountainside.
Displacement of the greater and lesser segments
has a profound effect on the bony and cartilaginous
septum. The extent of septal deviation evident in
Secondary Cleft Rhinoplasty:
Combining an Open Rhinoplasty
with the Dibbell Technique
and Tajima Incision
Roberto L. Flores and Court B. Cutting
R. L. Flores , M.D. ()
Division of Plastic Surgery ,
Indiana University Medical Center ,
705 Riley Hospital Drive, RI 2511 ,
Indianapolis , IN 46202 , USA
e-mail: rl fl ores@iupui.edu
C. B. Cutting , M.D.
Department of Plastic Surgery ,
Langone Medical Center ,
560 First Avenue, TH 169 ,
New York , NY 10016 , USA
e-mail: court.cutting@nyumc.org

690
R.L. Flores and C.B. Cutting
the cleft lip patient far surpasses that seen in the
typical cosmetic rhinoplasty. The anterior aspect
of the septum is typically dislocated from the
anterior nasal spine, and twisting of the anterior
septum can result in signi fi cant deviation of the
nasal tip. The anterior and caudal aspect of the
nasal septum should be separated from its aberrant
attachments to the nasal fl oor and relocated onto
the anterior nasal spine during reconstruction. The
twisting of the septum affects both the cartilagi-
nous as well as the bony septum as far posterior
as the sphenoid. This deviation can lead to severe
airway obstruction that is best relieved by a radical
submucous resection of the bony and cartilaginous
septum. As both the bony and cartilaginous sep-
tum can be signi fi cantly affected, the cartilaginous
and bony vaults are similarly deviated, leading to
twisting of the middle and upper thirds of the nasal
dorsum. Straightening of the dorsum therefore
requires both the bony and cartilaginous vault to
be addressed during reconstruction.
In the lower third of the nose, posterior col-
lapse of the lesser segment of the alveolus leads
to signi fi cant lateralization of the alar base. The
posterior rotation of the lesser alveolar segment
combined with the anterior rotation of the
greater segment leads to downward displace-
ment and rotation of the lower lateral cartilage.
The width of the lower lateral cartilage on the
affected side is increased, and the cartilage
itself tends to be thinner and fl oppier than on
the unaffected side. The aberrant shape and
position of the lower lateral cartilages also
affects the shape of the nasal tip skin. The nasal
tip skin tends to maintain a “memory” of its
original three-dimensional form and can resume
this original three-dimensional shape despite
dramatic changes made in the nasal tip carti-
lages [ 2 ] , a quality that can frustrate the rhino-
plasty surgeon who makes painstaking changes
to the underlying nasal framework.
44.3
Residual Deformities After
Primary Cleft Repair
Primary cleft lip rhinoplasty attempts to correct
the cleft nasal deformity at the time of cleft lip
repair. Although there are several techniques in
current use, the goals of reconstruction are similar
across the various techniques. In general, an
attempt is made to elevate and rotate the depressed
lower lateral cartilage into anatomic position, the
alar base is medialized, and the nostril sill is closed.
Many cleft surgeons close the nasal fl oor defect at
the time of cleft lip repair to aid future alveolar
reconstruction. The vestibular web is also often
addressed by direct excision or suture technique.
Unfortunately, there can be a degree of relapse
or incomplete correction after primary cleft rhi-
noplasty, or (more disappointing) primary rhino-
plasty is not attempted at the time of cleft lip
repair. The lower lateral cartilages remain
depressed and inferiorly rotated, the alar base has
relapsed to a lateral location, and the nostril sill is
closed, but a depression is visible on the nostril
fl oor. The rhinoplasty technique described therein
addresses these three common residual nasal
deformities affecting cleft lip patients.
44.4
General Principles in Cleft
Nasal Reconstruction
Secondary cleft rhinoplasty is ideally performed
after the time of full facial maturity. Midface hyp-
oplasia is a common fi nding, and type III malocclu-
sion should be surgically corrected by orthognathic
surgery prior to consideration for de fi nitive rhino-
plasty. Although this chapter focuses on a speci fi c
technique of lower lateral cartilage repositioning
and skin envelope reshaping, it is critical to the
success of the rhinoplasty to address all areas of
the nose. More speci fi cally, the extreme deviations
of the bony and cartilaginous dorsum commonly
seen in the cleft lip nose should be corrected with
thorough nasal osteotomy techniques and spreader
grafting as needed. Our preference is to address
deviation of the bony dorsum by a monobloc nasal
osteotomy as originally described by Blair [ 3 ] and
later modi fi ed by Cutting [ 4 ] . This procedure is
preceded by a radial submucous resection of the
bony and cartilaginous septum. Removal of the
cartilaginous septum, vomer, and perpendicular
plate as far posterior as the sphenoid also provides
relief to airway obstruction.
Re fi nement and balance of the nasal tip is critical
to any rhinoplasty procedure. In our hands, the most

