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

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M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_75, © Springer-Verlag Berlin Heidelberg 2013
75
75.1 Introduction
As common as it is, rhinoplasty is a complicated
operation and referred to as the “hardest opera-
tion in plastic surgery” even by some of the most
experienced surgeons. It requires a careful evalu-
ation of the patient, examination of the patient’s
external and internal nasal architecture, determi-
nation of the respiratory status, and understand-
ing of the patient’s desire. The position of the
nasal septal cartilage, the function and status of
the internal nasal valve, and any collapse on the
ala should be determined before the operation.
Mostly, primary rhinoplasty is successful and
satis fi es the patient both aesthetically and func-
tionally. However, sometimes these needs are not
met especially in inexperienced hands, leaving
patients unhappy and on rare occasion a func-
tional cripple. The deformities seen following a
primary rhinoplasty may be overresection of the
dorsum, saddle nose deformity, depression at the
supratip area, alar pinch deformity, and collapse
of the internal nasal valve.
Frequently, the patients who are candidates for
revisional surgery require cartilage grafting to cor-
rect their deformities. Since concomitant septo-
plasty is performed with resection of the septal
cartilage during the fi rst surgery, these patients
may require cartilage harvest from a distant site
like ear or rib. Additionally, ear cartilage might be
unavailable since it was harvested during a sec-
ondary rhinoplasty operation. Instead, alloplastic
implants can be used for this purpose. One of these
implants is porous polyethylene implant (Medpor-
Porex), which is used more and more frequently in
nasal surgery, particularly as fi ner and more deli-
cate special implants become available.
In these patients, the author used a thin saddle-
shaped porous polyethylene implant to overcome
aesthetic and functional deformities of patients who
had previous rhinoplasty operation (Fig. 75.1 ).
75.2
Preoperative
The patients (aged 21–50 years) presented com-
plaints of nasal deformity and dif fi culty of breathing
after primary rhinoplasty (Figs. 75.2 , 75.3 , and 75.4 ).
Closed rhinoplasty technique had been used in all
patients during the fi rst operation. All patients stated
that their main motivation for initial rhinoplasty was
mainly aesthetic although they had dif fi culty in
breathing due to septal deviation. Few of the patients
indicated that the dif fi culty of breathing started right
after the surgery, and most stated that it became
worse. All patients complained of the new aesthetic
appearance of their nose. On examination, all patients
Aesthetic and Functional
Restoration Using Dorsal
Saddle-Shaped Medpor
Implant in Secondary Rhinoplasty
Murat Türegün
M. Türegün , M.D.
Europlast , 1.Levent, Gül Sokak, No:6 ,
Beşiktaş İstanbul 34330 , Turkey
Department of Plastic and Reconstructive Surgery ,
Gülhane Military Academy ,
Etlik, Ankara , Turkey
e-mail: drmturegun@gmail.com

1076
M. Türegün
a
b
c
Fig. 75.1 Illustration shows ( a ) dorsum of the nose with
alar collapse and decreased angle of the internal valve and
( b ) placement of saddle-shaped Medpor implant at the
dorsum of the nose that widens the internal valve.
( c ) Saddle-shaped Medpor implant is seen
a
b

1077
75 Aesthetic and Functional Restoration Using Dorsal Saddle-Shaped Medpor Implant in Secondary
Fig. 75.2 ( a ) Preoperative patient with severe saddle nose
deformity following septorhinoplasty. Note the inverted V
deformity on the dorsum of the nose. ( b ) One-year follow-
up following correction of saddle nose deformity using
Medpor implant. Note the inverted V deformity corrected
a
b
Fig. 75.3 ( a ) Preoperative patient with saddle nose
deformity following septorhinoplasty. Note the pinched
lower lateral cartilage on the left side. Note the asymmetry
of the tip. ( b ) One-year follow-up following correction of
saddle nose deformity using Medpor implant. Alar pinching
is corrected as well as the tip asymmetry

1078
M. Türegün
Fig. 75.4 ( a ) Preoperative
patient, who had four
previous rhinoplasty
operations, was complaining
of a serious breathing
problem. The lower and
upper lateral cartilages have
been resected excessively.
Note the pinching lower and
upper lateral cartilage region
preoperatively. ( b )
Postoperatively, the nasal
collapse and saddle nose
deformity is corrected as
well as the tip asymmetry
and internal valve problem
a

1079
75 Aesthetic and Functional Restoration Using Dorsal Saddle-Shaped Medpor Implant in Secondary
b
Fig. 75.4 (continued)

1080
M. Türegün
had collapse of their ala during inspiration, depres-
sion at the supratip area, and asymmetry. Cottle sign
was positive in all patients.
75.3
Surgery
Via combination of bilateral rim and upper
trans fi xion incisions, a pouch is prepared on the
dorsum of the nose covering the upper and lower
lateral cartilages. Nasal mucosa must be protected
from any laceration. A saddle-shaped implant of
0.76 × 40 × 20 mm in dimension is prepared from
an ultrathin sheet of porous polyethylene implant
(Medpor®, Porex Surgical Inc., College Park, GA)
(Fig. 75.1 ). The implant is carefully introduced
into the pouch. The implant should be placed
like a bridge between bone and tip. Care must be
addressed to trim the margins to avoid step defor-
mity. Lateral margins should be sutured underlying
subdermal tissue. Once it is placed into the pouch,
the height of the septum makes the third dimension
for the implant. The incision is sutured carefully.
Following nasal passage splint (Doyle splints)
placement, a bandage and cast are applied.
75.4
Results
The patients were followed for a mean of 48 months.
All the patients were satis fi ed with their aesthetic
appearance (Figs. 75.2 , 75.3 , and 75.4 ). The supra-
tip depression and nasal asymmetries were resolved.
During inspiration, none of the patients had alar
collapse and Cottle sign was negative. They also
stated that their nasal breathing had improved fol-
lowing secondary surgery. In one patient, malposi-
tion of the implant was noted due to the pocket
created larger than needed. This was corrected sub-
sequently by simply shaving the implant. No extru-
sion or exposition of the implant was seen.
75.5
Discussion
One cause of nasal obstruction is known as nasal
valve collapse. This refers to narrowness and
weakness at the nasal valve, the narrowest part of
the nasal airway. The minimum cross-sectional
internal nasal valve area may decrease by 25% of
its preoperative value following rhinoplasty [ 1 ] .
Internal nasal valve stenosis and/or collapse are
the most common structural abnormalities in
patients with nasal obstruction complicating rhi-
noplasty and are uncommon in patients who have
not had previous nasal trauma or surgery.
Dynamic collapse of the upper lateral cartilage
may be noticeable on forced inspiration. Cottle
maneuver is a classic technique used to diagnose
an internal nasal valve disorder. Positivity indi-
cates an anatomical narrowing of the nasal valve
angle to less than 10–15° and is generally an indi-
cation for spreader graft placement to improve
the internal valve angle and function. On the
other hand, alar batten grafts are especially useful
for addressing nasal valve collapse caused by a
weak nasal sidewall. Besides Cottle maneuver,
another bene fi cial test to diagnose the internal
nasal collapse is to use the back end of a Q-tip or
another small instrument to elevate the sidewall
of the nose approximately 1–2 mm. If the patient
reports de fi nite bene fi t from this conservative
elevation of the nasal sidewall, then alar batten
grafts may be bene fi cial.
The incidence of postrhinoplasty nasal
obstruction severe enough to warrant evaluation
is approximately 10% [ 2 ] . Frequently, grafts have
to be used to correct secondary deformities due to
previous surgery. Although septal cartilage graft
is an ideal donor site, it has frequently been har-
vested or removed during the fi rst surgery. This
forces other donor areas to be used with increased
morbidity. One other option is to use an alloplas-
tic implant.
Clark and Cook [ 3 ] have used a “butter fl y”-
shaped autologous ear conchal cartilage graft to
treat upper lateral cartilage collapse and internal
nasal valve dysfunction after rhinoplasty. In their
series, 97% of the patients reported improvement
in breathing. The author (MT) has used a
“saddle”-shaped implant made from a thin sheet
of Medpor for the same purpose. This shape of
Medpor has never been used in prior reports.
With a single implant, the author (MT) was able
to treat upper lateral cartilage collapse and resolve
saddle nose deformity at the same time.

1081
75 Aesthetic and Functional Restoration Using Dorsal Saddle-Shaped Medpor Implant in Secondary
Medpor is a chemically pure, porous polyethylene
implant that can perform supportive functions. It
has good tissue biocompatibility permitting
ingrowth of connective tissue, leading to stability
at the recipient site [ 4 ] . Mechanically it is stable
under trauma and in the presence of contraction
forces of long-lasting scars [ 5 ] . It retains its shape
once given by the surgeon. We have used a saddle
shape, which was retained throughout the follow-
up period without any change.
Gurlek et al. [ 6 ] have used Medpor as a spreader
graft to treat alar collapse following rhinoplasty in
secondary and tertiary patients with no recurrence
of airway problems. Medpor has also been used as
a graft for dorsal augmentation [ 7 ] , to treat crooked
nose deformity [ 8 ] and external nasal valve col-
lapse [ 9 ] , in secondary cleft lip rhinoplasty [ 10 ]
and in nasal reconstruction [ 11, 12 ] . In a study
where 187 patients were treated with Medpor
implants, the complication rate was reported as
2.6% [ 4 ] . These consisted of early or late infec-
tions necessitating removal of the implants. All of
these patients were either heavily smoking or using
cocaine. Ozturk et al. [ 13 ] reported a case of bro-
ken Medpor implant 2 years after correction of a
postrhinoplasty saddle nose deformity. Care must
be taken especially in secondary cases where the
soft tissue is damaged and skin is thin and under
tension. In our series, careful evaluation of the
patients, fi nesse surgery with diligent dissection,
placing the incisions away from the implant, and
appropriate shaping of the Medpor resulted in no
early or late complications.
Various other alloplastic implants used in rhi-
noplasty are silicone [ 14 ] , Proplast [ 15 ] , Gore-
Tex [ 16 ] , and Dacron [ 17 ] . Silicone was reported
to have a high complication rate [ 14 ] . Proplast
was shown to have a high infection rate, and FDA
approval was withdrawn [ 18 ] . Although Gore-
Tex had good biocompatibility, it was found to
have a high infection rate [ 16 ] .
Conclusion
Medpor is an alloplastic implant that can be used
safely in secondary rhinoplasty to correct aes-
thetic and functional problems. It can be shaped
and sized according to the architecture of the
patient’s nose. Using a “saddle” shape enabled us
to treat different components of the postrhino-
plasty deformity with a single implant.
References
1. Grymer LF (1995) Reduction rhinoplasty and nasal
patency: change in the cross-sectional area of the nose
evaluated by acoustic rhinometry. Laryngoscope
105(4 Pt 1):429–431
2. Beekhuis GJ (1976) Nasal obstruction after rhino-
plasty: etiology and techniques for correction.
Laryngoscope 86(4):540–548
3. Clark JM, Cook TA (2002) The ‘butter fl y’ graft in func-
tional secondary rhinoplasty. Laryngoscope 112(11):
1917–1925
4. Romo T, Sclafani A, Sabini P (1998) Use of porous
high-density polyethylene in revision rhinoplasty and
in the platyrrhine nose. Aesthetic Plast Surg 22(3):
211–221
5. Mendelsohn M (2005) Straightening the crooked mid-
dle third of the nose: using porous polyethylene
extended spreader grafts. Arch Facial Plast Surg 7(2):
74–80
6. Gurlek A, Celik M, Fariz A, Ersöz-Oztürk A, Eren
AT, Tenekeci G (2006) The use of high-density porous
polyethylene as a custom-made nasal spreader graft.
Aesthetic Plast Surg 30(1):34–41
7. Pham RT, Hunter PD (2006) Use of porous polyethyl-
ene as nasal dorsal implants in Asians. J Cosmet Laser
Ther 8(2):102–106
8. Gurlek A, Ersoz-Ozturk A, Celik M, Firat C, Aslan S,
Aydogan H (2006) Correction of the crooked nose
using custom-made high-density porous polyethylene
extended spreader grafts. Aesthetic Plast Surg 30(2):
141–149
9. Romo T, Litner JA, Sclafani AP (2003) Management
of the severe bulbous nasal tip using porous polyeth-
ylene alloimplants. Facial Plast Surg 19(4):341–348
10. Romo T, Choe KS, Sclafani AP (2003) Secondary
cleft-lip rhinoplasty utilizing porous high-density
polyethylene. Facial Plast Surg 19(4):369–377
11. Romo T 3rd, Sclafani AP, Jacono AA (2000) Nasal
reconstruction using porous polyethylene implants.
Facial Plast Surg 16(1):55–61
12. Turegun
M,
Sengezer
M,
Guler
M
(1998)
Reconstruction of saddle nose deformities using
porous polyethylene implant. Aesthetic Plast Surg
22(1):38–41
13. Ozturk S, Sengezer M, Coskun U, Zor F (2002) An
unusual complication of a Medpor implant in nasal
reconstruction: a case report. Aesthetic Plast Surg
26(6):419–422
14. Tham C, Lai YL, Weng CJ, Chen YR (2005) Silicone
augmentation rhinoplasty in an oriental population.
Ann Plast Surg 54(1):1–7
15. Baran CN, Tiftikcioglu YO, Baran NK (2005) The
use of alloplastic materials in secondary rhinoplasties:

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32 years of clinical experience. Plast Reconstr Surg
116(5):1502–1516
16. Bracaglia R, Fortunato R, Gentileschi S (2005)
Secondary rhinoplasty. Aesthetic Plast Surg 29(4):
230–239
17. Fanous N, Samaha M, Yoskovitch A (2002) Dacron
implants in rhinoplasty: a review of 136 cases of tip
and dorsum implants. Arch Facial Plast Surg 4(3):
149–156
18. Rubin JP, Yaremchuk MJ (1997) Complications and
toxicities of implantable biomaterials used in facial
reconstructive and aesthetic surgery: a comprehensive
review of the literature. Plast Reconstr Surg 100(5):
1336–1353

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M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_76, © Springer-Verlag Berlin Heidelberg 2013
76
76.1
Introduction
The ultimate goal of rhinoplasty is to achieve a
natural and aesthetically pleasing appearance
while maintaining a functional airway. Rhinoplasty
is one of the most challenging procedures in facial
plastic surgery. Approximately 5–15% of patients
who undergo primary rhinoplasty undergo a sec-
ondary or revision procedure [ 1– 4 ] . Revision rhi-
noplasty adds another layer of complexity to an
already challenging operation – this challenge
increases exponentially with each additional revi-
sion procedure. One method to classify postrhino-
plasty deformities is anatomically by upper third,
middle third, and lower third [ 2, 5 ] . The middle
nasal vault is composed of the upper lateral carti-
lages and the nasal septum. Although not as com-
mon as lower third or nasal tip problems, middle
nasal vault abnormalities can be particularly
dis fi guring and contribute signi fi cantly to patient
dissatisfaction. Failure to properly address the
middle nasal vault in primary rhinoplasty can
contribute to bony dorsum and pollybeak defor-
mities, pinched supratip, uneven or wide upper
lateral cartilages, and midnasal asymmetry. This
chapter outlines the anatomy of the middle nasal
vault and highlights the common deformities in
the area that can occur after. The focus is on the
surgical techniques to address these conditions in
the setting of revision rhinoplasty.
76.2
Anatomy of the Middle
Nasal Third
The middle nasal vault is also known as the carti-
laginous dorsum or upper cartilaginous vault. It
is composed of the paired upper lateral cartilages
and the nasal septum (Fig. 76.1 ). The superior
border consists of the fusion of the upper lateral
cartilages to the quadrangular cartilage of the
septum [ 6 ] . This fusion often occurs as a T- or
Y-shaped con fi guration and is located on the
undersurface of the nasal bones with the attach-
ment being 2–3 mm cephalic to the caudal mar-
gin of the bones [ 6, 7 ] . The lateral border of the
cartilaginous middle vault consists of the fusion
of the upper lateral cartilages to the pyriform
apertures [ 6 ] . This fusion helps to establish the
trapezoidal con fi guration of the middle nasal
vault. While the superior and lateral borders are
Management of the Middle
Third in Revision Rhinoplasty
Jonathan Liang , Ji-Eon Kim , and Jonathan Sykes
J. Liang , M.D. • J. -E. Kim , M.D.
Department of Otolaryngology ,
University of California Davis ,
2521 Stockton Boulevard ,
Sacramento , CA , USA
e-mail: jonathan.liang@ucdmc.ucdavis.edu;
kimjieon@gmail.com
J. Sykes , M.D. ()
Facial Plastic and Reconstructive Surgery,
Department of Otolaryngology-Head and Neck Surgery ,
Davis Medical Center, University of California ,
2521 Stockton Boulevard , Sacramento , CA 95817 , USA
e-mail: jonathan.sykes@ucdmc.ucdavis.edu,
lisa.waters@ucdmc.ucdavis.edu

