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_17, © Springer-Verlag Berlin Heidelberg 2013
17
17.1
Historical Background
The concept of the ethnic nose has evolved over
time. In 1913, Schultz [ 1 ] characterized the typi-
cal “Black nose” as broad and fl attened, fre-
quently lacking in dorsal projection. The tip was
described as fl at and round, with fl ared alae and
an obtuse alar dome angle. A number of authors,
including Matory and Falces [ 2 ] , have com-
mented on the predilection for non-Caucasians to
have thick nasal skin with a large amount of sub-
cutaneous tissue.
Despite such stereotypical features, authors
more recently have pointed out the dif fi culty in
categorizing individual patients. In 1976, Stucker
[ 3 ] noted that few African-American patients
possessed all of the aforementioned racial char-
acteristics. Ofodile and James [ 4 ] performed an
anatomic study on 24 alar cartilages in 12 Black
American male cadavers and documented con-
siderable variability in morphology. They were
able to divide subjects into three distinct groups
and hypothesized that the considerable racial
crossings among Blacks, Whites, and Native
Americans in the United States could account for
the differences between the groups. In a volun-
teer sample of 108 African-American women,
Porter and Olson [ 5 ] found that the African-
American nose was in general shorter and broader
than that of its Caucasian counterpart. However,
the authors recognized signi fi cant variability in
facial features within their study population and
proposed dorsal nasal height as a means of sub-
categorization. Baker and Krause [ 6 ] analyzed
eight external nasal surface measurements in 196
non-White patients and found they were able to
divide their subjects into fi ve statistically
signi fi cant groups. Interestingly, the so-called
typical Negroid nose did not typify the most com-
mon Black American nasal con fi guration.
There is also substantial variability within the
Latino and Asian populations. Milgrim et al. [ 7 ]
photographically compared 97 Latino and 40
Caucasian women. They concluded that although
the average Latino nose could be categorized
anthropometrically as Mesorrhine, subjects with
Rhinoplasty in the Multiracial Nose
Thomas Romo III , Manoj T. Abraham ,
and Whitney Pafford
T. Romo III , M.D., FACS (*)
135 East 74th Street , New York , NY 10021 , USA
Division of Facial Plastic and Reconstructive Surgery ,
Lenox Hill Hospital and Manhattan Eye, Ear and Throat
Hospital , New York , NY , USA
e-mail: docromo@aol.com
M. T. Abraham , M.D.
New York Medical College, Facial Plastic,
Reconstructive & Laser Surgery, PLLC ,
P.O. Box 2179 , Poughkeepsie , NY 12601 , USA
e-mail: manoj_abraham@hotmail.com ,
info@nyfacemd.com
W. Pafford , M.D.
Department of Otolaryngology , Bellevue Hospital
Center , 462 First Ave , NBV 5 E 9 , New York ,
NY 10016 , USA
Department of Otolaryngology – Head and Neck
Surgery , New York University , New York , NY , USA
e-mail: paffow01@byumc.org , whitneypaff@yahoo.com

198
T. Romo III et al.
Caribbean ancestry more closely resembled
Platyrrhine norms while those of Central and South
American descent resembled Leptorrhine norms.
Similarly, Aung et al. [ 8 ] used a laser surface scan-
ner to carry out anthropometric measurements of
90 Oriental subjects. The authors determined that
the Oriental nose was, in general, broader in rela-
tion to height and had less tip projection, but also
noted three different subtypes. In a study of 206
Chinese adults of Han ancestry compared to 103
North American Caucasians, Wang et al. [ 9 ] dis-
covered that the Chinese nose fi ts the dimensions
of the nasofacial canon (nose width one-quarter of
the face width) signi fi cantly more frequently
(51.5%) than did the Caucasian nose (36.9%).
The conceptualization of ethnic rhinoplasty
has likewise changed dramatically in the litera-
ture. In the past, many authors assumed that non-
White patients sought rhinoplasty to gain a more
Caucasian appearance. Martin [ 10 ] reported that
both Black and Caucasian men in the United
States ranked Black women with Caucasian facial
features as more beautiful, while men in Nigeria
preferred women with Black features. Falces
et al. [ 11 ] and others connected this perception to
economic considerations. Patients may feel it
necessary to fi t the Caucasian ideal of beauty in
order to succeed in Western society. Given the
limitations of what rhinoplasty can achieve in
this context, Snyder [ 12 ] suggested the need for
increased preoperative consultations for the
achievement of realistic goals and the occasional
need for psychiatric evaluation.
In 1972, Pitanguy [ 13 ] described the currently
accepted ideal that the nose must be in harmony
with the rest of the face and the race of the indi-
vidual. Stucker [ 14 ] stressed the importance of
eliciting patients’ desires and expectations and
warned against imposing the aesthetic ideals of the
surgeon on patients. This view was lent credence
by Baker and Krause’s [ 6 ] survey of 196 non-
White employees and outpatients at the University
of Michigan, Ann Arbor. Their study revealed that
the vast majority of Black Americans considering
rhinoplasty did not desire Caucasian-type noses.
With the in fl ux of non-Caucasian immigrant
populations and the growth of ethnic minority com-
munities within many Western countries, and the
widespread acceptance and growing popularity of
cosmetic surgery in all segments of society, the
number of non-Caucasian patients requesting facial
plastic surgery is steadily on the rise. Internationally,
based on location, a surgeon’s practice could poten-
tially encompass only non-Caucasian patients. In
light of the increased diversity of patients request-
ing rhinoplasty, Yellin [ 15 ] pointed out that
Caucasian normative standards of facial analysis
are no longer suf fi cient in the new millennium.
Additional studies are necessary to better de fi ne
aesthetic ideals within the various racial groups.
17.2
Anatomy and Physiology
The racial and ethnic features of each patient’s
nose are determined by the underlying bony and
cartilaginous framework and by the covering skin
and soft tissue envelope. These characteristics are
determined at a genetic level but may be
in fl uenced to a certain extent by environmental
factors (nutrition, aging, trauma, surgery).
With the understanding that each patient’s nose
is unique and may not possess all the characteris-
tics typical of the “ethnic nose,” there are certain
features speci fi c to the non-Caucasian nose that
make rhinoplasty more challenging (Fig. 17.1 ).
Bone and cartilage support is often lacking, result-
ing in a wide dorsum with poor anterior projec-
tion (nasofacial angle less than 30°). The pyriform
aperture is wide. This lack of skeletal support, in
addition to thick skin and a prominent subcutane-
ous fi brofatty pad, contributes to a poorly pro-
jected tip that is amorphous and lacks de fi nition.
The nasal alae tend to be wider than the intercan-
thal distance and fl ared, with more horizontally
oriented nostrils. The premaxillary area is often
hypoplastic.
The differences in nasal anatomy are most
likely responsible for the differences in nasal
valve physiology observed by a number of
authors. In a recent study, Canbay and Bhatia
[ 16 ] used rhinomanometry to measure total nasal
resistance following nasal decongestion in 42
Caucasian and 32 Black healthy adults. They
demonstrated a highly statistically signi fi cant
decrease in the mean total airway resistance in
Blacks in comparison to Caucasians (0.136 Pa/
cm 3 /s in Blacks and 0.179 Pa/cm 3 /s in Caucasians

199
17 Rhinoplasty in the Multiracial Nose
by the anterior method, and 0.134 and 0.161 Pa/
cm 3 /s, respectively, by the posterior method). In a
similar study, Burres [ 17 ] used acoustic rhinom-
etry to study nasal valve physiology in 28 Asian
subjects. When compared to a non-Asian control
group, the author found that there was a statisti-
cally signi fi cant decrease in nostril asymmetry in
the Asian group (39% versus 59%) and that the
Mesorrhine nose was less likely to respond to an
externally applied adhesive strip dilator.
17.3
Preoperative Evaluation
As with any cosmetic surgery, a complete and
thorough preoperative evaluation is imperative
with ethnic rhinoplasty. It is absolutely essential
that the surgeon have a complete understanding
of the patient’s concerns and expectations of
nasal surgery. The goal of maintaining ethnic
identity congruent with the patient’s facial fea-
tures while improving nasal contour should be
discussed in light of the patient’s request.
Limitations imposed by ethnic anatomical fea-
tures and the slightly increased risk of complica-
tions should be carefully reviewed. Computer
modeling of projected outcome can be helpful in
grounding patients’ expectations, with the caveat
that the fi nal result may not exactly duplicate the
projection. Many patients do not have direct con-
tact with others who have had the procedure and
may base hopes and desires on inaccurate sources
of information. It is often helpful to have patients
meet with satis fi ed ethnic role models who have
already undergone the procedure. Patients who
have unrealistic expectations of rhinoplasty
should be dissuaded from having surgery and
encouraged to seek additional counseling.
Anterior nasal spine
(label)
Anterior nasal spine
(label)
a
b
Fig. 17.1 Comparing the anatomic features of ( a ) the gen-
eralized multiracial nose with that of ( b ) the Caucasian nose.
The diminished nasal bones and cartilages are depicted,
along with the prominent subcutaneous fi brofatty tissue pad
typically found in the non-Caucasian nose. This results in
less overall tip projection and a more amorphous tip and
dorsum. The anterior nasal spine and premaxillary area tend
to be more hypoplastic in the generic multiracial nose