691
44 Secondary Cleft Open Rhinoplasty: Combining the Dibbell Technique and Tajima Incision
reliable and durable rhinoplasty techniques to cor-
rect secondary cleft nasal tip deformities are based
on anatomic repositioning of the lower lateral carti-
lages. These techniques are the only ones that
attempt to replace the displaced framework of the
nose to an orthotopic position. In cases of a residual
depressed lower lateral cartilage associated with a
lateralized alar base and nostril apex overhang, we
have combined the open rhinoplasty with the
Dibbell technique and Tajima incision with great
success. This technique is often combined with
nasal tip suture techniques, cartilage graft struts,
and onlay grafts. However, the manners by which
these techniques are incorporated into the described
procedure to achieve speci fi c results are beyond the
scope of this chapter.
44.5
The Dibbell Technique
The Dibbell rhinoplasty is a closed rhinoplasty
technique that corrects depression of the lower
lateral cartilages, lateralization of the alar base,
shortening of the columella, and twisting of the
domes [ 5 ] . The technique involves superior and
lateral rotation of the depressed lower lateral car-
tilage and concurrent medialization of the alar
base through the creation of a bipedicle compos-
ite fl ap of lower lateral cartilage, nasal mucosa,
columella, and nostril fl oor. The technique
evolved from prior cleft rhinoplasty procedures,
including Blair [ 6 ] , who separated the lower lat-
eral cartilages and rotated the affected naris via
an incision through the length of the columella
and across the alar base, and later by Berkeley
[ 7 ] , who designed a more extensive incision
extending into the nasal tip skin.
A hemi-circle incision is made on the supe-
rior nostril rim, down the columella on the
affected side, and across the skin of the nasal sill
(Fig. 44.1 ). Another parallel incision is made
within the nose as an intercartilaginous incision
made in continuity with a hemimembranous
septum incision, and an incision inside the nasal
sill but outside the piriform aperture. This
bipedicle composite fl ap of lower lateral carti-
lage, columellar and nostril sill skin, and nasal
mucosa is then dissected free from the nose and
face. As the depressed lower lateral cartilage is
rotated superiorly and laterally, the alar base is
consequently pulled medially, concurrently cor-
recting malposition of both the nasal cartilage
and the alar base (Fig. 44.2 ). In the classic
description of the Dibbell technique, resection
of skin from the superior nostril rim and lower
lip as well as an extensive incision around the
alar base is required. This will be addressed
later in this chapter.
Nostril rim incision
Nostril rim incision
Intercartilaginous
incision
Bipedicle
composite flap
Scar
Repair incisions
Fig. 44.1 The Dibbell
technique

692
R.L. Flores and C.B. Cutting
44.6
The Tajima Incision
The Tajima inverted-U incision was designed to
access the lower lateral cartilage on the affected
side for anatomic repositioning and to recontour
the soft tissue envelope of the nose [ 8 ] . The
descent of the lower lateral cartilage on the
affected side of the nose commonly results in
obliteration of the soft triangle and nostril apex
overhang on frontal view of the patient. Through
a well-designed inverted-U incision, both of these
common deformities can be addressed. An inci-
sion is made along the junction of the columella
and membranous septum, just short of the mid-
point of the vertical height of the nostril apex on
the unaffected side. This incision is continued
superiorly into the depressed dome skin, tracing
an arc similar in shape to the nostril on the unaf-
fected side. The incision then continues inferiorly
into the nostril mucosa yet caudal to the lower
lateral cartilage. Through this access incision, the
lower lateral cartilages can be widely undermined
from the nasal skin envelope and anatomically
repositioned. The excess skin of the inverted-U
fl ap that is attached to the lower lateral cartilage
is thinned, rotated inferiorly, and tucked into the
nostril as the depressed lower lateral cartilage is
rotated superiorly. Closure of the new nostril rim
to the Tajima fl ap relocates the position of the
nostril apex and creates a soft triangle.
Super-periosteum
undermined area
Super-periosteum
undermined area
Skin rescction
Skin rescction
Super-cartilage
undermined area
Super-cartilage
undermined area
Fig. 44.2 The Dibbell
technique. The undermined
areas are shown in gray