1084
J. Liang et al.
fi xed, the caudal border is mobile as it transitions
into the lower cartilaginous vault. The scroll
region is variable and comprised of the interdigi-
tation of the cephalic border of the lower lateral
cartilages with the caudal border of the upper lat-
eral cartilages.
The internal nasal valve is a critical compo-
nent of the middle nasal vault. The internal nasal
valve is composed of the caudal margin of the
upper lateral cartilage, nasal septum, the fl oor of
the nose, and the anterior head of the inferior tur-
binate [ 8, 9 ] . The internal nasal valve has a cross-
sectional area of 55–83 mm 2 . It represents the
narrowest area of the nasal passage and is the
site of greatest nasal resistance [ 9 ] . The nasal
valve angle is formed by the junction between
the caudal margin of the upper lateral cartilage
and the nasal septum and is usually between 10°
and 20° [ 9 ] . Signi fi cant narrowing (less than 10°)
can contribute to nasal obstruction. The external
nasal valve, located at the entrance of the nasal
airway, is composed of the cutaneous and skele-
tal support (lower lateral cartilages) of the alar
wall [ 10 ] .
A previously operated middle nasal vault is
complicated by distorted anatomy, excessive scar-
ring, and decreased vascularity. The skin-soft tis-
sue envelope of the nose becomes less contractile
and redrapes poorly over the modi fi ed bony carti-
laginous framework due to the excessive fi brosis
and decreased vascularity.
76.3
Evaluation of the Patient
It is extremely important to carefully evaluate
the patient during preoperative consultation,
especially in the setting of revision surgery.
The surgeon should have a clear understanding
of the patient’s concerns and expectations. It is
extremely important to outline the goals of revi-
sion surgery in the context of the patient’s con-
cerns and expectations so that both the patient
and surgeon are on the same page. The surgeon
must also critically assess psychological aspects
of the patient that may dictate the patient’s ulti-
mate perception of the surgical outcome [ 11 ] .
Surgery should not be performed if the patient’s
expectations are unrealistic.
Preoperative evaluation begins with a detailed
history. This history should include the patient’s
speci fi c complaints related to the aesthetics and
function of the nose. It is important to ask the
patient about his or her satisfaction or lack thereof
with the current and previous appearance of his or
her nose. The surgeon should also ask the patient
about nasal obstruction and any exacerbating or
alleviating factors associated with the nasal
obstruction. Any prior nasal or facial surgery or
any previous maxillofacial trauma should be doc-
umented. If available, previous operative records
of the primary rhinoplasty should be reviewed.
Following a detailed history, a careful physical
examination should be performed. The examination
can be divided into two parts: the fi rst part focuses
on the aesthetics of the nose, and the second part
focuses on the functionality of the nose. An attrac-
tive nasal appearance is the result of a harmonious
relationship between nasal length and height.
Adjacent structures including the forehead and
upper lip contribute to the nasal pro fi le. Aesthetic
evaluation of the middle nasal third should include
careful inspection and palpation of the nasal dorsum
to analyze structure and support. The nose is pal-
pated for any irregularities and structural de fi cien-
cies. The relationship between the upper lateral
cartilages and the nasal bones should be carefully
examined with respect to midline. Asymmetries of
the middle third can result from upper lateral carti-
lages disjointed from the nasal bones or a severely
deviated underlying septum. Diagnosis of underlying
Fig. 76.1 Cadaveric dissection with removal of the nasal
skin depicting the lower and upper lateral cartilages. Note
the weak internal nasal valve at the junction of the upper
lateral cartilages with the nasal septum

1085
76 Management of the Middle Third in Revision Rhinoplasty
anatomic deformity is important to understand the
etiology of poor aesthetics – the speci fi c deformities
are outlined below.
Functional evaluation focuses on the patient’s
nasal breathing. In addition to observing the patient
during quiet respiration, it is important to deter-
mine functionality of the internal and external nasal
valve. In patients who complain of nasal obstruc-
tion, determining the precise location of nasal valve
collapse and whether the collapse is static or
dynamic is essential. Cottle maneuver is performed
which involves the surgeon elevating the cheek
superiorly and laterally to open the internal nasal
valve (Fig. 76.2 ). A modi fi ed Cottle maneuver is
performed with placement of a cotton tip applica-
tion along the lateral nasal sidewall, and the patient
is asked to note the site of maximal improvement
of air fl ow (Fig. 76.2 ). Anterior rhinoscopy with a
nasal speculum to assess the nasal septum, nasal
valve angle, and the inferior turbinates can also
highlight the cause of any nasal obstruction.
76.4
Etiologies of Middle Nasal
Third Problems (Table 76.1 )
Middle nasal third problems can be classi fi ed into
congenital, traumatic, and iatrogenic causes.
Although congenital and traumatic causes can pres-
ent special challenges for the rhinoplasty surgeon,
the focus of this chapter will be on iatrogenic etiolo-
gies that occur after prior surgery. Standard rhino-
plasty maneuvers, which are intended to improve
aesthetics, can decrease structural support. It is
important to consider that standard rhinoplasty
maneuvers can cause both functional and aesthetic
problems in the middle third of the nose.
The key to prevention of middle nasal third
etiologies is a fi rm understanding of factors in primary
a
b
Fig. 76.2 Preoperative assessment with the ( a ) traditional Cottle and ( b ) modi fi ed Cottle maneuvers to assess for
collapse of the internal nasal valve
Table 76.1 Etiology of middle nasal third problems after
rhinoplasty
Incisions
Intercartilaginous
Interrupts the scroll between
ULC and LLC
Postoperative healing may
create INV stenosis
Trans fi xion
Interrupts attachment of caudal
nasal septum to membranous
columella
Destabilizes LLC
Marginal
Destabilizes LLC
Techniques
Cephalic resection of
LLC
Weakens the scroll between
ULC and LLC (destabilizes
inferior ULC margin)
Dorsal hump
resection
Weakens attachment of ULC to
nasal septum
ULC resection
Weakens medial margin of
ULC
Postoperative scarring may
narrow INV

1086
J. Liang et al.
rhinoplasty that can lead to structural destabilization.
Sykes [ 6 ] presented an excellent table that summa-
rizes etiologies of middle nasal third problems, which
is presented below. Problems can arise from the type
of incision or the techniques used. Removal of the
dorsum hump often interrupts the medial attachment
of the upper lateral cartilages to the nasal septum
(Fig. 76.3 ). Furthermore, overresection of the upper
lateral cartilages can weaken the medial aspect and
cause excessive narrowing. Both these techniques
can lead to destabilization of the infrastructure of the
middle nasal vault. The best way to avoid these com-
plications is careful maintenance of a stable structure
during primary rhinoplasty.
76.5
Deformities of the Middle
Nasal Third
The external deformities encountered in the
previously operated nose are unusually complex
and dif fi cult to diagnose because of the distorted
anatomy and excessive scarring. Middle vault defor-
mities are the result of asymmetry or malposition
of the upper lateral cartilages. In a study looking
at rhinoplasty in multiply revised noses, Foda [ 12 ]
found that the most common aesthetic deformities
involving the middle nasal vault include pollybeak,
dorsal irregularities, dorsal saddling, and open roof
deformity. Furthermore, many previously oper-
ated noses will have more than one deformity [ 13 ] .
Middle nasal vault deformities can have signi fi cant
cosmetic and functional implications.
76.5.1 Saddle Nose Deformity
Saddle nose deformity is a concavity of the nasal
dorsum (Fig. 76.4 ). It is one of the most obvious
middle vault deformities. It is a depression of the
middle nasal vault in relation to the nasal tip and
bony nasal vault. It may result from overresection
of the cartilaginous and/or bony dorsum [ 5, 14 ] .
Preserving a minimum of 10 mm of dorsal and
Fig. 76.3 Sharp excision of a cartilaginous nasal dorsal
hump. Excessive resection can result in middle third
weakness and instability
Fig. 76.4 Saddle nose deformity associated with overre-
section of the nasal dorsum

1087
76 Management of the Middle Third in Revision Rhinoplasty
caudal septal cartilage has been advised to main-
tain support in this area and to prevent a saddle
nose deformity [ 15 ] . A classi fi cation of saddle
nose deformities has been described by Daniel
[ 16 ] . His classi fi cation system categorizes saddle
nose deformities into six types with varying
severity of the saddle nose, each with its recom-
mended method of repair: type 0 (pseudosaddle),
type I (minor: cosmetic concealment), type II
(moderate: cartilage vault restoration), type III
(major: composite reconstruction), type IV
(severe: structural reconstruction), and type V
(catastrophic: nasal reconstruction).
Treatment depends on the underlying cause. In
the case of revision rhinoplasty, dorsal de fi ciency
is often the cause [ 14 ] . Treatment is often with
dorsal onlay grafts. Septal cartilage is considered
the material of choice [ 14, 17 ] , but septal cartilage
is often in short supply, and auricular or costal car-
tilage may be needed. Alloplastic materials (Gore-
Tex, Mersilene, Medpor, Proplast) have been used
with good success, but carry the risk of infection,
in fl ammation, or extrusion [ 5, 18 ] . These materials
are often reserved for severe saddle deformities.
76.5.2 Pollybeak Deformity
Pollybeak deformity is a convexity of the nasal
supratip relative to the rest of the nose (Fig. 76.5 ).
The lower two-thirds of the nose take on the convex
pro fi le of a parrot’s beak [ 14 ] . The most common
causes of this deformity have been attributed to
underresection of the cartilaginous dorsum relative
to the bony dorsum, excessive nasal dorsum resec-
tion, excessive alar cartilage resection resulting in
decreased tip support, and excessive supratip scar
formation [ 5, 14 ] . Pollybeak deformity causes can
be classi fi ed into cartilaginous causes, resulting in
a lowered dorsum and loss of tip support, and soft
tissue causes resulting in supratip scarring [ 15 ] .
Treatment depends on the underlying cause.
Inadequate resection of the dorsal septum may
be addressed with re-resection at the anterior
septal angle to establish a correct tip-supratip
relationship [ 14 ] . Caution must be taken because
overresection may result in continued deformity.
A particularly challenging problem results when
overresection leads to supratip scar tissue forma-
tion from the inability of the overlying skin-soft
tissue envelope to contact to the new framework.
Cartilage grafting and conservative scar tissue
resection are used to address this problem [ 14 ] .
Additionally, steroid injections into the subcuta-
neous space have been described to address this
speci fi c problem, and Hanasono has noted soft
tissue atrophy with resolution of this deformity
with serial triamcinolone injections [ 19 ] .
76.5.3 Narrow Middle Nasal Vault/
Inverted “V” Deformity
Excessive narrowing of the middle nasal vault is
one of the most common deformities seen after
rhinoplasty [ 20 ] . This often occurs after hump
reduction, which is one of the most common
maneuvers in primary rhinoplasty. During hump
reduction, a T-shaped portion of the nasal septum
is excised and the upper lateral cartilages col-
lapse inferomedially. If the intranasal mucosa is
Fig. 76.5 A pollybeak deformity. Note the convexity of
the nasal supratip relative to the rest of the nose

1088
J. Liang et al.
disrupted with hump reduction, there may be
increased loss of medial support with excessive
inferomedial collapse of the upper lateral carti-
lages [ 7 ] . Other factors than can contribute to inf-
eromedial collapse of the upper lateral cartilages
over time include scar contracture and the nega-
tive pressure of nasal air fl ow [ 21 ] .
An inverted “V” deformity is a commonly seen
deformity associated with the narrow middle nasal
vault (Fig. 76.6 ). Both result from either excessive
resection of or collapse of the upper lateral carti-
lages inferomedially [ 15 ] . The inverted “V” defor-
mity is described as an overly narrow middle nasal
vault with a sharp transition between the prominent
caudal edges of the nasal bones and the cephalic
edges of the upper lateral cartilages. The promi-
nence of the caudal edges of the nasal bones can
give the nose a “washed-out” appearance [ 15 ] . With
hump reduction maneuvers, there may be overre-
section of the upper lateral cartilages or failure to
secure the upper lateral cartilages to the septum,
resulting in inferomedial displacement of the upper
lateral cartilages. This may result in internal nasal
valve collapse and nasal obstruction. The typical
signs may not be apparent for years after the proce-
dure. Patients with small nasal bones, weak upper
lateral cartilages, and dorsal septal deviations are at
greater risk of resulting in inverted “V” deformity
after rhinoplasty [ 14 ] .
This narrow middle nasal vault and inverted “V”
deformity is addressed by reestablishing the ana-
tomical relationship of the septum and upper lateral
cartilages often with a spreader graft or fi xation
sutures. This will be discussed at length below.
76.5.4 Open Roof Deformity
Open roof deformity usually follows hump removal
with inadequate medialization of the lateral nasal
walls. This may be caused by incomplete lateral
osteotomy, a greenstick fracture preventing com-
plete mobilization, or the presence of a superior
bony wedge between the septum and lateral nasal
wall. If left uncorrected, an open roof deformity
can lead to a depressed, wide, and fl attened nasal
dorsum. This deformity can often be addressed
with proper osteotomies and splinting [ 12 ] .
76.5.5 Crooked Nose Deformity
The crooked nose can be caused by curvatures or
asymmetries in the upper third, middle third, or
lower third of the nose (Fig. 76.7 ). Using the verti-
cal thirds principle, Murakami and Younger
described 26 different permutations of crooked
noses [ 22 ] . In the middle nasal vault, persistent
deviation of the nasal septum is the common culprit
of crooked nose deformities. Other causes include
unilateral depression of the upper lateral cartilages
or a collapse of an osteotomized lateral nasal wall
[ 23 ] . Treatment is multifactorial and includes sep-
toplasty, releasing upper lateral cartilages from the
septum, and use of spreader and only grafts [ 23 ] .
Fig. 76.6 An inverted “V” deformity showing the disrup-
tion of the normal brow-tip aesthetic line due to overly nar-
row lateral osteotomies and weak upper lateral cartilages

1089
76 Management of the Middle Third in Revision Rhinoplasty
76.6
Techniques to Address
the Middle Nasal Third
The middle nasal vault can be approached both
from an endonasal or external fashion. Fedok
has described using endonasal approach in revi-
sion rhinoplasty for limited abnormalities [ 24 ] .
Placement of spreader grafts and lateral nasal
sidewall onlay grafts can be accomplished via an
endonasally created pocket in the middle nasal
vault [ 24 ] . Advantages of the endonasal approach
include less surgical dissection, shorter operative
time, faster healing time, and less disruption of
the normal structure. Lack of exposure is the main
disadvantage, and the inspection and analysis of
the nose with palpation often requires an expe-
rienced surgeon. Open or external rhinoplasty
continues to be the popular approach for revision
cases because it allows for excellent exposure,
and revision surgery often requires addressing
multiple deformities or problem area (Fig. 76.8 ).
Fig. 76.7 Crooked nose deformity can be caused by cur-
vatures or asymmetries in the upper third, middle third, or
lower third of the nose. Middle third crooked noses pres-
ent many challenges to the surgeon
a
b
Fig. 76.8 ( a , b ) Open rhinoplasty approach to the middle third of the nose

1090
J. Liang et al.
With either the endonasal or external approach,
the upper lateral cartilages can be left connected
to the dorsal septum, or the upper lateral cartilage
can be divided from the dorsal septum to open the
middle vault [ 25 ] . In patients with a midline mid-
dle nasal vault where minimal reduction of the
cartilaginous dorsum is required, the upper lat-
eral cartilages can be left connected to the dorsal
septum [ 7, 21 ] . Toriumi described the use of sub-
mucosal spreader grafts placed in tunnels dis-
sected under the junction of the upper lateral
cartilage and dorsal septum. A high-positioned
tunnel and thick grafts are required to cantilever
the upper lateral cartilage off the septum to
address internal nasal valve collapse [ 7 ] . For
patients with asymmetric or deviated middle
nasal vault, it is bene fi cial to open the nasal vault.
This method allows exposure to address a devi-
ated septum or a high cartilaginous dorsum.
However, once the upper lateral cartilages are
disconnected from the dorsal septum, the struc-
tural weakness must be addressed.
A plethora of techniques used to reconstruct
the middle nasal vault have been described in the
literature. In primary rhinoplasty, they can be
used to strengthen the middle nasal vault infra-
structure. In revision rhinoplasty, they can be
used to correct complications of excessive dorsal
hump removal. The surgical techniques include
autologous cartilaginous grafts and reconstruc-
tive sutures. The ultimate goal of these surgical
maneuvers is to rebuild the middle nasal vault
infrastructure to improve aesthetic and functional
problems.
76.7
Spreader Grafts
Spreader grafts were fi rst described by Sheen and
Sheen [ 21 ] . They are rectangular cartilage grafts,
usually harvested from septal cartilage, placed
between the upper lateral cartilages and the dor-
sal margin of the nasal septum [ 21 ] (Figs. 76.9
and 76.10 ). These cartilage grafts not only later-
alize the upper lateral cartilages but also add
rigidity to the middle nasal vault to resist inward
motion on inspiration. Spreader grafts are com-
monly used in primary rhinoplasty via either a
closed or open approach to address internal nasal
valve collapse (Fig. 76.11 ). Spreader grafts are
easier to stabilize with direct sutures via the open
approach. In primary open rhinoplasty, the upper
lateral cartilages are divided from the nasal sep-
tum, and mucoperichondrial pockets are elevated
off the septum to accommodate the spread grafts
[ 7 ] . Grafts are usually harvested from septal car-
tilage. Grafts should extend from the osseocarti-
laginous junction to a point just caudal to the
septal angle, and the anterior margin of
the spreader grafts should not protrude above the
nasal septum. Sheen described placement of these
grafts into submucosal pockets along the dorsal
Fig. 76.9 Bilateral spreader grafts placed between the
dorsal nasal septum and the native upper lateral cartilages
Fig. 76.10 A 27-gauge needle fi xing the spreader graft
to the nasal septum. The grafts will then be fi xated with
horizontal mattress sutures

