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

975
69 Airway Patency in Aesthetic Rhinoplasty: Primary and Revisional Techniques
pyriform aperture narrowing. The internal valve
is also narrow with improvement in air fl ow when
cotton tip applicator used to support the valve.
Aes thetic analysis demonstrates poor tip support
and de fi nition, a concavity of the mid-nasal vault
and a dorsal hump.
Surgical treatment consisted of transnasal
enlargement of pyriform aperture to decrease
air fl ow resistance at the bony inlet (Fig. 69.3 ).
An external rhinoplasty was performed through
a columellar stair step incision. The septal car-
tilage was harvested to relieve obstruction and
for grafting. This was followed by takedown
of the bony and cartilaginous components of
the dorsal hump with in fracture of the nasal
bones to achieve the desired pro fi le and narrow-
ing. Application of extended spreader grafts to
internal valve improved airway support and
de fi ned the dorsal aesthetic lines (Fig. 69.7 ).
A columellar strut graft insures tip rotation
and external valve support (Fig. 69.8 ). Careful
reductions of the superior portion of the lower
lateral cartilages, leaving a 5-mm rim intact
inferiorly for airway support, and intradomal
sutures were placed to narrow the tip. Finally,
a bruised shield graft, from the septal cartilage,
was applied to improve tip de fi nition (Figs. 69.4
and 69.8 ).
Spreader grafts
Nasal septum
Fig. 69.7 Extended spreader grafts extending from under
nasal bones to caudal septum. These will restore dorsal
aesthetic lines as well as support the internal nasal valve
Fig. 69.8 Columellar strut
graft being used to support
and rotate the nasal tip as well
as open the external nasal
valve

976
F.D. Burstein
This case illustrates multiple areas of airway
compromise due to anatomically identi fi able
anomalies including pyriform aperture nar-
rowing and internal valve compromise. Her
relatively long and narrow midface contrib-
uted to her aesthetic and functional problems.
Identi fi cation of these anatomic anomalies
allowed for incorporation of airway improve-
ment into the aesthetic rhinoplasty. The dorsal
aesthetic lines were improved with the extended
spreader grafts which also opened the internal
nasal valve angle.
Tip rotation was enhanced with the columel-
lar strut graft which also provided support for the
external valve. The patient achieved her aesthetic
goals and a signi fi cantly improved nasal airway
by aligning techniques to achieve both functional
and cosmetic improvement (Fig. 69.6 ).

977
69 Airway Patency in Aesthetic Rhinoplasty: Primary and Revisional Techniques
Fig. 69.9 ( a ) Preoperative patient with a twisted exter-
nal nasal pyramid, severe internal and external valve
stenosis, aesthetic deformity, and severe internal and
external valve obstruction secondary to multiple traumas.
( b ) Postoperative with improvement in asymmetry of the
dorsum and tip, external valve support, and dorsal appear-
ance using asymmetric autologous grafts and conchal
grafts reconstruction
Case 2
This 58-year-old male had multiple football-
related injuries to the nose, resulting in a severely
twisted nasal pyramid and almost complete nasal
airway obstruction with severe snoring (Fig. 69.9 ).
He was diagnosed with sleep apnea and wears a
positive pressure device at night with only mild
improvement. He wishes to have a straighter, less
asymmetric nasal appearance and to improve his
airway. In addition, improving the nasal airway
may make the use of positive pressure airway

978
F.D. Burstein
more effective. Examination reveals external
asymmetry of the dorsum, midvault, and tip
involving bony and cartilaginous elements. The
external nasal valve is compromised by collapse
of the right lower lateral cartilage with inspira-
tion. The right internal nasal valve is stenotic.
The septum is severely deviated and telescoped
touching the turbinates. The inferior turbinates
are hypertrophied secondary to turbulent air fl ow.
Surgical treatment began with an external
nasal approach through a stair step incision and
degloving of the dorsal nasal skin envelope. The
septum was exposed by going between the medial
crura and footplates of the lower lateral carti-
lages. The septum was resected including the
caudal septum, perpendicular plate of ethmoid,
and vomer, leaving only a 2-cm strut of dorsal
septum intact. Both inferior turbinates were
trimmed to remove all points of contact with the
septum. The dorsal hump was carefully rasped
down, and the cartilaginous component trimmed
with an 11 scalpel until the desired dorsal contour
was achieved. Mucosal tunnels were elevated
between the septum and upper lateral cartilages
for placement of extended spreader grafts
(Figs. 69.4 and 69.10 ). The nasal bones were then
osteotomed via the intranasal route using a 2-mm
osteotome and a greenstick technique. With the
nasal bones centered, fi nal trimming of the dorsal
septum was done. The right-sided dorsal concav-
ity was corrected with a 5-mm-thick extended
spreader graft to open the nasal valve and
camou fl age the concavity (Fig. 69.10 ). A colu-
mellar strut graft was then placed onto the nasal
spine for tip support, replacing the excised caudal
septum. The cephalic margin of the left lower
lateral cartilage was trimmed. The right lower lat-
eral cartilage was very weak and concave. A con-
chal graft was harvested and used to fi ll the
concavity and restore tip symmetry (Fig. 69.5 ).
After replacing the skin envelope, the alar width
was equalized by excising asymmetric fl oor of
nose diamond shaped patterns.
The patient achieved his desired goals of nasal
symmetry by combining attention to reconstruc-
tion of structural elements with correction of his
Septum
Spreader graft
Larger cartilage
trimmed
Deficient
side augmented
with graft
Asymetric Tip
requires repositioning
a
b
Fig. 69.10 ( a , b ) Asymmetric extended spreader graft
for support of the internal valve and mask the dorsal septal
curvature. Conchal graft reconstruction of damaged lower
lateral cartilage restores tip contour and improves the
stability of the external valve

979
69 Airway Patency in Aesthetic Rhinoplasty: Primary and Revisional Techniques
airway problems (Fig. 69.9 ). The asymmetric
spreader graft and conchal graft to the external
valves contributed to improving airway support.
Asymmetric spreader grafts can camou fl age con-
cavities of the midvault, opening the nasal valve.
This is preferable to overresecting the dorsal sep-
tum which can result in a saddle nose deformity.
The degree of deformity of the left lower lateral
cartilage made it impossible to completely reshape;
therefore, an onlay bruised conchal graft was used.
This graft not only improved the nasal appearance
but also provided important external valve sup-
port. The severity of the septal twist necessitated
excision of the caudal septum since it was dis-
placed off the nasal spine. In order to prevent tip
drop, the supportive role of the caudal septum was
replaced by a columellar strut graft. This graft,
when centered, provides a stable base for advanc-
ing the displaced lower lateral cartilages and sup-
porting the external valve. The patient was able to
stop using his positive pressure ventilation at home
with good improvement in his sleep apnea.

980
F.D. Burstein
Fig. 69.11 ( a ) Preoperative patient with aesthetic and
functional problems after aesthetic rhinoplasty. ( b )
Postoperative after application of columellar strut for
external valve and tip support, tip grafts, and bruising of
the lower lateral cartilages to decrease their convexity
while maintaining external valve support with improved
dorsal aesthetic lines, re fi nement of the tip, and improve-
ment in both internal and external nasal valve support
(volumetric graft obtained from cephalic trimming of
lower lateral cartilages)
Case 3
This 22-year-old woman had previous rhino-
plasty elsewhere and was unhappy with the
aesthetic and functional result (Fig. 69.11 ). Exa-
mination reveals that the septum and bony pyra-
mid are deviated to her right. The right internal
valve is not patent, and there is turbinate hyper-
trophy. Aesthetic concerns include the external
deviation, a dorsum that was too high, and a
broad and amorphous tip.
Surgical treatment was through an external
rhinoplasty approach (Fig. 69.12 ). The septum
was transected with removal of the deviated caudal
septum and deviated central septum including
vomer and ethmoid plate. Both inferior turbinates
were trimmed and cauterized. The dorsum was
brought down with coarse to fi ne rasps and an 11
scalpel for the cartilaginous dorsum preserving
mucosa. The nasal bones were mobilized using a
2-mm intranasal osteotome, and greenstick frac-
ture was achieved to bring them to the midline.
Asymmetric spreader grafts were fashioned with
the thickest and longest one placed on the side of
her dorsal septal concavity (Figs. 69.4 and 69.10 ).
The cephalic margin of the lower lateral cartilages

981
69 Airway Patency in Aesthetic Rhinoplasty: Primary and Revisional Techniques
was trimmed without damaging the attachments of
the upper lateral cartilages, leaving 5 mm of intact
rim. The lateral crura were then bruised with a
guarded cartilage crusher to convert its curvature
from convex to concave (Fig. 69.12 ). A columellar
strut graft was placed between the footplates of the
lower lateral cartilages for tip support and sutured
in place (Fig. 69.8 ). A volumetric graft from the
lower lateral cartilages trimmings was placed
directly under the desired point of maximal tip
de fi nition to hide any irregularities and enhance tip
projection (Figs. 69.4 and 69.13 ). Finally, 2-mm
diamond excisions of the fl oor of nose mucosa
were carried out to decrease alar width.
The patient achieved her stated goals of nasal
re fi nement and improvement in her airway.
This case illustrates the use of various grafting
techniques in a secondary reconstruction. Various
grafts were used to improve airway support while
others to make subtle aesthetic enhancements.
Tip grafts
“Bruised”
alar cartilages
Fig. 69.12 Application of
columellar strut for external
valve and tip support, tip
grafts, and bruising of the
lower lateral cartilages to
decrease their convexity
while maintaining external
valve support
Fig. 69.13 Application of volumetric graft obtained
from cephalic trimming of lower lateral cartilages. ( a )
Graft is secured to footplates after being bruised. ( b ) Graft
is folded on itself to augment tip volume, resulting in
enhanced tip projection

982
F.D. Burstein
69.7
Discussion
The high-reported incidence of functionally adverse
results with rhinoplasty is due to numerous factors
in planning and execution of aesthetic and recon-
structive rhinoplasty. Most often, there are both
functional and aesthetic components that must be
addressed. Various authors have attributed airway
complications to aggressive resection of supporting
airway elements at the internal and external valve
levels. Certain techniques, such as complete trans-
action of the lower lateral cartilages, removal of
mucosa, and resection of the upper lateral cartilages
at the internal valve, will often compromise the air-
way as well as result in aesthetic compromise. Poor
planning and execution that result in mucosal scar-
ring, overresection of the dorsum, upper lateral car-
tilage damage, or malposition account for many
secondary airway complications.
The selected case studies illustrate how aes-
thetic and functional goals can be integrated in
planning and execution of primary and secondary
rhinoplasty. A thorough preoperative consulta-
tion for functional assessment and frank discus-
sion of aesthetic goals is essential. Computerized
imaging is a helpful tool in reaching an under-
standing of the aesthetic expectations envisioned
by the patient. This is particularly important in
secondary cases where there was often a commu-
nication breakdown between the initial surgeon
and patient. Key areas of both functional and aes-
thetic signi fi cance include the external valve and
internal valve. Preservation of at least 5 mm of
intact rim when trimming the lower lateral carti-
lages provides for adequate inspiratory support at
the level of the external valve. If the lower lateral
cartilage is damaged, malpositioned, or structur-
ally inadequate (Case 2), septal or conchal grafts
can be used as a bolster to achieve the desired
contour and provide airway support. If the caudal
septum and/or footplates of the lower lateral car-
tilages are damaged, structurally weak or absent
due to resection or trauma (Case 3), a columellar
strut graft can provide both structural airway sup-
port and tip support. The internal valve can be
compromised if the angle is decreased between
its structural components, this can be due to devi-
ation of the dorsal septum, traumatic separation,
or surgical resection of the attachments between
the upper and lower lateral cartilages and the sep-
tum and mucosal scarring. Great care is taken in
primary rhinoplasty to avoid resection of the cau-
dal attachments of the upper lateral cartilage to
the septum at the alar valve during trimming of the
tip cartilages. Likewise, the mucosa between the
septum and upper lateral cartilages is carefully
dissected and protected during the paring of the
dorsal cartilaginous septum. Complete avulsion
of the upper lateral cartilages from the nasal
bones resulting in a V deformity can be avoided
by using gentle rasping to take down the bony
dorsum rather than an osteotome. Judicious appli-
cation of autologous cartilage grafts as extended
spreader grafts to the internal valve can improve
air fl ow as well as to de fi ne or restore the dorsal
aesthetic lines. Infrequently, in secondary cases,
airway collapse can be observed lateral to the
internal valve. In these cases, a thin batten graft
can be applied as a strut between the septum and
pyriform aperture for airway support. Adjuvant
operative steps such as turbinectomy and enlarge-
ment of the pyriform aperture can be easily incor-
porated during rhinoplasty as indicated. They add
little operative time or morbidity and can greatly
enhance the functional result.
Conclusions
Incorporation of airway evaluation as part of
the initial encounter with a rhinoplasty patient
is highly advisable. Aesthetic re fi nements and
maintenance or improvement of the nasal air-
way should be the goal in rhinoplasty. This
can be achieved by incorporating the tech-
nique presented in this chapter into the sur-
geon’s rhinoplasty routine.
References
1. Elwany S, Thabet H (1996) Obstruction of nasal valve.
J Laryngol Otol 110(3):221–224
2. Grymer LF (1995) Reduction rhinoplasty and nasal
patency: change the cross-sectional area of the nose
evaluated by acoustic rhinometry. Laryngoscope 105
(4 Pt 1):429–431
3. Sheen JH (1984) Spreader graft: a method of recon-
structing the roof of the middle nasal vault following
rhinoplasty. Plast Reconstr Surg 73(2):230–239