200
T. Romo III et al.
A thorough physical examination, with spe-
cial attention to ethnic features that may impact
on the operative plan, should be performed. Skin
texture and quality and the nature of the subcuta-
neous fi brofatty pad are evaluated by inspection
and by palpation. Bony and cartilaginous dorsal
nasal support is determined. The size, strength,
and pliability of the upper and lower lateral carti-
lages are noted, and the patency of the nasal
valves is tested with the modi fi ed Cottle maneu-
ver. Tip projection, rotation, and de fi nition must
be studied. The width of the alae and any
de fi ciency in the premaxillary area are noted.
Occasionally, it may be necessary to consider
other facial plastic procedures (mentoplasty,
maxillary augmentation, cheiloplasty, etc.) in
conjunction with rhinoplasty in order to achieve
the optimal desired result.
17.4
Operative Technique
and Postoperative Care
Given the generalized de fi ciency of structural
support in the typical non-Caucasian nose, it is
important to implement augmentation rather than
the conventional reduction strategies to recon-
struct the nose. The authors practice the follow-
ing technique for ethnic rhinoplasty.
Ethnic rhinoplasty can be performed under
local anesthesia with monitored sedation, or
under general anesthesia, depending on patient
and surgeon preference, although general anes-
thesia is preferable given the challenging nature
of these cases. Topical vasoconstriction of the
nasal mucosa is achieved by placing a Merocel
sponge impregnated with 3–5 mL of 0.5% neo-
synephrine hydrochloride in each nostril. The
nose is then appropriately injected with 0.5%
lidocaine hydrochloride with 1:200,000 epineph-
rine bitartrate, taking care not to distort nasal
anatomy.
After good vasoconstriction and local anes-
thetic effect, we proceed with marking the
patient’s nasal tip and dorsum to ensure precise
placement of the planned dorsum-tip implant.
The location of the implant is outlined, making
sure it is positioned in the desired midline in
order to prevent asymmetric placement.
A septoplasty is then performed in standard
fashion, using a trans fi xation incision. Cartilage
is harvested, making sure to preserve adequate
anterior and dorsal struts. Cartilaginous and bony
spurs and deviations are corrected. Resection of
the anterior aspect of the inferior turbinate with
turbinate outfracture is useful in widening the
nasal cavity and increasing the aperture of the
internal nasal valve. The septal trans fi xation inci-
sions are closed using interrupted 4.0 chromic
sutures and the mucoperichondrial fl aps reap-
proximated with a 4.0 chromic mattress suture.
Because adequate septal cartilage is often lack-
ing in the ethnic nose, and because a signi fi cant
amount of augmentation material is typically
required to provide structural integrity to the recon-
structed ethnic nose, the authors have found Medpor
(porous high-density polyethylene [PHDPE]) to be
a perfectly suitable alloplastic alternative. All
implants are allowed to soak in gentamicin solution
prior to placement, and the patient is given one
dose of intravenous antibiotic.
The external decortication approach is highly
recommended in order to achieve the necessary
exposure for accurate placement of augmentation
grafts and for adequate nasal contouring (Figs. 17.2
and 17.3 ). An inverted gull-wing incision is made
along the narrowest part of the columella or along
a prominent columella-labial groove. The incision
is extended anteriorly in a marginal fashion to the
tip cartilages, and then partially along the alar car-
tilage margin. A blunt-tipped scissor is used to
dissect the skin envelope off of the columella,
over the tip cartilages and extending up to the dor-
sum. The dissection is carried out just under the
subcutaneous tissue, allowing defatting of the tip
and dorsal nasal skin. The underlying fi brofatty
tissue pad is then dissected up off the midcolu-
mella region and carried up over the tip and alar
cartilages to its insertion in the supratip region.
This fat pad, which we once used as a dorsal onlay
graft, is now routinely discarded.
The medial crura are separated down to the
anterior nasal spine and premaxilla. A small pre-
cise pocket is made in the area of the premaxilla
to accommodate multiple small-particle plumper
implants carved from a 1.1-mm-thick sheet of
Medpor (Fig. 17.3 ). Next, a straight thin strut is
fashioned from cartilage or from the 1.1-mm-thick

201
17 Rhinoplasty in the Multiracial Nose
Medpor sheet. This columella strut is positioned
in between the medial crural cartilages and stabi-
lized with interrupted 5.0 Monocryl sutures
(Fig. 17.3 ). The stitches are placed sequentially,
starting at the nasolabial angle and progressing to
the nasal tip, incorporating some lateral crural
steal. Additional tip support and medialization of
the dome and lower lateral cartilages can be
achieved with a 4.0 Prolene dome-binding suture
(Fig. 17.2 ). Given the typically de fi cient alar car-
tilages, aggressive cephalic trim of the lower lat-
eral cartilages is generally not necessary for tip
de fi nition.
A large Medpor nasal dorsum implant, with or
without the tip component depending on the
amount of augmentation desired, is then carved
to the appropriate shape using a #10 scalpel blade.
The ideal size and shape of the implant can be
determined by positioning it along the dorsum
under the skin envelope to check if it provides the
desired contour, using the preoperative skin
markings as a guide. A sheet of Alloderm (acel-
lular human dermal graft) can be wrapped around
the top of the implant to camou fl age any minor
irregularities. Once the implant has been carved
to satisfaction, two points are marked along the
body of the implant. These points are lined up
with two corresponding points marked on the
skin, and a temporary transcutaneous 4.0 Prolene
suture is used to slide the implant up into the
snugly fi tting nasal dorsal skin pocket (Fig. 17.3 ).
In this way, precise, symmetric positioning of the
dorsum-tip implant is assured. Placement of an
infratip lobule shield graft provides a smooth
contour with the columella. This graft is carved
from septal cartilage and secured in position
using a 6.0 Prolene suture (Fig. 17.2 ). The trans-
verse columella incision is reapproximated with
an interrupted 5.0 Vicryl deep layer, followed by
interrupted 6.0 nylon sutures for skin closure.
The marginal incisions are closed with 5.0 mild
chromic sutures.
If necessary, the nasal alae can be narrowed
using a pointed caliper to perform carefully mea-
sured curved excisions at the nasal base [ 18 ] .
Excision of vestibular skin will reduce nostril
size, while excision of skin along the cutaneous
alar margin will reduce nasal base width and
fl are. When vestibular skin is resected, a medial
skin fl ap should be preserved to decrease the like-
lihood of nasal sill notching. Sheen [ 19 ] warns
against performing alar base reduction when the
nostrils are wide but not fl ared, since this will
cause an acute angulation of the alae to the nasal
base and may lead to a pinched appearance of the
nose. Lateral osteotomies can be performed
Preoperative platyrrhine nose
Dorsal implant
Dorsal implant
Plumper implants
Plumper implants
Infratip lobule
septal cartilage
graft
Infratip lobule
septal cartilage
graft (transparent)
Dome suture
Columella strut
Columella strut
Medial crural
sutures
Fig. 17.2 The reconstructed multiracial nose. A Medpor
dorsal-tip implant, columella strut, and premaxillary
plumper implants are shown in position. Suture placement
is illustrated best in the base view. The infratip lobule car-
tilage shield graft is shown as transparent for the sake of
clarity. ( Inset ) Preoperative multiracial nose. Note blunted
tip de fi nition due to thin poorly supported lower lateral
cartilages and thick fi brofatty pad. The widely fl ared alae
are improved by calibrated diamond-shaped sill excisions

202
T. Romo III et al.
through the nasal base incisions to further de fi ne
the nasal dorsum. The alae are then exactingly
reapproximated using 5.0 polyglactin (Vicryl)
deep sutures and interrupted 6.0 nylon sutures for
the skin. The skin closure is begun at the most
superior lateral edge of the incision in order to
hide any irregularities of closure within the
medial intranasal portion of the incision. If addi-
tional narrowing of the nasal base is required,
vertical diamond-shaped skin ellipses can be
excised inside the nasal sills. These incisions are
closed with interrupted 6.0 nylon sutures.
The nose is taped externally, to reduce postop-
erative edema, and a cast (Aquaplast) applied.
Placement of intranasal Silastic (silicone rubber
sheets) septal splints is helpful in promoting heal-
ing if there are extensive lacerations of the muco-
perichondrial septal fl aps. The Silastic sheets are
cut to the appropriate size, placed on either side
of the septum, and anchored anteriorly with a 4.0
nylon through-and-through stitch. The use of a
nonadherent intranasal dressing (Telfa or a
Merocel sponge wrapped in Telfa) is useful in
decreasing postoperative oozing. The dressing is
lubricated in antibacterial ointment (Bacitracin),
positioned in the anterior aspect of the nasal cav-
ity bilaterally, and secured loosely to the other
with a stitch to prevent any chance of aspiration.
The nasal packing is removed 1–2 days post-
operatively, and the patient encouraged to use
saline irrigation. The nasal cast, Silastic splints,
and stitches are removed 5–7 days after surgery.
Occasionally, precise injection of steroid into the
supratip during follow-up may be necessary to
a
b
d
c
Fig. 17.3 Precise placement of Medpor implants accomplished through an external rhinoplasty approach: ( a ) Plumper
implant. ( b ) Columella strut. ( c ) Dorsal-tip implant. ( d ) Infratip lobule cartilage graft

203
17 Rhinoplasty in the Multiracial Nose
prevent excess scar formation and enhance tip
de fi nition, avoiding a Polly beak deformity.
17.5
Outcome and Complications
Using techniques described herein, the vast major-
ity of non-Caucasian patients undergoing rhino-
plasty are happy with the result of surgery. Romo
and Shapiro [ 20 ] reported 100% satisfaction with
cosmesis in 75 patients, 2–7 years following eth-
nic rhinoplasty using autogenous cartilage grafts
and the techniques described at that time. In a
follow-up study of 187 patients (35.3% non-Cau-
casian) using Medpor implants, only one patient
requested revision of a dorsal implant [ 21 ] . This
favorable result is in large part predicated by
ensuring that patients understand the goals and
limitations of ethnic rhinoplasty and have realistic
expectations of surgery (Figs. 17.4 and 17.5 ).
In experienced hands, complications are
rare, even in dif fi cult cases of ethnic rhinoplasty.
However, non-Caucasian patients are more
prone to scarring and keloid formation, and
risk of patient dissatisfaction is increased given
the inherent limitations imposed by ethnic
nasal anatomy, and often unachievable patient
expectations.
In their study of 75 patients who underwent
ethnic rhinoplasty utilizing the techniques
described, Romo and Shapiro [ 20 ] noted no major
complications and only occasional minor compli-
cations. Four patients had notching of the trans-
verse columella incision, three had observable
suture tract marks along the alar closure, and
one patient had an alar incision granuloma.
Incorporation of a two-layer tension-free closure
eliminated all such minor complications. The
authors report that critical evaluation of the nasal
reconstruction revealed a moderate diminution of
tip projection in eight patients. All patients under-
went reconstruction with autogenous cartilage
grafts, and no signi fi cant absorption or extrusion
of the grafts was noted.
a
b
d
c
Fig. 17.4 Excision of diamond-shaped nasal sill soft
tissue to decrease width of the multiracial nose.
( a ) Presillectomy wide base multiracial nose. ( b ) Exact
measurement of planned sill resection. ( c ) Left diamond-
shaped sillectomy. ( d ) Closure of bilateral sillectomies