1091
76 Management of the Middle Third in Revision Rhinoplasty
edge of the septum [ 21 ] . Mattress sutures are
used to secure the grafts to the septum. Spreader
grafts can be used to widen a narrow nose,
straighten a deviated nose, lengthen a short nose,
or improve a functionally obstructed nose.
While spreader grafters are commonly used to
address a narrow middle vault in primary rhino-
plasty, spreader grafts are recommended for the
pinched appearance of the middle nasal vault in
secondary rhinoplasty [ 21, 26, 27 ] . The presence
of scar tissue and previous cartilage resection pres-
ents additional challenges with use of spreader
grafts in revision rhinoplasty. Furthermore, the
structural support of the middle nasal vault is often
compromised in patients seeking revision rhino-
plasty after dorsal hump reduction. Inferiomedial
collapse of the supper lateral cartilages can occur
after primary rhinoplasty, as discussed above.
Placement of spreader grafts allows widening the
middle vault and repositioning the upper lateral
cartilages along the dorsal margin of the sep-
tum. This helps to restore the normal trapezoidal
con fi guration of the middle nasal vault.
Variations of the standard spreader graft have
also been described to address middle nasal third
problems. Gruber et al. described a spreader fl ap,
which is a medially rotated upper lateral cartilage
that acts like a spreader graft [ 28 ] . In this technique,
no grafts are harvested, but instead, the upper lateral
cartilage is released from the cartilaginous septum
and rolled on itself into a tunnel along its underside
and secured with sutures. This has also been termed
an autospreader fl ap. Yoo and Most [ 29 ] found that
midvault reconstruction using this autospreader
graft may help prevent postoperative nasal obstruc-
tion due to midvault collapse. Spreader grafts can
also be placed along the dorsum septum instead of
in between the septum and upper lateral cartilages.
The dorsal onlay spreader grafts addresses dorsal
de fi ciency, internal nasal valve collapse, and asym-
metry [ 30 ] . Unilateral or bilateral spreader grafts
can be placed in a dorsal onlay fashion to provide
strength and symmetry to the middle nasal vault.
Using grafts of different widths in the setting of
bilateral dorsal onlay spreader grafts can be used
to correct external dorsal asymmetry [ 30 ] . A dorsal
onlay spreader graft is especially useful to address
saddle nose deformity.
76.8
Onlay Grafts
Onlay grafts have also been placed centrally in the
supratip region of the nose or laterally to provide
support to the nasal sidewall. In revision rhino-
plasty, the upper lateral cartilages may not be eas-
ily identi fi able, and there may be paucity of septal
cartilage to use for grafting. Centrally placed
onlay grafts are often described as butter fl y grafts
[ 6 ] (Fig. 76.12 ). This is usually harvested from
auricular cartilage because the natural curvature
Fig. 76.11 Spreader grafts used to widen the internal
nasal valve
Fig. 76.12 Butter fl y grafts sutured to the native infra-
structure. This helps to support the middle nasal third

1092
J. Liang et al.
allows placement of a curved graft with the convex
side outward to provide optimal support and con-
tour for the supratip region. The butter fl y graft can
be sutured to or tucked under the lower lateral car-
tilages for fi xation. Overresection of the lateral
crura from previous cephalic trim can result in
collapse of the lateral nasal wall at the internal
nasal valve. A laterally placed concave conchal
cartilage onlay graft can be placed over the col-
lapsed region of the lateral nasal wall and secured
with plicating sutures [ 27, 31 ] (Fig. 76.13 ).
Additionally, an alar batten onlay graft can be
placed superiorly over the scroll area to decrease
internal nasal valve collapse in addition to address-
ing the external nasal valve.
76.9
Flaring Sutures
A fl aring suture is a horizontal mattress suture
used to reposition the upper lateral cartilages in a
more lateral position [ 32 ] (Fig. 76.14 ). The use of
fl aring sutures has been described to improve the
cross-sectional area of the internal nasal valves.
Schlosser and Park describe using 5-0 nylon mat-
tress sutures to span the upper lateral cartilages
and nasal dorsum horizontally [ 33 ] . Tightening
the suture increases the angle of the nasal valve.
The goal of fl aring sutures is to visibly reposition
the upper lateral cartilages in a more superior and
lateral position. Flaring sutures can be used con-
comitantly with spreader grafts to increase air
fl ow more than spreader grafts alone [ 32 ] .
Conclusions
Revision rhinoplasty is a challenge for any facial
plastic surgeon. The middle nasal vault presents
unique challenges in the setting of revision
a
b
Fig. 76.13 ( a ) Design and ( b ) placement of a lateral onlay graft for nasal alar and sidewall support
Fig. 76.14 Effect of a fl aring suture on the internal nasal
valve

1093
76 Management of the Middle Third in Revision Rhinoplasty
rhinoplasty. Common deformities include a sad-
dle nose, pollybeak appearance, narrow middle
third with an inverted “V” appearance, open roof,
and crooked nose. Multiple deformities can be
present due to similar etiologies of destabiliza-
tion. Successful revision rhinoplasty requires the
surgeon to understand the complex interplay
between the normal nasal anatomy and the scar
tissue creased from prior surgeries. Multiples
techniques have been described in the literature
to correct the function and cosmetic limitations
associated with these deformities. They include
the use of spreader grafts, onlay grafts, and fl aring
sutures. While mastering the techniques of revi-
sion rhinoplasty is important, recognition of the
deforming and destabilizing forces in the middle
nasal third is what permits the proper repair.
References
1. Kamer FM, McQuown SA (1988) Revision rhino-
plasty: analysis and treatment. Arch Otolaryngol Head
Neck Surg 114(3):57–266
2. Vuyk HD, Watts SJ, Vindyak B (2000) Revision rhino-
plasty: review of deformities, aetiology and treatment
strategies. Clin Otolarngol Allied Sci 25(6):476–481
3. Bagal AA, Adamson PA (2002) Revision rhinoplasty.
Facial Plast Surg 18(4):233–244
4. Thomson C, Mendelson M (2007) Reducing the inci-
dence of revision rhinoplasty. J Otolaryngol
36(2):130–134
5. Parkes ML, Kanodia R, Machida BK (1992) Revision
rhinoplasty: an analysis of aesthetic deformities. Arch
Otolaryngol Head Neck Surg 118(7):695–701
6. Sykes JM (2008) Management of the middle nasal
third in revision rhinoplasty. Facial Plast Surg
24(3):330–347
7. Toriumi DM (1995) Management of the middle nasal
vault. Oper Tech Plast Reconstr Surg 2:16–30
8. Bridger GP (1970) Physiology of the nasal valve.
Arch Otolaryngol 92(6):543–553
9. Kasperbauer JL, Kern EB (1987) Nasal valve physiol-
ogy: implications in nasal surgery. Otolaryngol Clin
North Am 20(4):699–719
10. Constantian MB (1994) The incompetent external
nasal valve: pathophysiology and treatment in pri-
mary and secondary rhinoplasty. Plast Reconstr Surg
93(5):919–931
11. Vuyk HD, Zijlker TD (1995) Psychosocial aspects of
patient counseling and selection: a surgeon’s perspec-
tive. Facial Plast Surg 11(2):55–60
12. Foda HM (2005) Rhinoplasty for the multiple revised
nose. Am J Otolaryngol 26(1):28–34
13. Adamson PA (1990) The failed rhinoplasty. In: Gates
G (ed) Current therapy in otolaryngology – head and
neck surgery. BC Decker, Toronto, pp 137–144
14. Cobo R (2008) Correction of dorsal abnormalities in
revision rhinoplasty. Facial Plast Surg 24(3):327–338
15. Paun SH, Nolst Trenite GJ (2008) Revision rhino-
plasty: an overview of deformities and techniques.
Facial Plast Surg 24(3):271–287
16. Daniel RK (2007) Rhinoplasty: septal saddle nose
deformity and composite reconstruction. Plast
Reconstr Surg 119(3):1029–1043
17. Romo T 3rd, Kwak ES (2006) Nasal grafts and
implants in revision rhinoplasty. Facial Plast Surg
Clin North Am 14(4):373–387
18. Ansari K, Asaria J, Hilger PA, Adamson PA (2008)
Grafts and implants in rhinoplasty – techniques and
long-term results. Oper Tech Otolaryngol 19:42–58
19. Hanasono MM, Kridel RW, Glasgold MJ, Koch RJ
(2002) Correction of the soft tissue pollybeak using
triamcinolone injection. Arch Facial Plast Surg 4(1):
26–30
20. Holt GR, Garner ET, McLarey D (1987) Postoperative
sequelae
and
complications
after
rhinoplasty.
Otolaryngol Clin North Am 20(4):853–876
21. Sheen JH (1984) Spreader graft: a method of recon-
structing the roof of the middle nasal vault following
rhinoplasty. Plast Reconstr Surg 73(2):230–237
22. Murakami CS, Younger RA (1995) Managing the
post-rhinoplasty or post-traumatic crooked nose.
Facial Plast Surg Clin North Am 3(4):421–448
23. Roofe SB, Murakami CS (2006) Treatment of the
posttraumatic and postrhinoplasty crooked nose.
Facial Plast Surg Clin North Am 14(4):279–289
24. Fedok FG (2008) Revision rhinoplasty using the
endonasal approach. Facial Plast Surg 24(3):293–309
25. Swartout B, Toriumi DM (1992) Rhinoplasty. Curr
Opin Otolaryngol Head Neck Surg 15:219–227
26. Sheen JH, Sheen AP (1987) Aesthetic rhinoplasty.
Mosby, St. Louis
27. Johnson CM, Toriumi DM (1990) Open structure rhi-
noplasty. Saunders, Philadelphia
28. Gruber RP, Park E, Newman J, Berkowitz L, Oneal R
(2007) The spreader fl ap in primary rhinoplasty. Plast
Reconstr Surg 119(6):1903–1910
29. Yoo S, Most SP (2011) Nasal airway preservation
using the autospreader technique. Arch Facial Plast
Surg 13(2):74–137
30. Mazzola RF, Felisati G (1997) Secondary rhinoplasty:
analysis of the deformity and guidelines for manage-
ment. Facial Plast Surg 13(3):163–177
31. Cheney ML (1993) Reconstructive grafting by the
open nasal approach. Facial Plast Clin North Am
1:99–109
32. Park SS (1998) The fl aring suture to augment the
repair of the dysfunctional nasal valve. Plast Reconstr
Surg 101(4):1120–1122
33. Schlosser RJ, Park SS (1999) Surgery for the dysfunc-
tional nasal valve. Cadaveric analysis and clinical out-
comes. Arch Facial Plast Surg 1(2):105–110

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DOI 10.1007/978-3-642-28053-5_77, © Springer-Verlag Berlin Heidelberg 2013
77
77.1
The Drooping Tip
77.1.1 Pertinent Anatomy
and Etiology
The cartilaginous framework and the skin and soft
tissue envelope are the primary in fl uences of nasal
tip shape, position, and de fi nition. Tip support has
been classically divided into the major and minor
tip support mechanisms. The three major tip sup-
port mechanisms include the cartilage of the
medial and lateral crura, the fi brous attachments
of the medial crural footplates to the posterior
caudal septum, and the fi brous attachments
between the lateral crura to the upper lateral carti-
lages. Minor tip support mechanisms include the
interdomal ligaments, the dorsal cartilaginous
septum, the fi brous attachments of the lower lat-
eral crura to the pyriform aperture, the attach-
ments of the alar cartilage to the overlying skin
and soft tissue envelope, the membranous septum,
and the nasal spine (Figs. 77.1 and 77.2 ).
Primary rhinoplasty whether endonasal or
external typically disrupts one or more of the tip
support mechanisms. A postrhinoplasty drooping
tip usually results from unanticipated or uncom-
pensated loss of the tip support mechanisms. The
rhinoplasty surgeon must be able to anticipate,
plan, and compensate for the destabilized nasal tip.
The standard transcolumellar, intercartilaginous,
trans fi xion, and marginal incisions serve to inter-
rupt tip support mechanisms and must be accounted
for by the rhinoplasty surgeon. Examples of desta-
bilizing maneuvers include aggressive resection of
the lower lateral cartilage, unnecessary complete
trans fi xion incisions, aggressive reduction of the
nasal spine or anterior septal angle, and overzeal-
ous interrupted strip techniques. In addition, in
accordance with the tripod theory of nasal tip posi-
tion [ 1 ] , failure to recognize and address exces-
sively long lateral crura or weak and short medial
crura can result in a ptotic nasal tip postoperatively
if corrective measures are not implemented.
77.1.2 Surgical Evaluation
and Management
Careful inspection and palpation is of paramount
importance when evaluating the ptotic nasal tip.
Restoring the Drooping Tip
and Hanging Columella
in Revision Rhinoplasty
A. Joshua Zimm and Samieh Sam Rizk
A. J. Zimm , M.D.
Department of Otolaryngology – Head and Neck
Surgery, Facial Plastic Surgery , Lenox Hill Hospital ,
1421 Third Avenue , New York , NY 10028 , USA
Department of Otolaryngology – Head and Neck
Surgery, Facial Plastic Surgery , Manhattan Eye,
Ear, and Throat Hospital ,
1421 Third Avenue , New York , NY 10028 , USA
e-mail: drzimm@drjoshuazimm.com
S. S. Rizk , M.D. ()
Manhattan Facial Plastic Surgery and Park Avenue
Facial Plastic Surgery , Lenox Hill Hospital ,
1040 Park Avenue , New York , NY 10028 , USA
Manhattan Facial Plastic Surgery and Park Avenue
Facial Plastic Surgery , Manhattan Eye, Ear,
and Throat Hospital , 1040 Park Avenue,
New York , NY 10028 , USA
e-mail: drsamrizk@aol.com

1096
A.J. Zimm and S.S. Rizk
Valuable information such as the size, strength,
shape, position, and integrity of the lower lateral
cartilages is obtained. The surgeon will also be
able to ascertain the amount of scar tissue as well.
The rhinoplasty surgeon must also evaluate the
projection, rotation, tip de fi nition, and symmetry
of the alar cartilages, the nasolabial angle, alar base
width, and nasal length. Typically, the patient with
tip ptosis after rhinoplasty will have an under-
projected, underrotated tip with an acute nasolabial
angle. In addition, it is not uncommon for there to
be a concomitant pollybeak deformity present,
either related to inadequate reduction of the carti-
laginous dorsum, loss of tip projection and support,
or excessive scar tissue formation. Also, excessive
long lateral crura or weak and short medial crura
must be recognized during the preoperative evalu-
ation to allow for appropriate surgical planning.
The speci fi c cause of the ptotic nasal tip will
dictate the approach for management. Commonly,
adjustments in projection and rotation will have to
be made along with reestablishing the tip support
mechanisms that have been disrupted in the previ-
ous operation. The external rhinoplasty approach
is most commonly used by the senior author to
address the drooping tip in revision rhinoplasty.
The external approach allows for a more accurate
diagnosis, excellent exposure for suturing multiple
grafts including tip grafts, batten grafts, columel-
lar struts, cap grafts, and onlay grafts. This is
especially helpful in cases of tip asymmetries.
One notable exception to the external approach
for tip ptosis in revision rhinoplasty is in cases
of a redundant anterior membranous septum with
posterior maxillary recession as the etiology of
the acute nasolabial angle. In that case, if tip sup-
port is adequate, an endonasal approach is used,
and through the complete trans fi xion incision,
the anterior membranous septum is resected and
plumping grafts are placed followed by the place-
ment of septocolumellar sutures to maintain tip
support and position.
Fig. 77.1 Nasal tip anatomy

1097
77 Restoring the Drooping Tip and Hanging Columella in Revision Rhinoplasty
That exception aside, the external approach is
most commonly used. Cartilage grafts are
harvested initially. Auricular cartilage, if neces-
sary, is harvested through a posterior auricular
incision. Septal cartilage, if present, is harvested
usually through a hemitrans fi xion incision so as
to not further disrupt a major tip support mecha-
nism if possible. If there is a caudal septal devia-
tion, it is addressed at this time, freeing it from
the nasal spine, repositioning it, and suturing it to
the nasal spine periosteum with a 5.0 polydiox-
anone (PDS) suture. At least a 1-cm caudal and
dorsal septal strut is left in place, more if the car-
tilage is weak. Irradiated costal cartilage is
utilized if the septal or auricular cartilage is
insuf fi cient.
The external approach is made by connecting
bilateral marginal incisions to an inverted “v”
transcolumellar incision. The dissection plane
proceeds immediately super fi cial to the alar carti-
lages to avoid thinning of the skin fl ap or fenes-
tration of the skin especially in cases where there
is excessive scar tissue. If the dorsum needs
modi fi cation, the dissection continues to the
radix. Once the skin and soft tissue envelope has
been elevated, a detailed analysis ensues. The
lower lateral cartilages are examined for strength,
integrity, symmetry, and scar tissue with speci fi c
attention to the lateral crura, domes, and medial
crura. Also, the skin and soft tissue envelope is
evaluated for thickness, and the anterior septal
angle is evaluated for its role in tip support.
Excessive scar bands and contractures are
released to allow for complete mobilization of the
lower lateral cartilages. The lower lateral cartilages
are then carefully inspected for integrity, symme-
try, excessive resection, malposition, or cartilage
splitting techniques. Displaced cartilage fragments
are realigned if possible after freeing them from the
vestibular skin. Excessive height of the lateral crura
is managed by cephalic trim if necessary, always
using care to preserve at least 7 mm of lateral crural
vertical height if the cartilage is strong and 8 mm if
it is weak. Overresected lateral crura often require
alar batten grafts to prevent airway collapse. Septal
cartilage and auricular cartilage grafts are carefully
sculpted and sutured onto the remnant alar carti-
lages using meticulous technique to ensure sym-
metry with 5.0 PDS sutures. Inter- and intradomal
sutures are placed as necessary using horizontal
mattress sutures of 4.0 or 5.0 PDS. These are placed
for increased tip de fi nition and projection and to
correct excessive dome separation or bi fi dity.
Lateral crural overlay is an effective technique
to address the excessively long lateral crura as a
cause for the drooping nasal tip (Fig. 77.3 ). It can
result in increase rotation, deprojection, and
increased tip support. The lower lateral cartilages
are freed from the underlying vestibular skin in
the middle of the lateral crus. Then a vertical
incision is made in the lateral crus approximately
8–10 mm lateral to the dome. The tip is then
Fig. 77.2 Nasal tip support originates from ( A ) the inherent
strength of the lateral crura, ( B ) the forward projection of the
anterior septal angle, ( C ) the interdomal ligaments, ( D ) the
fi brous connections between the upper and lower lateral car-
tilages, ( E ) the fi brous attachments between the medial crura
and the caudal septum, and ( F ) the fi brous connections
between the lower lateral cartilages and the pyriform aper-
ture (From Konior [ 2 ] , with permission from Elsevier)