983
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_70, © Springer-Verlag Berlin Heidelberg 2013
70
70.1
Introduction
Rhinoplasty unto itself is perhaps the most chal-
lenging aesthetic surgical operation. Secondary
rhinoplasty is further specialized and requires a
diverse and vast experience with concepts and
techniques in primary rhinoplasty. The surgeon
attempting secondary rhinoplasty should have ini-
tial experience with revisions not only of their
own rhinoplasty patients but those of many other
surgeons where a wide range of problems have
been encountered. The Middle Eastern patient
represents additional unique dif fi culties in how
their nasal morphology should be properly han-
dled [ 1– 13 ] . This ethnic group represents a diverse
group of ethnic subgroups. For simpli fi cation, the
term “Middle Eastern” refers to patients from
North African countries (Morocco, Algeria, Libya,
and Egypt), Gulf countries (Saudi Arabia, Iraq,
UAE, Kuwait, Iran, and Oman), and other regional
ethnic regions (Turkey, Lebanon, Syria, Armenia,
Assyria, Afghanistan, Pakistan, and India) [ 1, 8 ] .
While some do not consider India and Pakistan to
be the Middle East, nasal morphology is similar in
spectrum to those of other regions under study.
It is common to undergo a rhinoplasty in late
teenage and early adolescent years, particularly
in countries such as Iran [ 4 ] . First or second gen-
eration immigrants from these regions in the
United States continue that tradition and may
even receive rhinoplasty as a “Persian New Year
(Nowrooz)” gift or graduation present. Often, the
classic patient presents as a young female with
overall attractive facial features with a signi fi cantly
imbalanced nose. Due to the commonality of
receiving nasal surgery fairly young, secondary
and revision patients also present at relatively
young ages unless trepidation prevailed until the
late 20s or early 30s.
Many have returned to their country of ethnic
origin for savings on surgical fees but tend to seek
secondary surgery in the United States. There
seems to be a difference in aesthetic taste and
style as one travels from country to country. For
example, there is a bias toward sharper more dra-
matic tip shaping, dorsal pro fi le curvature, sharper
supratip breakpoints, and nasolabial angles among
some surgeon in the country of origin. Although a
minor group of patients request or like these aes-
thetic changes, the majority who receive a nasal
shape that they feel is off balance or has irregu-
larities eventually seek a secondary procedure as
they get a bit older. There is valid apprehension to
undergo a second, sometimes third and fourth,
procedure, but the obvious anatomical problems
(aesthetic and functional) easily justify and are
proportionate to the patient’s concerns.
The large volume of Middle Eastern patients
that would bene fi t from rhinoplasty and who
Secondary Rhinoplasty
in the Middle Eastern Patient
Ashkan Ghavami
A. Ghavami , M.D.
Plastic Surgery ,
UCLA David Geffen School of Medicine
Los Angeles, CA , USA
433 N. Camden Drive, Suite 780 ,
Beverly Hills , CA 90210 , USA
e-mail: ashghavami@yahoo.com

984
A. Ghavami
complete the goal of having one produce a large
volume of patients who then require a revision
procedure. The anatomical abnormalities range
from frank midvault collapse and overresection
of dorsum/tip structures to more subtle nasofacial
imbalances that are simply racially incongruent.
“Racial incongruity” is a term that describes an
awkward disharmony between the nose and eth-
nic facial features [ 1, 6 ] . An overt example is a
triangular, exaggerated narrowing of the nasal
base in an African-American patient. In Middle
Eastern patients, it can present as an excessively
reduced dorsal pro fi le line leading to a severe
suptratip breakpoint, ending with an overrotated
nasal tip. The primary goals in the Middle Eastern
nose are presented in Fig. 70.1 .
Middle Eastern revision rhinoplasty patients
are very meticulous in their goals and can be hard
to please (if the analysis and treatment plan is not
clearly laid out), however, the second or third time
around, they seem to be more apt to listen care-
fully, express their speci fi c goals, and conduct a
more thorough search for their revision surgeon.
They are more invested in the process, often older,
and more independent in their decision-making
compared to their primary rhinoplasty. If a com-
prehensive consultation is carried out and the
goals are clearly elucidated, then the outcomes
and level of satisfaction will be signi fi cantly
improved. While the secondary deformities seen
in Middle Eastern patients are also common in
other ethnic groups needing secondary rhino-
plasty, there are a myriad of speci fi c challenges
that warrant this comprehensive discussion.
The most common nasal imbalances and irreg-
ularities encountered are listed in Table 70.1 .
Fig. 70.1 Goals of Middle Eastern rhinoplasty (when
these goals are not adhered to or deviated from, the risk of
a secondary operation increases): (1) moderate dorsum
reduction, (2) narrow the wide nasal bones, (3) debulk
fi brofatty tissue, (4) de fi ne nasal tip, (5) address tip under-
projection, (6) address hyperdynamic tip, (7) correct alar
fl aring, (8) correct nostril asymmetries, and (9) correct
nostril-tip (lobule imbalance)

985
70 Secondary Rhinoplasty in the Middle Eastern Patient
Nasal bone and midvault collapse (often asym-
metric with obvious osteotomy lines/shadows)
are common, as is inadequate treatment of the
nasal tip tripod. Soft tissue defects and cartilage
warping/twisting from weakened framework and
lack of support grafts prevail in the tip complex.
Dorsal resection of the common large nasal hump
is either inadequate or excessive. A “segmental-
ized” appearance is usually seen especially on the
anteroposterior view where the tip midvault and
bony dorsum look divided into three units. Tip
shaping with tip shaping sutures alone is usually
not possible. Contour grafts and tip shaping grafts
are almost always necessary to overcome the tip
deformities and to provide proper support, shape,
and projection. Lastly, lateral crural position and
length are often inadequately treated, which
makes for a long nasal appearance and persistent
dynamic and static droopiness to the tip.
In this chapter, the nasal components have
been divided into skin/soft tissue, cartilage frame-
work, and osseous (bony) vault segments, to help
delineate the spectrum of problems commonly
seen. Case studies will show some of the classical
mistakes made in the primary operation and the
component-driven corrective maneuvers. It is the
author’s opinion that the majority of secondary
rhinoplasties should be performed using an open
approach because the array of anatomical distor-
tions is complex. In the author’s practice, the
majority of primary operations requiring revisions
were initially performed as a “closed” rhinoplasty,
which may serve as the impetus for the plethora of
secondary deformities that present so readily. As
with all rhinoplasty, at least 12 months should
pass from the primary operation or from the most
recent nasal procedure, to allow for complete soft-
ening of scar tissue. Middle Eastern noses may
necessitate an even longer waiting period as scar
formation and severity of deformities can be quite
extensive and prolonged. Prolonged edema and
scar remodeling can be seen for up to 2 years.
Finally, functional issues will not be addressed
since they are addressed elsewhere in this book.
However, it should be noted that secondary func-
tional issues almost always accompany signi fi cant
aesthetic problems in nasal shape. Deviations,
asymmetries, and alar arch issues often correlate
to internal valve and external valve dysfunction.
Untreated turbinate hypertrophy is also com-
monly seen. Turbinate bony micro-out-fracture
and turbinate mucosal reduction, either thermally
or with conservative direct resection, may be nec-
essary. In this author’s experience, the primary
operation was usually inadequate in dealing with
primary airway issues with the magnitude of sep-
tal deviation poorly treated or ignored. This is
fortunate because there is usually plenty of septal
cartilage available for the secondary operation.
The sequence of secondary treatment in Middle
Eastern patients is outlined in Table 70.2 . The
fi rst component to be discussed is osseous.
70.2
Bone
Bony irregularities are very common [ 14 – 17 ] .
Many surgeons underestimate the importance of
the osseous in fl uence on the overall nasal shape
and do not take time to ensure initial bony sym-
metry and shape in the primary operation. It is not
Table 70.1 Common secondary deformities
Bone
Skin/soft tissue
Asymmetric dorsal
aesthetic lines (DAL)
Noncontractility
Wide bony vault
Super fi cial dermal injury
Collapsed nasal bone(s)
Poor scarring
Obvious bony step-off
(visible osteotomy)
Vestibule retraction (soft
triangle)
Excess bone height
Excess alar base bulk
Excess reduction (washed
out DAL)
Excess sill (interalar
distance)
Inverted V-deformity
Overreduced alar base/sill
Open roof
Septal perforation
Cartilage
Functional
Transection or
overresection
Internal valve narrowed
Malposition
External valve
incompetence
Weakened/diminutive
Septal deviation
(untreated)
Excess length (LLC)
Turbinate hypertrophy
(untreated)
Inadequate breakpoints
Collapse
Irregularities
Supratip fullness
Persistent tip drop/excess nasal length

986
A. Ghavami
enough to simply rasp down a bit of the dorsal
hump and maybe bring the bones medially. Dorsal
overresection is corrected with augmentation
while dorsal under-resection or irregular contours
that present are corrected by reduction. Both cir-
cumstances require some form of augmentative
or camou fl age grafting to smooth the overall con-
tour. Osteotomies may be excessive or incom-
plete. Secondary osteotomies and nasal bone
repositioning should be performed after compo-
nent (cartilage and bony) dorsal reduction.
Overreduction of the dorsal hump can create
the classic inverted-V deformity or wash out the
dorsal aesthetic lines. Dorsal aesthetic lines
should fl ow down from the medial eyebrow in a
gentle curvilinear line toward the nasal tip
de fi ning points (Fig. 70.2 ). Asymmetry presents
as one nasal sidewall being wider than the other.
One side or both bony sidewalls can also be col-
lapsed posteriorly into the nasal cavity. In the
author’s opinion, percutaneous, discontinuous
osteotomies decrease the chance of collapse as
more soft tissue attachments are preserved. This
is the preferred technique in secondary rhino-
plasty as well.
The angle of the nasal bones should be
assessed and the height of the osteotomy altered
from side to side depending on the angle and ini-
tial nasal bone height on each side. The more
obtuse side should receive an osteotomy line
that is lower (closer to the maxilla) with a sec-
ond (double) osteotomy a few millimeters above
the fi rst. After the dorsal aesthetic lines are sym-
metric and narrowed suf fi ciently, fi nal contour
Table 70.2 Sequence of techniques in secondary
rhinoplasty
Skin/soft tissue elevation
Delineation of cartilage frame that is intact
Separation of septum from upper lateral crura
(submucoperichondrial undermining)
Component dorsal reduction (if indicated)
Osteotomies
Correction of caudal septal/nasal spine issues/
deviations
Septal harvest
Spreader grafts (autospreaders if possible)
Final dorsal smoothing
Dorsal augmentation (if indicated)
Tip complex reshaping/strengthening
Columellar strut (medial crural height setting)
Lower lateral crural strut treatment (grafts and/or
transection/transposition)
Tip shaping sutures (if possible)
Onlay tip grafts (if indicated)
Other contour grafts (crushed, remnants, soft alar
transition smoothing)
Skin undersurface correction
Nasal shape reassessment
Smoothing maneuvers to soft tissue/cartilage
relationships
Partial skin closure (columella and vestibule)
Final contour grafts placed (if indicated)
Alar base and sill treatment
Final closure
Turbinate treatment
Taping and splinting
Note : This is a general guideline and each secondary treat-
ment plan should be customized to what the nasal mor-
phology dictates as well as the preferences of the individual
surgeon
Fig. 70.2 Dorsal aesthetic lines: gentle curvilinear lines
should start at the medial brows and gentle curve medially
as they slowly curve lateral to meet the paradomal region