693
44 Secondary Cleft Open Rhinoplasty: Combining the Dibbell Technique and Tajima Incision
44.7
Limitations of the Dibbell
Technique and Tajima Incision
Although the Dibbell technique and Tajima inci-
sion are useful in correcting common persisting
cleft nasal deformities, there are limitations to
these techniques. Both rhinoplasty techniques
require an upper lip incision along the site of the
previous cleft lip incision to aid in medial reposi-
tioning of the alar base [ 5, 8 ] . Although this addi-
tional incision may be of bene fi t in patients with
suboptimal upper lip scars, it may be undesirable
in patients with near-perfect upper lip reconstruc-
tion. The additional incision around the alar base
used in the Dibbell technique can be problematic,
as scars in this area tend to heal poorly. The closed
rhinoplasty incision patterns of both techniques
provide a limited exposure to the lower lateral car-
tilages, which can be problematic when re fi ned tip
work is attempted. In our experience, the affected
lower lateral cartilage tends to be fl oppy and often
requires columellar strut reinforcement as well as
cartilage grafts to the nasal tip [ 9 ] . This detailed tip
cartilage work is facilitated by a wide exposure of
the lower lateral cartilages. Indeed, many cleft sur-
geons advocate using an open rhinoplasty tech-
nique in the majority of secondary cleft nasal
repairs [ 4, 9, 10 ] . The Dibbell technique also does
not address the problems of skin envelope archi-
tecture, which can limit the aesthetic result of
comprehensive nasal reconstruction.
44.8
Evolution of the Combined
Dibbell/Tajima Open
Rhinoplasty
The combined Dibbell/Tajima open rhinoplasty
technique was developed to capitalize on the
bene fi ts of the Dibbell technique and Tajima
incision while also addressing their limitations.
Correction of the depressed lower lateral carti-
lage, foreshortened columella, nostril fl oor
notch, and lateralized alar base is performed by
rotation of the Dibbell composite fl ap. The addi-
tion of the Tajima inverted-U incision to the
nostril rim corrects the nostril apex overhang
and recti fi es a degree of asymmetry in the nasal
tip skin envelope. By combining the Dibbell
technique and Tajima incision with a hemi-open
rhinoplasty on the opposite side, full exposure
of the lower lateral cartilages can be achieved
without vascular compromise of the Dibbell
bipedicle composite fl ap. Reposition, excision,
suture, and grafts of the lower lateral cartilages
can all be done under direct vision. The upper
lip incision, requisite to the classic description
of the Dibbell technique and Tajima incision, is
not needed, and an incision around the alar base
is avoided.
44.9
Indications for the Combined
Dibbell/Tajima Open
Rhinoplasty
The combined Dibbell/Tajima open rhinoplasty
is indicated for patients with a residual unilateral
cleft lip nasal deformity consisting of a lateral-
ized alar base, depressed lower lateral cartilage,
and nostril apex overhang [ 9 ] . If one or more of
these deformities is not present, this incision
technique should not be used or should be
adjusted to address the patient’s presenting defor-
mity. For example, a patient with a depressed
lower lateral cartilage and nostril apex overhang
but with an anatomically located alar base should
not undergo a Dibbell incision, as this will result
in further medialization of the alar base and cre-
ation of a micronostril. Instead, a Potter technique
can be combined with a Tajima/open rhinoplasty
incision as a means to correct lower lateral carti-
lage malposition without changing the position
of the alar base.
The authors traditionally perform this proce-
dure after the time of full facial maturity and do
not recommend performing this technique on
the growing face. It should be noted that this
technique addresses speci fi c deformities of the
lower lateral cartilage, alar base, and skin enve-
lope. The procedure does not address the sep-
tum, the middle or upper vault, or nasal airway,
and deformities of these areas should be thor-
oughly corrected, as in any rhinoplasty proce-
dure. Failure to address the complete nasal
deformity will result in less than acceptable

694
R.L. Flores and C.B. Cutting
outcomes. Additional procedures on the carti-
lage framework may be indicated and combined
with this rhinoplasty technique.
44.10 Technique of Combined
Dibbell/Tajima Open
Rhinoplasty
The combined Dibbell/Tajima open rhinoplasty
moderately diverges from the classic descrip-
tion of each technique. Nostril rim skin is not
excised as originally described by Dibbell, 5 but
preserved as part of the Tajima inverted-U fl ap,
thinned, rotated inferiorly, and tucked into the
nose. Dibbell originally advocated the use of
external bolsters to maintain the position of the
lower lateral cartilages. Similarly, Tajima relied
on “ fi brosis” to retain cartilage position [ 8 ] . In
our hands, suture and cartilage graft techniques
have been more reliable than bolsters to main-
tain cartilage architecture [ 4, 9 ] . In addition,
we have found the upper lip and alar base inci-
sions unnecessary when these techniques are
combined.
A Tajima inverted-U incision is marked on
the affected nostril. The height and shape of
the Tajima incision should match the unaf-
fected nostril with a slight degree of over com-
pensation. The medial limb of the Tajima
incision is extended inferiorly to meet a hemi-
transcolumellar incision directed toward the
unaffected side (Fig. 44.3 ). After the infusion
of local anesthesia, the Tajima and hemi-
transcolumellar incisions are made. An open
rhinoplasty exposure of the nasal tip is then
performed in continuity with the Tajima
inverted-U incision (Fig. 44.4 ). The inverted-U
fl ap of nasal skin and mucosa is thinned and
rotated inferiorly. After the upper and lower
lateral cartilages are fully exposed, the anterior
component of the Dibbell incision is made by
incising the anterior border of the nostril fl oor
at a point just medial to the alar base. This nos-
tril fl oor incision is continued medially and
superiorly to meet the lateral corner of the
transcolumellar incision. The medial and mid-
dle crura are then bluntly separated through the
open rhinoplasty incision. The nostril fl oor is
then separated from the upper lip through the
Dibbell incision. An incision is made along the
posterior-medial border of the lateral crus and
continued inferiorly as a hemimembranous
septum incision, then laterally across the fl oor
Nostril rim incision
Intercartilaginou
incision
Combined repair incisions
Open rhinoplasty
incision
Fig. 44.3 The incision
pattern for the
combined open rhinoplasty
Dibbell/Tajima
technique