204
T. Romo III et al.
Fig. 17.5 ( Left ) Preoperative multiracial nose. ( Right ) One year postoperative following multiracial rhinoplasty

205
17 Rhinoplasty in the Multiracial Nose
Falces et al. [ 11 ] have described problems
with skin redraping and prolonged nasal tip
edema in non-Caucasian patients. In a follow-up
study, Matory and Falces [ 2 ] reported implant
displacement, infection, fracture, and extrusion
in 4 of 134 ethnic rhinoplasties. The authors felt
that prolonged edema, scars, racial incongruity,
and asymmetry were potential problems associ-
ated with ethnic rhinoplasty.
17.6
Future and Controversies
The art and science of rhinoplasty is continually
evolving. In recent years, there has been a shift
towards open-rhinoplasty techniques, especially
in challenging cases such as ethnic rhinoplasty.
The authors feel that the open decortication
approach offers the best visualization, allowing
for accurate graft placement when needed.
Achievement of adequate aesthetic reconstruc-
tion may be more limited with classic intranasal
techniques used more extensively in the past.
The need for osteotomies during ethnic rhino-
plasty has been debated in the literature. Some
authors contend that the illusion of a wide nasal dor-
sum is created by lack of dorsal height in non-Cau-
casians [ 3, 14, 22, 23 ] . These authors advocate
placement of a dorsal augmentation graft without
nasal osteotomies. Matory and Falces [ 2 ] suggested
that osteotomies may actually overnarrow the dor-
sum with respect to the lobule, creating racial incon-
gruity. However, the authors agree with Rohrich
[ 24 ] who recommends osteotomies if the nasal bony
width is greater than 80% of the intercanthal dis-
tance. Narrowing of the upper third of the nose must
be done in proportion with alar base reduction and
increased tip projection and sculpting in order to
ensure a balanced appearance to the nose.
The quest continues for the ideal alloplastic
implant material when adequate nasal septal carti-
lage is not available. This topic is particularly rel-
evant in ethnic rhinoplasty since septal cartilage if
often de fi cient in the non-Caucasian nose. Other
autologous and homologous graft materials have
been considered. Auricular cartilage may be har-
vested, but use is often restricted due to the innate
curvature of the cartilage. Ortiz Monasterio and
Michelena [ 25 ] described the use of rib cartilage
for the correction of the ethnic nose, but warping
of the graft is a problem. Split calvarium, iliac,
olecranon, and other bony graft materials have
also been proposed. Almost all homologous graft
materials (irradiated cartilage) and many autolo-
gous grafts are prone to resorption or fracture. All
autologous graft materials, excluding nasal septal
cartilage, are saddled with the inherent and poten-
tially signi fi cant morbidity of a second operative
donor site and additional operative time. On the
other hand, autologous grafts are less likely to
become infected or extrude. Toriumi [ 26 ] points
out that unlike alloplastic material, autologous
grafts are unlikely to permanently harm the over-
lying soft tissue envelope of the nose.
Because of ease of availability and carving, many
synthetic materials have been introduced for use in
nasal reconstruction (silicone rubber [Silastic], poly-
amide mesh [Supramid], polytetra fl uoroethylene
carbon [Proplast, Te fl on], polypropylene mesh
[Prolene], polyethylene terephthalate [Mersilene
mesh], expanded polytetra fl uoroethylene [e-PTFE,
Gore-Tex]). However, high rates of infection, extru-
sion, and resorption, along with excessive fi brosis
and contracture due to chronic foreign body response,
have left most surgeons dissatis fi ed. Most of these
implant materials are not rigid enough to provide
structural support and have been used primarily for
augmentation purposes. L-shaped silicone struts do
provide some structural support and have been used
in non-Caucasian rhinoplasty, since the implant is
better protected by the thick overlying skin. Deva
et al. [ 27 ] reviewed their experience with silicone
nasal implants in 422 patients, the majority (98%)
Southeast Asian women. The study highlighted a
9.7% complication rate (due to hemorrhage, dis-
placement, extrusion, overprominence, supratip
deformity, and excessive pressure) requiring removal
of the graft and a 15.8% patient dissatisfaction rate.
In the authors’ opinion, porous high-density poly-
ethylene (PHDPE—Medpor) alloplastic implants
offer the greatest promise. Medpor implants are rigid
and allow fi brovascular ingrowth, promoting stabil-
ity and resistance to infection. In 1998, Romo et al.
[ 21 ] published a retrospective review of 187 patients
who had undergone nasal reconstruction with
Medpor implants (66 patients for non-Caucasian

206
T. Romo III et al.
rhinoplasty and 121 patients for revision surgery).
Postoperative follow-up ranged from 6 months to
3.5 years, with an average of 26 months.
Complications were limited to fi ve patients (2.6%),
all of whom had impaired healing secondary to
heavy smoking, cocaine abuse, collagen vascular
disease, or multiple previous surgeries. Of these,
three patients had early infection and two patients
had delayed infection necessitating implant removal.
Implants were easily removed, without damage to
the overlying soft tissue and skin envelope. Additional
favorable long-term results are forthcoming.
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North Am 20(4):877–894
15. Yellin SA (1997) Aesthetics for the next millennium.
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16. Canbay EI, Bhatia SN (1997) A comparison of nasal
resistance in White Caucasians and Blacks. Am J
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18. McKinney PW, Mossie RD, Bailey MH (1988)
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19. Sheen JH (1978) Aesthetic rhinoplasty. Mosby, St.
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20. Romo T III, Shapiro AL (1992) Aesthetic reconstruc-
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22. Hubbard TJ (1998) Bridge narrowing in ethnic noses.
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Raven, New York, pp 2648–2655
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mentation rhinoplasty techniques for the correction of
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DOI 10.1007/978-3-642-28053-5_18, © Springer-Verlag Berlin Heidelberg 2013
18
18.1
Introduction
The nose is the central and most prominent aes-
thetic facial landmark. It divides the face in half
and de fi nes many of the common measures of
facial proportions (Fig. 18.1 ). When in balance
with the rest of the face, it is an important compo-
nent of perceived facial beauty. When it is too
prominent, too short, too wide, or off-center, it
can contribute to facial disharmony. Rhinoplasty
can be an important adjuvant procedure when
combined with surgery of the jaws or surgery for
facial aging. There have been many books, arti-
cles, and seminars on the subject, with ardent
opinions as to the merits of a particular philoso-
phy or surgical technique. It is apparent that many
different approaches can yield gratifying results
in the proper hands. The following is a personal
approach to aesthetic rhinoplasty based on the
author’s experience with over 5,000 procedures
over 25 years. This is the basic approach that the
author has demonstrated and taught to the plastic
surgery residents. This chapter is a brief synopsis
of a methodology that has provided consistent
good results with a minimum of aesthetic, func-
tional, or postoperative problems.
18.2
Consultation
The initial consultation for a patient requesting
primary aesthetic rhinoplasty should include a
detailed medical history, review of any previous
nasal procedures, and careful attention to the
patient’s stated aesthetic goals. The nose should
be examined externally and with a nasal specu-
lum; any anatomic or functional anomalies should
be documented and brought to the patient’s atten-
tion. A speculum examination of the nasal cavity
can give important clues to potential functional
problems that could be aggravated by aesthetic
nasal surgery. These concerns should be dis-
cussed with the patient and if necessary addressed
at the time of aesthetic surgery. Overall facial
aesthetics should be discussed with particular
emphasis on the underlying bony anatomy of the
face. A patient with what appears to be a dispro-
portionately large nasal pyramid may in fact have
a small chin which is amplifying the disharmony.
An overly projected nasal tip may be more prom-
inent in a patient with maxillary retrussion and so
forth. A lateral cephalometric radiograph can be
useful in verifying the clinical impression in
cases of skeletal disharmony.
In addition to external examination, photo-
graphic documentation is essential for documen-
tation and treatment planning. At a minimum,
Aesthetic Rhinoplasty Utilizing
Various Techniques Depending
on the Abnormality
Fernando D. Burstein
F. D. Burstein , M.D., FACS, FAAP
Clinical Prof Plast Reconstr Surgery Emory Univ, 975
Johnson Ferry NE Road, Suite 100 ,
Atlanta , GA 30342 , USA
Division of Plastic and Reconstructive Surgery ,
Emory University , Atlanta , GA , USA
Center for Craniofacial Disorders, Childrens
Healthcare of Atlanta , Atlanta , GA , USA
e-mail: fernandodburstein@yahoo.com