987
70 Secondary Rhinoplasty in the Middle Eastern Patient
rasping with a fi ne-tuning rasp or diamond rasp
should be performed. Rarely, the nasal bone(s)
will have to be lateralized instead, using a Boise
elevator while out-fracturing. The overall goal is
smooth, appropriately positioned dorsal aes-
thetic lines.
Once osteotomies are complete, the necessity
for augmentation versus camou fl age grafting of
the dorsum can be assessed. Dorsal augmentation
cartilage sources are listed in Table 70.3 and
depend on the surgeon’s comfort level and pref-
erence. A rhinoplasty surgeon performing sec-
ondary rhinoplasty should be adept at all the
techniques of cartilage harvesting. Silicone and
other solid materials should not be used in sec-
ondary cases because the presenting deformities
and soft tissue characteristics demand autoge-
nous grafts for more effective, safer, and long-
term outcomes. Diced cartilages, with or without
wrapping in temporal fascia, and/or solid rib car-
tilage grafts are the preferred techniques [ 18, 19 ] .
The advantage of the diced cartilage is it allows
for molding (Fig. 70.3 ). This is a particular
advantage in secondary situations where there
are a lot of surface irregularities that translate
from the bone-cartilage frame that need to be
smoothed over.
Lastly, an inadequately reduced bony dorsum
simply receives more rasping. However, it is very
important to assess the availability of septal car-
tilage when simultaneously reducing the carti-
laginous dorsum. Septal fracturing and collapse
can occur if the septum was weakened in the pri-
mary operation. Spreader grafts are the work-
horses, but temporary pinning/wiring may be
required to hold up the septum and nasal bones as
a cohesive unit. It is important to note that the
position, angle, and integrity of the upper lateral
cartilages and septum mimic the position of the
bony vault.
70.3
Cartilage Frame
This is perhaps the most challenging aspect of
secondary rhinoplasty in any patient population.
The substantial primary dimensions of excessive
septal height, lateral crural length/width, and
medial crural variations make secondary defor-
mities more likely. Surgeons, many times, either
perform too much or too little in the technical
maneuvers they execute during the primary oper-
ation. This is the simplistic and most important
factor to keep in mind when evaluating a second-
ary patient. The magnitude of destructiveness to
the cartilage frame or lack of effective structural
shape and support needs to be clearly observed
Table 70.3 Sources for dorsal augmentation
Diced cartilage (septum, ear, and/or rib)
Diced cartilage wrapped in temporal fascia
Diced or other cartilage onlay covered in Alloderm
Crushed/softened septal or conchal cartilage
Rib graft with K-wire fi xation
Alloderm (minimal augmentation/mostly camou fl age)
Temporal fascia or tensor fascia lata (camou fl age only)
Note : Silastic and other foreign implant material are not
recommended
a
b
Fig. 70.3 ( a , b ) Diced cartilage graft wrapped in tempo-
ral fascia: the source for the diced cartilage can be septal,
conchal, or rib. Here, both conchal and septal cartilage
were used and then wrapped in temporal fascia.
Compression of the saline soaked cartilage into a tubular
shape is facilitated by the 1-mL syringe

988
A. Ghavami
and noted preoperatively [ 20, 21 ] . Common
deformities relate to lack of understanding and
respect for the nasal tripod. Since a large hump
and long droopy tip complex is usually encoun-
tered during the primary operation, it is tempting
for surgeons to overresect the dorsal bony and
cartilaginous hump as well as the caudal septum.
This leads to an unnatural sloping to the dorsal
pro fi le and a persistently long and droopy tip.
Since many primary operations from around
the world are being performed using closed tech-
niques with minimal to no grafting, septal donor
cartilage is typically abundant. If septal cartilage
is scant, then conchal cartilage is the next best
option. After ear, the next option is rib cartilage.
The integrity and stability of the medial crura,
lateral crura, alar arch, and domes (middle crura)
should be assessed after all cartilage framework
has been dissected from within the scar encase-
ment [ 22– 24 ] . We will separate the cartilage
frame into its components, beginning with the
upper lateral crura.
70.4
The Upper Lateral Crura
The upper lateral crura (ULC) are critical in over-
all nasal form and function. If they have been
overresected or collapsed, correction is manda-
tory to avoid subsequent functional and aesthetic
problems. Spreader grafts will correct most prob-
lems in this region. Midvault narrowing or wid-
ening should only be evaluated after nasal bone
correction has been performed. The ULC are
connected to the nasal bones and heavily
in fl uenced by the nasal bone position. If ULC
irregularities persist after performing bony altera-
tions, then spreader grafts or autospreader grafts
should be utilized to support them while estab-
lishing a uniform and smooth nasal contour tran-
sition from radix to tip complex [ 25 ] . If dorsal
augmentation is not indicated, then a persistent
open roof deformity should be corrected using
long spreader grafts. They may need to be secured
to the nasal bones with drill holes.
If dorsal augmentation is required, the upper
lateral crura-septal relationship must be estab-
lished fi rst to set the platform for augmentation.
If enough ULC are present and the bony open
roof is not excessive, then autospreader grafts can
be used. This will preserve cartilage donor for
other struts and grafts that may be required. If
not, then true spreader grafts will be necessary
and can provide for a more natural dorsal contour
line while opening the internal valve angle.
Augmentation of the dorsum either to restore
dorsal height or to re fi ne and camou fl age dorsal
contour is usually required in some form or other.
Augmentation material can be made of diced car-
tilage wrapped in fascia (temporal), rib graft,
and/or softened matrices of conchal and septal
remnants covered with a fascial or alloplastic
overlay. After osteotomies are complete, nasal
height will increase a few millimeters, and less
augmentation than previously thought may be
indicated.
Presence of dorsal excess in both the bony
vault and midvault is the most easily treated.
A component dorsal reduction should be per-
formed prior to septal harvesting. By using an
incremental approach to reduction of the bony and
cartilaginous dorsum, overreduction is avoided. It
is important to avoid or correct the presence of
supratip fullness. This is a common complaint of
Middle Eastern patients. They never like fullness
in the supratip, just as they do not like too sharp of
a break in this region. Fullness is avoided by cre-
ating a signi fi cant differential between the dorsal
height and dome projection (6–10 mm). In addi-
tion, the position and rotation of the tip complex
must be strong. If secondary tip drop occurs, the
supratip fullness will become more prominent and
tip projection will appear inadequate. The upper
lateral crura should be conservatively trimmed so
that there is also no excess in width in the scroll
area. This is a very sensitive region to future col-
lapse, so maintenance of some extra support to the
posterolateral region of the lower lateral crura is
preferred over removing too much here.
70.5
The Medial Crura
Fortunately, the medial crura are almost always
intact. Dissection, injury, and instability are usu-
ally reserved to the (lower lateral crura) LLC and

989
70 Secondary Rhinoplasty in the Middle Eastern Patient
domes. However, primary medial crura problems
that have not been addressed do need to now be
handled. It is rare to see excessive medial crural
length treated in closed primary rhinoplasty.
Columellar struts are usually not present, although
this is changing as open rhinoplasty seems to be
gaining more and more popularity. Poor rotation
and elevation of inherently long droopy nasal tips
leads to secondary issues with medial and lateral
crural (LLC) length discrepancies. In order to
establish optimal tip projection and position, a
columellar strut graft and lower lateral crural
strut grafts are often needed. The medial crura
can be excessively short relative to the LLC.
After securing a columellar strut and adjusting
medial crural length, LLC length and position
can then be addressed. If the middle crura or
dome cartilages have been injured or transected,
simple resuturing, with or without graft rein-
forcement, is usually successful. However, tip
projection will likely need to be increased since
damaged cartilages do not sit as stout when they
have been previously injured. Infratip and dome
grafts can improve tip complex durability and
overcome the weakening forces of prior damage.
70.6
The Lower Lateral Crura
It is helpful to preoperatively document the integ-
rity of the tip complex stability by observing and
by palpation of the tip to assess its position and
support. If the lower lateral crura were not origi-
nally supported with strut grafts and/or reduced
in their length, then a long and pointy tip may be
present. It is not uncommon to see “cheating” to
produce instantaneous tip projection and narrow-
ness during the primary operation by destruction
of lower lateral crura integrity via a “Goldman
tip” (transection at the domes) procedure
(Fig. 70.4 ). This may be seen more commonly
when the primary operation was done outside of
the United States.
Secondary correction of the LLC may require
placement of lower lateral crura (alar strut) strut
grafts to stent the external valve and reposition
the LLC either more caudal or cephalad (Fig. 70.5 )
[ 26 ] . There may also be inadequate length to the
LLC. By positioning the LLC struts all the way to
the domes (anterior to the lateral genu), the LLC
component of the nasal tripod can now allow for
optimal tip position and shape. Typically the LLC
are not in alignment and symmetric as one inevi-
tably has migrated posteriorly or cephalically.
After scar and soft tissue release, the LLC can be
supported with various types of strut grafts. Alar
retraction is also caused by this iatrogenically
induced migration, or lack of attention to native
LLC malposition. If struts have not fully cor-
rected the alar retraction, then an alar contour
graft can be used to complete alar rim form.
Figure 70.5 shows the various possibilities in cor-
recting secondary LLC malposition which can
require transection. Subdomal grafts also assist in
realigning the domal segments and can help fl are
out LLC that are stubborn and continue to col-
lapse [ 27 ] . The author will try this more simple
approach fi rst before resorting to long LLC strut
grafts since they use up a lot of the available car-
tilage donor grafts [ 28 ] .
Onlay grafts that are meticulously beveled or
crushed can be placed on top of the LLC to cor-
rect depressions and sharp lateral genu points.
However, if suf fi cient LLC integrity is available,
a lateral crural turnover fl ap can be used [ 29 ] .
A commonly encountered problem is that of
weakened LLC and domal segments, which
twist and migrate medially. This produces a
Fig. 70.4 Middle crura transected (Goldman procedure):
correction requires reapproximation of the crural elements
and usually further strength is needed via onlay grafts and
a columellar strut

990
A. Ghavami
b
a
Fig. 70.5 Lower lateral crural transection, transposi-
tion, and struts: ( a ) note the various possibilities in
manipulation of lower lateral crural position, length,
and support. Struts are not always necessary and
commonly depend on the native strength of the lower
lateral crus. ( b ) Intraoperative view of lateral crural
strut graft in place to strengthen and reposition attenu-
ated LLC

991
70 Secondary Rhinoplasty in the Middle Eastern Patient
“pinched tip” that often deviates to one side. Tip
suturing techniques can be employed through-
out the tip shaping process; however, they play
less of a role in secondary cases since the carti-
lage is not as malleable and strong [ 30– 34 ] .
After adjusting LLC/tripod length and stability,
contour irregularities should be softened and
camou fl aged. A harsh drop-off from the domes
to the alar region can require more than just strut
support. Cartilage remnants can be sutured to
the surface of the LLC to fi ll depressions such as
an unsightly lateral genu transition point [ 35 ] .
Final assessment of the cartilage frame
in fl uence on the skin surface should be made
before correction of scarring or alar base issues.
Crushed cartilage grafts can be placed in select
regions as indicated. It is best to place these grafts
after soaking them in saline and with a bayonet
forceps. After partial closure of the vestibular
incisions and columella, tighter pockets will be
present to accept these grafts. They can be molded
in place. The most common sites that require these
grafts are the rhinion (dorsal bone-cartilage point),
soft triangle, infratip, and paradomal regions.
They provide an elegant fi nal contour enhance-
ment and harsh cartilage edges can be softened.
70.7
Skin/Soft Tissues
The skin of Middle Eastern patients varies greatly.
The majority, however, demonstrate “noncontrac-
tility” in their skin envelope. This is worst when
skin is thicker and is common because of the
expanded skin sleeve present primarily due to an
excessively large bony and cartilage frame (i.e.,
large dorsal hump and long lower lateral crura).
While many patients, particularly female patients,
do have a thinner skin envelope, postoperative
problems related to the unpredictable nature of
skin contraction is also a source of frustration in
secondary cases. The hard soft tissue scarring
encases the delicate tip cartilage (Fig. 70.6 ). This
makes both dissection and treatment of skin irreg-
ularities dif fi cult. Dissection should be performed
meticulously to delineate out the existing carti-
lage frame. The lower lateral crura are commonly
damaged and scant. Their integrity is usually not
intact, and, at times, secondary cases become a
game of “putting the puzzle pieces together.”
Since the cartilage frame is weak, dissection
needs to preserve whatever cartilage continuity is
present by “hugging” the cartilage with the angled
scissors and or scalpel blade. If dissection is car-
ried too super fi cial, two devastating and irrevers-
ible events may occur: (1) the dermis and soft
tissue will become damaged, and (2) there will be
a large amount of hard scar tissue leftover to later
dissect off the cartilage remnants. By staying
beneath the scar plane and super fi cial to the crura,
the goals of revealing the structures in their native
state and preserving vascularity to the overlying
skin are simultaneously attained.
While thinning out the bulky skin/soft tissue
in the paradomal and other tip aesthetic units is
bene fi cial to creating pleasing nasal highlights in
primary rhinoplasty, revisional debulking must
be ultraconservative. It is tempting to thin out
scarred skin, but proper techniques should focus
more on shaping the cartilage framework and
allowing that to in fl uence the skin and external
Fig. 70.6 Extensive scarring encasing remnant carti-
lages: meticulous dissection to delineate the native carti-
lages left behind from the primary operation is mandatory
in order to improve outcomes and better healing of skin/
soft tissues