695
44 Secondary Cleft Open Rhinoplasty: Combining the Dibbell Technique and Tajima Incision
Cartilage scoring
Alar base reposition
Tip suture fixation
Fig. 44.4 The lower lateral
cartilages and the alar base
have been anatomically
repositioned through
an open rhinoplasty
exposure
of the nose along the border to the nasal
mucosa. This composite bipedicle fl ap is mobi-
lized from the rest of the nose and upper lip.
The inferior attachments of the alar base are
completely mobilized from the underlying
bone. Once the Dibbell/Tajima fl ap has been
fully mobilized, the correct location of the alar
base is sighted and the alar base is fi xed to the
periosteum of the anterior nasal spine using a
long-lasting absorbable suture. If the lower lat-
eral cartilages are felt to be fl oppy and lacking
support, a columellar strut may be considered
and placed at this time. The superior end of the
columellar strut usually projects beyond the
lower lateral cartilages for increased tip
de fi nition and projection. The medial crura are
then fi xed in their corrected position using fi ne
permanent sutures. Tip re fi nement procedures
are performed, and additional tip grafts are
placed as needed. The open rhinoplasty inci-
sion is closed in the usual fashion. The Tajima
inverted-U incision is then removed of under-
surface fat and trimmed. The Tajima incision is
closed with half-buried mattress sutures.
44.11 Evidence of Ef fi cacy
The authors have previously demonstrated last-
ing correction of alar base position, columellar
length, and nostril apex overhang using the com-
bined Dibbell/Tajima open rhinoplasty [ 9 ] . There
was no incidence of cartilage graft infection or
ischemia to the nasal fl aps. There was no required
use of upper lip and alar base incisions, and the
revision rate associated with this procedure was
low (Figs. 44.5 ).

696
R.L. Flores and C.B. Cutting
Fig. 44.5 ( a ) Preoperative patient. ( b ) Postoperative
following the combined open rhinoplasty Dibbell/Tajima
technique. Note the improvement on the lower lateral
cartilage and alar base position as well as the correction of
the nostril apex overhang

697
44 Secondary Cleft Open Rhinoplasty: Combining the Dibbell Technique and Tajima Incision
References
1. Spira M, Hardy S, Gerow F (1970) Correction of nasal
deformities accompanying unilateral cleft lip. Cleft
Palate J 7:112–123
2. Cutting C, Bardach J, Pang R (1989) A comparative
study of the skin envelope of the unilateral cleft-lip
nose subsequent to rotation-advancement and triangu-
lar fl ap lip repairs. Plast Reconstr Surg 84(3):409–417
3. Blair V, Brown J (1930) Mirault operation for single
harelip. Surg Gynecol Obstet 51:81–98
4. Cutting C (1994) Cleft lip nasal reconstruction. In:
Rees T, LaTrenta G (eds) Aesthetic plastic surgery, 2nd
edn. Saunders, Philadelphia, pp 497–532
5. Dibbell D (1982) Cleft lip nasal reconstruction: cor-
recting the classic unilateral defect. Plast Reconstr
Surg 69(2):264–271
6. Blair V (1925) Nasal deformities associated with con-
genital cleft of the lip. J Am Med Assoc 84:185–187
7. Berkeley W (1959) The cleft lip nose. Plast Reconstr
Surg 23(6):567–575
8. Tajima S, Maruyama M (1977) Reverse-U incision
for secondary repair of cleft lip nose. Plast Reconstr
Surg 60(2):256–261
9. Flores RL, Sailon AM, Cutting CB (2009) A novel cleft
rhinoplasty procedure combining an open rhinoplasty
with the Dibbell and Tajima techniques: a 10-year
review. Plast Reconstr Surg 124(6):2041–2047
10. Chen KT, Noordhoff MS (1992) Open tip rhinoplasty.
Ann Plast Surg 28(2):119–130