1098
A.J. Zimm and S.S. Rizk
repositioned, and the overlapped margins of the
lateral crura are sutured with two transcartilagi-
nous horizontal mattress 5.0 PDS sutures.
A columellar strut is often used to reinforce
the medial crural component of the nasal tripod
in patients who have tip ptosis after rhinoplasty.
It stabilizes weak medial crura and can straighten
medial crura that are buckled. The strut is posi-
tioned between the medial crura in a precise
pocket that extends from just super fi cial to the
anterior nasal spine to the junction of the medial
crura and intermediate crura. It is typically
sutured to the medial crura with 2 or 3 5.0 PDS
horizontal mattress sutures. It is important to pre-
serve the natural divergence of the intermediate
crura that forms the infratip break (Fig. 77.4 ).
Caudal septal extension grafts can be used to
enhance tip support and correct a retracted colu-
mella in patients who underwent an overaggressive
resection of the caudal septum. Plumping grafts
are also helpful in patients with an acute nasola-
bial angle to augment the premaxilla.
Tip grafting is an important technique to
enhance tip de fi nition or support when there are
Fig. 77.4 Placement of a columellar strut
Fig. 77.3 Lateral crural
overlay technique for
correction of tip ptosis
secondary to excessively
long lateral crura. ( a ) The
midsection of the lateral crus
is divided after elevating it
away from the underlying
vestibular skin. The dome is
rotated superiorly ( arrow ) to
correct tip ptosis, and the
transection margins are
overlaid. ( b ) The nasal tip is
stabilized by suturing the
overlapping crural margins
with side-by-side mattress
sutures aperture
(From Konior [ 2 ] , with
permission from Elsevier)

1099
77 Restoring the Drooping Tip and Hanging Columella in Revision Rhinoplasty
de fi ciencies or weaknesses in the alar cartilages
(Fig. 77.5 ). Shield grafts can be helpful in aug-
menting tip projection and stabilizing the ptotic
tip. The graft must be carefully beveled to avoid
any visible edges especially in thin-skinned
patients. The shield graft is typically placed after
the suture stabilization of the columellar strut.
Occasionally, the caudal margins of the medial
and intermediate crura must be shaved to provide
a smooth surface for the graft. Also, the graft ide-
ally has a curvature to accommodate the transi-
tion from the medial crura to the intermediate
crura so as to avoid effacement of the infratip
break. The graft typically requires three sets of
sutures, each to the caudal margins of the medial,
intermediate, and lateral crura. If additional pro-
jection is required, the superior edge of the shield
graft can project above the domes as necessary.
Additional re fi nement can be performed with the
graft in situ as necessary to correct any irregulari-
ties or asymmetries.
It is important to also address the supratip.
If supratip fullness or a pollybeak persists after
repositioning maneuvers to increase projection
are performed, the etiology of the persistent
pollybeak must be ascertained and corrected.
Cartilaginous pollybeak deformities determined
by palpation are addressed by incremental shav-
ing of the dorsal septal cartilage in the supratip
region (Fig. 77.6 ). In patients with thick skin or
excessive scar tissue in the supratip after the pre-
vious rhinoplasty, scar tissue or fi bro fatty tissue
can be debulked albeit with great care to avoid
visible cartilage graft edges [ 2 ] .
77.2
The Hanging Columella
Often in revision rhinoplasty, there can be
alar-columellar disproportion that persists or was
created by the original surgeon. It is of paramount
importance to distinguish the etiology of the
disproportion. In this section, we will discuss
management of the hanging columella, describe
the normal anatomy of the alar-columellar rela-
tionship, illustrate how to distinguish a hanging
a
b
Fig. 77.5 ( a ) Onlay tip graft and columellar strut. ( b ) Shield graft

1100
A.J. Zimm and S.S. Rizk
columella from a retracted ala or pseudohanging
columella, and describe how maneuvers in pri-
mary rhinoplasty can alter the normal alar-colu-
mellar relationship.
77.2.1 Pertinent Anatomy
and Etiology
Classic descriptions in texts describe the normal
alar-columellar relationship as being between 2
and 4 mm of visible columella below the alar
margin on pro fi le view [ 3 ] . This de fi nition fails to
describe the appropriate position of the alar mar-
gin as it pertains to the alar-columellar relation-
ship. A retracted ala can give the appearance of a
hanging columella and must therefore be differ-
entiated from it because they are managed differ-
ently. Excessive nostril show with a droopy tip,
short upper lip, long lateral crus, and strong lateral
crus with no apparent notching is suggestive of a
hanging columella. In contradistinction, the pres-
ence of alar notching, weak or de fi cient lateral
crura, retraction of the alar margin, or an alar
margin with excessive curvature is suggestive of
alar retraction or a pseudohanging columella.
A hanging columella can be preexisting and
go unrecognized by the previous surgeon, or it
can be a result of previous surgery. In the evalua-
tion of a hanging columella, the important ana-
tomic structures to consider are the caudal
cartilaginous septum, the membranous septum,
and the medial and intermediate crus (Fig. 77.7 ).
Anatomic deformities that make up the hanging
columella deformity include an excessively long
caudal cartilaginous septum, a redundant mem-
branous septum, and a wide, curved, convex, or
vertically oriented medial/intermediate crura.
Other causes include a long medial crus with
bowing or a C-shaped curvature or a broad
a
b
Fig. 77.6 ( a ) Preoperative 20-year-old female with a
drooping nasal tip secondary to loss of tip support and a
pollybeak deformity. ( b ) One year postoperative after a
secondary rhinoplasty with an external approach. The car-
tilaginous pollybeak was removed, and a columellar strut
was placed. A dome-binding suture in tip was placed, and
the anterior caudal septum and membranous septum were
reduced, and septocolumellar sutures were placed

1101
77 Restoring the Drooping Tip and Hanging Columella in Revision Rhinoplasty
a
b
Fig. 77.7 ( a ) The appearance of a normal alar-columel-
lar relationship, with the relevant anatomic components
being the caudal septum, membranous septum, and the
medial and intermediate crus. ( b ) The hanging columella
deformity can be the result of excess membranous sep-
tum, prominent caudal septum, excessively wide medial
and intermediate crus, downwardly curved medial crus, or
overly long lower lateral cartilages (From Kridel and Chiu
[ 4 ] , with permission from Elsevier)

1102
A.J. Zimm and S.S. Rizk
vestibular vault and medial crural ptosis [ 4, 5 ] .
Other causes particular to previous rhinoplasty
include a columellar strut or a caudal septal
extension graft that protrudes caudally. Suturing
bi fi d medial crura can make the columella more
prominent. Also, a shield graft that is too thick or
excessive plumping grafts can also contribute to
the hanging columella. The loss of tip projection
and rotation from previous rhinoplasty can also
result in relative excessive columellar show.
77.2.2 Surgical Evaluation
and Management
Management of the hanging columella, like most
maneuvers in rhinoplasty, is based upon identify-
ing the etiology. For the excessive cartilaginous
caudal septum or redundant membranous septum,
it is typically excised via a trans fi xion incision.
This can be achieved entirely via an endonasal
approach. If increased rotation is desired, a trian-
gular wedge of caudal septum is removed with
the base of the triangle oriented dorsally. If coun-
terrotation is desired, the base of the triangle is
oriented toward the nasal spine. If no rotation is
desired, a straight piece is removed. As always, at
least 1–1.5 cm of caudal septum is preserved to
maintain tip support.
When excising membranous septum, an ellipse
of membranous septum is removed with the wid-
est portion of the ellipse being positioned over
the area of greatest columellar protrusion [ 4 ] .
The trans fi xion incision is then closed followed
a
b
Fig. 77.8 ( a ) Preoperative 24-year-old female with drooping nasal tip and hanging columella. ( b ) Two years postoperative
after an external rhinoplasty with caudal septal resection as well as a columellar strut, lateral crural steal, and a tip onlay graft

1103
77 Restoring the Drooping Tip and Hanging Columella in Revision Rhinoplasty
by the placement of septocolumellar sutures with
4.0 PDS to maintain tip projection and rotation
(Figs. 77.8 and 77.9 ). On occasion, an overly
prominent nasal spine will have to be reduced if
it is a signi fi cant part of the hanging columella,
but this is not very common.
For an overly bowed or wide medial crura,
shaving of the medial crura at the junction of the
medial and intermediate crura is performed, and
the medial crura are then sutured together. For
excessively long or curved medial crura, some
have espoused a medial crural overlay technique
followed by placement of a columellar strut [ 6, 7 ] .
As described earlier in this chapter, with exces-
sively long lower lateral cartilages, a lateral crural
overlay technique can be used. Other options such
as the tongue-in-groove technique have been advo-
cated by Kridel to set the medial crura back over
the septum. An algorithm for use of this technique
in the management of the hanging columella has
also been previously described by Kridel [ 4, 8 ] .
Finally, in revision cases where the cause of the
hanging columella is caused by previous graft
placement, the responsible graft (shield graft, col-
umellar strut, caudal septal extension graft, or
plumping grafts) is removed or modi fi ed.
Conclusions
Revision rhinoplasty presents a unique chal-
lenge for the rhinoplasty surgeon. Managing
nasal tip ptosis due to disruption of tip support
mechanisms can be achieved by identifying the
underlying etiology and restructuring and repo-
sitioning the nasal tip using a variety of tech-
a
b
Fig. 77.9 ( a ) Preoperative 45-year-old male who presented
for secondary rhinoplasty with a drooping nasal tip, hanging
columella, a pollybeak deformity, and a deviated nasal
septum. ( b ) One year postoperative following external
septorhinoplasty with a columellar strut, onlay tip grafts,
bilateral spreader grafts, removal of pollybeak, bilateral
lower lateral cartilage battens, and reduction of the redun-
dant caudal cartilaginous septum and membranous septum

1104
A.J. Zimm and S.S. Rizk
niques including suturing and cartilage grafting
most commonly via an external rhinoplasty
approach. Management of the hanging colu-
mella is predicated upon determining the etiol-
ogy of the deformity and being able to
distinguish it from alar retraction. Once this has
been determined, the rhinoplasty surgeon is
then able to select from a variety of techniques
at their disposal to restore the proper alar-colu-
mellar relationship and achieve the aesthetic
goals desirable to both the patient and surgeon.
References
1. Anderson JR (1969) The dynamics of rhinoplasty. In:
Proceedings of the ninth international congress of oto-
laryngology. Exerpta medica international congress
series no. 206, Elsevier Inc., Amsterdam, pp 708–710
2. Konior RJ (2006) The droopy nasal tip. Facial Plast
Surg Clin North Am 14(4):291–299
3. Powell N, Humphreys B (1984) Proportions of the aes-
thetic face. Thieme-Stratton Inc., New York
4. Kridel RW, Chiu RJ (2006) The management of alar
columellar disproportion in revision rhinoplasty. Facial
Plast Surg Clin North Am 14(4):313–329
5. Adamson PA, Tropper GJ, McGraw BL (1990) The
hanging columella. J Otolaryngol 19(5):319–323
6. Adamson PA (2000) Anatomic considerations in the
management of the hanging columella. Arch Facial
Plast Surg 2(3):178–179
7. Joseph EM, Glasgold AI (2000) Anatomical consider-
ations in the management of the hanging columella.
Arch Facial Plast Surg 2(3):173–177
8. Kridel RW, Scott BA, Foda HM (1999) The tongue-in-
groove technique in septorhinoplasty. A 10-year expe-
rience. Arch Facial Plast Surg 1(4):246–256

Part IX
Miscellaneous

1107
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_78, © Springer-Verlag Berlin Heidelberg 2013
78
78.1
Introduction
Nasal reconstructive surgeons are frequently
challenged by the demand for cartilage grafts
to repair nasal framework defects created by
trauma, previous surgical resection, or congenital
deformities. A myriad of components have been
used as grafting material in nasal reconstruc-
tion. These include autologous, allogenic, and
synthetic implants and grafts. Allogenic grafts
carry the risk of immune rejection and disease
transmission, whereas the use of synthetic grafts
may be complicated by infection, extrusion, and
foreign body reactions [ 1– 4 ] . The combination of
synthetic-autologous grafts such as septal carti-
lage fragments sutured to a resorbable polydiox-
anone plate or porous high-density polyethylene
(PHDPE) coated with human septal chondro-
cytes has been used. However, limited autolo-
gous tissue availability and possible immune
response, respectively, continue to be concerns
[ 5, 6 ] . Autologous grafts, particularly cartilage,
continue to be the most favored reconstruc-
tive material for the nose. Potential autologous
cartilage donor sites include the nasal septum,
auricle, and rib. Nasal septal cartilage possesses
signi fi cant advantages over these other cartilage
donor tissues due to its favorable structural prop-
erties, ease of harvest, and minimal donor site
morbidity. Because it is fi rm and nonmalleable, it
possesses excellent supportive properties which
enable it to resist deformity during the contrac-
tile healing process of the nasal skin-soft tissue
envelope. Auricular cartilage does not possess
these advantages due to its innate elastin con-
tent and its curvilinear shape. The acquisition
of costal cartilage is associated with moderate
to signi fi cant morbidity, and its use is associ-
ated with an unpredictable degree of absorption
and warping. Although nasal septal cartilage is
the favored material for nasal reconstruction by
anecdotal accounts [ 7 ] , its use is limited by its
fi nite amount of tissue availability and potentially
suboptimal geometry or thickness to repair some
defects. The fabrication of engineered human
septal cartilage can offer the potential to produce
adequate quantities of autologous cartilage from
a small donor specimen in order to create grafts
in de fi ned shapes and sizes.
Tissue engineering refers to the study of the
principles of tissue growth and regeneration and
the production of functional replacement tissue
for clinical use [ 8 ] . In this rapidly developing
interdisciplinary fi eld, cells are embedded in an
engineered extracellular matrix (ECM) in combi-
nation with speci fi c nutrients and molecules to
produce an optimal environment for tissue growth
and maturation. The majority of the advances
Advancing the Art of Rhinoplasty
with Tissue Engineering
Deborah Watson and Marsha S. Reuther
D. Watson , M.D. () • M. S. Reuther , M.D.
Division of Otolaryngology – Head and Neck Surgery,
Facial Plastic and Reconstructive Surgery ,
University of California, San Diego School of Medicine ,
3350 La Jolla Village Drive, 112-C ,
San Diego , CA 92161 , USA
e-mail: debwatson@ucsd.edu ; mreuther@ucsd.edu

1108
D. Watson and M.S. Reuther
achieved in cartilage tissue engineering have
involved articular cartilage for use in orthopedic
reparative surgery. These developments have led
to the fi rst FDA-approved use of human autolo-
gous chondrocytes in 1994. Autologous chondro-
cyte implantation (ACI) is used to restore articular
cartilage defects of the knee. The procedure
involves two stages. In the fi rst stage, a sample of
cartilage is obtained from a patient arthroscopi-
cally and this is digested to isolate the chondro-
cytes. The cells are grown in vitro in a laboratory
for approximately 4–6 weeks. The patient then
undergoes a second procedure in which the chon-
drocytes are injected into the damaged area where
they form new cartilage [ 9, 10 ] . ACI has actually
been reported to have improved clinical outcomes
when compared to other cartilage replacement
procedures [ 9 ] .
A similar process is suggested for the clinical
application of tissue-engineered septal cartilage;
however, solid graft implantation is anticipated
instead. During the initial procedure, a small
piece of septal cartilage would be harvested from
the patient. The tissue would be sent sterile to a
laboratory (Fig. 78.1 ) where the tissue is pro-
cessed. Several key steps are involved in the fab-
rication of septal cartilage constructs. The
harvested specimen from a donor requires diges-
tion of the extracellular matrix (ECM) in order to
isolate the chondrocytes. The cells are then pro-
liferated in monolayer culture. During monolayer
expansion, the chondrocytes undergo a shift
toward a fi broblastic phenotype in a process
called dedifferentiation [ 11, 12 ] . By culturing the
cells in a three-dimensional (3D) environment,
redifferentiation tends to occur. This restores the
correct chondrocytic phenotype, and appropriate
cartilaginous ECM can be produced [ 13– 15 ] .
These redifferentiated cells are then further incu-
bated to form neocartilage constructs which can
eventually be used for clinical application.
The aim of this chapter is to describe some
tissue culture methods that are used to optimize
the biochemical, structural, and metabolic prop-
erties of tissue-engineered human septal carti-
lage. Associated challenges and emerging
developments in the fi eld of septal cartilage tis-
sue engineering will be discussed.
a
b
Fig. 78.1 ( a ) Septal cartilage specimen is harvested from the patient. ( b ) The tissue is transported in a sterile tube to
the laboratory