992
A. Ghavami
nasal appearance. Once the support frame and
nasal frame is fi nalized, the skin can be redraped
and edema/blood gently squeezed out to reveal
the necessity for any soft tissue trimming. At this
time, careful thinning of the skin envelope in
select areas (often the supratip and paradomal
areas) may be bene fi cial. The subdermal plexus
should not be breached and the skin undersurface
should look and feel uniform. Any dents or
signi fi cant variations in skin thickness will show
clearly postoperatively and be unsightly when
fi nal edema resolves.
Permanent super fi cial injuries to the skin orig-
inate from previous primary rhinoplasty or an
unsuccessful revisional surgery. In these situa-
tions, it is prudent to only minimally debulk and,
instead, use temporal fascia or allograft material
such as Alloderm TM (LifeCell Corp., Branchburg,
NJ) to camou fl age these areas during healing.
Subsequent fi llers to correct the super fi cial dam-
age may be required. Judicious use of a postop-
erative steroid injection regimen may serve useful
also once the framework has been reestablished.
Poor alar base, mucosal, and columellar scar-
ring and step-offs can be easily revised. Vestibular
thickened scars and internal lining retraction will
require wide release and meticulous undermin-
ing. Re-apposition that avoids step-offs will be
successful. The most troublesome region is that
of the soft triangle. Retraction in this area is com-
mon and usually requires a combination of lateral
crural repositioning, alar rim grafts, tissue release,
and direct soft triangle direct grafting. These
grafts should be secured because postoperative
migration of cartilage frame, grafts, and/or soft
tissue was likely the initial culprit.
70.8
Alar Base/Sill
The most common issues seen in the alar base are
(1) inadequate interalar narrowing or fl are correc-
tion, (2) asymmetric nostril aperture and alar base
volume, and (3) excessive narrowing or an
arti fi cial appearance to alar base/nostrils. The
easiest problem to correct is inadequate fl are and
interalar correction. This is why this author pre-
fers conservative primary narrowing and alar
base Weir-type excisions. More tissue removal
can be performed at 1-year post rhinoplasty;
however, reversal of excess tissue removal is
extremely challenging and sometimes impossi-
ble. To correct, simple caliper-guided re-excision
of alar base and/or sill regions will be successful.
It is helpful to measure the skin distance from tip
to alar-cheek junction to determine the amount of
alar fl are reduction required. Basilar view should
be carefully studied both preoperatively and
intraoperatively and excess fl are beyond the
medial canthus removed, if indicated. In ethnic
patients with thick skin and excessively bulky
nasal tips, it is best to err on the side of “less is
more” so that a disharmony is not created between
the tip re fi nement possible and the magnitude of
nostril alteration [ 36– 39 ] .
Similarly, previous alar and nostril modi fi cations
that are asymmetric can be remeasured and made
symmetric with asymmetric skin/soft tissue exci-
sion. The most challenging situation is one where
the nostril aperture has been excessively narrowed.
If the patient is seen within the fi rst 3 months, nos-
tril dilators that are commercially available may
either correct or prepare the area for later revision.
Surgically, lateral crural strut grafts and alar con-
tour grafts can fl are out the alar rims. This will bow
out the external valve and improve the nostril con-
striction somewhat. Release of the alar base and
resuturing more laterally can also be attempted.
Augmentation of the alar base and restoration of the
fl ared and convex curvature of the alar-cheek region
are usually required to complete the alar revisions.
Augmentation can utilize fat or dermofatty tissue
grafts, pedicled fl aps from the cheek, or alloplastic
material. The author prefers using excised scar tis-
sue, remnant crushed or diced cartilage grafts, fas-
cia, or perichondrium. The choice of autogenous
material largely depends on availability.
Excessive sill excision is the most dif fi cult to
reverse or correct. A tunneled superiorly based
nasolabial fl ap can be interposed to expand the
sill. This can be performed bilaterally, but patients
should be thoroughly consented regarding the
nasolabial fold scarring and the staged nature of
this procedure. This fl ap can also be performed
using a two- or three-staged technique without
tunneling. Skin grafts from the ear can also be
used with or without cartilage depending on the
severity of skin retraction.

993
70 Secondary Rhinoplasty in the Middle Eastern Patient
Case 1 (Fig. 70.7 )
a
Fig. 70.7 ( a ) Preoperative 26-year-old Iranian (Persian)
female who had tip overprojection, supratip fullness,
uni fi ed pointy “Goldman” tip, under-resection of the dor-
sum, infratip lobule fullness, and dynamic tip droopiness.
( b ) Postoperative following reversal of the Goldman tip
by reapproximation of the transected middle crura, com-
ponent dorsal reduction, low-to-low percutaneous (J-type)
osteotomies, a tip onlay graft, a columellar strut, alar con-
tour grafts, subdomal graft, a softened/crushed infratip
shield graft, turbinoplasty, and spreader grafts
70.9
Cases

994
A. Ghavami
This 26-year-old Iranian (Persian) female pre-
sented with tip overprojection, supratip fullness,
uni fi ed pointy “Goldman” tip, and under-resection
of the dorsum. She also complained of infratip
lobule fullness and dynamic tip droopiness. An
open secondary rhinoplasty was performed. The
Goldman tip was reversed by reapproximation of
the transected middle crura. A component dorsal
reduction was performed, as well as low-to-low
percutaneous (J-type) osteotomies, a tip onlay
graft, a columellar strut, alar contour grafts, sub-
domal graft, and a softened/crushed infratip shield
graft. Cartilage source was septal and right con-
cha. A turbinoplasty was also performed as well as
spreader grafts. She is happy with the result. She
also received three sessions of steroid injections.
b
Fig. 70.7 (continued)

995
70 Secondary Rhinoplasty in the Middle Eastern Patient
Case 2 (Fig. 70.8 )
a
Fig. 70.8 ( a ) Preoperative 22-year-old Lebanese-American
female who had a prior unsatisfactory rhinoplasty. She
had persistent and inadequately treated width of her nose,
poor dorsal aesthetic lines, bulbous tip, convex dorsal
pro fi le line, and wide nostrils. ( b ) Postoperative; after
open rhinoplasty J-type percutaneous osteotomies,
autospreader fl aps, component dorsal reduction, tip
de fi ning sutures, columellar strut, onlay tip and infratip
grafts (minimally crushed), soft triangle graft, soft tissue
scar debulking, and alar base and sill excisions

996
A. Ghavami
This 22-year-old Lebanese-American female
had a prior unsatisfactory rhinoplasty. She was
unhappy with the persistent and inadequately
treated width of her nose as a whole. She was par-
ticularly concerned with her wide dorsal aesthetic
lines, bulbous tip, convex dorsal pro fi le line, and
b
Fig. 70.8 (continued)

997
70 Secondary Rhinoplasty in the Middle Eastern Patient
Case 3 (Fig. 70.9 )
Fig. 70.9 ( a ) Preoperative 25-year-old Iranian-American
female with persistent long nose and droopy tip despite a
previous open rhinoplasty with continued deformities
including long, droopy nose with an unre fi ned tip, and tip
projection was excessive as was her overall nasal length,
lower lateral crural length, and medial crural length. ( b )
Postoperative following reduction of the nasal tripod via
transection and shortening of her lower later and medial
crura as well as bilateral short lateral crural strut grafts
(these do not extend into a soft tissue pocket in the alar
base). This also corrected her alar columellar imbalance.
She had re-osteotomies percutaneously as well as a com-
ponent dorsal reduction of her dorsal pro fi le for the persis-
tent hump and had her depressor septi nasi muscle
completely resected, and she received one session of ste-
roid injection to the supratip and paradomes at 3 months
a

998
A. Ghavami
wide nostrils. She required an open rhinoplasty with
attention to narrowing and re fi ning of everything.
Speci fi c techniques include J-type percutaneous
osteotomies, autospreader fl aps, component dorsal
reduction, tip de fi ning sutures, columellar strut,
onlay tip and infratip grafts (minimally crushed),
b
Fig. 70.9 (continued)

999
70 Secondary Rhinoplasty in the Middle Eastern Patient
soft triangle graft, and soft tissue scar debulking.
Alar base and sill excisions were performed since
the previous ones were insuf fi cient and too conser-
vative. Cartilage source was septal. A prophylactic
turbinoplasty was also performed.
This 25-year-old Iranian-American female
presented a very challenging case that involved
correction of her persistently long nose and
droopy tip despite a previous open rhinoplasty
with continued deformities including long,
droopy nose with an unre fi ned tip. Her tip projec-
tion was excessive as was her overall nasal length,
lower lateral crural length, and medial crural
length. Her nasal tripod required reduction via
transection and shortening of her lower lateral
and medial crura as well as bilateral short lateral
crural strut grafts (these do not extend into a soft
tissue pocket in the alar base). This also corrected
her alar columellar imbalance. Furthermore, she
did require re-osteotomies percutaneously as well
as a component dorsal reduction of her dorsal
pro fi le for the persistent hump. Depressor septi
nasi muscle was completely resected [ 40 ] . She
received one session of steroid injection to the
supratip and paradomes at 3 months. While her
result is not ideal, she is realistic about the limita-
tion of her nose and is very happy with the results
of the revision.
References
1. Rohrich RJ, Ghavami A (2009) Rhinoplasty for Middle
Eastern noses. Plast Reconstr Surg 123(4):1343–1354
2. Daniel RK (2009) Middle Eastern rhinoplasty in the
United States. Part I. Primary rhinoplasty. Plast
Reconstr Surg 124(5):1630–1639
3. Daniel RK (2009) Middle Eastern rhinoplasty in the
United States. Part II. Secondary rhinoplasty. Plast
Reconstr Surg 124(5):1640–1648
4. Ghavami A, Rohrich RJ (2009) Discussion of Daniel
RK. Middle Eastern rhinoplasty in the United States:
parts 1 and 2. Plast Reconstr Surg 124(5):1649–1651
5. Ghavami A, Rohrich RJ (2009) The ethnic rhino-
plasty. In: Aston SJ, Steinbrech DS, Walden JL (eds)
Aesthetic plastic surgery. Saunders, London
6. Rohrich RJ, Muzaffar AR (2003) Rhinoplasty in the
African-American patient. Plast Reconstr Surg 111(3):
1322–1339
7. Rohrich RJ, Kenkel JM (1998) The de fi nition of
beauty in the Northern European. In: Matory WE Jr
(ed) Ethnic consideration in facial aesthetic surgery,
chapter 8. Lippincott-Raven, Philadelphia
8. Bizrah MB (2002) Rhinoplasty for Middle Eastern
patients. Facial Plast Surg Clin North Am 10(4):381–396
9. Beheri GE (1984) Rhinoplasty in Egyptians. Aesthetic
Plast Surg 8(3):145–150
10. Foda HM (2004) External rhinoplasty for the Arabian
nose: a columellar scar analysis. Aesthetic Plast Surg
28(5):312–316
11. Guyuron B (1998) The Middle Eastern nose. In:
Matory WE Jr (ed) Ethnic consideration in facial aes-
thetic surgery. Lippincott-Raven, Philadelphia
12. Flowers RS (1977) The surgical correction of the non-
Caucasian nose. Clin Plast Surg 4(1):69–87
13. Gonzales-Ulloa M (1984) The fat nose. Aesthetic
Plast Surg 8(3):135–140
14. Rohrich RJ, Muzaffar AR, Janis JE (2004) Component
dorsal hump reduction: the importance of maintaining
dorsal aesthetic lines in rhinoplasty. Plast Reconstr
Surg 114(5):1298–1308
15. Guyuron B (1989) Guarded burr for deepening of naso-
frontal junction. Plast Reconstr Surg 84(3):513–516
16. Sheen JH, Sheen A (1987) Aesthetic rhinoplasty, 2nd
edn. Mosby, St. Louis
17. Peck GC (1984) Techniques in aesthetic rhinoplasty.
Thieme-Stratton, New York
18. Daniel RK, Calvert JW (2004) Diced cartilage grafts
in rhinoplasty surgery. Plast Reconstr Surg 113(7):
2156–2171
19. Daniel RK (2008) Diced cartilage grafts in rhino-
plasty surgery: current techniques and applications.
Plast Reconstr Surg 122(6):1883–1891
20. Gunter JP, Hackney FL (2007) Clinical assessment and
facial analysis. In: Gunter JP, Rohrich RJ, Adams WP
(eds) Dallas rhinoplasty: nasal surgery by the masters,
2nd edn. Quality Medical Publishing, St. Louis, p 105
21. Adams WP Jr, Rohrich RJ, Hollier LH, Minoli J,
Thornton LK, Gyimesi I (1999) Anatomic basis and
clinical implications for nasal tip support in open versus
closed rhinoplasty. Plast Reconstr Surg 103(1):255–261
22. Constantian MB (1993) Functional effects of alar car-
tilage malposition. Ann Plast Surg 30(6):487–499
23. Constantian MB (2005) The boxy nasal tip, the ball tip,
and alar cartilage malposition: variations on a theme –
a study in 200 consecutive primary and secondary rhi-
noplasty patients. Plast Reconstr Surg 116(1):268–281
24. Ghavami A, Janis JE, Acikel C, Rohrich RJ (2008)
Tip shaping in primary rhinoplasty: an algorithmic
approach. Plast Reconstr Surg 122(4):1229–1241
25. Byrd HS, Meade RA, Gonyon DL Jr (2007) Use of
the autospreader fl ap in primary rhinoplasty. Plast
Reconstr Surg 119(6):1897–1902
26. Gunter JP, Friedman RM (1997) Lateral crural strut
graft: technique and clinical applications in rhino-
plasty. Plast Reconstr Surg 99(4):943–952
27. Guyuron B, Poggi JT, Michelow BJ (2004) The sub-
domal graft. Plast Reconstr Surg 113(3):1037–1040
28. Ghavami A (2011) The lower lateral crura: transec-
tion, transposition, and struts. In: 16th annual rhino-
plasty society annual meeting, Boston, 2011