699
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_45, © Springer-Verlag Berlin Heidelberg 2013
45
45.1
Cleft Lip Nasal Deformity
Cleft lip rhinoplasty presents a unique set of chal-
lenges to the facial reconstructive surgeon. The
procedure itself is considered both functional and
cosmetic, and while the outward appearance is
most noticeable, cosmesis cannot be addressed
adequately without also addressing the functional
deformities in cleft lip nasal rhinoplasty. There
exists a myriad of techniques and modi fi cations
in approaching this challenge, but no one univer-
sally accepted treatment or algorithm exists.
Included in this arsenal of approaches are both
surgical and nonsurgical techniques, and one
needs to rely on clinical judgment in order to
determine which option is indicated.
The goal of cleft lip rhinoplasty is to restore
natural nasal contours by addressing the symme-
try of the nasal tip and nasal ala while at the same
time restoring function by assessing both the
internal and external nasal valve regions. The
extent of the deformity depends on the degree of
lip abnormality, such as unilateral, bilateral,
incomplete, or complete. Unique deformities
which must be examined when repairing cleft lip
nasal deformities include columellar malposition
or shortening, asymmetric and malpositioned
nasal ala, absent nasal base, alar webbing or scar-
ring, and misalignment of the upper and lower
lateral cartilages. As discussed in a recent publi-
cation from our group, the three nasal deformities
that pose the most dif fi culty to the reconstructive
surgeon include the asymmetric nasal base (pyri-
form crest de fi ciency), malposition of the nasal
ala on the cleft side, and alar webbing [ 1 ] .
Both unilateral and bilateral cleft lip nasal
deformities may be addressed surgically, and
each poses their own set of challenges when con-
sidering nasal repair. We will discuss each of
these unique types of repair separately, but we
must fi rst consider the underlying structural and
functional issues. When examining the cleft lip
patient, one must bear in mind that the nasal
defect involves four separate layers: skin, carti-
lage, bone, and mucosa that must each be
addressed by cleft lip rhinoplasty. It is also impor-
tant to consider that while the soft tissue defor-
mity of the cleft lip is the most striking, the
underlying bony midface asymmetry and muscu-
lar de fi ciencies contributing to the deformity
must be evaluated and addressed in order to
obtain a good cosmetic and functional outcome
(Table 45.1 ).
Rhinoplasty for Cleft
and Hemangioma-Related
Deformities
Judy Pan and Sherard A. Tatum III
J. Pan , M.D. ()
Department of Otolaryngology and Pediatrics ,
Upstate Medical University , 750 E. Adams St. Syracuse ,
NY 13210 , USA
e-mail: panju@upstate.edu
S. A. Tatum III , M.D.
Division of Facial Plastic Surgery ,
Center for Cleft and Craniofacial Surgery,
Upstate Medical University ,
750 E. Adams St. , Syracuse , NY 13210 , USA
Department of Otolaryngology and Pediatrics ,
Upstate Medical University,
State University of New York ,
Syracuse , NY , USA
e-mail: tatums@upstate.edu

700
J. Pan and S.A. Tatum III
45.2
Unilateral Cleft Lip Nasal
Deformities (Fig. 45.1 )
Cleft lip is thought to occur as a result of malfor-
mation, deformation, or a combination of these
two mechanisms [ 3 ] . Patients with a unilateral
cleft lip have hypoplastic growth of the maxilla
and pyriform aperture on the cleft side that may
be due to a combination of disunion of the maxil-
lary and medial nasal processes during embryo-
genesis along with muscular misinsertion on the
cleft side. In unilateral cleft lips, both the septo-
premaxillary ligament and the orbicularis oris are
thought to be of importance in development of
nasal deformities [ 4, 5 ] . Latham in 1969 was the
fi rst to identify the connection between the cau-
dal septum and the periosteum of the premaxilla,
the septo-premaxillary ligament, and hypothe-
sized that this connection may aid in anterior
growth of the premaxilla and maxilla through
tension created by septal growth [ 4 ] . Seigel et al.
[ 6 ] subsequently showed that the removal of the
septo-premaxillary ligament in early develop-
ment led to stunted midfacial growth in chimpan-
zees. Along with the asymmetric midface growth,
the unilateral, unopposed vector of tension cre-
ated by the septo-premaxillary ligament between
the caudal septum and the premaxilla on the non-
cleft side contributes to septal and columellar
deviation away from the cleft.
The aberrant insertion pattern of the orbicu-
laris oris on the cleft side further contributes to
the nasal deformity seen in cleft lip patients.
Rather than forming a complete ring with mid-
line union, the orbicularis oris inserts onto the
columella on the non-cleft side and onto the lat-
eral portion of the alar base on the cleft side. This
is thought to further lateralize the columella
toward the non-cleft side and contribute to the
posterolateral displacement of the lateral crura of
the lower lateral cartilage (LLC) on the cleft side.
The posterolateral displacement of the lateral
crura was once thought to be associated with
abnormal development of the LLC itself. Further
investigations by Park et al. [ 7 ] demonstrated,
however, that the LLC is actually not abnormal in
length but that the lateral crura is elongated while
the medial crura is shortened due to the tension
vectors being applied on the lateral crura by the
orbicularis oris muscle. This tension also leads to
a blunted dome angle and introversion of the
lateral crura that has been postulated to contribute
to vestibular webbing. Also noted in cleft patients
is a misalignment of the upper lateral cartilages
Table 45.1 Cleft-associated nasal deformities seen in both unilateral and bilateral cleft palate patients
Unilateral cleft lip
Bilateral cleft lip
Nasal tip
Medial crus of LLC shorter on cleft
side
Medial crura of LLC short bilaterally
Lateral crus of LLC longer on cleft
side
Lateral crura of LLC long bilaterally
Lateral crus of LLC may be caudally
displaced
Lateral crura displaced caudally and produce
hooding of alar rim
Alar dome on cleft side is fl at and
displaced
Alar domes poorly de fi ned and widely
separated, laterally producing an amorphous tip
Columella
Short on cleft side
Short with wide base
Base directed to non-cleft side
Nostril
Horizontal orientation on cleft side
Horizontal orientation bilaterally
Alar base
Displaced laterally, posteriorly, and
inferiorly
Displaced laterally, posteriorly, and inferiorly
Nasal fl oor
Usually absent
Usually absent bilaterally
Nasal septum
Caudal de fl ection to non-cleft side
and posterior deviation to cleft-side
In a complete bilateral cleft lip and palate, the
septum is midline; however, if cleft on one side
is incomplete, then septum deviates toward the
less affected side
Adapted from Sykes [ 2 ]