1109
78 Advancing the Art of Rhinoplasty with Tissue Engineering
78.2
Biochemical Properties
of Hyaline Cartilage
Three types of cartilage exist in the human body:
hyaline (articular, septal, costal, tracheal, and
bronchial cartilage), elastic (auricular and epiglot-
tis), and fi brocartilage (annulus fi brosus, menisci
of joints, ligamentous and tendinous insertion sites
onto bone) [ 16, 17 ] . Cartilage is relatively hypo-
cellular and avascular, with the ECM comprising
approximately 95% of the tissue volume [ 17 ] . The
ECM of hyaline cartilage is predominantly com-
posed of sulfated glycosaminoglycan (sGAG), a
type of proteoglycan, and type II collagen, which
represents markers for metabolically active and
robust cells and the formation of viable tissue.
Type II collagen content, in combination with a
speci fi c proportion of sGAG, is what gives septal
cartilage its strength. Therefore, the goal of septal
cartilage engineering is to produce neocartilage
with a comparable composition to native septal tis-
sue in order to produce tissue with the most opti-
mal properties for nasal reconstruction.
Tissue engineering literature contains direct
comparisons of the proliferative and chondro-
genic potential of cartilage tissue. Chia et al. [ 18 ]
found that human septal chondrocytes possess a
signi fi cantly higher proliferation rate compared
with auricular chondrocytes. Similar results were
obtained in another study [ 19 ] that showed greater
proliferative potential in monolayer culture of
human nasal septal chondrocytes compared with
auricular cells. Choosing cells with superior prolif-
erative potential is prudent given that the successful
expansion of cells in monolayer culture is a crucial
fi rst step in cartilage construct formation.
In addition to proliferative capacity, the chon-
drogenic potential of various tissue sources is an
important consideration for tissue engineering. In
a comparison of human nasal septal and auricular
chondrocytes, after 3 weeks of culture, engi-
neered septal cartilage demonstrated higher GAG
content compared with auricular cartilage [ 20 ] .
Another study [ 21 ] established that human adult
nasal chondrocytes proliferate four times faster
and have a signi fi cantly higher chondrogenic
capacity compared with articular cartilage, con-
cluding that septal chondrocytes are as favorable,
if not a better source, than articular chondrocytes
for autologous cartilage engineering.
78.3
Isolation of Chondrocytes
from Harvested Cartilage
A number of chondrocytes must be expanded
in vitro before adequate quantities of tissue can be
created. This process begins with enzymatic diges-
tion of cartilage to isolate the chondrocytes from
their ECM. The chondrocytes are then expanded
in two-dimensional monolayer culture. However,
monolayer culture induces loss of the chondro-
cytic phenotype. This process of dedifferentiation
is marked by a physical change in the chondrocyte
from a rounded, polygonal shape (characteristic of
native chondrocytes) to a spindle-shaped appear-
ance (characteristic of fi broblasts). This is accom-
panied by a change from the production of type II
collagen (characteristic of native chondrocytes) to
type I collagen (characteristic of fi broblasts) [ 11,
12 ] . The type of collagen produced is a useful
determinant of the cells’ phenotype and differenti-
ated status [ 13 ] . If a dedifferentiated chondrocyte
regains its native phenotype, it is referred to as red-
ifferentiated. Because monolayer culture is a con-
venient and reliable method for expansion of cell
numbers, the associated dedifferentiation of cells
presents a signi fi cant challenge in tissue engineer-
ing. Potential solutions focus either on maintain-
ing chondrocyte phenotype during in vitro cell
multiplication or on inducing redifferentiation.
Multiple factors in fl uence chondrocyte redifferen-
tiation, including media composition, growth fac-
tors, cell seeding density, 3D scaffold properties,
and physical stimulation. In turn, these factors
affect the ability of chondrocytes to produce func-
tional cartilaginous matrix and thereby form clini-
cally useful cartilage constructs.
78.4
Three-Dimensional
Tissue Culture
Multiple studies have shown that redifferentiation
of expanded cells can be induced by transferring
them to three-dimensional culture [ 13, 14, 18 ] .

1110
D. Watson and M.S. Reuther
This can be achieved by seeding chondrocytes into
a three-dimensional gel or onto a scaffold. Using
such a culture system mimics the normal 3D envi-
ronment for chondrocytes in vivo. Scaffold mate-
rial can be either synthetic or natural. Synthetic
materials have been used extensively in articular
cartilage engineering. These include polylactic
acid (PLA), polyglycolic acid (PGA), and their
derivatives. Their popularity stems from their easy
production and molding ability. However, the
major fl aw with any synthetic material is biocom-
patibility, and these materials are broken down
into acidic byproducts which cause in fl ammation,
foreign body reactions, and chondrocyte death
[ 19 ] . As a result, the majority of current tissue
engineering research has been focused on natural
materials. Natural scaffolds can be subdivided into
protein-based matrices, such as collagen and fi brin,
and carbohydrate-based matrices, such as alginate,
agarose, chitosan, and hyaluronan [ 19 ] . In addition
to using scaffolds, some studies have employed
cell-based approaches to achieve 3D culture con-
ditions. Naumann et al. [ 22 ] expanded septal chon-
drocytes in monolayer culture and centrifuged
them to form macroaggregates that were then
allowed to free fl oat in culture for 3 weeks. These
macroaggregates contained type II collagen and
GAG, but at lower levels than native cartilage. In
addition, type I collagen was also present, indicat-
ing the existence of some degree of chondrocyte
dedifferentiation. Unfortunately, the macroaggre-
gates did not possess suf fi cient strength to undergo
mechanical testing.
Recent studies in cartilage tissue engineering
have focused on cells suspended in alginate as a
method to circumvent the problem of cellular
dedifferentiation [ 20, 21 ] . Alginate is a copoly-
mer of l -glucuronic acid and d -mannuronic acid
that polymerizes to form a gel in the presence of
calcium. It can easily be depolymerized with the
addition of a calcium chelator, such as sodium cit-
rate or ethylenediaminetetraacetic acid, thereby
releasing chondrocytes and their cell-associated
matrix (CAM). Articular chondrocytes cultured in
alginate beads have been shown to secrete a matrix
similar to that found in native human cartilage [ 23 ] .
Similarly, septal chondrocytes cultured in alginate
form a rim of CAM containing high levels of
GAG and type II collagen [ 15 ] . Upon depolymer-
ization of the alginate, this tightly adherent matrix
remains associated with the cells.
The use of alginate as a 3D culture system was
furthered by Masuda et al. [ 24– 26 ] in the develop-
ment of a novel scaffold-free system for the for-
mation of tissue-engineered cartilage called the
alginate-recovered-chondrocyte (ARC) method.
Chondrocytes are fi rst cultured in alginate in the
form of beads under optimal conditions to enable
the chondrocytes to maintain their rounded shape
and their molecular phenotype and produce a
proteoglycan-rich matrix. After the alginate beads
are dissolved, the cells along with their CAM
are recovered and seeded onto a semipermeable
membrane for further culture to allow integra-
tion of the cells in a 3D con fi guration to form a
cohesive matrix. The ARC method was then used
by Chia et al. [ 18 ] to create cartilage constructs
from human nasal septal chondrocytes. The ARC
constructs resembled native cartilage grossly and
histologically, and possessed signi fi cant structural
stability. When compared with septal chondrocytes
cultured on PGA scaffolds or in monolayer, cells
encapsulated in alginate show superior GAG accu-
mulation [ 14 ] . Upon histological examination, the
alginate beads contained spherical chondrocytes
surrounded by ECM, an appearance similar to that
of native cartilage. In contrast, the PGA scaffolds
and monolayer cultures contained elongated cells
with scant staining for GAG, features consistent
with a dedifferentiated phenotype.
Protein-based matrices have also been studied
as possible scaffold material for septal cartilage
tissue engineering. Sage et al. [ 27 ] cultured frag-
ments of septal cartilage with and without fi brin
glue and found increased cell proliferation and
ECM production in the fragments cultured with
fi brin. A similar result was found when septal
chondrocytes were combined with fi brin glue and
seeded onto PGA scaffolds. Improved chondro-
cyte expansion and GAG synthesis were identi fi ed
[ 28 ] . In another study, septal chondrocytes were
embedded in fi brin sealant and injected subcuta-
neously into nude mice. After 3 weeks, the
implanted tissue resembled cartilage both grossly
and histologically with positive staining for GAG
and type II collagen [ 29 ] .

1111
78 Advancing the Art of Rhinoplasty with Tissue Engineering
Collagen has also been tested as a scaffold for
septal cartilage engineering. Because collagen is
a major component of the cartilage ECM, it
appropriately mimics the natural environment of
chondrocytes in native tissue. Asawa et al. [ 30 ]
cultured septal chondrocyte pellets in monolayer
and in a type I collagen gel. After 3 weeks of cul-
ture, the monolayer cultured cells maintained
their size, while the pellets grown in the type I
collagen gel exhibited signi fi cant shrinkage, as
well as increased expression of in fl ammatory
mediators and matrix metalloproteinases. This
raises the concern that a collagen type not nor-
mally present in septal cartilage may not provide
the proper environment for septal chondrocytic
growth and subsequent cartilage formation.
Chondrogenesis of bone marrow mesenchymal
stem cells has been studied using type II collagen
hydrogel [ 31 ] ; however, studies examining chon-
drocyte growth using this material are lacking.
Future research in the area of collagen scaffolds
for use in cartilage engineering is warranted.
78.5
Optimization of Culture
Medium
Enhancement of culture medium is another
strategy employed to promote chondrocyte pro-
liferation and redifferentiation. The majority of
cartilage tissue engineering studies to date have
used fetal bovine serum (FBS) to supplement
growth medium. However, recent studies sug-
gest that human serum (HS) is superior to FBS
in its ability to promote proliferation and chon-
drogenesis. In a study by Gruber et al. [ 32 ] ,
human septal chondrocytes exhibited a threefold
increase in proliferation during multiple passages
in monolayer with 10% HS compared with 10%
FBS. Chua et al. [ 33 ] recently reported enhanced
proliferation of human septal chondrocytes in
monolayer culture with HS when compared
with 2% FBS. Cells were then cultured in a 3D
con fi guration, and those cultured with HS showed
qualitative superiority in mechanical proper-
ties. Similarly, Alexander et al. [ 34 ] showed that
human nasal septal chondrocytes cultured in
monolayer showed increased proliferation when
using pooled HS compared with FBS controls.
Cells were subsequently transferred to a 3D alg-
inate scaffold and exhibited a fourfold increase in
cellularity when grown in 10% HS compared to
a 2.5-fold increase in 10% FBS. The study also
demonstrated an increase in GAG per DNA in the
pooled HS group relative to the 10% FBS group.
This was due to both increased chondrocyte pro-
liferation and increased GAG production per
cell. In addition, enzyme-linked immunosorbent
assay analysis of the samples showed that total
type II collagen per DNA was over sixfold higher
in each of the HS groups compared with FBS
controls (Fig. 78.2 ). These studies propose that
50
**
**
**
Type II Collagen
Type II Collagen per DNA (µg/µg)
FRM
CAM
** p < 0.0005
45
40
35
30
25
20
15
10
5
0
10% FBS
10% HS
20% HS
2% HS
Fig. 78.2 Quantity of type
II collagen per DNA after
alginate culture is shown for
both cell-associated matrix
( CAM ) and far-removed
matrix ( FRM ). Each of the
HS groups contained
signi fi cantly more type II
collagen than the FBS group

1112
D. Watson and M.S. Reuther
culture medium supplemented with HS improves
cell proliferation and the biochemical properties
of engineered human nasal septal cartilage.
The addition of speci fi c growth factors to
enhance chondrocyte proliferation, redifferentia-
tion, and ECM production is another important
approach utilized in many articular cartilage
studies. Studies have shown that the addition
of transforming growth factor beta (TGF- b ),
fi broblast growth factor 2 (FGF-2), insulin-like
growth factor 1 (IGF-1), platelet-derived growth
factor (PDGF), and bone morphogenic protein-2
(BMP-2) increases proliferation during mono-
layer expansion of human nasal septal chondro-
cytes [ 17, 18, 35– 42 ] . van Osch et al. [ 43 ] cultured
human nasal septal chondrocytes in monolayer
and then suspended the cells in alginate beads
that were cultured in media supplemented with
TGF- b 2 and IGF-1 as well as growth factor-free
media as the control. Cells cultured with growth
factors produced more GAG and type II collagen
relative to controls, although this result was only
demonstrated in cells obtained from young sub-
jects. Similarly, Tay et al. [ 17 ] showed that septal
chondrocytes expanded in medium supplemented
with TGF- b 1, FGF-2, and PDGF-BB, and then
grown in 3D culture with TGF- b 1 and dexam-
ethasone, exhibited enhanced redifferentiation.
Hicks et al. [ 44 ] found a signi fi cant increase in
GAG production in 3D alginate constructs grown
in media supplemented with FBS, BMP-2, and
BMP-7, as compared to FBS alone. The combination
of both BMP-2 and BMP-7 produced far superior
results than either growth factor alone.
Alexander et al. [ 45 ] studied the effects of
supplementing media with both HS and speci fi c
growth factors. Septal cartilage constructs were
cultured in media supplemented with HS, IGF-1,
and growth differentiation factor 5 (GDF-5), and
these were compared with constructs cultured in
media containing only HS. The constructs cul-
tured with the growth factors were 12-fold thicker
(Fig. 78.3 ) and had signi fi cantly more GAG and
type II collagen accumulation compared with HS
alone. In addition, these constructs possessed
superior biomechanical properties. Overall, these
studies suggest that speci fi c growth factors in
combination with human serum can be used to
improve redifferentiation of human septal chon-
drocytes during culture.
78.6
Modulation of Oxygen Tension
Oxygen is essential for cell survival and prolif-
eration due to its central role in the electron trans-
port chain in oxidative phosphorylation, allowing
for the synthesis of adenosine triphosphate. Aside
from being a vital nutrient, oxygen also in fl uences
developmental processes, including the forma-
tion of cartilage [ 46– 48 ] . The speci fi c mecha-
nisms by which oxygen in fl uences these processes
have not been elucidated; however, many studies
have con fi rmed oxygen’s effects on cartilage tis-
sue development. The majority of these studies
have focused on articular cartilage. In general,
cartilage is avascular and receives all of its blood
supply from the surrounding perichondrium.
Within healthy articular cartilage, the concentra-
tion of oxygen is relatively low at about 1–7.5%.
Chondrocytes embedded in cartilage are well
10% FBS
10% HS
2% HS with
growth factors
Fig. 78.3 Representative constructs cultured in FBS and HS alone, and HS with growth factors

1113
78 Advancing the Art of Rhinoplasty with Tissue Engineering
adapted to this reduced level of oxygen and adjust
their metabolism accordingly [ 49 ] .
There appears to be increasing evidence sup-
porting a favorable effect of reduced oxygen ten-
sion on in vitro cartilage matrix metabolism.
Recent studies suggest that low oxygen tension is
an important culture condition that is capable of
augmenting redifferentiation and chondrogenesis
[ 50 ] . Wernike et al. [ 51 ] seeded porous polyure-
thane scaffolds with bovine articular chondro-
cytes and cultured these under normoxic (21%
oxygen) or hypoxic (5% oxygen) conditions with
simultaneous mechanical stimulation. After
4 weeks of culture, increased levels of type II col-
lagen and aggrecan (proteoglycan) mRNA and
decreased levels of type I collagen mRNA were
noted in the cultures performed under reduced
oxygen tension as compared with normoxic cul-
tures. Additionally, hypoxic constructs had a
higher GAG content than normoxic constructs.
Henderson et al. [ 50 ] studied the effect of oxygen
tension on the culture of rabbit chondrocytes.
Rabbit chondrocytes were expanded at either
21% or 5% oxygen and then cultured as cartilage
aggregates at 21% and 5% oxygen tension. The
chondrocytes under the hypoxic condition con-
tained more total GAG and total collagen than
chondrocytes expanded in normoxic conditions.
Real-time polymerase chain reaction analysis of
collagen expression showed upregulated levels of
type II collagen expression during monolayer
expansion and aggregate culture at 5% oxygen
compared with 21% oxygen. This study demon-
strates that the type of collagen being produced at
the low oxygen tension tends to be more favor-
able for construct engineering.
Only one report in the literature describes
varying oxygen tension during the culture of
septal chondrocytes. In this study by Malda et al.
[ 52 ] , human nasal septal chondrocytes were iso-
lated and cultured in monolayer under standard
conditions. The cells were then cultured in pel-
let form for 21 days at 21%, 5%, or 1% oxygen.
Culturing chondrocytes in 21% oxygen resulted
in decreased pellet size and decreased GAG con-
tent and production of collagen II and IX. These
pellets also showed increased expression of col-
lagen type I, attesting to their dedifferentiated
phenotype. However, pellet cultures at 5% and
1% oxygen exhibited abundant expression of col-
lagen type II after 21 days and showed no stain-
ing of collagen type I at that time. In addition,
these pellets had signi fi cant GAG content, with
the 1% group showing the highest GAG con-
tent. This study supports the tendency that low
oxygen tension may stimulate the redifferentia-
tion of dedifferentiated adult human nasal septal
chondrocytes.
While the modulation of oxygen tension in the
culture of tissue-engineered articular cartilage
constructs has been promising, there are no pub-
lished studies demonstrating the production of
clinically relevant neocartilage constructs under
hypoxic conditions. Oxygen modulation during
nasal septal chondrocyte culture warrants further
attention.
78.7
Bioreactor Culture Systems
Mechanical stimuli have been shown to favorably
in fl uence cartilage formation and, therefore,
would be an important factor to take into account
during the development of tissue-engineered car-
tilage [ 53 ] . To address this issue, bioreactors have
been created that allow for the control of mechan-
ical stimuli and fl uid fl ow. Many different biore-
actor systems have been created, and these can be
classi fi ed according to the type of stress being
applied. The more commonly studied bioreactors
include rotating vessels, spinner fl asks, direct
perfusion bioreactors, and dynamic compression
bioreactors. Much has been accomplished using
bioreactors for articular cartilage engineering.
Pazzano et al. [ 54 ] studied articular chondro-
cytes seeded onto PGA and poly- l -lactic acid
scaffolds cultured in a direct perfusion bioreactor
for 4 weeks. A direct perfusion bioreactor allows
for continuous perfusion of medium through the
construct. They found a signi fi cant increase in
GAG, collagen synthesis, and DNA content in
the constructs cultured in the bioreactor com-
pared with static culture. Similarly, Wu et al. [ 55 ]
tested a perfusion system using a higher linear
velocity of 10 m m/s and formed constructs with a
composition of 25% GAG and 15% type II collagen,