208
F.D. Burstein
anterior-posterior and right and left pro fi le views
are recommended. A worm’s eye view can be
helpful in patients with a wide nasal base.
Computerized imaging is an essential part of my
surgical preparation and an important tool for
enhancing communication with the patient. The
staff images the patient, and a written consent is
obtained documenting that the images are “poten-
tial results” and may vary. The author is very
wary of the patient that demands a nose that she
or he sees in a movie magazine. The computer-
ized images are used as a real time guide during
the procedure. In formulating a surgical plan, the
author considers the patient’s desires, the relevant
anatomy, and the results of computerized images.
This plan is presented to the patient and discussed
in detail to insure that their expectations are real-
istic. An outlined plan based on these factors may
look something like this:
1. Dorsal hump bony and cartilaginous. Reduce
dorsum with slight concavity and reduce supra
tip septum.
2. Wide bony pyramid. Bilateral lateral osteoto-
mies with infracture.
3. Amorphous wide nasal tip. Cephalic trim,
intradomal sutures, and graft tip. Reduce alar
base width.
18.3
Anesthesia
The author performs all aesthetic nasal surgery
under a general endotracheal anesthetic super-
vised by a board-certi fi ed anesthesiologist. Only
minor revisions are done under local with oral
sedation. The proper topical and in fi ltrative anes-
thetic administration will greatly decrease opera-
tive and postoperative bleeding. Along with
better visualization during the procedure, the
patient’s postoperative discomfort will be greatly
reduced. Pledgets impregnated with 4% cocaine
are placed between the inferior and middle tur-
binates to anesthetize and constrict the mucosa.
The supratrochlear, supraorbital, infraorbital,
and anterior ethmoidal nerves are blocked with
0.5% mepivicaine with epinephrine, and the sub-
cutaneous nasal tissues are in fi ltrated (Fig. 18.2 ).
If septal work is to be done, the septal mucosa is
also in fi ltrated. Less than 10 cc is used for all
injections. It is useful to allow 15 min for maxi-
mal vasoconstriction to occur before starting the
operation.
18.4
Surgery
An external rhinoplasty approach is used in
nearly all of the aesthetic nasal operations, and
the author has done so for nearly 20 years. There
are advantages and disadvantages to both the
external and internal approaches to rhinoplasty,
but on balance, the author much prefers the exter-
nal approach. The exposure afforded by this
approach is wonderful for teaching purposes
since cause and effect of various maneuvers can
be easily demonstrated. Important technical
points that will minimize undesirable results
include meticulous closure of the columellar inci-
sion and careful reattachment of suspensory and
connecting ligaments that are taken down for
exposure. It is important to let the patient know
that there will be numbness of the nasal skin for
Fig. 18.1 Measuring ideal facial proportions using
Ricketts “Golden Rule”

209
18 Aesthetic Rhinoplasty Utilizing Various Techniques Depending on the Abnormality
several weeks and that often the nose will feel
indurated during the healing process. These con-
ditions are temporary, but in cold climates care
must be taken to avoid nasal frostbite until sensa-
tion returns.
For purposes of clarity, the author has divided
the operative procedure into several distinct
steps. These are described in the order that the
author recommends performing, which is a logi-
cal progression that avoids repetition and redun-
dancy, allowing an orderly and predictable
procedure. There are countless variations on
every step of the rhinoplasty procedure based on
anatomic factors, the surgeon’s preferences and
experience, and surgical goals. The basic tech-
nique employed is broken down into several
logical progressive stages from which creative
variations can be added according to the sur-
geon’s experience. These steps are illustrated for
instructive purposes for reductive rhinoplasty
with tip modi fi cation.
18.5
Exposure
The location and design of the columellar inci-
sion is critical. Placing the incision in the distal
third of the columella hides it from the frontal
view and makes dissection easier (Fig. 18.3 ). A
stair-step incision breaks up the incision line,
thus camou fl aging it since no segment is more
than 3–4 mm in length. Alignment of the incision
is facilitated by simply fi tting the right angles
back together at the end of the procedure. The
nasal skin is quite adherent in this area and a fi ne
69 beaver blade is recommended for the initial
dissection. Using a thumb hook, the nasal ves-
tibular skin is everted, demonstrating the edge of
the lower lateral cartilages. The incision is car-
ried from the columella along the edge of the car-
tilages from medial to lateral, leaving a 5-mm rim
of intact vestibular skin. Leaving this rim will
prevent visible scars and distortion of the rim.
Sharp scissor dissection of the lower lateral
Anterrior ethmoid n.
Cocainized plodgcil
Intraorbital n.
Supraorbital n.
Supratrochlear n.
Fig. 18.2 Administration
of in fi ltrative and topical
anesthetic in preparation for
rhinoplasty. Note block of all
sensory innervation and
mucosal vasoconstriction are
key to successful surgery and
recovery

210
F.D. Burstein
cartilages is carried out until they are fully
exposed. The rest of the dissection over the dor-
sum is easily carried out with blunt scissors,
protecting the skin with an elevator. At this stage,
the entire external nasal anatomy will be visible.
I take a moment to correlate the actual anatomy
with my surgical plan at this stage and modify it
as necessary. Important anatomic points are the
amount of cartilaginous versus bony dorsal hump,
thickness of the skin, and intradomal fat versus
cartilage width.
18.6
Dorsum
After exposure has been achieved, the dorsal com-
ponent can be addressed. If septal grafts are
required, they are obtained at this point by dis-
secting between the medial crura and carefully
separating the mucoperichondrium from the sep-
tum (Fig. 18.4 ). A 1-cm caudal strut and 1–2-cm
dorsal strut are left intact as the central septum is
harvested with a swivel knife. The septal muco-
perichondrium is then sutured back together with
a mattress suture of 4-0 gut (Fig. 18.5 ). This oblit-
erates a potential dead space and hematoma for-
Fig. 18.3 Location and design of external rhinoplasty
incision. Note right angles. This hides scar and makes
accurate reapproximation possible
Nasal septum
(1.5 cm intact)
1 cm intact
Ethmoid
Verner
Harvoat
Fig. 18.4 Septal harvesting.
Note that both dorsal and
caudal septal struts are
maintained. Approach is
through external incision
going between footplates

211
18 Aesthetic Rhinoplasty Utilizing Various Techniques Depending on the Abnormality
mation, making packing unnecessary. Next the
periosteum of the dorsum is elevated with a Joseph
elevator; this allows the rasp to work without
interference. Coarse to fi ne rasps are used to bring
the bony dorsum down to the desired level; no
osteotomes are used. This allows gradual, con-
trolled contouring of the bony dorsum under direct
visualization (Figs. 18.6 and 18.7 ). The cartilagi-
nous component is then trimmed using either sep-
tal right angle scissors or a #11 scalpel blade. The
nasal skin fl ap is frequently returned to its original
position, and the dorsum is palpated as well as
visually inspected several times as the pro fi le is
adjusted a millimeter at a time until the pro fi le
matches the patients desires. The computerized
imaging photos are invaluable in this step. In some
instances, the upper lateral cartilages may need to
be trimmed along their juncture with the septum
to reduce projection of the dorsum. The mucosa
should be carefully dissected prior to trimming to
avoid penetrating into the nasal cavity. Reduction
of the nasal dorsum will almost always result in a
fl attening of the dorsum or “open roof” as the
peak of the bony cartilaginous dorsum is removed
(Fig. 18.7 ). Lateral osteotomies can minimize this
effect while at the same time reducing the appar-
ent nasal bony width which is often desirable.
A 2-mm straight osteotome is often used for the
lateral osteotomies. No tunnels are necessary
before introducing the osteotome at the level of the
pyriform aperture. The tip of the osteotome should
be fl ush with the maxilla and follows the juncture
of the nasal bones and maxilla to the level of the
medial canthus where it is turned at a right angle,
to the long axis of the nasal bones, continuing the
osteotomies toward the nasal dorsum (Fig. 18.8 ).
The 2-mm osteotome produces a perforated paper
effect by leaving the periosteum attached along the
lines of the osteotomy enhancing stability. Care
should be taken to control the osteotome to avoid
perforating the nasal mucosa, which can result in
bleeding. This technique results in an osteotomy
that is fl ush with the maxilla preventing a visible
or palpable “rocker deformity” and is inherently
stable. No packing is necessary to hold the nasal
bones in place. Once the osteotomies are complete,
attention is turned to the nasal tip.
18.7
Tip
The plethora of variations of nasal tip anatomy
makes tip work a creative part of rhinoplasty.
There are many maneuvers that can be performed
Remnant of
nasal sepium
Muceperiosteum
Fig. 18.5 Resorbable
mattress sutures placed
between septal mucoper-
ichondrium fl aps obliterating
dead space. No packing
is used

212
F.D. Burstein
to achieve the desired nasal tip results. The par-
ticular techniques employed will depend on the
patient’s goals, the quality and thickness of the
overlying nasal skin, and available graft material.
Most often, the lower lateral cartilages will be too
wide and initial trimming is required. The carti-
lages are incised with a micro tip Colorado needle
cautery sparing the mucosa and the desired seg-
ment is removed with sharp scissors (Fig. 18.9 ).
Care is taken not to damage the lower border of
the upper lateral cartilage especially at its junc-
ture with the septum to preserve the internal nasal
valve. A minimum of 4 mm of rim cartilage
should be left intact to provide airway support to
the external valve.
In patients requiring only minimal narrowing
of the nasal tip with reasonably thin skin, this
cephalic trimming may be all that is required to
achieve the desired aesthetic result. It can be cou-
pled with suturing of the footplates and domes to
further narrow and project the tip. Only resorb-
able 5-0 PDS sutures are used for this. It is impor-
tant that the tip-de fi ning point be the lower lateral
cartilages and not the septum to prevent a polly
beak deformity. It may be necessary to trim the
distal septum if it projects beyond the most distal
point of the dome. If the tip is still too wide or the
lateral aspect of the domes too rounded, a simple
bruising using a cartilage crusher, while protect-
ing the mucosa, can soften this curve while insur-
ing nasal airway support (Fig. 18.10 ).
In cases where the tip is bi fi d or under-
projected or the skin is too thick to show the
desired highlights tip, grafting may be indicated.
Autologous tissues in rhinoplasty are used only
to avoid problems with rejection, infection, and
Fig. 18.6 Exposure of dorsum. ( a ) Bony dorsum modi fi ed with coarse to fi ne rasps. ( b ) The cartilaginous dorsum is
reduced with #11 scalpel. ( c ) Inset shows fl attening of dorsum with open roof being created