701
45 Rhinoplasty for Cleft and Hemangioma-Related Deformities
(ULCs) in relation to the LLCs with lack of the
usual overlap between the two structures. This
can lead to not only decreased tip support but also
weak ULCs with narrowing of the internal nasal
valves and lack of support for the LLCs allowing
for further inferior displacement of the LLC on
the cleft side. All of these fi ndings contribute to
the unilateral cleft lip nasal deformity: columella
deviation to the non-cleft side, more posterior
cleft alar base compared to the non-cleft side, the
non-cleft alar base being further from the midline
than normal, and more posterior cleft-side pyri-
form margin compared to the non-cleft side [ 8 ] .
45.3
Bilateral Cleft Lip Nasal
Deformity (Fig. 45.2 )
The same theories stated above for the unilateral
cleft lip nasal deformity can also be applied to
the bilateral cleft nasal deformity. There is the
absence of the lip and maxilla that causes the
posterolateral displacement of the alar base with
the resulting widening of the nose, but the sym-
metry of the columella is not affected if the cleft
is relatively symmetric. The insertion of the
septo-premaxillary ligament is symmetric; there-
fore, there is no change in the region involving
the anterior septum and the columella. The inser-
tion of the orbicularis oris musculature into the
alar base bilaterally leads to widening of the nose
and fl attening of the lower lateral cartilages.
Similar to the unilateral deformity, the primary
characteristics of the bilateral deformity revolve
around the lower one-third of the nose. The nasal
dorsum may lack of height, but it is usually not
deviated. Characteristics of the bilateral cleft lip
nasal deformity therefore include a broad, fl at,
bi fi d tip; wide alar bases; and a short columella.
The nasal tip is usually in the midline in the
bilateral complete deformity. If one side of the
lip is more involved than the other, the short col-
umella is typically deviated toward the less
involved side and pulls the tip in that direction.
The lower lateral cartilages demonstrate short
a
b
Fig. 45.1 ( a , b ) Unilateral cleft lip deformity. Abnormal
direction and insertion of muscle fi bers of medial and
lateral segments of the cleft into the cleft margin, the
area of the ala nasi (laterally), and the base of the colu-
mella (medially). Dark line indicates arterial supply
(Friedman et al. [ 9 ] )
Fig. 45.2 Bilateral cleft lip deformity. Abnormal muscle
anatomy of a complete bilateral cleft. Both lateral muscle
segments insert into the alae nasi, with the prolabium
completely devoid of muscle tissue. Arterial supply is
indicated by a dark line (Friedman et al. [ 9 ] )

702
J. Pan and S.A. Tatum III
medial crura and long lateral crura. The domes
of the lower lateral crura are splayed, contribut-
ing to a poorly de fi ned, frequently bi fi d tip. The
dome angle is obtuse and widened. The alar
bases are posterior, lateral, and inferior, giving
rise to fl aring of the base and widening of the
nostril. The tension on the lower lateral carti-
lages leads to introversion and webbing of the
vestibule. The septum is in the midline in the
complete bilateral deformity and deviated cau-
dally toward the less involved side if an asym-
metry exists [ 8 ] .
45.4
Preoperative Planning
and Evaluation
Cleft lip rhinoplasty is now commonly per-
formed as a 2- to 3-stage repair. It is important
to mention that this was not always the case as
repair of the cleft nasal deformity in young chil-
dren was once considered detrimental to mid-
face growth. McComb and Coghlan reported
their 18-year experience with primary cleft lip
nasal deformity repair at the time of primary lip
repair in which no adverse effects on nasal and
midface growth were noted when compared to
age-matched normal and cleft-lip controls [ 10 ] .
Primary repair of the CLND is now accepted as
standard of care by many reconstructive sur-
geons. There also appears to be a great bene fi t
to performing primary rhinoplasty in cleft
patients at a young age [ 11 ] . We have since seen
that the repairs performed during this fi rst stage
remain stable into adulthood and improve the
overall cosmetic outcome in these patients [ 12 ] .
Primary repair is now routinely performed at the
time of initial cleft lip repair (3–6 months of
age). The goal of primary repair is to close the
anterior nasal fl oor; to relocate the posteriorly,
inferiorly, and laterally displaced alar base; and
to achieve early symmetry to the nasal base and
tip. A second-stage intermediate repair may be
considered at or just before school age but is not
always necessary. The intermediate procedures
are less involved and seek to correct gross defor-
mities and allow symmetric nasal growth and a
more successful de fi nitive procedure. De fi nitive
rhinoplasty is routinely performed in the teenage
patient after nasal growth has been completed,
usually around age 14 in women and 16 in men.
At this point in time, restructuring of the inter-
nal and external nasal anatomy can be per-
formed. The goals of surgery are the creation of
symmetry and de fi nition of the nasal base and
tip, relief of nasal obstruction, and management
of nasal scarring and webbing.
45.5
Presurgical Treatments
Prior to the primary cleft repair, multiple tech-
niques may be used to manipulate both the soft
tissue and bony deformities associated with the
cleft. Three techniques have been well docu-
mented in the literature including taping and
massaging of the cleft soft tissue with stretch
applied toward the non-cleft side, lip adhesion
(requiring a separate trip to the operating room),
and orthopedic devices. Lip adhesion involves
sewing the edges of the cleft together at about
6 weeks of age and then returning 6 weeks later
to perform the actual repair. Advocates of the lip
adhesion state that it reduces the tension on the
fi nal repair and can potentially narrow the scar.
However, this does require an additional surgery,
and some surgeons complain about the scar tissue
present during the second procedure [ 13 ] . Another
option involves presurgical nasoalveolar molding
(PNAM). This is an intraoral alveolar molding
device with nasal prongs that works to expand the
nasal vestibular lining, reorient the lower lateral
cartilages to improve tip symmetry, lengthening
the columella, and align the alveolar segments.
Compliance is a unique disadvantage to PNAM,
compared to lip adhesion [ 12 ] .
45.6
Multidisciplinary Approach
While the craniofacial reconstructive surgeon
plays a vital role in restoring the outward appear-
ance and function of the cleft lip nose, it has long
been established that cleft lip patients bene fi t
greatly from a multidisciplinary team care
approach [ 14, 15 ] . At our institution, as with