1000
A. Ghavami
29. Janis JE, Trussler A, Ghavami A, Rohrich RJ, Gunter
JP (2009) Lower lateral crura turnover fl ap in primary
rhinoplasty. Plast Reconstr Surg 123(6):1830–1841
30. Behmand RA, Ghavami A, Guyuron B (2003) Nasal
tip sutures part I: the evolution. Plast Reconstr Surg
112(4):1125–1128
31. Guyuron B, Behmand RA (2003) Nasal tip sutures
part II: the interplays. Plast Reconstr Surg 112(4):
1130–1145
32. Tebbetts JB (1994) Shaping and positioning the nasal
tip without structural disruption: a new systematic
approach. Plast Reconstr Surg 94(1):61–77
33. Rohrich RJ, Adams WP Jr (2001) The boxy nasal tip:
classi fi cation and management based on alar cartilage
suturing techniques. Plast Reconstr Surg 107(7):
1849–1863
34. Rohrich RJ, Raniere J Jr, Ha RY (2002) The alar contour
graft: correction and prevention of alar rim deformities
in rhinoplasty. Plast Reconstr Surg 109(7):2495–2505
35. Toriumi DM (2006) New concepts in nasal tip con-
touring. Arch Facial Plast Surg 8(3):156–185
36. Gunter JP, Rohrich RJ, Friedman RM (1996)
Classi fi cation and correction of alar-columellar dis-
crepancies in rhinoplasty. Plast Reconstr Surg 97(3):
643–648
37. Daniel RK (2001) Rhinoplasty: large nostril/small
tip disproportion. Plast Reconstr Surg 107(7):
1874–1881
38. Guyuron B, Ghavami A, Wishnek SM (2005)
Components of the short nostril. Plast Reconstr Surg
116(5):1517–1624
39. Guyuron B (2001) Alar rim deformities. Plast
Reconstr Surg 107(3):856–863
40. 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

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M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_71, © Springer-Verlag Berlin Heidelberg 2013
71
71.1
Introduction
The recent increase in aesthetic facial surgery and
use of the Internet to obtain information in Asia
has yielded a more discriminating, informed patient
with higher expectations. Consequently, the num-
ber of revision rhinoplasties has increased rapidly.
To correct postoperative rhinoplasty deformities, it
is important to identify the deformity using a sys-
temic approach. However, most facial analysis
studies have been based on Caucasian characteris-
tics, and none have analyzed the deformities of
postrhinoplasty patients in Asians, although obvi-
ous ethnic differences exist in the features and
treatment of revision rhinoplasty [ 1, 2 ] .
More than in any other surgery, rhinoplasty
has the highest potential for a secondary surgery.
The reasons for a secondary rhinoplasty include
patient dissatisfaction over the cosmetic result of
surgery and complications. Because surgical
complication is usually accompanied by a cosmetic
failure, it is dif fi cult to make a clear distinction
between the two aspects. Rhinoplasty is per-
formed with a clear cosmetic purpose in mind,
and whether the patient is satis fi ed with the aes-
thetic outcome determines the success or failure
of the surgery. However, as this is strictly a sub-
jective matter, it is inevitable that the level of sat-
isfaction varies from person to person. This fact
is a major reason behind the relatively high likeli-
hood of a secondary surgery. In addition, it is
quite common to see the use of an implant mate-
rial during rhinoplasty; thus, surgical complica-
tions deriving from the natural properties of the
implant material lead to greater chances of sec-
ondary surgery. Furthermore, changes in the sup-
porting structure of the nose occurring as a
consequence of surgery can over time greatly
affect the shape and function of the nose. This
also is another factor that increases the likelihood
of a revision surgery. Clearly, then, revision rhi-
noplasty is an extremely complex fi eld of surgery
that involves various dif fi cult problems, and sur-
geons must be fully aware of the dif fi culty and
importance of revision surgery.
71.2
Surgical Technique-Related
Problems of Revision Surgery
The technical dif fi culties related to revision sur-
gery as compared to primary surgery are the fol-
lowing [ 3 ] :
1. Distorted normal anatomical structure due to
previous operation.
2. Dif fi culties in the dissection of the skin and
cartilaginous tissue.
Revision Rhinoplasty of Asian Noses
Chan Hum Park
C.-H. Park , M.D., Ph.D.
Department of Otorhinolaryngology – Head and Neck
Surgery , Chuncheon Sacred Heart Hospital, Hallym
University College of Medicine , 153 Kyo-Dong ,
Chunchon, Kangwon , 200-704 , Korea
Nano Bio Regenerative Medical Institute, Hallym
University , Chunchon , Korea
e-mail: hlpch@paran.com

1002
C.H. Park
3. Heightened risk of infection due to compro-
mised blood supply in the revision wound.
4. Higher probability of severe contracture of the
wound during recovery compared to the pri-
mary surgery, thereby increasing the risk that
the surgical result would be contrary to
expectation.
5. As opposed to the increasing dif fi culty in
obtaining suf fi cient amount of autologous
graft material, the need for such a graft
becomes greater than in a primary surgery.
6. The damage to the nasal supporting structure
caused by the primary surgery can be aggra-
vated by the secondary surgery.
71.3
Types of Problems Requiring
Secondary Surgery and
Methods of Treatment
In revision rhinoplasty, as an absolute anatomic
diagnosis is often dif fi cult to make preoperatively,
patients are asked to consider the risks and bene fi ts
of the surgery and to return for a second consulta-
tion [ 4 ] . Their attitude is thought to be more posi-
tive at the reevaluation when photographs
outlining the deformity are reviewed with the
patient and the limitations of revision surgery are
reiterated. The surgeon must feel con fi dent that
the patient is a good psychological candidate
before undertaking this surgery. During surgery,
the preoperative diagnosis is con fi rmed or a dif-
ferent diagnosis is made by direct observation [ 5 ] .
In addition, many noses on which an operation is
performed will have more than one deformity
[ 13 ] . Adamson categorized revision rhinoplasty
patients according to the number of deformities
present. In his study, 50% of the patients had 1
deformity, 30% had 2 deformities, and 20% had 3
or more deformities. Unlike other studies in which
almost all of the patients were Caucasians, the
patients in our data were all Asians, and the most
common location of a deformity was the upper
third (89%, 75 patients), followed by the lower
third (68%, 57 patients) (Table 71.1 ).
In Korea, unlike among Western countries
where complex tip surgery or reduction is fre-
quently performed, the most common surgery
being carried out is the dorsal augmentation and tip
projection surgery [ 2, 3 ] . Various materials have
been used to perform dorsal augmentation, which
is known to be the most common rhinoplasty
among Asians. But to date, a completely suitable
and ideal material for this procedure is yet to be
discovered. The best implant materials currently in
use in dorsal augmentation are the autologous
cartilage and the autologous bone. However, the
drawbacks of using these materials are that they are
dif fi cult to acquire in suf fi cient quantity, they require
a supplementary surgery to harvest the materials,
and they are absorbable. Among the alloplastic
implants used in the past are numerous synthetic
materials such as Supramid, Mersilene (woven
polyethylene terephthalate mesh), Proplast (porous
polytetra fl uoroethylene and pyrolyzed carbon),
and silicone. More recently, Gore-Tex, Medpor,
and Alloderm (acellular human dermal allograft)
are
being
used
for
dorsal
augmentation
(Table 71.2 ).
The deviated dorsum is due to subluxation or
a deviated septum in the upper portion of the
nose, unequal treatment of the two nasal bones,
or failure to correct preexisting asymmetry [ 6, 7 ] .
Since most patients had undergone augmentation
previously, the asymmetry seen in this study was
mainly due to inadequate insertion or dislocation
of graft material, bony asymmetry secondary to
incomplete osteotomies, or preexisting bony
asymmetry [ 8– 10 ] . The author most often treats
the dorsal deviation with a rasp, camou fl age graft,
and Gore-Tex augmentation. The most common
abnormality in the lower nasal third in terms of
nasal tip position is underprojection, the majority
of which is caused by the disruption of one or
Table 71.1 Type of revision rhinoplasty deformity
Location of
deformity
Upper
third
Middle
third
Lower
third
Upper + middle
third
Upper + lower
third
Middle + lower
third
Entire
nose
No. of patients (%)
75 (89)
22 (26)
57 (68)
4 (5)
37 (44)
4 (5)
13 (15)

1003
71 Revision Rhinoplasty of Asian Noses
more of the three important tip support mecha-
nisms, namely, the attachment of the medial crura
to the nasal septum, the shape and resilience of
the alar cartilages, and the attachment of the alar
cartilages to the upper lateral cartilages. Most of
the underprojection of nasal tips was due to the
absorption of graft materials used in the previous
surgery. The evaluation of nasal tip shape showed
that asymmetry was common. Directly related to
the loss of tip projection, the dorsal angles widen,
changing the tip from pointed to a wider, blunted
trapezoid shape. Subsequently, the skin soft tis-
sues must adapt to the smaller nasal tip cartilage
skeleton, leading to skin thickening and blunting
[ 11 ] . Scar formation, particularly after traumatic
dissection of the soft tissue envelope from the
nasal skeleton, may further compound the prob-
lem [ 2, 9 ] . For the tip, to correct deformities, the
transdormal and interdormal suture technique, col-
umellar struts, and onlay grafts are used [ 12– 14 ] .
Saddlenose, the most common problem in middle
third, is due to the excessive removal of bone or
cartilage from the nasal dorsum [ 13 ] . Rhinoplasty
of Asian noses differs in many fundamental ways
from that of Caucasian noses (Tables 71.3 , 71.4 ,
and 71.5 ).
71.4
Dorsal Augmentation
for Asian Nose
The objective of Asian rhinoplasty is often aug-
mentation of both the depressed dorsum and
receded tip. But Caucasian rhinoplasty frequently
mandates the reduction of a prominent dorsum or
bulbous tip. The underlying nasal anatomy of
Table 71.2 Previous rhinoplasty: analysis
Augmentation – 64 patients
Graft material
Silicone
Gore-Tex
Rib cartilage
Septal cartilage
Injection
No. (%)
27 (42)
23 (36)
9 (14)
3 (5)
2 (3)
Tip surgery – 62 patients
Graft material
Septal cartilage
Silicone
Auricular cartilage
Rib cartilage
Injection
No. (%)
38 (62)
13 (21)
9 (15)
1 (1)
1 (1)
Upper third operation – 43 patients
Operating technique
Medial & lateral
osteotomy
Rasping
Medial & interme-
diate osteotomy
Camou fl age
No. (%)
25 (58)
8 (18)
7 (16)
3 (7)
Table 71.3 Deformities of the lower third
Deformities
No. (%)
Tip
Asymmetric
44 (77)
Full
32 (58)
Underprojecting 24 (42)
Contracted
6 (9)
Overprojecting
1 (1)
Columella
Hanging
5 (8)
Retracted
4 (7)
Deviated
4 (7)
Alar retraction
17 (30)
Asymmetric nasal valve
16 (28)
Table 71.4 Deformities of the middle third
Deformities
No. (%)
Saddlenose
10 (46)
Widened middle dorsum
6 (27)
Uneven middle dorsum
5 (23)
Pollybeak
5 (23)
Pinched supratip
3 (14)
Table 71.5 Deformities of the upper third
Deformities
No. (%)
Dorsum
Deviated
64 (85)
Irregular
62 (82)
Widened
13 (17)
Infection
11 (15)
Implant showing
10 (13)
Overaugmentation
8 (10)
Protrusion
6 (8)
Underaugmentation
5 (6)
Blunting nasofrontal angle
1 (1)
Park et al. [ 3 ]