213
18 Aesthetic Rhinoplasty Utilizing Various Techniques Depending on the Abnormality
Fig. 18.7 Open roof as result
of bringing down nasal bones
and septum. This creates a
fl attened dorsum that should be
addressed
Periosteal ‘bridges’
Lateral osteotomies
Fig. 18.8 Lateral osteotomy technique.
A “perforated paper” effect is achieved.
Periosteal attachments also help with the
stability of the osteotomies

214
F.D. Burstein
extrusion that can occur with prosthetic materials.
In primary rhinoplasty, the septum and other
cartilaginous trimmings provide a plethora of
materials that can be sculpted to achieve an aes-
thetically pleasing tip. Some basic graft types
are the cephalic trim materials, septal columel-
lar, shield, and button grafts (Figs. 18.10 , 18.11 ,
18.12 , and 18.13 ). In almost all cases, the edges
of the grafts should be softened or “bruised” to
prevent an edge effect. The degree of softening
required will depend on how thick the nasal skin
is and how thick the graft is. If the skin is very
thick, requiring a more substantial graft to show
highlights, the edges of the grafts can be bev-
eled with a scalpel rather than bruised with a
Fig. 18.9 Nasal tip. Lower lateral cartilage trimmed
leaving a 4-mm rim of intact cartilage to support external
nasal valve
“Bruised”
alar cartilages
Tip grafts
Fig. 18.10 Composite of
various tip-modifying
techniques. Note bruising of
lateral crura to reduce nostril
convexity. Tip grafts to de fi ne
and project tip can be stacked
if necessary
Tip grafts
a
b
Fig. 18.11 ( a ) bruising of
alar cartilage to reduce
convexity. ( b ) suture and
stacking techniques to
increase tip projection

215
18 Aesthetic Rhinoplasty Utilizing Various Techniques Depending on the Abnormality
cartilage crusher to retain stiffness. The cephalic
trimmings are thin supple grafts that can be
doubled over and stacked to fi ne tune nasal tip
projection; care should be taken to preserve the
thin perichondrium to maintain structural integ-
rity. The graft should be placed on top of the
native lower lateral cartilages exactly where the
tip-de fi ning points are desired. The placement
can be checked by simply unfurling the nasal
skin fl ap and inspecting the effect. The septal
cartilage can be used for a variety of grafts
including shield shapes and button shapes.
These grafts are fairly substantial and relatively
rigid, making them ideal for patients having
thicker skin. Columellar grafts are used to pro-
vide tip support and projection as well as to
rotate the tip-de fi ning point to the desired angu-
lation (Fig. 18.14 ). In cases of a hooked or
droopy tip, they are often combined with trim-
ming of the distal dorsal septum to shift the tip
in an upward direction (Figs. 18.15 and 18.16 ).
A small pocket is created at the level of the
nasal spine and the graft is inserted contacting
the spine. The medial crura and footplates are
secured to the strut graft with mattress sutures
and then walked to the tip. As the dome is
reached, nasal tip width is converted to tip pro-
jection. The angle, of the strut, relative to the
medial crura and footplates of the graft inser-
tion will help to determine the nasolabial angle.
The strut should not project beyond the domes.
Additional grafts can then be added as required.
After the tip work has been completed, the skin
is closed with 5-0 Prolene at the stair step inci-
sion and 5-0 chromic for the intranasal
portion.
18.8
Base Width
After closing all incisions, the base width is eval-
uated and compared to the desired width on the
imaging photographs. This step is undertaken
only after all tip and dorsal modi fi cations have
been completed. Columellar grafts, intradomal
sutures, and other maneuvers that increase tip
projection will tend to narrow the nasal base. A
diamond-shaped pattern of skin and mucosa is
removed from the fl oor of nose just medial to the
alar attachments to the facial skin (Fig. 18.17 ).
This hides the incision intranasally while allow-
ing signi fi cant width reduction. In addition, it
preserves the natural curvature of the lateral
crura avoiding a grafted look seen with alar exci-
sion techniques. Absorbable sutures are used for
closure.
Fig. 18.12 Shield-type tip graft being applied. Note that
highest point of graft will be tip-de fi ning point
Fig. 18.13 Columellar strut graft between lower lateral
cartilages. It will provide support, allowing for tip narrow-
ing and rotation

216
F.D. Burstein
18.9
Special Situations in Primary
Aesthetic Rhinoplasty
Surgery of the non-European ethnic nose can seem
intimidating. In the USA, the most common ethnic
groups seeking aesthetic nasal improvement are
those of African American and Asian lineage
(Fig. 18.18 ). Most commonly, the tip width and
projection are the primary concern. Occasionally the
dorsum is also an issue. The fi rst step is, as always,
communicating with the patient as to realistic goals
and expectations. The imaging computer is a valu-
able adjuvant in this regard. Keep in mind that almost
all patients wish to keep their ethnic nasal identity
and simply desire improvement in terms of propor-
tions, tip de fi nition, or dorsal height (Fig. 18.19 ).
a
a
b
b
c
Fig. 18.14 ( a ) Male complaining of hooking of nose with
a plunging tip and prominent hump. He desires a natural
appearance. ( b ) Columellar strut graft used to rotate tip
upward and decrease plunging. ( c ) Postoperative following
columellar strut graft. Note decrease in dorsal hump and
increased nasal labial angle as tip rotates upward

217
18 Aesthetic Rhinoplasty Utilizing Various Techniques Depending on the Abnormality
a
b
Fig. 18.15 ( a ) Young woman with large nasal dorsal hump and resulting plunging tip. Plunging made worse with
facial animation. ( b ) Postoperative after bony and cartilaginous dorsum reduction, columellar strut, and tip grafting
a
b
Fig. 18.16 ( a ) Patient desiring aesthetic improvement. Note plunging tip, dorsal hump, and amorphous tip. ( b ) Postoperative
after dorsal hump reduction, cephalic tip trimming, columellar strut, and shield grafting to tip improve aesthetics

218
F.D. Burstein
a
b
b
c
Fig. 18.17 ( a – b ) Technique used to decrease nasal base
width. Incisions are well hidden. Preoperative young
woman desiring aesthetic improvement of nose. Complains
of amorphous wide tip. ( c ) Postoperative following
cephalic trim, intradomal sutures, and small crushed
round cartilage graft to tip. Nasal base narrowed

219
18 Aesthetic Rhinoplasty Utilizing Various Techniques Depending on the Abnormality
a
b
Fig. 18.18 ( a ) Preoperative woman complaining of
excessive tip and alar width as well as lack of tip de fi nition.
Note shortened tip on lateral view. Wants to maintain eth-
nic characteristics and look natural. ( b ) Postoperative
after alar base reduction, cephalic trim, dome placation,
and stacked septal shield grafts to lengthen tip

220
F.D. Burstein
The author’s preference is to only use autologous tis-
sues to augment the tip or dorsum. The most fre-
quent complaint is an amorphous wide tip. In these
cases, the standard external approach is used.
Often a fi bro fatty collection between the
domes is present splaying the tip. This tissue is
removed, the septum is exposed between the
footplates, and cartilage is harvested. Next the
cephalic margins of the lower lateral cartilages
are trimmed, and the lateral crura remnant is
often bruised to convert the curvature from con-
vex to slightly concave. This maneuver will help
in re fi ning the tip. If tip support is de fi cient, the
septal cartilage can be used as a columellar graft
advancing the medial crura on this pillar of sup-
port. These septal and or cephalic trimmings are
then used to create a tip-de fi ning point. If modest
dorsum augmentation is desired, a stacked septal
graft is ideal. Alternatively, a bruised conchal
graft can be used. For the rare cases of extreme
dorsal de fi ciency, a carved costal cartilage graft is
preferred to prosthetic materials. Great caution
should be used in contemplating lateral narrow-
ing osteotomies if the nasal bones are short since
the osteotomies may be quite unstable and result
in less dorsal projection if they collapse into the
nasal vault. Finally, after all incisions have been
closed, the alar base is addressed. The diamond
excision can be carried right to the juncture of the
nares and facial skin, allowing a marked narrow-
ing of the nasal base without visible scars. This
maneuver can also soften nares fl aring. I have not
had either hypertrophic or keloid scars form from
the nasal incisions.
a
b
Fig. 18.19 ( a ) Preoperative young man complaining of overall width of nose, dorsal hump and wide nostrils. ( b )
Postoperative following takedown of hump, alar base reduction, cephalic trim, and small shield graft to tip

221
18 Aesthetic Rhinoplasty Utilizing Various Techniques Depending on the Abnormality
18.10 Dressings and Postoperative
Care
No intranasal packing is used. The nose is
dressed with Steri-Strips and a thermoplastic
dressing. Oral analgesics, 3 days of oral antibi-
otics, and a Medrol dose pack are prescribed.
Cold packs and head elevation are recom-
mended. Showering is allowed the next day. The
columellar sutures and splint are removed in
5–7 days, and normal activity, including exer-
cise, can be resumed. This regimen results in
minimal postoperative discomfort and swelling.
Most patients take little if any of the prescribed
narcotics and report minimal discomfort. The
patient can see an approximation of the fi nal
result as soon as the dressings are removed. As
part of the preoperative preparation, written
instructions and education on perioperative care
is given to the patient and verbally reviewed
before and after the procedure. Mild swelling
and numbness can be expected for 4–6 weeks.
The fi nal result will take 9–12 months to see as
grafts heal and residual skin edema gradually
resolves.
18.11 Revisional Surgery
Despite the surgeon’s best efforts, minor revi-
sions may be necessary. In the author’s experi-
ence, a 4% revision rate has been consistent from
year to year. At least 9 and preferably 12 months
is waited before considering revisional surgery.
Most of the revisions involve minor dorsal rasp-
ing, scar revision, or alar width adjustment.
Almost all can be done in an of fi ce setting under
local with oral sedation.
Fig. 18.20 ( a ) Technique for HOM. Note osteotomy
well below mental foramen and tooth roots. Leaving mus-
cles attached to the inner cortex of the advanced chin will
tighten neck improving cervical mental area in older
patients. ( b ) Preoperative young woman complaining of
having a nose that is too prominent. Note retrussive chin
increasing
perceived
disproportion
of
nose.
( c )
Postoperative after HOM, 5 mm straight advancement,
and reduction of nasal dorsum. Note improvement in
overall facial proportions
Digastric and platysma
placed under strectched
after advancement
a