1114
D. Watson and M.S. Reuther
and 60% PGA with no type I collagen. They pur-
ported that the absence of type I collagen and
enhanced cellularity and matrix deposition was
the result of the direct perfusion. Davisson et al.
[ 56 ] found that constructs subjected to perfusion
at 10 m m/s during culture had signi fi cantly higher
DNA content than those cultured statically. With
9 days of continuous perfusion, they noticed
increased GAG synthesis and deposition com-
pared to static controls. Sheehy et al. [ 57 ] studied
the effect of dynamic rotational culture on por-
cine chondrocyte constructs. They found that
rotation signi fi cantly increased GAG and colla-
gen production in constructs compared with static
culture. These studies suggest that bioreactor sys-
tems for the culture of articular cartilage con-
structs may promote chondrogenesis and enhance
tissue maturation.
The application of bioreactors for septal tissue
engineering has been limited. Gorti et al. [ 58 ]
observed a more mechanically robust construct
with handling when human septal chondrocytes
were cultured in a slowly turning lateral vessel
bioreactor for 6 weeks compared to constructs
cultured in a spinner fl ask for 14 days; however,
no tests were performed to con fi rm the biome-
chanical integrity. Rotter et al. [ 59 ] cultured con-
structs on resorbable polymer fl eece in a perfusion
culture vessel for up to 14 days. They reported
that all the constructs maintained their original
size and shape after 10 days in perfusion culture
and the integrity of the polymer scaffolds was
maintained. Histological evaluation of the con-
structs con fi rmed the presence of ECM and col-
lagen; however, no quantitative measurements
were obtained. More recently, Bichara et al. [ 60 ]
seeded human septal chondrocytes into nonde-
gradable porous poly(vinyl alcohol) (PVA)
hydrogel to create biosynthetic constructs. These
were either directly implanted into nude mice or
fi rst cultured in a spinner fl ask bioreactor system
for 10 days and then implanted into the mice. The
constructs were then compared after 6 weeks of
in vivo implantation. They found that the con-
structs initially cultured in the bioreactor had
higher levels of DNA, GAG, and hydroxyproline
(a measure of collagen). In addition, these con-
structs showed a 22% increase in compressive
strength. Overall, the use of bioreactors in
tissue-engineered articular and septal cartilage
has been promising, but more research in this
area is needed.
78.8
In Vivo Cartilage Maturation
Articular cartilage tissue engineering studies have
shown that in vivo maturation of chondrocytes
seeded on scaffolds improves the histological and
mechanical properties of the engineered tissue.
In vivo implantation replicates the natural envi-
ronment in which cartilage grows and matures.
Many studies use nude mice as an animal model as
they are athymic and de fi cient in thymus-derived
lymphocytes; therefore, they are able to accept
xenografts with minimal immune response to the
foreign tissue. Rotter et al. [ 59 ] created neocartilage
constructs by seeding human nasal septal chondro-
cytes onto an Ethisorb polymer. The constructs
were subcutaneously implanted into nude mice for
6, 12, and 24 weeks. Complete resorption of the
polymer was seen after 12 weeks, but they found
nonuniform distribution of sGAG and type II col-
lagen. In another study, Chua et al. [ 33 ] embedded
human septal chondrocytes in a polyethylene oxide
and polypropylene oxide copolymer and injected
this subcutaneously into nude mice. The explanted
tissue showed increased proliferation and histo-
logical similarity to native cartilage. Haisch et al.
[ 61 ] implanted polyglycolic/poly- l -lactic acid
polymer septal cartilage constructs into nude mice
for 6 and 12 weeks. When compared to native tis-
sue, the resulting constructs had abundant ECM.
Of interest, the compressive modulus of the con-
structs was comparable to that of native tissue. In
a study by Farhadi et al. [ 62 ] , septal chondrocytes
were loaded on esteri fi ed hyaluronan mesh and
implanted in nude mice for 2 weeks either directly
after cell seeding or after 2 or 4 weeks of preculture
in chondrogenic medium. They found that follow-
ing in vivo implantation, the constructs continued
to develop and maintained their size and shape.
In vivo studies have also been performed
using alginate as a 3D culture matrix. Dobratz
et al. [ 63 ] suspended human nasal septal chon-
drocytes in alginate and injected the suspension

1115
78 Advancing the Art of Rhinoplasty with Tissue Engineering
percutaneously into nude mice. The cartilage
was harvested after 14 weeks and analyzed. The
histological architecture of the explants was
similar to native cartilage; however, not all of the
samples were homogenous in composition, and
foci of fi brous differentiation were observed. A
different group studied in vivo implantation of
human nasal septal chondrocyte constructs pro-
duced using the ARC method. After 1 month
of static culture, the constructs were implanted
in nude mice and allowed to mature in vivo for
30 or 60 days. In vivo implantation allowed the
cartilage constructs to mature from a translucent,
fragile gelatinous disk to an opaque, fi rm disk
resembling native septal cartilage (Fig. 78.4 ).
Histological evaluation of the tissue demonstrated
an increase in ECM and homogenous cell distri-
bution when compared to the pre-implant con-
struct. Additionally, the mechanical properties of
the in vivo-matured constructs approached those
of native human septal cartilage (manuscript in
preparation).
Current efforts are targeted at investigating
in vivo maturation of engineered nasal septal car-
tilage constructs in a larger animal model. Rabbit
septal chondrocytes have been harvested and
used to create neocartilage constructs using the
ARC method. These were implanted subcutane-
ously in rabbits and allowed to mature for 30 or
60 days. The explants were compared with engi-
neered tissue matured in vitro in static culture for
30 or 60 days. Preliminary testing has demon-
strated increased collagen content and improved
mechanical properties in the explants compared
to constructs cultured in static conditions (manu-
script in preparation).
78.9
Cartilage Tissue Engineering
Using Stem Cells
Recently, stem cells have gained signi fi cant atten-
tion as an attractive source of cells for cartilage
tissue engineering. Their ease of availability,
ability to self-replenish, and potential to differen-
tiate into a variety of different cell types make
them promising for reconstructive surgery [ 19 ] .
A number of sources of stem cells with chondro-
genic potential have been studied, including bone
marrow, muscle, fat, and embryo.
Bone marrow-derived mesenchymal stem cells
(BMSCs) have been the focus of recent cartilage
tissue engineering studies due to their relative ease
of harvest and superior chondrogenic ability [ 19 ] .
While BMSCs can differentiate into bone, carti-
lage, fat, or connective tissue, chondrogenic differ-
entiation can be induced in vitro with TGF- b [ 53 ] .
Elder et al. [ 64 ] seeded porcine BMSCs on porous
transwell inserts and cultured these for 4 or 8 weeks
in media containing TGF- b growth factors. They
found that the neocartilage constructs were fi rm
and easily handled with forceps. In addition, the
a
b
Fig. 78.4 Photographs of
representative constructs
pre- ( a ) and post- ( b ) 30-day
subcutaneous implantation
in a nude mouse. In vivo
implantation stimulated
construct maturation from a
translucent, fragile
gelatinous disk to an
opaque, fi rm disk
resembling native septal
cartilage

1116
D. Watson and M.S. Reuther
constructs increased in thickness, GAG, and colla-
gen content between 4 and 8 weeks and the tissue
predominantly contained type II collagen. Zhang
et al. [ 65 ] wrapped synthetic scaffolds in a BMSC-
derived chondrocyte sheet and incubated them in
a spinner fl ask for 4 weeks and then transplanted
them into nude mice for an additional 4 weeks.
Histological analysis showed cartilage-like tissue
on the exterior of the construct, but the interior was
replaced by fi brous tissue.
Adipose tissue-derived stem cells have gained
importance as a potential source of stem cells due
to their ease of harvest and high cell yield [ 66 ] .
Mahmoudifar et al. [ 67 ] cultured human adipose-
derived stem cells under dynamic conditions in
PGA scaffolds with combinations of growth fac-
tors and observed GAG production, but their lev-
els of collagen type II expression were lacking in
the constructs. Some improvement in collagen
expression was seen with the use of a bioreactor
culture system.
Embryonic stem cells (ESCs) would be an
interesting source of cells for cartilage tissue
engineering due to their virtually limitless ability
to expand and their potential to differentiate into
several types of tissue. ESCs are derived from the
inner cell mass of blastocysts. Unfortunately,
they would not be autologous in origin, and these
cells have been reported to be tumorigenic and
form teratomas in vivo [ 68 ] . While it is possible
to promote ESC differentiation toward a speci fi c
phenotype, challenges still exist surrounding the
safety of their use. Further research is required to
completely understand the mechanism of chon-
drogenesis and how to apply the use of ESCs in
cartilage tissue engineering while preventing cel-
lular mutations and uncontrolled growth.
Conclusions
The ability to engineer human septal cartilage
could have a profound impact on nasal recon-
structive surgery. It would eliminate the risks
associated with the use of synthetic or cadaveric
implants while providing virtually limitless
quantities of autologous tissue with minimal
morbidity. The strategies employed to produce
and optimize engineered tissue have expanded
to include variations in medium composition,
three-dimensional growth systems, and dynamic
culture environments. As a result, the creation
of septal cartilage constructs is feasible at this
time, but efforts to improve the properties of
engineered tissue are ongoing in order to pro-
duce optimal tissue for surgical implantation.
References
1. Tardy ME Jr, Denneny J 3rd, Fritsch MH (1985) The
versatile cartilage autograft in reconstruction of the
nose and face. Laryngoscope 95(5):523–533
2. Komender J, Marczynski W, Tylman D, Malczewska
H, Komender A, Sladowski D (2001) Preserved tissue
allografts in reconstructive surgery. Cell Tissue Bank
2(2):103–112
3. Collawn SS, Fix RJ, Moore JR, Vasconez LO (1997)
Nasal cartilage grafts: more than a decade of experi-
ence. Plast Reconstr Surg 100(6):1547–1552
4. Romo T 3rd, McLaughlin LA, Levine JM, Sclafani AP
(2002) Nasal implants: autogenous, semisynthetic, and
synthetic. Facial Plast Surg Clin North Am 10(2):
155–166
5. Boenisch M, Nolst Trenite GJ (2010) Reconstruction
of the nasal septum using polydioxanone plate. Arch
Facial Plast Surg 12(1):4–10
6. Kim SW, Dobratz EJ, Ballert JA, Voglewede AT, Park
SS (2009) Subcutaneous implants coated with tissue-
engineered cartilage. Laryngoscope 119(1):62–66
7. Sajjadian A, Rubinstein R, Naghshineh N (2010)
Current status of grafts and implants in rhinoplasty:
part I. Autologous grafts. Plast Reconstr Surg 125(2):
40e–49e
8. MacArthur BD, Oreffo RO (2005) Bridging the gap.
Nature 433(7021):19
9. Harris JD, Siston RA, Pan X, Flanigan DC (2010)
Autologous chondrocyte implantation: a systematic
review. J Bone Joint Surg Am 92(12):2220–2233
10. Jones DG, Peterson L (2007) Autologous chondro-
cyte implantation. Instr Course Lect 56:429–445
11. von der Mark K, Gauss V, von der Mark H, Muller P
(1977) Relationship between cell shape and type of
collagen synthesized as chondrocytes lose their carti-
lage phenotype in culture. Nature 267(5611):531–532
12. Homicz MR, Schumacher BL, Sah RL, Watson D
(2002) Effects of serial expansion of septal chondro-
cytes on tissue-engineered neocartilage composition.
Otolaryngol Head Neck Surg 127(5):398–408
13. Benya PD, Shaffer JD (1982) Dedifferentiated chondro-
cytes reexpress the differentiated collagen phenotype
when cultured in agarose gels. Cell 30(1):215–224
14. Homicz MR, Chia SH, Schumacher BL, Masuda K,
Thonar EJ, Sah RL, Watson D (2003) Human septal
chondrocyte redifferentiation in alginate, polyglycolic
acid scaffold, and monolayer culture. Laryngoscope
113(1):25–32

1117
78 Advancing the Art of Rhinoplasty with Tissue Engineering
15. Chia SH, Homicz MR, Schumacher BL, Thonar EJ,
Masuda K, Sah RL, Watson D (2005) Characterization
of human nasal septal chondrocytes cultured in alg-
inate. J Am Coll Surg 200(5):691–704
16. Mainil-Varlet P, Aigner T, Brittberg M, Bullough P,
Hollander A, Hunziker E, Kandel R, Nehrer S,
Pritzker K, Roberts S, Stauffer E (2003) Histological
assessment of cartilage repair: a report by the
Histology Endpoint Committee of the International
Cartilage Repair Society (ICRS). J Bone Joint Surg
Am 85-A(Suppl 2):45–57
17. Tay AG, Farhadi J, Suetterlin R, Pierer G, Heberer M,
Martin I (2004) Cell yield, proliferation, and postex-
pansion differentiation capacity of human ear, nasal,
and rib chondrocytes. Tissue Eng 10(5–6):762–770
18. Chia SH, Schumacher BL, Klein TJ, Thonar EJ,
Masuda K, Sah RL, Watson D (2004) Tissue-
engineered human nasal septal cartilage using the
alginate-recovered-chondrocyte method. Laryngoscope
114(1):38–45
19. Getgood A, Brooks R, Fortier L, Rushton N (2009)
Articular cartilage tissue engineering: today’s research,
tomorrow’s practice? J Bone Joint Surg Br 91(5):
565–576
20. Guo JF, Jourdian GW, MacCallum DK (1989) Culture
and growth characteristics of chondrocytes encapsulated
in alginate beads. Connect Tissue Res 19(2–4):277–297
21. Hauselmann HJ, Aydelotte MB, Schumacher BL,
Kuettner KE, Gitelis SH, Thonar EJ (1992) Synthesis
and turnover of proteoglycans by human and bovine
adult articular chondrocytes cultured in alginate
beads. Matrix 12(2):116–129
22. Naumann A, Dennis JE, Aigner J, Coticchia J, Arnold J,
Berghaus A, Kastenbauer ER, Caplan AI (2004)
Tissue engineering of autologous cartilage grafts in
three-dimensional in vitro macroaggregate culture
system. Tissue Eng 10(11–12):1695–1706
23. Hauselmann HJ, Masuda K, Hunziker EB, Neidhart
M, Mok SS, Michel BA, Thonar EJ (1996) Adult
human chondrocytes cultured in alginate form a
matrix similar to native human articular cartilage. Am
J Physiol 271(3 Pt 1):C742–C5236
24. Masuda K, Hejna M, Thonar EJ (2000) Alginate-
recovered-chondrocyte method (ARC method): a
novel two-step method for the formation of cartilage
tissue. Trans Orthop Res Soc 25:620
25. Masuda K, Miyazaki T, P fi ster B et al (2002) Human
tissue engineered cartilage by the alginate-recovered
chondrocyte method after an expansion in monolayer.
Trans Orthop Res Soc 27:467
26. Masuda K, Sah RL, Hejna MJ, Thonar EJ (2003) A
novel two-step method for the formation of tissue
engineered cartilage: the alginate-recovered-chondro-
cyte (ARC) method. J Orthop Res 21(1):139–148
27. Sage A, Chang AA, Schumacher BL, Sah RL, Watson
D (2009) Cartilage outgrowth in fi brin scaffolds. Am
J Rhinol Allergy 23(5):486–49137
28. Watson D, Sage A, Chang AA, Schumacher BL, Sah
RL (2010) Growth of human septal chondrocytes in
fi brin scaffolds. Am J Rhinol Allergy 24(1):e19–e22
29. Vinatier C, Gauthier O, Masson M, Malard O, Moreau
A, Fellah BH, Bilban M, Spaethe R, Daculsi G,
Guicheux J (2009) Nasal chondrocytes and fi brin
sealant for cartilage tissue engineering. J Biomed
Mater Res A 89(1):176–185
30. Asawa Y, Ogasawara T, Takahashi T, Yamaoka H,
Nishizawa S, Matsudaira K, Mori Y, Takato T, Hoshi
K (2009) Aptitude of auricular and nasoseptal chon-
drocytes cultured under a monolayer or three-dimen-
sional condition for cartilage tissue engineering.
Tissue Eng Part A 15(5):1109–1118
31. Bosnakovski D, Mizuno M, Kim G, Takagi S,
Okumura M, Fujinaga T (2006) Chondrogenic differ-
entiation of bovine bone marrow mesenchymal stem
cells (MSCs) in different hydrogels: in fl uence of col-
lagen type II extracellular matrix on MSC chondro-
genesis. Biotechnol Bioeng 93(6):1152–1163
32. Gruber R, Sittinger M, Bujia J (1996) In vitro cultiva-
tion of human chondrocytes using autologous human
serum supplemented culture medium: minimizing
possible risk of infection with pathogens of prion dis-
eases. Laryngorhinootologie 75(2):105–108
33. Chua KH, Aminuddin BS, Fuzina NH, Ruszymah BH
(2004) Human serum provided additional values in
growth factors supplemented medium for human chon-
drocytes monolayer expansion and engineered cartilage
construction. Med J Malaysia 59(Suppl B):194–195
34. Alexander TH, Sage AB, Schumacher BL, Sah RL,
Watson D (2006) Human serum for tissue engineering
of human nasal septal cartilage. Otolaryngol Head
Neck Surg 135(3):397–403
35. Quatela VC, Sherris DA, Rosier RN (1993) The human
auricular chondrocyte: responses to growth factors.
Arch Otolaryngol Head Neck Surg 119(1):32–37
36. Ka fi enah W, Jakob M, Demarteau O, Frazer A, Barker
MD, Martin I, Hollander AP (2002) Three-dimensional
tissue engineering of hyaline cartilage: comparison of
adult nasal and articular chondrocytes. Tissue Eng
8(5):817–826
37. Masuda K, P fi ster BE, Sah RL, Thonar EJ (2006)
Osteogenic protein-1 promotes the formation of tissue-
engineered cartilage using the alginate-recovered-chon-
drocyte method. Osteoarthritis Cartilage 14(4):384–391
38. Vetter U, Zapf J, Henrichs I, Gammert C, Heinze E,
Pirsig W (1989) Human nasal septal cartilage: analy-
sis of intracellular enzyme activities, glycogen con-
tent, cell density and clonal proliferation of septal
chondrocytes of healthy adults and acromegalic
patients. Connect Tissue Res 18(4):243–254
39. Bujia J, Sittinger M, Wilmes E, Hammer C (1994)
Effect of growth factors on cell proliferation by human
nasal septal chondrocytes cultured in monolayer. Acta
Otolaryngol 114(5):539–543
40. Dunham BP, Koch RJ (1998) Basic fi broblast growth
factor and insulin-like growth factor I support the growth
of human septal chondrocytes in a serum-free environ-
ment. Arch Otolaryngol Head Neck Surg 124(12):
1325–1330
41. Lavezzi A, Mantovani M, Della Berta LG, Matturri L
(2002) Cell kinetics of human nasal septal