703
45 Rhinoplasty for Cleft and Hemangioma-Related Deformities
many others, we have a cleft and craniofacial
team consisting of a pediatric facial plastic and
reconstructive surgeon, pediatric orthodontist,
otolaryngologist, speech pathologist, audiologist,
geneticist, nutritionist, and a professional pho-
tographer. This multidisciplinary team approach
allows for better coordinated care of the patient
[ 16 ] . Work-up of our cleft lip patients consists of
a multidisciplinary evaluation in our Cleft and
Craniofacial Clinic followed by a team discus-
sion of treatment plans. We do not routinely per-
form laboratory or imaging studies other than
photography on our cleft lip patients prior to or
following repair of the lip and nasal deformity.
45.7
Surgical Technique
Various degrees of clefting exist. Basic repair
principles will be discussed in both unilateral and
bilateral cleft rhinoplasty with the understanding
that some degree of variation must be present
based on the degree of severity of deformity.
45.7.1 Unilateral Cleft Lip Nasal
Deformity (Fig. 45.3 )
The primary rhinoplasty for both unilateral and
bilateral cleft lip nasal deformities involves
a
b
c
Fig. 45.3 Unilateral cleft lip nasal deformity. ( a ) Medial
dissections to release the attachments of the lower lat-
eral cartilage. ( b ) Lateral dissections to release the
attachments of the lower lateral cartilage. ( c ) Application
of bolsters to reposition the cleft lower lateral cartilage

704
J. Pan and S.A. Tatum III
establishing a symmetric nasal tip and base of
appropriate width with closure of the nasal sill
and anterior fl oor. The nasal repair can be per-
formed through the Milliard advancement-
rotation lip repair incision. Lateral alar lobule
and medial columellar tunnels are created in
order to free the lower lateral cartilage from
the external nasal skin [ 17 ] . During closure of
the sill, the cleft-side nostril is formed sym-
metrically with the other side or slightly wider.
A slightly wide cleft-side nostril is much easier
to correct than a slightly narrow one. Once the
lip is closed and the alar bases aligned, the
lower lateral cartilage is then repositioned and
shaped with either transcolumellar interdomal
sutures or transnasal bolsters [ 2 ] . The goal is to
increase cleft-side tip projection (slight over-
correction is useful here too) and improve tip
symmetry. Future de fi nitive rhinoplasty inter-
ventions would involve septoplasty in order to
relieve nasal obstruction and obtain grafting
material, assessment and addressing the lower
cartilage symmetry, and improvement of tip
de fi nition [ 18 ] .
Secondary rhinoplasty can be thought of as
intermediate or de fi nitive. Patients with signi fi cant
nasal deformity with or without primary rhino-
plasty may bene fi t from limited surgery to
improve nasal appearance and/or function in the
6–11 years of age range. They would still likely
need de fi nitive repair later. If there are no press-
ing reasons for early intervention, delay to the
early- or mid-teen years allows for more de fi nitive
correction.
Intermediate rhinoplasty can be done with or
without lip revision. The goals and maneuvers
are similar to primary rhinoplasty. Symmetry of
the nasal tip, nostril shape and size, sill width,
and alar rim curvature are all important. Limited
correction of anterior septal de fl ections can also
be desirable.
The nasal tip is approached through previous
incisions around the nasal base. Dissection is car-
ried through the columella and lateral alar lobule
with tenotomy scissors over the lower lateral car-
tilage separating the cartilage from the external
skin. The cleft-side tip projection is increased
with lateral crural steal. The dome can be sup-
ported either with pledgets as in primary rhino-
plasty or dome-binding sutures placed through
the opposite nasal vestibule. In cases of severe
nostril stenosis or deformity, an intercartilaginous
incision may be necessary to allow adequate
medial advancement. Vestibular Z-plasties can be
used to fi ll in the advancement defect or treat
stenosis. An anteriorly deviated septum can be
scored and/or elevated from the maxilla to allow
repositioning.
De fi nitive rhinoplasty is typically reserved
until near facial maturity. The bony defects of the
maxilla along the pyriform aperture and the mal-
position of the premaxilla need to be addressed
before de fi nitive rhinoplasty (Fig. 45.4 ) [ 19 ] .
Alveolar bone grafting is done not only to fi ll
the alveolar defect but also to augment the
de fi cient cleft-side pyriform crest. This grafting
can have a dramatic effect on nasal base symme-
try. There is not a universally accepted time for
alveolar bone grafting, but it is usually performed
between the ages of 7 and 11, after the primary lip
and palate procedures [ 20 ] . In addition to the
above-mentioned goals, the posterior septum and
bony pyramid can be addressed as necessary. An
open approach is generally recommended employ-
ing a midcolumellar inverted-V incision. It is pos-
sible to incorporate lip scars at the columellar
base if they are close enough and the columella is
relatively short. Multiple cartilage grafts can be
harvested from the septum and used for columel-
lar struts, tip grafts, lateral strut or batten grafts,
rim grafts, or spreader grafts. A concave lateral
crus can be removed and replaced inverted to
improve alar contour.
Fig. 45.4 Left side alveolar bone defect