222
F.D. Burstein
c
b
Fig. 18.20 (continued)
18.12 Adjuvant Procedures
18.12.1 Genioplasty (Horizontal
Osteotomy of the Mandible,
HOM)
HOM is often performed in conjunction with aes-
thetic rhinoplasty. Most frequently, it is done to
balance facial proportions (Fig. 18.20 ). Patients
with retromicrogenia, vertical midface hyperpla-
sia, or an obtuse cervical mental angle can bene fi t
from HOM (Fig. 18.21 ). Most often, advance-
ment is indicated in order to improve the pro fi le,
in conjunction with reductive rhinoplasty, but
vertical reduction or lengthening is also possible.
In older patients, an additional bene fi t of HOM
with advancement is improvement in the neck
pro fi le. HOM is done through an intraoral
approach using prebent titanium plates available
in 2-mm increments. This allows fairly precise
correlation to the patient’s computerized imaging
pro fi le. Care is taken to avoid the inferior alveolar
nerve as it exits the mental foramen and to keep
the osteotomy at least 5 mm below the cuspid
roots. The mentalis muscle is reattached with
resorbable sutures, and supporting tape is placed
on the chin for 5 days.
Conclusions
Aesthetic rhinoplasty can seem daunting to
the young plastic surgeon starting practice. A
simple systematic approach to rhinoplasty will
help link cause and effect for the surgeon. The
use of the external direct approach allows
immediate feedback on the operating table,
improving the consistency of results.

223
18 Aesthetic Rhinoplasty Utilizing Various Techniques Depending on the Abnormality
Further Readings
1. Bronz G (1999) The role of the computer imaging sys-
tem in modern aesthetic plastic surgery. Aesthetic Plast
Surg 23(3):159–163
2. Cardenas-Camarena L, Guerrero M (1999) Use of car-
tilaginous autografts in nasal surgery: 8 years of expe-
rience. Plast Reconstr Surg 103(3):1003–1014
3. Correa A, Sykes J, Ries W (1999) Considerations
before rhinoplasty. Otolaryngol Clin North Am 32(1):
7–14
4. Daniel R (1992) The nasal tip: anatomy and aesthetics.
Plast Reconstr Surg 89(2):216–224
5. Daniel R, Lessard M (1984) Rhinoplasty: a graded
aesthetic-anatomical approach. Ann Plast Surg
13(5):436–451
6. Fruscella P (1997) Cephalometric analysis and postop-
erative results in aesthetic rhinoplasty. Aesthetic Plast
Surg 21(2):79–85
7. Johnson C, Toriumi D (eds) (1990) Open structure
rhinoplasty. W.B. Saunders Co, Philadelphia
8. Greer S, Matarasso A, Wallach SG, Simon G, Longaker MT
(2001) Importance of the nasal-to-cervical relation-
ship to the pro fi le in rhinoplasty surgery. Plast
Reconstr Surg 108(2):522–531
9. Guyuron B (1988) Precision rhinoplasty. Part I: the
role of life size photographs and soft tissue cephalo-
metric analysis. Plast Reconstr Surg 81(4):489–499
10. Kamer F, Pieper P (2004) Nasal tip surgery: a 30 year
experience. Facial Plast Surg Clin North Am 12(1):
81–92
11. Kamer F, Churukian M (1984) Shield graft for the
nasal tip. Arch Otolaryngol 110(9):608–610
12. Kawamoto H (2000) Osseous genioplasty. Aesthetic
Surg J 20:509–516
13. Ortiz-Monesterio F, Olmedo A, Oscoy L (1981) The
use of cartilage grafts in primary aesthetic rhinoplasty.
Plast Reconstr Surg 67(5):597–605
a
b
Fig. 18.21 ( a ) Preoperative patient with retrussive long chin and dorsal hump before and after surgery. ( b ) Postoperative
after HOM designed to move forward 7 mm and upward 3 mm; nasal dorsum reduced

224
F.D. Burstein
14. Rees T (ed) (1980) Aesthetic plastic surgery. W.B.
Saunders Co, Philadelphia, pp 51–387
15. Rohrich R, Muxaffar A, Janis J (2004) Component
dorsal hump reduction: the importance of maintaining
dorsal aesthetic lines in rhinoplasty. Plast Reconstr
Surg 114(5):1298–1308
16. Sheen J, Sheen A (1998) Aesthetic rhinoplasty, 2nd
edn. C.V. Mosby Co., St. Louis
17. Williams EF 3rd, Lam SM (2002) A systematic, grad-
uated approach to rhinoplasty. Facial Plast Surg
18(4):215–222

225
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_19, © Springer-Verlag Berlin Heidelberg 2013
19
19.1
Technology
The Sonopet ultrasonic bone aspirator is a device
initially developed for applications in neurosurgery
and orthopedic surgery requiring precise bone
removal without attendant soft tissue injury. The
instrument works on the principle of ultrasonic
vibration, which can emulsify contacted bone with
minimal heat production [ 1, 2 ] . It consists of the
main control unit, the handpiece, the tip, and the
foot control (Fig. 19.1 ). The handpiece allows for
concurrent irrigation and suction (Fig. 19.2 ), while
a piezo electric element exposed to alternating cur-
rent vibrates the tip at a speci fi c frequency. The tip
motion, both longitudinal and torsional, will emul-
sify contacted bone with minimal thermal conduc-
tion to the surrounding tissues. Bone removal and
three-dimensional sculpting can, therefore, occur
under direct visualization. Currently Food and
Drug Administration (FDA) approved for use in
the head and neck, the device has been utilized for
bony dorsal hump and nasal spine removal, tur-
binate reduction (senior author’s experience), endo-
scopic transorbital decompression (senior author’s
experience), and dacryocystorhinostomy [ 3 ] .
19.2
Advantages over Conventional
Techniques
The authors have previously described the fi rst
use of an ultrasonic bone aspirator to sculpt the
nasal dorsum and reduce the nasal spine (sonic
rhinoplasty) without the shortcomings of the
osteotome, rasp, or powered rasp [ 4 ] . Correction
of bony deformities is an integral part of most
rhinoplasty surgery. Successful correction results
in a natural pro fi le with an uninterrupted, smooth
brow tip aesthetic line. Success, however, requires
mastering techniques, which are limited by the
instruments available to the rhinoplasty surgeon.
The Rubin osteotome, for example, reduces
the dorsal hump through a high impact, blunt
force osteotomy typically performed without
direct visualization. Even with precise surgical
technique, the Rubin osteotome tends to follow
pathways of thinner bone and can result in over-
resection, underresection, or uneven resection
of the dorsal hump. Moreover, osteotomies in
individuals with previous nasal fractures or brit-
tle nasal bones can prove challenging. Improper
use of the osteotome can result in palpable con-
tour irregularities that can be bothersome to
patients.
Sonic Rhinoplasty: Sculpting with
the Ultrasonic Bone Aspirator
Edmund A. Pribitkin , Leela S. Lavasani ,
Carol Shindle , and Jewel D. Greywoode
E. A. Pribitkin , M.D. (*) • L. S. Lavasani , M.D.
C. Shindle , ASN • J. D. Greywoode , M.D.
Department of Otolaryngology-Head and Neck Surgery,
Thomas Jefferson University, 925 Chestnut Street,
Sixth Floor , Philadelphia ,
PA 19107 , USA
Department of Otolaryngology-Head and Neck Surgery ,
Thomas Jefferson University ,
Philadelphia , PA , USA
e-mail: edmund.pribitkin@jefferson.edu;
leela.lavasani@gmail.com ; cshindle@juno.com ;
jewel.greywoode@gmail.com

226
E.A. Pribitkin et al.
The carbide rasp’s versatility and precision
overcome many of the Rubin osteotome’s limita-
tions, yet shearing forces can result in weakening
of the osseocartilaginous vault, which can lead to
avulsion of the upper lateral cartilages or trau-
matic bone regeneration. There can also be injury
to the soft tissue envelope or the overlying nasal
skin. The shape of the instrument limits its use in
deepening the glabellar angle. Finally, it is impos-
sible to address irregularities with the rasp once
the osteotomies have been made and the nasal
bones are mobile.
The powered rasp for nasal hump reduction
permits precise, incremental bone reduction
under limited direct visualization [ 5 ] . Three-
dimensional sculpting with rounding of bony
edges and asymmetric treatment of bones can be
performed when necessary. The low-impact
nature of the instrument also is of bene fi t in
patients with brittle bones or following nasal
trauma. Nonetheless, the instrument cannot sculpt
unstable bone fragments and has a limited appli-
cation in dif fi cult to access areas such as the gla-
bella and nasal spine. If improperly used,
underlying cartilage injury and overlying skin
injury may occur.
The ultrasonic bone aspirator lacks the short-
comings of osteotomes, rasps, and other powered
rhinoplasty instruments. The surgeon can use the
ultrasonic bone aspirator under direct vision to
precisely and incrementally remove bone while
continuously irrigating the fi eld free of debris.
Three-dimensional bone sculpting permits deep-
ening of the glabellar angle, rounding of fl at nasal
contours, and correction of asymmetries with less
aggressive osteotomies. Even following osteoto-
mies, mobile bone fragments may be contoured
without the risk of bony or cartilaginous avulsion
(Fig. 19.3 ). As demonstrated through histologic
analysis (Fig. 19.4 ), the ultrasonic bone aspirator
a
b
Fig. 19.1 ( a ) Ultrasonic
bone aspirator console.
( b ) Universal handpiece