1118
D. Watson and M.S. Reuther
chondrocytes in vitro: importance for cartilage graft-
ing in otolaryngology. J Otolaryngol 31(6):366–370
42. Richmon JD, Sage AB, Shelton E, Schumacher BL,
Sah RL, Watson D (2005) Effect of growth factors on
cell proliferation, matrix deposition, and morphology
of human nasal septal chondrocytes cultured in mono-
layer. Laryngoscope 115(9):1553–1560
43. van Osch GJ, Marijnissen WJ, van der Veen SW,
Verwoerd-Verhoef HL (2001) The potency of culture-
expanded nasal septum chondrocytes for tissue engi-
neering of cartilage. Am J Rhinol 15(3):187–192
44. Hicks DL, Sage AB, Shelton E, Schumacher BL, Sah
RL, Watson D (2007) Effect of bone morphogenetic
proteins 2 and 7 on septal chondrocytes in alginate.
Otolaryngol Head Neck Surg 136(3):373–379
45. Alexander TH, Sage AB, Chen AC, Schumacher BL,
Shelton E, Masuda K, Sah RL, Watson D (2010)
IGF-1 and GDF-5- promote the formation of tissue-
engineered human nasal septal cartilage. Tissue Eng
Part C Methods 16:1213–1221
46. Malda J, Martens DE, Riesle J, Tramper J, van
Blitterswijk CA (2003) Cartilage tissue engineering:
controversy in the effect of oxygen. Crit Rev
Biotechnol 23(3):175–194
47. Bassett CA, Herrmann I (1961) In fl uence of oxygen
concentration and mechanical factors on differentiation
of connective tissues in vitro. Nature 190:460–461
48. Pawelek JM (1969) Effects of thyroxine and low oxy-
gen tension on chondrogenic expression in cell cul-
ture. Dev Biol 19(1):52–72
49. Murphy CL, Sambanis A (2001) Effect of oxygen ten-
sion and alginate encapsulation on restoration of the
differentiated phenotype of passaged chondrocytes.
Tissue Eng 7(6):791–806
50. Henderson JH, Ginley NM, Caplan AI, Niyibizi C,
Dennis JE (2010) Low oxygen tension during incuba-
tion periods of chondrocyte expansion is suf fi cient to
enhance postexpansion chondrogenesis. Tissue Eng
Part A 16(5):1585–1593
51. Wernike E, Li Z, Alini M, Grad S (2008) Effect of
reduced oxygen tension and long-term mechanical
stimulation on chondrocyte-polymer constructs. Cell
Tissue Res 331(2):473–483
52. Malda J, van Blitterswijk CA, van Geffen M, Martens
DE, Tramper J, Riesle J (2004) Low oxygen tension
stimulates the redifferentiation of differentiated adult
human nasal chondrocytes. Osteoarthritis Cartilage
12(4):306–313
53. Vinatier C, Mrugala D, Jorgensen C, Guicheux J,
Noel D (2009) Cartilage engineering: a crucial combi-
nation of cells, biomaterials and biofactors. Trends
Biotechnol 27(5):307–314
54. Pazzano D, Mercier KA, Moran JM, Fong SS, DiBiasio
DD, Rulfs JX, Kohles SS, Bonassar LJ (2000)
Comparison of chondrogenesis in static and perfused
bioreactor culture. Biotechnol Prog 16(5):893–896
55. Wu F, Dunkelman N, Peterson A, Davisson T, De La
Torre R, Jain D (1999) Bioreactor development for tissue-
engineered cartilage. Ann N Y Acad Sci 875:405–411
56. Davisson T, Sah RL, Ratcliffe AR (2002) Perfusion
increases cell content and matrix synthesis in chon-
drocyte three-dimensional cultures. Tissue Eng
8(5):807–816
57. Sheehy EJ, Buckley CT, Kelly DJ (2011) Chondrocytes
and bone marrow-derived mesenchymal stem cells
undergoing chondrogenesis in agarose hydrogels of
solid and channelled architectures respond differen-
tially to dynamic culture conditions. J Tissue Eng
Regen Med 5(9):747–758
58. Gorti GK, Lo J, Falsa fi S, Kosek J, Quan SY, Khuu
DT, Koch J (2003) Cartilage tissue engineering using
cryogenic chondrocytes. Arch Otolaryngol Head
Neck Surg 129(8):889–893
59. Rotter N, Aigner J, Naumann A (1999) Behavior of
tissue-engineered human cartilage after transplanta-
tion into nude mice. J Mater Sci Mater Med
10(10/11):689–693
60. Bichara DA, Zhao X, Hwang NS, Bodugoz-Senturk
H, Yaremchuk MJ, Randolph MA, Muratoglu OK
(2010) Porous poly(vinyl alcohol)-alginate gel hybrid
construct for neocartilage formation using human
nasoseptal cells. J Surg Res 163(2):331–336
61. Haisch A, Duda GN, Schroeder D, Groger A,
Gebert C, Leder K, Sittinger M (2005) The mor-
phology and biomechanical characteristics of sub-
cutaneously implanted tissue engineered human
septal cartilage. Eur Arch Otorhinolaryngol 262(12):
993–997
62. Farhadi J, Fulco I, Miot S, Wirz D, Haug M, Dickinson
SC, Hollander AP, Daniels AU, Pierer G, Heberer M,
Martin I (2006) Precultivation of engineered human
nasal cartilage enhances the mechanical properties
relevant for use in facial reconstructive surgery. Ann
Surg 244(6):978–985
63. Dobratz EJ, Kim SW, Voglewede A, Park SS (2009)
Injectable cartilage: using alginate and human chon-
drocytes. Arch Facial Plast Surg 11(1):40–47
64. Elder SH, Cooley AJ, Borazjani A, Sowell BL, To H,
Tran SC (2009) Production of hyaline-like cartilage
by bone marrow mesenchymal stem cells in a self-
assembly model. Tissue Eng Part A 15(10):
3025–3036
65. Zhang J, Liu L, Gao Z, Li L, Feng X, Wu W, Ma Q,
Cheng X, Chen F, Mao T (2009) Novel approach to
engineer implantable nasal alar cartilage employing
marrow precursor cell sheet and biodegradable scaf-
fold. J Oral Maxillofac Surg 67(2):257–264
66. Gabay O, Sanchez C, Taboas JM (2010) Update in
cartilage
bio-engineering.
Joint
Bone
Spine
77(4):283–286
67. Mahmoudifar N, Doran PM (2010) Chondrogenic dif-
ferentiation of human adipose-derived stem cells in
polyglycolic acid mesh scaffolds under dynamic cul-
ture conditions. Biomaterials 31(14):3858–3867
68. Toh WS, Lee EH, Cao T (2011) Potential of human
embryonic stem cells in cartilage tissue engineering
and regenerative medicine. Stem Cell Rev 7(3):
544–559

1119
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_79, © Springer-Verlag Berlin Heidelberg 2013
79
79.1
Introduction
The vernacular used in rhinoplasty can some-
times be confusing. Clinicians will often use dif-
ferent terms to describe the same object. This can
lead to some confusion especially for the novice
rhinoplasty surgeon. The term “posttraumatic
rhinoplasty” refers to the treatment rendered to a
nose that has been traumatized previously, with
or without an attempt to repair the initial injury
(i.e., closed reduction of nasal bone fracture), but
without any previous rhinoplasty. This is not to
be confused with a “secondary rhinoplasty”
where the secondary operation is essentially a
revision surgery to address residual deformities
from the initial rhinoplasty [ 1 ] .
Posttraumatic rhinoplasty is quite challenging.
Primary rhinoplasty has a high revision rate, and
one can deduce that a posttraumatic rhinoplasty
carries an ever higher rate of revision [ 2 ] . Although
there are many studies dealing with posttraumatic
rhinoplasty, there are no speci fi c studies looking
at the rate of revision surgery in this type of opera-
tion [ 1– 5 ] . This chapter is designed to familiarize
the reader with a step-by-step approach to the
management of the patient with a posttraumatic
deformity.
79.2
Preoperative Evaluation
Posttraumatic rhinoplasty should be approached
in a similar fashion as a primary rhinoplasty,
albeit with some inherent differences. A com-
plete preoperative evaluation is imperative in
order to determine an accurate diagnosis. Details
of the mechanism of the initial injury, timing of
injury, records of any previous surgical treatment,
and premorbid photographs should be sought.
Another important consideration is the presence
of nasal air fl ow obstruction at present time and
around the time of the initial repair of nasal
trauma. Patients should be asked to subjectively
assess their nasal appearance at present time and
compare it to before the initial trauma.
Clinical examination of the nose should
include a complete intranasal speculum evalua-
tion to determine the status of the septum, nasal
mucosa, and turbinates, and the presence of any
synechiae. Nasal endoscopy and CT scans should
also be considered in complex cases. Evaluation
of the septum is perhaps one of the key compo-
nents of the preoperative exam since many
patients will require harvesting of the septum as a
grafting material during a posttraumatic rhino-
plasty. Previous fractures or buckling of the sep-
tum should be noted since these factors may
impact the availability of adequate amount of
grafting materials. Alternative sources of grafting
Algorithm for Posttraumatic
Rhinoplasty
Tirbod Fattahi
T. Fattahi , M.D., DDS
Department of Maxillofacial Surgery,
Facial Aesthetic Surgery , University of Florida Health
Science Center Jacksonville , 653-1 W. 8th Street ,
Jacksonville , FL 32209 , USA
e-mail: tirbod.fattahi@jax.u fl .edu

1120
T. Fattahi
materials (ear cartilage graft, costochondral
grafts, homologous irradiated rib, or alloplasts)
should be considered in these patients [ 6– 8 ] .
Since many patients with posttraumatic nasal
deformities will have air fl ow restriction, it is pru-
dent to determine the integrity of the internal
nasal valves with a Cottle maneuver [ 1, 9 ] .
Considered the narrowest portion of the nasal
complex, this small area (10–15 ¢ valve) is a fre-
quent cause of air fl ow obstruction. Patients who
are required to use breathing strips over their
nasal dorsum will often have collapse of the
internal nasal valves.
Clinical examination of the nose should also
determine the cause and degree of nasal devia-
tion. While the septum may be the cause of the
many nasal deviations (“…as the septum goes, so
does the nose”), the bony vault may also be the
culprit. Therefore, both components should be
carefully examined.
Quality of the skin soft tissue drape should
also be assessed at this time. Thick, sebaceous
skin tends to fi brose more following a rhinoplasty
and will oftentime require exaggerated augmenta-
tion in order to achieve an aesthetic outcome; this
is no different in posttraumatic rhinoplasty [ 10 ] .
Also, attention should be directed to any perinasal
lacerations from the initial time of injury. Full-
thickness lacerations around the nasal tip may
impede an open rhinoplasty approach unless col-
lateral blood supply to the tip has been already
established with time. The author will typically
wait up to 9 months following repair of a full-
thickness nasal tip laceration before attempting an
open approach to the nose. Endonasal approaches
may be more prudent in these cases.
As with any rhinoplasty procedure, good qual-
ity photography with an appropriate background
as well as an appropriate rhinoplasty worksheet
(e.g., Gunter) are required when fi nalizing the
surgical plan for a patient with a posttraumatic
rhinoplasty.
79.3
Timing of Repair
Posttraumatic rhinoplasty can be done anytime
following the initial trauma; however, most clini-
cians tend to wait 6–8 weeks after the injury (or
initial repair) before performing this procedure to
allow for resolution of swelling and a better
determination of any persistent air fl ow restric-
tions. As mentioned earlier, in cases where full-
thickness perinasal lacerations were present at
the initial time of injury, posttraumatic rhino-
plasty through an open approach must be delayed
for several months in order to prevent any vascu-
lar compromise to the nasal tip region.
79.4
Surgical Approach
Although a posttraumatic rhinoplasty can be
approached through an endonasal approach, the
open structure rhinoplasty offers the widest view
of the surgical fi eld and the best visualization of
the deformity [ 11, 12 ] . The author routinely uses
the open approach in posttraumatic rhinoplasties.
Similarly, a wide approach to the septum must
also be utilized. While Killian and hemitrans fi xion
approaches are available, a dorsal approach
through an open rhinoplasty technique will offer
the widest view of the septum and may facilitate
graft procurement [ 13, 14 ] .
79.5
Sequence of Surgical
Procedures
The author’s preferred sequence of procedures in
posttraumatic rhinoplasty is as follows:
1. Open approach through an inverted “V”
transcolumellar incision connected to bilateral
marginal incisions
2. Degloving of the nasal complex in a subper-
ichondrial plane up to the radix and then
switching to a subperiosteal plane over the
nasal bones to the nasion
3. Hump reduction (if necessary)
4. Caudal septal exposure through transecting
the transdomal ligaments between the medial
crura
5. Elevation of bilateral mucoperichondrial fl aps
on either side of the septum all day back to the
vomer and ethmoid bones
6. Harvesting of quadrangular septum following
a submucous resection leaving a 1.0-cm “L”
strut for dorsal and tip support