1004
C.H. Park
Asian patients also is remarkably different, exhib-
iting a thicker skin envelope and weaker, ill-de fi ned
cartilages. The surrounding facial structures tend
to be fl atter in their dimensions because of a fuller
upper eyelid, shallower orbital socket, malar hyp-
oplasia, and premaxillary de fi ciency. The fl atter
contour of the Asian midface limits the amount of
augmentation that can be achieved without dis-
turbing the overall facial harmony and balance.
And we will fi nely describe the dorsal augmenta-
tion for Asian nose. If we cannot understand the
dorsal augmentation of nose, we cannot perform
the revision rhinoplasty in Asian.
71.4.1 Basic Knowledge of Dorsal
Augmentation
Dorsal augmentation is a surgery that is per-
formed for the purpose of elevating the nasal dor-
sum using an autologous tissue or an alloplastic
implant when the nasal dorsum has been lowered
by a congenial cause, trauma, in fl ammation, or
reduction rhinoplasty. The method of dorsal aug-
mentation and the degree of elevation are chang-
ing with the times. In the past, the protruding
nose common among celebrities was popular but,
more recently, a more inconspicuous and natural-
looking nose is popular. Thus, to achieve a suc-
cessful augmentation, the surgeon needs to be
attentive not only to the harmony surrounding the
nose but the contemporary trend of beauty. The
preoperative considerations that require the sur-
geons’ attention are [ 15 ] :
1. It is unwise to determine the shape of the
patient’s nose based solely on numerical fac-
tors without considering the overall harmony
of the patient’s face, and there might be a dis-
crepancy between the ideal shape of the nose
and that desired by the patient. However, the
surgeon must always be mindful of the ideal
shape of the nose when contemplating a dorsal
augmentation.
2. The elements of an ideal Asian nose are:

(a) The length of the nose equals two-thirds
vertical length of the midface.

(b) The height of the nasal tip equals one-
third length of the nose.

(c) The width of the nasal bony part is 75–85%
that of the width of the alar base.

(d) The width of the alar base is the same
with the width of the palpebral fi ssure.

(e) Nasofrontal angle is 30–35°.

(f) Columellar labial angle among men is
90–95° and 95–100° among women.

(g) Viewing from the lateral, the columella pro-
trudes forward 2–3 mm more than the alar rim.
3. Generally, if only a slight augmentation is
needed, dermal fat graft, septal cartilage graft,
or conchal cartilage graft is used. In case of an
intermediate degree of augmentation, silicone
or Gore-Tex is usually used. And in cases
where 8 mm or more of augmentation is
needed, the use of costal cartilage graft or iliac
bone graft is recommended. Nevertheless, the
use of an autologous tissue must always be
given top priority.
4. The degree of augmentation must always be
decided with the nasal tip surgery in mind.
Just elevating the nasal dorsum will not make
the nose beautiful. The nasal tip must be a lit-
tle bit higher than the nasal dorsum in order to
make a supratip break. Thus, if the nasal dor-
sum is elevated a lot, the nasal tip must be
raised in proportion, and if the nasal dorsum is
raised a little, the degree of the nasal tip pro-
jection is adjusted accordingly. One must be
mindful of the fact that the nasal dorsum and
nasal tip surgeries are surgeries that must be
performed to achieve a mutual harmony rather
than as separate surgeries.
5. Analyzing and making reference of the preop-
erative photographs of the patient can be help-
ful in determining the size of the implant
material and the method of surgery needed.
71.5
Length of the Nose
Determining the length of the implant also deter-
mines the length of the nose. Thus, it is important
to make the correct decision regarding the suit-
able length of the patient’s nose. For patients with
a round-shaped face and small eyes and mouth, a
shorter nose is more suitable than a longer nose.
Conversely, for patients with an elongated and

1005
71 Revision Rhinoplasty of Asian Noses
angled face, a long and elevated nose with a clear
de fi nition is more suitable than a small nose.
Likewise, harmony of the nose with the overall
surrounding structure is important. Also, exces-
sive augmentation and lengthening of the nose
can always result in disasters such as the extru-
sion of the implant. Therefore, any request by the
patient for an excessive augmentation must be
rejected outright.
The relationship to the chin should be taken
into consideration. Although a close relationship
exists between the chin and the nasal tip surgery
and between the chin and dorsal augmentation, it
is often disregarded. The chins of Koreans are
generally retruded so that if just a dorsal augmen-
tation is performed, it would in many cases make
the chin look even more retruded. If patients with
a low nasal dorsum and tip as well as a preexist-
ing microgenia or retrognathia undergo surgery
to elevate the low nasal dorsum and tip, it will
result in the lip and chin being repositioned rela-
tively further backward. Thus, to maintain the
symmetry of the face, it is desirable to perform
genioplasty
concurrently
or
subsequently
(Fig. 71.1 ).
The thickness of the patient’s skin must be
taken into consideration. If a dorsal augmentation
is performed excessively on a patient whose skin
is too thin, there is a risk that the outline of an
implant will become visible or an extrusion of the
implant will take place. Conversely, a skin that is
too thick has the disadvantage of decreasing the
effect of nasal augmentation. Therefore, in case
of a thin skin, it is preferable to use soft implants
such as Gore-Tex or autologous implants rather
than silicone. In case of a thick skin, a relatively
solid material such as silicone or reinforcement
Gore-Tex should be preferred.
Fig. 71.1 ( Left ) Preoperative patient with a micrognathia. ( Right ) Following tip projection surgery, the patient’s chin
seems more drawn back

1006
C.H. Park
The surgeon must verify whether or not there
are any physiological or anatomical problems
within the nasal cavity. Should septal deviation,
turbinate hypertrophy, or sinusitis exists within
the nasal cavity, the patient may complain of an
increased nasal obstruction despite being highly
satis fi ed cosmetically. Thus, it is advisable to
always be fully aware of any problems within
the patient’s nasal cavity prior to surgery.
Particular attention is required when there is
infection within the nasal cavity as the risk of
infection
following
dorsal
augmentation
increases in such a case. In addition, in case the
patient is diagnosed with chronic in fl ammation
due to allergic rhinitis so that blowing or touch-
ing the nose is unavoidable, there is a high risk
that scarring will occur at the incision area or
that the implant will migrate. In such a case,
medication such as antihistamine needs to be
prescribed.
The occupation and the circumstances sur-
rounding the patients need to be considered. The
general population or housewives generally pre-
fer a natural-looking but slightly augmented nose,
while entertainers or those working in service-
oriented fi elds prefer robust-looking features and
relatively high nose. Therefore, deciding the
extent of dorsal augmentation based on patient’s
occupation can reduce possible discontent that
may arise later on.
71.6
Trimming the Implant
71.6.1 Determining the Elevation
of Each Individual Area
The surgeon should reexamine the contents of
consultation and preoperative photographs of
the patient carefully before undertaking a sur-
gery. Though the surgeon need not be swayed
by the wishes of the patient, determining the
degree of augmentation corresponding to the
wishes of the patient in mind can reduce post-
operative complaints. Basically, if the nasal
dorsum is augmented, the nose will appear lon-
ger, the nose will look narrower, and the inter-
canthal distance between the eyes will look
shorter.
71.6.1.1 Nasion (Nasal Root)
1. Both edges of the alloplastic implant to be
inserted should be trimmed to be as slim as
possible.
2. If an area between the eyes that already looks
crowded together is excessively elevated
through dorsal augmentation, it can worsen
the harmony between the nose and eyes and
cause patient dissatisfaction. Therefore, not
only must one be cautious of performing this
procedure but the patient must be fully advised
on this possibility prior to surgery.
3. In case of a fl at forehead, if this area is overly
augmented or augmented all the way to the
upper nasion region, a lion nose, a nose with-
out a distinct starting point, can result
(Fig. 71.2 ). Therefore, it is desirable to take
the relationship with the forehead into consid-
eration
when
deciding
the
extent
of
augmentation.
71.6.1.2 Nasal Dorsum
In determining the fi nal height of the nasal dor-
sum, the shape subsequent to a nasal tip or hump
surgery or following the performance of an
osteotomy needs to be taken into consideration.
Therefore, in most cases, it is best to decide on
the height of the nasal dorsum after such proce-
dures are completed. In particular, when implants
such as silicone or costal cartilage with a certain
level of hardness are being used, care must be
exercised on the following aspects while trim-
ming the base area of the implant:
1. The base of the silicone or costal cartilage
must be trimmed so that it tightly contacts
with the contour of the nasal dorsum.
Otherwise, the nasal dorsum area will get dis-
jointed, creating a seesaw phenomenon, with
up and down motion by palpation, after sur-
gery and causing the implant to become devi-
ated. It will also cause the implant to show
through the skin. Also, in cases where the
implant is inserted without fi rst removing the
hump, the base of the implant coming in touch
with the hump does not conform to the con-
tour of the hump. In contrast, Gore-Tex or
other soft implants rarely lead to a seesaw
phenomenon, but the irregular contour of the
nasal dorsum can become evident.

1007
71 Revision Rhinoplasty of Asian Noses
2. Both sides of the implant must be made sym-
metrical through trimming, and the surgeon
should consider the fact that if the implant is
asymmetrical, it can slide down toward one side.
3. Among the silicone products, those that come
without any holes should be perforated with
two or three small holes so that the surround-
ing tissues can grow into it. Doing so will help
fi xate the silicone.
71.6.1.3 Supratip
The cases between men and women are different.
It is preferable that the lateral view of the supratip
among men should be fashioned in a straight shape
(Fig. 71.3 ), while, among women, it is advisable to
trim the supratip in order to lower it slightly, so the
nasal tip area becomes prominent in the form of a
delicately concave dorsal line (Fig. 71.3 ).
71.7
Implant Material
Materials used in rhinoplasty can be divided
largely between an autogenous tissue, the allo-
plastic material, and the homologous material.
Certainly, the best implant material is the autolo-
gous tissue. However, in cases such as among
Asians where substantial dorsal augmentation is
needed, there is often no choice but to use an allo-
plastic implant. Alloplastic implants generally
need to satisfy the requirements of biocompati-
bility, nontoxicity, chemical safety, and nonim-
munity. They must also not induce infection and
cancer or produce toxic substance while being
dissolved within the body. Also, during recovery,
it should be able to preserve the original size,
shape, and solidity. Currently, the most common
alloplastic implants in use that suf fi ce these con-
ditions are silicone, Gore-Tex, and Medpor.
However, as each respective surgeon tends to
profess the superiority of his or her own favorite
implants, surgeons performing their very fi rst
surgery can become confused. Nevertheless, as
alloplastic implants, unlike autologous tissue,
can always lead to problems, individual surgeons
should have a thorough understanding on the
strengths and weaknesses of each respective
material [ 16, 17 ] .
71.7.1 Silicone (Silicone Rubber,
Silicone Elastomer)
71.7.1.1 Advantages
1. With its stable chemical structure, silicone
causes little tissue reaction.
2. It is easy to handle, and various ready-made
products make application convenient.
Fig. 71.2 A patient with a fl at forehead undergoing excessive augmentation at the nasion, which can result in a lion
nose