227
19 Sonic Rhinoplasty: Sculpting with the Ultrasonic Bone Aspirator
will not injure underlying cartilage. Moreover,
neither mechanical nor thermal injury to overly-
ing tissues can occur.
19.3
Surgical Technique: Sculpting
the Nasal Bones
Sonic rhinoplasty employs established approaches
and techniques of nasal surgery. Following a
subsuper fi cial musculoaponeurotic system eleva-
tion of the skin and soft tissue envelope overlying
the upper and lower lateral cartilages, the upper
lateral cartilages are submucosally separated
from the septum. The periosteum overlying the
nasal bones is completely dissected free using a
Cottle elevator. The septum and upper lateral car-
tilages are lowered with a scalpel.
In order to address the bony dorsum, an
Aufricht retractor is inserted underneath the soft
tissue envelope to allow full visualization of the
nasal bones. Next, the ultrasonic bone aspirator
equipped with the Spetzler Claw tip (Fig. 19.5 ) is
used to sculpt the nasal bony dorsum to match the
lowered cartilaginous dorsum. The ultrasonic
bone aspirator’s longitudinal torsional motion
with concurrent irrigation and suction allows for
precise graded removal of bone in a clean surgi-
cal fi eld (Fig. 19.6 ). The soft tissue envelope is
periodically redraped, and the pro fi le view
inspected to assess the amount of dorsal hump
reduction. The ultrasonic bone aspirator will not
reduce the underlying cartilaginous septum or
upper lateral cartilages, and these will be reduced
separately (Fig. 19.7 ). Once the desired dorsal
height and contour of the dorsum is achieved, any
necessary tip re fi nement and middle vault recon-
struction is performed. Medial and lateral osteot-
omies are performed using curved guarded
osteotomes if needed (Fig. 19.8 ).
19.4
Extended Applications
The ultrasonic bone aspirator may be used in
numerous novel ways to more easily address
challenging nasal deformities. For example, nasal
spine reduction (Fig. 19.9 ) can be achieved under
Fig. 19.2 Spetzler Claw tip allowing concurrent irriga-
tion through white plastic sleeve and irrigation through
claw aperture
Fig. 19.3 In this revision of a forehead fl ap, the ultra-
sonic bone aspirator was used to reduce the bony dorsal
hump and contour the nasal bones following infracture.
Note the lack of injury to the underlying cartilages and the
smooth nasal bone edges. Char is from bipolar cautery of
the septal mucoperichondrium

228
E.A. Pribitkin et al.
direct visualization with greater facility and
potentially greater precision than that achieved
through osteotomy [ 6 ] . Overresection of the nasal
spine or caudal septum can be avoided so as to
prevent associated tip ptosis and columellar
retraction.
In some patients, despite adequate bony and
cartilage hump reduction, a prominent glabella
disrupts the nasofrontal angle, leading to an unat-
tractive nasal pro fi le. Traditionally, glabellar
reduction is achieved with specialized carbide or
Fig. 19.4 Hematoxylin-eosin low power magni fi cation: ( Left ) normal cartilage. ( Right ) Cartilage surface treated with
the ultrasonic bone aspirator. Healthy chondrocytes appear in both specimens ( arrows )
Fig. 19.5 Reduction of the bony dorsum is achieved
under direct visualization
Fig. 19.6 Ultrasonic bone aspirator reducing bony dorsum
Fig. 19.7 Resultant open sky deformity. Note that upper
lateral cartilages and any residual cartilaginous septum
need to be taken down separately. They will not be reduced
with the ultrasonic bone aspirator

229
19 Sonic Rhinoplasty: Sculpting with the Ultrasonic Bone Aspirator
power-assisted rasps, but these methods are tech-
nically dif fi cult and offer poor visualization.
Other methods employ diamond burrs; however,
the rotating tip can cause soft tissue injury to the
forehead or nasal skin. The ultrasonic bone aspi-
rator enables precise, graded deepening of the
prominent glabella under direct visualization
(Fig. 19.10 ). Moreover, glabellar sculpting may
be accomplished before or after nasal bone
osteotomy and infracture.
The ultrasonic bone aspirator also enables the
sculpting of mobile bone fragments, smoothing of
bony edges, and reducing of the convexity associ-
ated with curved nasal bones. Irregularities or
asymmetries in the mobile nasal bones following
osteotomies are dif fi cult to address with tradi-
tional methods such as rasps or drills due to poten-
tial avulsion of the mobile fragments. Because the
vibratory motion of the ultrasonic bone aspirator
removes bone through a light application with no
applied torque, there is no risk of fragment avul-
sion. Moreover, there can be no thermal injury or
spooling of surrounding soft tissues. We use the
ultrasonic bone aspirator to re fi ne nasal contours
Fig. 19.8 ( Upper ) Preoperative. ( Lower ) Postoperative after bony dorsum reduction with the ultrasonic bone aspirator
(Figure used with permission of Laryngoscope-Fukushima and Sameshima [ 1 ] )

230
E.A. Pribitkin et al.
and smooth bony irregularities in nearly every
case involving nasal bone osteotomies. The capa-
bility to smooth rough edges and prevent palpable
and/or visible irregularities following osteotomies
effectively prevents contour irregularities, espe-
cially in thin-skinned individuals. Moreover, the
ultrasonic bone aspirator can fl atten convex nasal
bones that disrupt a smooth brow-tip aesthetic
line (Fig. 19.11 ). Lateral osteotomies will narrow
the dorsum but will not straighten the dorsum if
the nasal bones are curved. Sculpting of the nasal
bones avoids complications associated with inter-
mediate osteotomies, which may become visible
or palpable and which may lead to nasal bone
collapse.
The ultrasonic bone aspirator was adapted for
use in septoplasty and inferior turbinoplasty.
Following local elevation of a mucoperichondrial
fl ap, bony septal spurs may be emulsi fi ed by the
ultrasonic bone aspirator with minimal disruption
of surrounding septal tissues. Following soft tis-
sue elevation, the inferior turbinates are reduced
by emulsifying the conchal bone. This technique
preserves the overlying stromal tissue and mucosa
in a manner similar to that described by Mabry
(Fig. 19.12 ) [ 7 ] .
Fig. 19.9 ( a ) Preoperative. ( b ) Postoperative nasal spine
reduction with the ultrasonic bone aspirator (Figure used with
permission of Laryngoscope-Fukushima and Sameshima [ 1 ] )
Fig. 19.10 ( Left )
Preoperative female with
dorsal hump and prominent
glabella. ( Right ) Six month
postoperative after dorsal
hump reduction and
deepening of glabella.
Dashed line denotes the
Frankfort horizontal plane.
The glabellar prominence is
outlined between the solid
lines (Figure used with
permission of Archives of
Facial Plastic Surgery-
manuscript under review)

231
19 Sonic Rhinoplasty: Sculpting with the Ultrasonic Bone Aspirator
Fig. 19.11 ( Left ) Preoperative male patient with curved
nasal bones. ( Right ) Six month postoperative with
straighter nasal bones after contouring with the ultrasonic
bone aspirator (Figure used with permission of Archives
of Facial Plastic Surgery-manuscript under review)
a
b
Fig. 19.12 ( a ) Ultrasonic bone aspirator and emulsi fi ed conchal bone. ( b ) Appearance of inferior turbinate following
submucosal resection of conchal bone with the ultrasonic bone aspirator

232
E.A. Pribitkin et al.
19.5
Shortcomings
Shortcomings of the ultrasonic bone aspirator
include greater surgical time and cost. Although
the increase in operative time is dif fi cult to quan-
tify, the authors feel that the instrument setup time
and increased time spent more precisely sculpting
the nasal bones likely add 10–15 min to each case.
The main unit cost itself is greater than $100, 000,
and each tip cost is greater than $200. However,
the instrument has applications in neurosurgery,
orthopedic surgery, and ophthalmology and,
therefore, would be a cost-effective purchase for a
hospital anticipating interdepartmental use. Cost
savings may also be realized by using the device
for ancillary procedures otherwise requiring
instrumentation such as inferior turbinoplasty.
Conclusion
Sonic
rhinoplasty
allows
graded
bony
re fi nements without damaging surrounding
structures and affords excellent visualization
for achieving superior functional and cosmetic
outcomes. Associated complications are rare.
More precise and versatile than competing
osteotomes and rasps, the ultrasonic bone
aspirator enables three-dimensional sculpting
of the nasal dorsum and spine, deepening of
the glabellar angle, turbinoplasty, and con-
touring of mobile bone fragments without the
risk of bony or cartilaginous avulsion.
Disclosure Edmund A. Pribitkin, M.D. is a consultant
for Stryker, Inc.
References
1. Fukushima T, Sameshima T (2007) Skull base approaches
to dif fi cult and complex aneurysms. Skull Base Issue S1
Volume 17 Abstract 177.
2. Sivak-Callcot JA, Linberg JV, Patel S (2005) Ultrasonic
bone removal with the Sonopet Omni: a new instru-
ment for orbital and lacrimal surgery. Arch Ophthalmol
123(11):1595–1597
3. Davis RE, Raval J (2003) Powered instrumentation for
nasal bone reduction. Arch Facial Plast Surg 5(5):
384–391
4. Abe T (2002) New devices for direct transnasal surgery
on pituitary adenomas. Biomed Pharmacother 56(Suppl
1):171s–177s
5. Guyuron B, Behmand R (2003) Caudal nasal devia-
tion. Plast Reconstr Surg 111(7):2449–2457
6. Davis RE (2005) Diagnosis and surgical management
of the caudal excess nasal deformity. Arch Facial Plast
Surg 7(2):124–134
7. Mabry RL (1982) “How I do it” – plastic surgery.
Practical suggestions on facial plastic surgery. Inferior
turbinoplasty. Laryngoscope 92(4):459–461