705
45 Rhinoplasty for Cleft and Hemangioma-Related Deformities
45.7.2 Bilateral Cleft Lip Nasal
Deformity (Fig. 45.5 )
The bilateral cleft lip nasal deformity is not a
bilateral version of the unilateral cleft lip nasal
deformity. It is typically worse. The columella is
often very short or absent. There is minimal tip
projection, and the alar base is too wide with
diminished skeletal support.
On the positive side, the nose is usually fairly
symmetric. Authors vary with their interventions
for primary rhinoplasties for bilateral cleft lip
nasal deformities. Some favor just alar reposition-
ing at the time of lip repair, while others perform
more aggressive tip rhinoplasty [ 21, 22 ] . One
concern about aggressive tip rhinoplasty during
primary lip repair is compromise of philtral blood
supply. Compared to unilateral cleft lip nasal
deformity repair though, the bilateral cleft lip
nasal deformity frequently relies on intermediate
rhinoplasty for the major goal of lengthening the
columella. De fi nitive rhinoplasty, however, is
similar for both unilateral and bilateral cleft lip
nasal deformities as the goal is to correct any
residual de fi ciencies and irregularities.
The dissection for bilateral primary tip rhino-
plasty is similar to unilateral. Tenotomy scissors
are used to dissect through the columella and lat-
eral alar lobules to separate the lower lateral car-
tilages from the external skin. Fibrofatty tissue is
removed from the interdomal area if accessible.
Transvestibular dome-binding sutures with or
without pledgets are placed to medialize the lat-
eral crura and lengthen the mesial crura. This is
where care must be taken not to overtighten the
suture and compromise blood supply to the phil-
tral fl ap. The alar rim skin is similarly recruited
from lateral to medial to gain length in columel-
lar skin. This causes some bunching in the tip
area which formerly was resected leaving an
external scar. Now the bunching is left to settle
down over time.
The intermediate rhinoplasty is focused on
columellar lengthening (Fig. 45.6 ). In cases
where primary rhinoplasty was not done or suc-
cessful, columellar lengthening is necessary to
improve severe deformity as well as enhance
growth potential. In the past, this was done with a
Cronin procedure which is a V to Y advancement
of nasal sill skin into the columella. This tech-
nique leads to advancement of the mesial crura
up toward the tip reducing tip support. This can
however be done independent of the lower lateral
cartilages to recruit skin while still performing
lateral crural steal in the cartilages.
The current trend is to recruit lateral crura
toward the tip and infra tip skin into the columella
by medializing and narrowing it (Fig. 45.7 ).
Trimming of the soft tissue triangle area may be
necessary during redraping and closure of the
columellar skin.
45.8
Postoperative Complications
There are not many reports of complications
after cleft rhinoplasty in the literature. Alef did
report the complications from their 86 primary
Fig. 45.5 Bilateral cleft lip nasal deformity, note the
relative nasal symmetry

706
J. Pan and S.A. Tatum III
cleft lip rhinoplasty procedures. They had four
patients (no postoperative antibiotics) with nasal
tip infection at approximately 3 months postop-
eratively, all of which required surgical drainage.
Based on their study, they recommended both
preoperative and postoperative antibiotics ( fi rst-
generation cephalosporin) in primary cleft lip
rhinoplasty. If the infection fails to resolve, they
recommended removal of any retained sutures
and surgical drainage/irrigation. They also
described 2 out of 24 patients with nasal bolsters
that were secured with transseptal sutures who
developed columellar and septal infections approx-
imately 6–8 weeks postoperatively. They, there-
fore, advised that if nasal bolsters are to be used,
then adequate parental education is necessary in
order to detect signs of bolster-related complica-
tions [ 23 ] .
a
b
c
Fig. 45.6 The columella is lengthened by ( a ) the recruitment of the lateral crura toward the tip and ( b ) the infra tip skin
toward the columella. ( c ) Skin closure