1008
C.H. Park
3. Relative hardness makes it suitable for fash-
ioning the desired nasal shape for Asians with
a thick skin.
71.7.1.2 Disadvantages
1. A formation of a fi brous capsule around the
implant can make it show through or become
crooked.
2. Because the surrounding connective tissue
cannot grow into the silicone, the implant can
be displaced.
3. There is a risk that severe skin tension can
lead to infection or extrusion.
4. Stiff sensation can cause discomfort among
patients.
71.7.1.3 Types of Silicone
In the past, surgeons used to fashion customized
silicone implants to fi t the nose of individual
patients from a silicone block. However, the cur-
rent trend is for doctors to use the ready-made
dorsal implants that are available in various shapes
and sizes. Depending on its hardness, the silicone
can be divided between the soft, medium, and
hard types. If a semitransparent silicone was used
for dorsal augmentation, there are instances where
the outline of the silicone becomes visible when
the patient exposes her nose to bright light. This
can be prevented by using a white silicone but,
comparative to a semitransparent product, there is
a drop in the degree of purity. The skin of Asians,
compared to Westerners, is thicker so that there is
a lesser risk of an implant extrusion after surgery.
Thus, silicone is being used with relative safety
for Asians. The reported results of a long-term
follow-up study conducted after implanting sili-
cone for Asians were excellent. Nevertheless,
constant care against the shortcomings of silicone
is needed, and the importance of regular checkup
should be stressed upon the patient (Fig. 71.4 ).
71.7.1.4 Precautions During the
Use of Silicone
Silicone is relatively easy to handle and there are
many ready-made products available in the mar-
ket. The ready-made products can be divided
a
b
Fig. 71.3 Difference in the ideal pro fi le. Male ( a ) and female ( b )

1009
71 Revision Rhinoplasty of Asian Noses
largely into L- and I-shaped implants (Fig. 71.5 ).
In the past, an L-shaped or a variation of I-shaped
silicone (covering the nasal tip) capable of cov-
ering all the way to the nasal tip was favored.
However, because the nasal tip area is an area
that is always exposed to exterior stimulation,
however thick the Asian nasal tip subcutaneous
tissue may be, there is a risk that continued stim-
ulation and aging may lead to extrusion. Thus,
an I-shaped implant that can utilize silicone at
the nasal dorsum area and an autologous mate-
rial (septal cartilage, conchal cartilage) at the
nasal tip area should be selected. In addition, an
I-shaped product with holes in the silicone is
effective in preventing displacement by allowing
the surrounding tissues to grow into the holes.
Because silicone always has a stronger solid-
ity compared to other implants, one must always
watch out for possible extrusion and visibility:
1. In cases where the skin is too thin
2. When patients had a previous experience of
in fl ammation due to silicone
3. When the periosteum of the nasal dorsum is so
severely damaged that a pocket cannot be
created
4. When a capsule was created excessively by a
preexisting silicone or when the skin is ren-
dered thin by removing the capsule
In such cases, the use of implants (autologous
tissue, Gore-Tex, etc.) other than a silicone should
be considered.
71.7.1.5 Method of Inserting
the Silicone
To insert the silicone, an open rhinoplasty
approach or an endonasal approach is used. As
with other implants, when inserting silicone, one
must be mindful of the following aspects: The
pocket must be made precisely. The subperiosteal
placement of silicone implant may lead to the
resorption of the underlying nasal bone by exert-
ing too much pressure. However, if it is inserted
above the periosteum, the implant can shift when
touched and become visible. Therefore, the
implant must be inserted within the subperiosteal
space, and, even with the risk of bone resorption,
in reality that is not a problem because a rela-
tively thick fi brous capsule gets formed around
the implant. At this time, one must be mindful of
the fact that, in the case of open rhinoplasty
approach, one can locate the subperiosteal space
fi rsthand by using a Joseph knife or periosteal
elevator at the juncture of the nasal bone and
upper lateral cartilage (Fig. 71.6 ). However, in
the case of an intranasal approach, it is often
Fig. 71.4 Following insertion of silicone: ( Top )
Extrusion. ( Bottom ) Infection
Fig. 71.5 Diverse types of silicone implant. I-shaped and
L-shaped silicone implants

1010
C.H. Park
dif fi cult to accurately locate the subperiosteal
plane. In particular, beginners frequently tend to
create a pocket in the space above the periosteum
which is relatively easy to dissect. In the case of a
pocket created above the periosteum, if the space
is felt with a periosteal elevator, it would feel a bit
sleek, and if it is lifted toward the skin, it can be
raised smoothly without any resistance from the
surrounding tissues. However, when a pocket is
created at the precise space, it will convey a
de fi nite feel of the periosteal elevator scrubbing
against the bone. And when lifted toward the
skin, there will be a distinct feel of the surrounding
tissues being stretched (Fig. 71.7 ). A beginner
Fig. 71.6 ( Left ) After incising the junctional area between the bone and the cartilage with a Joseph knife. ( Right )
Carefully perform dissection with an elevator
Fig. 71.7 ( Left ) Preoperative patient with mild depres-
sion of the nasal dorsum and deviation is unhappy with
her fl at nose. ( Right ) However, though the fl at nose is
corrected through dorsal augmentation, the patient is
unhappy with the deviation of the nasal dorsum, which
has become conspicuous even after augmentation

1011
71 Revision Rhinoplasty of Asian Noses
will usually begin by attempting to dissect the
central part of the nasal bone and the midline of
the keystone area meeting up with the upper lat-
eral cartilage in order to search for the subpe-
riosteal space. However, this area is extremely
dif fi cult to dissect because it is a transitional area
between the nasal bone and the upper lateral car-
tilage which is strongly fused with the perios-
teum, and it can result in an errant dissection of a
wrong space. Therefore, to create a precise
pocket, make a small incision at an area 5–6 mm
lateral to the midline of the keystone area using a
Joseph knife, and then insert a periosteal elevator
into the subperiosteal space and gradually create
a pocket toward the midline.
The size of the pocket must be fashioned pre-
cisely. The size of the pocket should be made
slightly larger than the implant with just enough
space for the implant and a surgical tool holding
the implant to be jammed through. Also, a space
needs to be created evenly on either side. If not,
and one side is made larger than the other, the
implant can break away from the center, and if a
hematoma occurs within the pocket, the implant
can incline toward one side.
The base of the silicone must be in close con-
tact with the nasal dorsum. The nasal dorsum and
the base of silicone should be trimmed to the
point that they almost adhere closely together.
Otherwise, the implant will become detached and
a seesaw phenomenon occurs after surgery, caus-
ing a hematoma to form and the implant to
become deviated and show through the skin.
Deviated nose must be corrected prior to insert-
ing the silicone. Prior to surgery, a minor nasal
deviation stays relatively hidden when the nose is
low. However, following dorsal augmentation,
even when a silicone is inserted into a precisely
fashioned pocket, the elevated nasal dorsum tends
to seriously expose the deviation to view. This
makes the patients who were generally unaware
of their nasal deviation complain of nasal devia-
tion after the surgery instead. Therefore, it is
advisable to straighten or camou fl age even the
slightest preexisting deviated nose before insert-
ing the silicone (Fig. 71.7 ).
It is best to use silicone on the nasal dorsum
and to use an autologous cartilage (septal carti-
lage, conchal cartilage) to perform surgery on the
nasal tip. Unlike the nasal dorsum, the nasal tip is
an area that is always shifting and exposed to fre-
quent contact. Thus, it is preferable to use an
autologous cartilage when operating on the nasal
tip to avoid in fl ammation and silicone extrusion
(Fig. 71.8 ).
71.7.2 Gore-Tex
Gore-Tex, next to silicone, is the most widely
used alloplastic implant, and currently the use of
Gore-Tex is on the increase. In the case of sili-
cone, because it does not induce tissue ingrowth,
there is a possibility of in fl ammation, extrusion,
as well as postoperative problems such as forma-
tion of a capsule and contracture. To overcome
these problems, an implant with porosity was
developed which, because it induces the surround-
ing tissue to grow inward through the pore, has
the advantage of an increased stability and lower
instances of capsule formation. Among the porous
implants, the most representative one is Gore-Tex
(expanded
polytetra fl uoroethylene
(ePTFE)),
which is being widely used in recent days. Gore-
Tex currently in use in rhinoplasty includes 1- to
2-mm-thick nonreinforced soft tissue augmenta-
tion (SAM) sheet, 4.5- to 7-mm-thick reinforced
SAM, and 2.2- to 3.4-mm reinforced nasal
implant. The fi ne mesh net made up of ePTFE
nodule connected with a fi ne fi bril is made up of
pores which on average are 22 m m (0.5–30 m m) in
size and, when inserted into the body, is intended
to generate ingrowth of the connective tissues
such as fi broblast, capillary, and collagen within
the pore. This is in turn useful for postoperative
immobilization and stabilization, as well as mini-
mizing wound contracture [ 16– 18 ] .
Reinforcement Gore-Tex is fl uorinated ethyl-
ene propylene (FEP) reinforced to ePTFE which,
compared to nonreinforcement Gore-Tex, pos-
sesses a certain level of hardness while maintain-
ing fl exibility so that it is easy to create the
desired shape. However, because Gore-Tex is
fl exible and soft compared to other materials,
there is a drawback of a weak structural support
(Fig. 71.9 ).

1012
C.H. Park
a
b
Rhinoplasty worksheet
Hospital No:
Name:
Sex/Age:
Operation Name:
Open
Type:
Goal:
Anesthesia:
Dorsal:
Left
Right
Nasal crest remove
Class:
Sepatum:
Dorsum/Tip
Septal cartilage
Gore-Tex
Rib
Nasal bone
Aricular cartilage
Silicone
Others:
Closed
Primary
Scoring:
Caudal:
Left
Right
Revision
GA
LA
cosmetic
Corrective
Septoplasty
c
Septorhinoplasty
Rhinoplsty
Fig. 71.8 ( a ) Preoperative patient complaining of low nasal
dorsum and deviated nose. ( b ) After correcting the deviation
of the cartilaginous area using septoplasty, silicone was
applied on the nasal dorsum and a tip graft performed on the
nasal tip using a septal cartilage. There are no signs of devi-
ated nose. ( c ) Dorsal augmentation using silicone

1013
71 Revision Rhinoplasty of Asian Noses
71.7.2.1 Advantages
1. Chemically stable structure that causes lim-
ited tissue reaction.
2. Postinsertion stability is high due to tissue
ingrowth into the pore structure. Also, because
it does not form a capsule, there is less chance
of visibility through the skin compared to
silicone.
3. Compared to the silicone, there is less risk of
an extrusion even in cases of severe skin
tension.
4. The soft feel lessens patient discomfort.
71.7.2.2 Disadvantages
1. The porous structure of Gore-Tex results in
20% decrease in volume after it is inserted.
2. The soft nature of the implant makes insertion
dif fi cult and, in some cases, causes the edge to
crumple.
3. Expensive.
4. The removal from the tissue is more dif fi cult
than for silicone.
5. Reports of a delayed in fl ammation are increas-
ing, and outcome data are not adequately
accumulated to date.
71.7.2.3 Precautions for the Use
of Gore-Tex
Gore-Tex, unlike silicone, is an alloplastic
implant with a porous structure that requires
special attention in connection with the fol-
lowing [ 19 ] :
1. As in all other alloplastic implants, patients
must be warned about the possibility of infec-
tion and in fl ammation, as well as delayed
in fl ammation from the implant (Fig. 71.10 ).
2. One must be cautious of using Gore-Tex in
case of in fl ammation within the nasal cavity
(sinusitis, vestibulitis, and active acne). Also,
when performing operations (osteotomy,
Fig. 71.9 Various types of Gore-Tex, sheet-shaped Gore-Tex, and products manufactured from block-shaped rein-
forcement, as well as Gore-Tex instruction manual of various Gore-Tex products