1121
79 Algorithm for Posttraumatic Rhinoplasty
7. Performing lateral and medial osteotomies
(if necessary) to straighten the nasal complex
8. Opening of the internal nasal valves by sepa-
rating the upper lateral cartilages from the
dorsal septum for placement of spreader
grafts (if indicated preoperatively)
9. Tip plasty including placement of inter- and
intradomal sutures as well as placement of col-
umellar strut grafts, various tip grafts, and
cephalic trim of lower lateral crura if necessary
10. Closure of all incisions including a quilting
suture to reapproximate mucoperichondrial
fl aps of the harvested septum
11. Alar base modi fi cation (if necessary)
12. Turbinate reduction (if necessary)
13. Placement of dressings and splints
79.6
Surgical Pearls
Although the above surgical sequence is quite
similar to any open structure rhinoplasty, there
are subtle differences worth mentioning. Elevation
of the soft tissue envelope and degloving of the
nose can be quite tedious in posttraumatic cases
due to scarring from the original trauma or soft
tissue lacerations. Posttraumatic rhinoplasty
should be considered a tissue-sparing procedure;
all available cartilage grafts should be kept avail-
able until the completion of the case. This
includes the cartilaginous component of the dor-
sal hump reduction.
Exposure of the septum can also be challeng-
ing especially if the septum has been fractured or
buckled before. Bony spurs can be encountered
while elevating mucoperichondrial fl aps which
may lead to buttonholing of the overlying fl ap. It
is the opinion of the author that the dorsal
approach can give the widest exposure to the sep-
tum which will then facilitate graft procurement.
Every available piece of the quadrangular sep-
tum should be harvested to restructure the nose.
Clearly, one must maintain an appropriate height
and width to the “L” strut for future support of
the nose. It is also prudent to remove the dorsal
hump before performing a submucous resection;
this way, one can be certain that a 1.0-cm strut
will be maintained following harvesting of the
septum.
If the bony vault appears deviated, the
threshold for performing osteotomies should be
very low. Lateral osteotomies in particular are
helpful in correcting deviation of the frontal pro-
cesses of the maxilla and in closing an open roof
deformity following resection of a large dorsal
hump. Intermediate osteotomies are also quite
useful in posttraumatic rhinoplasties [ 15 ] .
If collapse of the internal valves is suspected
or if the mid-vault appears de fi cient, spreader
grafts should be placed between the upper lateral
cartilages and the dorsal septum. Grafts can be
fashioned long enough caudally to render further
support to the caudal septum if the remaining
septum appears weak or twisted.
If the caudal septum appears to be de fl ected
off the anterior nasal spine (ANS) and nasal crest
of the maxilla, it should be completely released
and reset. Scoring of the septum may assist in
weakening it and allow for its repositioning. In
severe de fl ection, the caudal septum can be
sutured directly into the anterior nasal spine by
drilling a small hole within the ANS and passing
a suture through it [ 16, 17 ] .
Every posttraumatic rhinoplasty patient at our
institution is consented for harvesting of ear
grafts. This is due to the often paucity of graft
materials during a posttraumatic rhinoplasty. If
signi fi cant restructuring of the nose is needed,
then further consideration should be given to har-
vesting of costochondral grafts. Alloplasts and
irradiated homologous rib grafts are also avail-
able for these purposes.
All open structure rhinoplasties should have
tip support; otherwise, tip ptosis can occur.
Columellar strut grafts are excellent in providing
tip support and tip projection. These grafts are
placed between the medial crura and rest on the
soft tissue envelope of the ANS.
Hypertrophic inferior turbinates should be
out-fractured in order to improve air fl ow restric-
tion. Although several techniques exist regarding
management of inferior turbinates, complete tur-
binectomy should not be routinely performed due
to postoperative patient complaints including dry
nose and crusting [ 18– 20 ] .
External splints are very important in redrap-
ing the soft tissue envelope of the nose. They are
typically left in place for 5–7 days; the author

1122
T. Fattahi
routinely replaces the external splint on the 5th
postoperative day with a new splint which is worn
for another 3–4 days. Internal splints are used as
deemed necessary.
79.7
Postoperative Considerations
If internal splints are used, postoperative antibi-
otics should be maintained for a few days; other-
wise, perioperative and limited antibiotic use is
appropriate. As mentioned before, external splints
are removed between the 5th and 7th days fol-
lowing surgery and can be replaced as necessary.
Minor revision surgery following posttraumatic
rhinoplasty should be delayed several months;
however, if the nose is grossly deviated at the fi rst
few postoperative visits, it will remain grossly
deviated! Time will not cure this; revision sur-
gery should be performed much sooner.
Conclusions
Posttraumatic rhinoplasty is a challenging
operation. Multiple factors such as air fl ow
obstruction, septal injuries, lack of appropri-
ate grafting material, patient’s subjective com-
plaints, and the often gross deviation of the
nasal complex contribute to the dif fi culty of
this operation. Thorough preoperative evalua-
tion and surgical execution are imperative in
order to optimize the fi nal outcome.
References
1. Fattahi T, Steinberg B, Fernandes R, Mohan M, Reitter
E (2006) Repair of nasal complex fractures and the
need for secondary septo-rhinoplasty. J Oral Maxillofac
Surg 64(12):1785–1789
2. Walkter J, Gutowski K, Shama L, Marcus B (2009)
National interdisciplinary rhinoplasty survey. Aesthet
Surg J 29(4):295–301
3. Sheen JH (1981) Aesthetic aspects of post-traumatic
nasal reconstruction: a case study. Clin Plast Surg
8(2):193–200
4. Rohrich RJ, Adams WP Jr (2000) Nasal fracture man-
agement: minimizing secondary nasal deformities.
Plast Reconstr Surg 106(2):266–273
5. Higuera S, Lee EI, Cole P, Hollier LH Jr, Stal S (2007)
Nasal trauma and the deviated nose. Plast Reconstr
Surg 120(7 Suppl 2):64S–75S
6. Constantian MB (1995) Rhinoplasty in graft depleted
patient. Oper Tech Plast Reconstr Surg 2:67–81
7. Romo T 3rd, Zoumalan RA (2007) Porous polyethyl-
ene implants in rhinoplasty: surgical techniques and
long-term
outcomes.
Oper
Tech
Otolaryngol
18:284–290
8. Kridel RW, Ashoori F, Liu ES, Hart CG (2009) Long-
term use and follow-up of irradiated homologous cos-
tal cartilage grafts in nasal reconstruction. Arch Facial
Plast Surg 11(6):378–394
9. Fattahi T (2008) Internal nasal valve: signi fi cance in
nasal air fl ow. J Oral Maxillofac Surg 66(9):
1921–1926
10. Daniel RK (2010) Middle eastern rhinoplasty: anat-
omy, aesthetics, and surgical planning. Facial Plast
Surg 26(2):110–118
11. Toriumi DM (2002) Structural approach to primary rhi-
noplasty. Facial Plast Surg Clin North Am 10(1):1–22
12. Tebbetts JB (2006) Open and closed rhinoplasty
(minus the versus): analyzing processes. Aesthet Surg
J 26(4):456–459
13. Pirsig W (2006) Septal deviation: the origin of sys-
tematic submucous resection of the nasal septum.
Facial Plast Surg 22(4):217–222
14. Becker DG (2003) Septoplasty and turbinate surgery.
Aesthet Surg J 23(5):393–403
15. Westreich RW, Lawson W (2005) Perforating double
lateral osteotomy. Arch Facial Plast Surg 7(4):257–260
16. Guyuron B, Behmand RA (2003) Caudal nasal devia-
tion. Plast Reconstr Surg 111(7):2449–2457
17. Pastorek NJ, Becker DG (2000) Treating the caudal
septal de fl ection. Arch Facial Plast Surg 2(3):217–220
18. Lee DH, Kim EH (2010) Microdebrider-assisted versus
laser-assisted turbinate reduction: comparison of
improvement in nasal airway according to type of tur-
binate hypertrophy. Ear Nose Throat J 89(11):541–545
19. Leong SC, Kubba H, White PS (2010) A review of
outcomes following inferior turbinate reduction sur-
gery in children for chronic nasal obstruction. Int J
Pediatr Otorhinolaryngol 74(1):1–6
20. Leong SC, Eccles R (2010) Inferior turbinate surgery
and nasal air fl ow: evidence-based management. Curr
Opin Otolaryngol Head Neck Surg 18(1):54–59

1123
Index
A
ACI . See Autologous chondrocyte implantation (ACI)
Adams, W.P. Jr. , 536, 1058
Adipose tissue-derived stem cells , 1116
Aesthetic rhinoplasty. See also Rhinoplasty
airway patency ( see Airway patency)
anesthesia , 208, 209
caudal septal extension graft ( see Caudal septal
extension graft (CSEG))
congenital depressed nasal dorsum , 592, 594
dressings and postoperative care , 221
external rhinoplasty ( see External rhinoplasty
incision)
facial proportion measures , 207, 208
fascia graft ( see Fascia graft)
genioplasty , 222–223
Hispanic nose , 181
initial consultation
computerized imaging , 208
photographic documentation , 207–208
skeletal disharmony , 207
speculum examination , 207
revisional surgery , 221
Agarwal, A. , 110
Aiach, G. , 349
Airway patency
asymmetric extended spreader graft , 978
columellar strut grafts , 975, 981
extended spreader grafts , 974, 975
nasal airway anatomy , 970–971
physical examination , 969–970
planning , 971
preoperative patient , 974, 977, 980
technique
autologous cartilage , 972, 973
conchal graf , 973
costal cartilage grafts , 973
pyriform stenosis , 972
volumetric graft , 981
Alar base
Middle Eastern rhinoplasty patients , 188, 992
reduction
alar-hooding reduction , 430, 432
alar soft tissue excision techniques,
principles , 434
algorithm , 431, 433
anesthetic considerations , 431
complications , 432–433
excessive alar fl are reduction , 428–431
large nostrils, asymmetric nostrils ,
427–429
postoperative , 219, 220
preoperative evaluation , 425–426
wide lower third , 426–429
variations in con fi guration , 48
width, measurement of , 120–121
Alar batten grafts , 451–453, 459–462, 465–466
Alar cartilages
bi fi d and sharp nasal cupola , 679, 696–697
bulbous and hypertrophied tip , 679, 688–689,
694–695
cephalic rotation/tip plasty , 252, 254
clown tip , 679, 681
crushed and wide nasal tip , 679, 690–691
downward tip , 679, 686–687
frontal view , 39
large hypertrophied , 679, 682–683
lateral crus, rotation of , 363
morphology , 39–40
nasal tip , 679, 680
OFF surgical technique , 920
overprojected nasal tip reduction ( see Overprojected
nasal tip reduction)
projecting nasal tip , 679, 698–699
rhinomegaly , 679, 700–701
rotated lateral wing of , 363
rounded and wide nasal tip , 679, 684–685
tip asymmetry , 679, 702–703
very thick skin , 679, 680, 692–693
wide and luxated nasal tip , 679, 681
Alar fl are reduction , 428–431
Alar-hooding reduction , 430, 432
Alar retraction , 435, 774, 965
Alar rim grafts , 116, 154, 436, 466, 469–471, 546
Alar strut graft , 546
Alef, M. , 705
Alexander, T.H. , 1111, 1112
Alginate-recovered-chondrocyte (ARC) , 1110
Alsarraf, R. , 945
Amodeo, C. , 99
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5, © Springer-Verlag Berlin Heidelberg 2013

1124
Anchor graft
alar-columella disharmony , 435
alar spreader grafts , 436
comments , 437–444
nasal tip pinching , 435
operative technique , 436–437
rigidity , 436
Anderson, J.R. , 890
Anderson’s tripod model , 912
Anterior nasal spine (ANS)
multiracial nose vs. Caucasian nose , 199
posttraumatic rhinoplasty , 1119
Antibiotics , 714
Aquamid
complications , 769, 770
petite operation , 770–771
technique
direct injection image technique , 768
dosages of , 768, 769
number vs. dosage , 767
preoperative patient , 767–769
ARC . See Alginate-recovered-chondrocyte (ARC)
Asawa, Y. , 1111
Asian noses, revision rhinoplasty
costal cartilage
advantages , 1023
applications , 1030–1032
case history , 1033–1034
disadvantages , 1023
harvesting techniques , 1024–1027
inserting techniques , 1027–1028
precautions , 1024
trimming , 1027, 1028
dorsal augmentation
costal cartilage ( see Costal cartilage)
dermis-fat , 1034, 1035
preoperative considerations , 1004
Gore-Tex
advantages , 1013
block-shaped (reinforced) Gore-Tex , 1015–1016,
1018
disadvantages , 1013
intranasal approach , 1018–1023
open approach technique , 1016–1018
precautions , 1013–1014
selection , 1014–1015
sheet-shaped Gore-Tex , 1015–1017
types , 1011, 1013
implant trimming
nasal dorsum , 1006–1007
nasion (nasal root) , 1006, 1007
supratip , 1007, 1008
length
micrognathia , 1005
physiological/anatomical problems , 1006
lower third deformity , 1003
middle third deformity , 1003
previous analysis , 1002, 1003
silicone
advantages , 1007–1008
disadvantages , 1008
insertion method , 1009–1012
precautions , 1008–1009
types , 1008
surgical technique-related problems , 1001–1002
upper third deformity , 1003
Asian rhinoplasty
anatomical considerations , 163
dorsal augmentation
alloplastic implants , 164
autologous tissue , 164–166
Caucasians , 163–164
Gore-Tex , 168
homologous tissue , 164, 166, 167
revision surgery , 163
silicone , 166, 168
nasal tip surgery
cartilage graft technique , 168
cephalic resection , 168
multilayer tip grafting , 169, 170
onlay tip graft , 171
septal extension graft , 171–173
shield graft , 169
VDD , 169, 171
Asymmetric extended spreader grafts , 978
Aubry, M. , 349
Augmentation rhinoplasty
cartilage grafts
complications , 655, 656
congenital depressed nasal dorsum , 592–595
cutting and cleaning , 586–587
deformed nasal dorsum , 644–646
depressed nasal dorsum , 598–599, 647–654
ear concha , 585, 586
experimental study , 655
hypertrophic nasal alae , 596, 597
nasal septum , 585, 586
placement of , 589–591
primary rhinoplasty , 634, 647–654
rasping of bone , 588
retracted nasal tip , 598–599
secondary rhinoplasty , 644
Sheen cartilage graft , 596, 597
wide nasal pores , 596, 597
wide nasal tip , 596, 597
fascia grafts
moderate depression of nasal dorsum , 600–603
nasal deviation , 604–606
nasal hump , 607–609
thin skin and subcutaneous tissue , 604–606
Hispanic nose , 181
Permacol ( see Permacol)
rolled fascia graft , 610
depressed nasal dorsum , 610–613
depressed radix , 614–616, 623–630
dorsal hump , 628
fallen nasal tip , 614–616, 629–630
hump of nasal dorsum , 614–616
Index

1125
lateral nasal dorsum , 617–619
moderate deformity , 620–622
moderate hump of nasal dorsum , 623–625
nasal alae , 631–633
nasal hump , 629–630
nasal septum , 626–627
nasal tip , 623–625, 628, 631–633
retracted columella , 629–630
retraction of columella , 614–616
thick skin nose , 629–630
surgical technique
deep temporal fascia , 634–635
depressed radix , 639–643
dorsal hump , 642–643
elongated nose , 642–643
fallen nasal tip , 639–641
moderate nasal hump , 639–641
nasal tip and alae , 634, 636–638
retracted chin , 639–641
sharp nasolabial angle , 639–641
tip nasal fall , 642–643
wide nasal pore , 639–641
ultradiced rib cartilage graft ( see Ultradiced rib
cartilage graft)
Auricular cartilage graft , 380–384, 748, 1057
Autogenous grafts , 753, 1058
Autografts , 363–364, 482
Autologous cartilage , 164, 972, 973
Autologous chondrocyte implantation (ACI) , 1108
Autospreader grafts , 551
B
Baker, H.L. , 197, 198
Balanced rhinoplasty , 182, 263
Banner technique , 906–908
batten-type grafts , 899–900
caudal septal shortening , 900–901
cephalic resection , 899
columellar-septal fi xation , 899–900
crura lateralis , 899
Sheen-type tip graft , 897
short shield graft , 897, 898
vestibular skin reduction , 901
Barsky, A.J. , 95
Batson, O.V. , 58
Batten grafts , 899–900
BDD . See Body dysmorphic disorder (BDD)
Benito-Ruiz, J. , 754
Berinstein, T.H. , 713
Berman, M. , 877
Berman, W.E. , 899
Bi fi d nose
outcome analysis and critique , 277, 281
patient’s facial analysis , 277, 279
postoperative series , 277, 281
preoperative series , 277, 278
surgical technique , 277
intraoperative procedures , 277, 279
standard brief operation note , 277, 280
Bilateral spreader grafts , 546, 547, 552, 562, 1090, 1103
Bioreactor culture systems , 1113–1114
Blair, V. , 690, 691
Block-shaped Gore-Tex , 1015–1016, 1018
BMSCs . See Bone marrow-derived mesenchymal stem
cells (BMSCs)
Body dysmorphic disorder (BDD)
body image , 81
classi fi cation , 78, 79
clinical implications , 86–89
cognitive-behavioral models , 81
cosmetic and plastic surgery , 77
cosmetic rhinoplasty , 81–82
features
anxiety/personality disorder , 80
assessment , 79
distorted perception , 78
mental/nonmental health treatment , 78
pathophysiology , 80
prevalence , 79
mental disorder , 77
neurobiological issues , 80–81
personality
BDDQ , 86
categorical and dimensional methods , 85
DAPI , 85
de fi nition , 83
DSM-IV classi fi cation , 84
dysmorphic symptoms , 85
features , 83
fl uvoxamine , 85
MMPI , 84
psychiatric illnesses , 77
restorative , 78
self-esteem , 82–83
Body Dysmorphic Disorder Questionnaire (BDDQ) , 82
Boltzmann superposition principle , 536
Bone
injury , 935–936
secondary rhinoplasty
diced cartilage graft , 987
dorsal aesthetic lines , 986
dorsal augmentation , 987
osteotomies , 986–987
Bone marrow-derived mesenchymal stem cells (BMSCs) ,
1115–1116
Bone morphogenic protein-2 (BMP-2) , 1112
Bönisch, M. , 233
Bony vault , 942–944, 967
Bossae , 458, 965, 967
Botulinum toxin , 5
contraindications , 796
indications , 796
nasolabial angle, opening of , 795
objectives , 795
protocol , 795–796
treatment of columella , 795
Botulinum toxin A (BTxA) , 796
Index