1014
C.H. Park
septal reconstruction) that may create commu-
nication with the nasal cavity, there is a high
risk of infection.
3. The volume of a sheet-shaped Gore-Tex can
decrease about 20%, while a block-shaped
Gore-Tex can lose about 16% of its volume.
This is due to the fact that Gore-Tex is made
up of a porous structure that can shrink under
pressure, and this factor needs to be taken into
consideration.
4. It is bene fi cial to administer antibiotics prior
to inserting Gore-Tex as well as after sur-
gery. It is essential to soak Gore-Tex in saline
solution containing Betadine or antibiotics
before use.
Before handling Gore-Tex, be sure to wash the
glove clean of powder or other foreign substance.
Gore-Tex is a comparatively safe and FDA-
approved implant that can overcome the short-
comings of silicone but, due to its porous
structural characteristics, is always susceptible to
in fl ammation and shrinkage. However, contrary
to some assertions, it is the position of the author
that Gore-Tex is not dif fi cult to shape and remove
during secondary surgery and that there should
not be any major problem if it is used correctly
with full understanding of its characteristics.
71.7.2.4 Selection of Gore-Tex
Among the various Gore-Tex available, the type
that is currently being most widely used includes
the nonreinforced soft tissue augmentation
(SAM) sheet, the so-called soft Gore-Tex, and
the reinforced soft tissue augmentation(SAM)
block, otherwise called the hard Gore-Tex. Most
recently, a prefabricated implant for nasal aug-
mentation purpose is being introduced into the
market. Each respective type has its own dis-
tinctive characteristics. Gore-Tex sheet, for
example, is the softest product available, and its
strong points are that it blends naturally with the
overlying skin, is suitable when only a slight
augmentation is needed, and the base side of the
implant does not require any special carving to
fi t the nasal dorsum. Conversely, the disadvan-
tages are as follows: Because the sheet can be
either rolled or folded when being used, they
require a suture fi xation in case of the use of
multiple layers, they are dif fi cult to insert, and
the risk of the sheet getting crumpled makes it
dif fi cult to fabricate when a substantial augmen-
tation is necessary. In the case of a Gore-Tex
block, however, though the surgeon needs to
process it to match the patient’s nasal dorsum
and it has a lesser hardness than silicone, it has
a
b
Fig. 71.10 Case of a delayed in fl ammation 2 years after a Gore-Tex sheet was used to augment the nasal dorsum. ( a )
Preoperative. ( b ) Two years postoperative

1015
71 Revision Rhinoplasty of Asian Noses
a greater hardness compared to the sheet so that
it is easy to fabricate, suitable for substantial
augmentation, and easy to use because the risk
of it getting curled is relatively low.
71.7.2.5 Method of Trimming and
Inserting Gore-Tex According
to Each Individual Type
Sheet-Shaped Gore-Tex
Trimming a Sheet-Shaped Gore-Tex
Sheet-shaped Gore-Tex is 2 mm thick, and usu-
ally, according to the intended degree of aug-
mentation, an 8-mm-wide sheet should be
multilayered with twofold (4 mm)–threefold
(6 mm) and used. While doing this, suture both
ends with nylon or PDS to prevent the sheet
from opening up, and then the supratip side
must be trimmed as thin as possible into a trian-
gular shape, while the end of the nasion area
must also be trimmed and made as thin as pos-
sible (Fig. 71.11 ). Unlike silicone and other
alloplastic implant, it is frequently dif fi cult to
cut Gore-Tex using a common blade. In such a
case, it can be processed using a pair of small
Metzenbaum scissors. In addition, although the
softness of the sheet makes it unnecessary to
trim the nasal dorsum area, if the surface of the
nasal dorsum is uneven, this uneven surface of
the nasal dorsum can be re fl ected directly on the
skin, thus requiring special attention. The merit
and demerit of Gore-Tex sheet are its low solid-
ity providing a natural texture to the nasal dor-
sum, but conversely this quality can render it
highly probable that its end can become bent or
curled during its insertion.
Technique of Inserting a Sheet-Shaped Gore-Tex
Because Gore-Tex sheet, unlike silicone, is soft
and has a low solidity, care must be taken to pre-
vent it from folding while it is being inserted.
Method of insertion can be divided largely
between two types, and it is all right for the sur-
geon to choose the method of his choice
(Figs. 71.12 and 71.13 ). Only, make sure to feel
for the nasal dorsum with fi ngers for any bent a
after the implant is inserted and do not forget to
use an elevator to straighten it out. In the case of
Gore-Tex, although there is a less risk of extru-
sion than silicone, an autologous tissue must
always be used at the nasal tip.
Block-Shaped (Reinforced) Gore-Tex
Trimming
Unlike the sheet-shaped Gore-Tex, the block-
shaped Gore-Tex has a certain level of hard-
ness, so it is easy to carve with a blade. Similarly
to silicone, a block-shaped Gore-Tex needs to
be pretrimmed to approximately match the
patient’s nose using an appropriate-sized block
(a rectangular parallelopipedon which is about
3–5 mm thick, 8–10 mm wide, and 5–6 cm
long). Then, it must be prepared for surgery by
gas sterilization. During surgery, a blade should
be used to adjust it to the patient’s nasal dorsum
and then applied to the patient. Currently, there
are ready-made nasal augmentation products in
a
b
Fig. 71.11 ( a ) Suturing a Gore-Tex sheet together. ( b ) Fastening the sheets to the area requiring partial insertion of
Gore-Tex

1016
C.H. Park
the market which are relatively easy to carve
and use.
One must be mindful of the following when
trimming a block-shaped Gore-Tex:
In most cases, either a #15 blade or #11 blade
is used for trimming. And because the block-
shaped Gore-Tex has a softer quality than sili-
cone, instead of forcing the blade, it is best to
trim it in a softly twirling manner. In addition,
when trimming the dorsal part of the implant, it is
useful to use a razor that is rolled in a curved
shape (Fig. 71.14 ).
As in trimming silicone, the decision regard-
ing the length should be based on the distance
between the nasion or nasal root and the supratip
and preferably should be about 3.5–4.0 cm long
and about 8 mm wide. Also, the edge should be
as thin as possible.
Insertion Technique
The insertion technique of a block-shaped Gore-
Tex, same as in inserting silicone, can either be
an open rhinoplasty approach or an intranasal
approach.
Open Approach Technique
Because it allows for a direct visual veri fi cation
during insertion, a block-shaped Gore-Tex can be
positioned accurately and easily. However, unlike
silicone, still there is a risk that the end part can
c
a
b
Fig. 71.12 ( a ) Inserting a sheet-shaped Gore-Tex using a
bayonet forceps after grasping the front part of a sheet-
shaped Gore-Tex with a bayonet forceps and beginning
inserting in a slightly lifting manner. ( b ) When the implant
reaches the correct position, fi xate it to the bone by pene-
trating a needle through the skin of the nasal dorsum and
the implant so that it does not slip away from the desired
location when the forceps is withdrawn ( c ) Subsequently,
the nasal dorsum must be felt with fi ngers to check for any
bent areas and then use an elevator to straighten it. As
occasion demands, it is sometimes sutured to the lower
lateral cartilage to make it secure

1017
71 Revision Rhinoplasty of Asian Noses
become curled. Thus, after it is inserted, the nasal
dorsum should be palpated for any bent area, and
an elevator should be used to straighten any bent
area (Fig. 71.15 ). Furthermore, to immobilize the
implant, the implant can be sutured to the lower
lateral cartilage or to the nasal dorsal skin trans-
cutaneously, which can be removed a week after
surgery.
Rhinoplasty worksheet
Hospital No:
Name:
Sex/Age:
Fig. 71.13 ( Superior ) Preoperative patient with a low
nasal dorsum and blunt tip. ( Middle ) Postoperative after
dorsal augmentation is performed using a sheet-shaped
Gore-Tex. ( Inferior ) Technique of augmentation of the
nasal dorsum involves applying a sheet-shaped Gore-Tex
after making it twofold (4 mm) and the augmentation of
the nasal tip involves using a septal cartilage to perform
multiple onlay grafts and struts

1018
C.H. Park
Intranasal Approach (Figs. 71.16 and 71.17 )
After making marginal incisions bilaterally,
which are essential for tip surgery and to better
adjust the symmetry, use a pair of iris scissors to
dissect all the way to the upper lateral cartilage
and the nasal bone junction area. Using a Joseph
knife, make an incision at the junction between
the upper lateral cartilage and the nasal bone
large enough for the elevator to enter. Then, using
an elevator, create a correct-sized pocket. If there
a
b
Fig. 71.15 Technique of inserting a block-type Gore-Tex. ( a ) Beginning insertion of shaped Gore-Tex. ( b ) Completing
the insertion
Fig. 71.14 Trimming a block-shaped Gore-Tex

1019
71 Revision Rhinoplasty of Asian Noses
a
b
g
h
e
c
d
f
Fig. 71.16 Technique of performing a Gore-Tex augmen-
tation rhinoplasty using an intranasal approach: ( a , b )
After making marginal incisions bilaterally, which are
essential for tip surgery and to better adjust the symmetry,
( c ) a pair of iris scissors is used to dissect all the way to the
upper lateral cartilage and the nasal bone junction area. ( d )
Using a Joseph knife, make an incision at the junction
between the upper lateral cartilage and the nasal bone large
enough for the elevator to enter. ( e ) Using an elevator, a
correct-sized pocket is created. ( f ) If there is a hump at the
nasal dorsum, it is good to remove the hump. ( g , h ) After
using a preharvested septal cartilage to fashion a multiple-
cap graft and strut, ( i , j ) use a needle to fi xate each and then
suture them. ( k , l ) After placing Gore-Tex on the nasal dor-
sum to perform augmentation, using a razor, trim the area
coming in touch with the nasal dorsum. ( m ) Gore-Tex is
inserted. ( n ) It is essential to verify that there is no bent
area and to use an elevator to make it straight if a bent area
is found. ( o ) Suture the incision site and following an alar
base resection, ( p ) perform suture over that area

1020
C.H. Park
Fig. 71.16 (continued)
i
j
k
l
n
p
m
o

1021
71 Revision Rhinoplasty of Asian Noses
a
b
c
Fig. 71.17 ( a ) Preoperative. ( b ) Postoperative. ( c ) Rhinoplasty worksheet

1022
C.H. Park
is a hump at the nasal dorsum, it is good to remove
the hump. After using a preharvested septal carti-
lage to fashion a multiple-cap graft and strut, use
a needle to fi xate each and then suture them. After
placing Gore-Tex on the nasal dorsum to perform
augmentation, using a razor, trim the area coming
in touch with the nasal dorsum. After Gore-Tex is
inserted, it is essential to verify that there is no
bent area and to use an elevator to make it straight
if a bent area is found. Finally, suture the incision
site and, following an alar base resection, per-
form suture over that area.
A 48-year-old male underwent rhinoplasty
using a dorsal silicone implant 7 years ago and
was unhappy with underprojecting tip and the
deviated nose. This case had an underprojecting
tip together with the deviation of the right dorsum
due to silicone. The patient had revision surgery in
which a 4-mm-thick reinforcement Gore-Tex
implant was used for dorsal augmentation after
removal of a silicone implant, and interdormal and
transdormal suture was used to lower the nasal tip.
Postoperatively, there is the desired projecting
nasal tip and dorsal augmentation (Fig. 71.18 ).
a
b
Fig. 71.18 ( a ) Preoperative 48-year-old male who had
rhinoplasty using a dorsal silicone implant 7 years previ-
ously and is unhappy with underprojecting tip and the
deviated nose. There was an underprojecting tip together
with the deviation of the right dorsum due to silicone. ( b )
One month after revision surgery in which a 4-mm-thick
reinforcement Gore-Tex implant was used for dorsal
augmentation after removal of a silicone implant and inter-
dormal and transdormal suture was used to lower the nasal
tip. The desired nasal tip and dorsal augmentation was
achieved. ( c ) Operative procedure of removal of silicone,
reinforcement Gore-Tex implant used for dorsal augmen-
tation after removal of a silicone implant, and interdormal
and transdormal suture used to lower the nasal tip

1023
71 Revision Rhinoplasty of Asian Noses
71.8
Dorsal Augmentation Using
a Costal Cartilage
When a substantial amount of dorsal augmen-
tation is needed, costal cartilage is an excel-
lent autologous implant which can be harvested
in great quantity and carved in a variety of
shapes [ 20 ] .
71.8.1 Advantages
1. Can be harvested in great quantity and is easy
to carve into various shapes.
2. High survival rate, resistance against infec-
tion, and has a relatively low absorption rate.
3. Can be used when previous surgeries cause
in fection or contracture of the alloplastic
implant.
4. It can also be used more safely than an allo-
plastic implant when a substantial augmenta-
tion is needed.
71.8.2 Disadvantages
1. Warping can occur following surgery.
2. Scarring of the chest.
3. Lengthy operation time due to the time
involved in harvesting.
4. Harvesting the implant usually requires gen-
eral anesthesia.
c
Fig. 71.18 (continued)