233
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_20, © Springer-Verlag Berlin Heidelberg 2013
20
20.1
State of the Art
The surgical techniques of deviated noses have
evolved gradually. Reduction and mobilization
techniques causing a weakening of the structural
supports have given way to a more conservative
surgery involving restructuring and increases.
In 1952, King and Ashley [ 1 ] had suggested
that the mobilization of the entire nasal septum
was necessary to obtain a right frame. Currently,
Gubisch [ 2 ] is using successfully for over 25 years
an “extracorporeal septoplasty” based on this
principle. Since 1996, he uses an open approach
to detach the bony and the septal cartilage in one
piece. He uses cartilaginous incisions associated
with cartilaginous or bony spreader graft some-
times using a drill for thinning. He also has
experience of PDS plates to stabilize the graft, as
suggested by Bönisch and Mink [ 3, 4 ] . He
reported a revision rate of 7% and irregularities
of the dorsum complaints of 8–11%.
The stability of the septal cartilage and the
irregularities of the dorsum are the reported prob-
lems related to this technique. In order to over-
come these problems, some authors like Senyuva
Guzel [ 5 ] and Gubisch [ 6 ] have proposed to fi x
the septum to the upper cartilage by open
approach. Finally after the completion of the
open roof, he places a cartilaginous onlay graft
on the dorsum as suggested by McKinney [ 7 ] in
order to reduce irregularities.
Currently, in conservative surgery, autogenous
cartilage graft is used to replace, reinforce, or
rebuild the osteochondreal structure component
[ 8 ] . The idea is to maintain an L-shaped strut at
the septum after releasing alar and triangular car-
tilage. The association of septal batten graft,
spreader graft, scoring incisions, and suturing
techniques allows recovery of the septum. Some
authors have used camou fl age techniques whose
goal is to create an illusion of a straight nose by
cartilage grafting of the nasal anatomy various
components [ 9 ] . In the middle third, the challenge
is twofold: correction of the deviation and preser-
vation of the internal nasal valve. Repositioning
of the triangular cartilages from the septum is the
key point. The interest of “extracorporeal rhino-
septoplasty” is to obtain a masterpiece self-
stabilizing and to simultaneously correct the
irregularities of the dorsum. This piece acts as a
cartilaginous keystone ensuring its stability and
Extracorporeal Rhinoseptoplasty
Francois Disant , Delphine Vertu-Ciolino ,
and Nicolas Beck
F. Disant , M.D. (*)
Pavillon U Hopital Edouard Herriot ,
3 place d’Arsonval , 69003 Lyon , France
Department of Otolaryngology, Head and Neck
Surgery, Facial Plastic Surgery , Edouard Herriot
Hospital, University of Claude Bernard Lyon ,
1, 5 Place d’Arsonval , 69437 Lyon Cedex , France
e-mail: francois.disant@chu-lyon.fr
D. Vertu-Ciolino , M.D.
Pavillon U, Hôpital Edouard Herriot ,
5 place d’Arsonval , 69003 Lyon , France
e-mail: delphine.vertu-ciolino@chu-lyon.fr
N. Beck , M.D.
Service d’ORL-CCF , Chu de Dijon ,
Dijon , France
e-mail: dr.becknicolas@gmail.com

234
F. Disant et al.
that of the nasal arch. The piece is a result of the
various procedures conventionally used to correct
the septum: the spreader graft, the L-shaped strut
graft, and the cartilaginous onlay graft. The
replacement of the newly constructed model using
an endoscope provides an easy and accurate tool
to ensure proper positioning on the bottom of the
anterior nasal spine. The upper lateral cartilages
build on the spreader grafts laterally, avoiding col-
lapse of the internal valve, and superiorly in the
open roof between the nasal bones.
The authors believe that the problem of stabil-
ity at long term is assured by its threefold support
system. Thus, the pattern is biomechanically sta-
ble over time.
Using the model of the “extracorporeal rhino-
septoplasty” has the advantage that it can be used in
an endonasal approach. The construction of the
model is stepwise and therefore repeatable. The
best indication of “extracorporeal rhinoseptoplasty”
is the reconstruction of the middle third of the nose,
deviated noses even more when the overlaying skin
is thin requiring a perfect regular structure.
20.2
Surgical Technique
of “Extracorporeal
Rhinoseptoplasty”
The principle of this technique is to remove the
whole septal cartilage and the cartilaginous dor-
sum in one piece and then to make a cartilaginous
model corresponding to the nose framework.
This is performed using a closed approach: First
step is the septoplasty by a right-sided intersepto-
columellar hemitrans fi xion incision, bilateral
detachment in the subperichondral plane, and
exposure of the entire cartilaginous and bony
septum, which is required to remove the carti-
laginous septum and the cartilaginous dorsum in
one piece. By doing so, a signi fi cant amount of
autologous material can be obtained to extracor-
poreally built the framework .
Initially in this step, we perform a 180° rota-
tion of the levy so that the edge of the posteroin-
ferior wall becomes the anterosuperior corner. In
fact, the posteroinferior septum makes a good
support on the anterior nasal spine, between the
medial crura of the alar cartilages.
Then the different parts of the framework are
drawn: one septal L-shaped strut, two spreader
grafts, and one cartilaginous onlay graft
(Fig. 20.1 ):
1. Septal L-shaped strut: The sagittal supporting
element on which will be sewn other cartilage
grafts. This L-shaped piece will rest on the
lower anterior nasal spine and anteriorly
between the medial crura like a columellar
strut. (Projected size should be 3.5 × 3.5 cm.)
2. Spreader grafts: They should be attached
superiorly and laterally to the septal L-shaped
strut to reconstruct the cartilaginous dorsum
allowing maintenance of the width of the sub-
unit dorsi-nasal (Sheen lines) and a stable sup-
port to the upper cartilage avoiding collapse of
the internal valve. On their superior plan, a
stair-shaped incision is to be performed in the
posterior region with a depth of 1 mm to
accommodate
cartilaginous
onlay
graft.
(Projected size should be +/− 2.5 × 0.5 cm.)
3. Cartilaginous onlay graft: It will be sewn on
the upper surface of spreader grafts. It will
close the bony dorsum. (Projected size should
be 2.5 × 0.5 cm.)
The grafts are secured to them by poly fi lament,
resorbable sutures, as Vicryl ® (Fig. 20.2 ). Once the
framework has made, the osteocartilaginous struc-
ture will be corrected. A subperiosteal dissection
to the level of the radix of the nose is performed.
Fig. 20.1 Different parts of the framework: 1 – septal
L-shaped strut; 2 – spreader grafts; 3 – cartilaginous onlay
graft

235
20 Extracorporeal Rhinoseptoplasty
The authors strive to achieve an extramucosal
technique. Resection of the bony hump and lateral
osteotomies (in-fracture) can be performed.
Finally the model is replaced; it must be deli-
cately positioned, either under direct vision with
a “Aufrich ecarteur” or using a video-assisted
endoscopic system. The framework is introduced
through the interseptocolumellar way, in a sagit-
tal direction. The anterior angle of the septal
L-shaped strut based on the lower anterior nasal
spine and cartilaginous onlay graft is directed
upward and backward based on the residual bone
at the dorsum nasofrontal angle. The body of the
model is located between the upper cartilages.
When positioning, try to lock the spreader grafts
as an interlocking “LEGO ® ” in the open
roof residual (Fig. 20.3 ). This produces a self-
assembling stable reconstruction in all three spe-
cial planes, creating a symmetrical and regular
dorsum; a transcolumellar traction suture is used
when placing the framework; Reuter valves are
attached for stabilizing the assembly. The
projection of the upper cartilages is adjusted to
spreader grafts (Figs. 20.4 , 20.5 , 20.6 , and 20.7 ).
Fig. 20.2 Real framework
a
b
Fig. 20.3 Modelization “LEGO ® ” of the framework,
construction, and the positioning between the nasal spine
and the bony part of the nose. Yellow : septal L-shaped
strut; black : spreader grafts; green : cartilaginous onlay
graft; white : nasal bone. ( a ) Framework without cartilagi-
nous on lay draft after pushing down. ( b ) Framework with
cartilaginous on lay draft after pushing down

236
F. Disant et al.
Fig. 20.4 Reconstructed nose on coronal section view, showing the framework positioning ( a ) at the bony nose and
( b ) at the cartilaginous nose
a
b
Fig. 20.5 ( a , b ) Framework in situ

237
20 Extracorporeal Rhinoseptoplasty
a
b
Fig. 20.6 ( a ) Preoperative 28-year-old woman with nasal deviation ( I-shaped nose ), a dorsal hump, and an internal
valve collapse. ( b ) Postoperative after “extracorporeal rhinoseptoplasty”

238
F. Disant et al.
a
b
Fig. 20.7 ( a ) Preoperative 21-year-old woman with nasal
deviation, airway obstruction, C-shaped nose , a dorsal
hump, and retrogenia. ( b ) Postoperative result with a
straight dorsum, the restoration of balance dorsal aesthetic
lines, and better chin correction with good labial
competence

239
20 Extracorporeal Rhinoseptoplasty
References
1. King ED, Ashley FL (1952) The correction of the
internally and externally deviated nose. Plast Reconstr
Surg (1946) 10(2):116–120
2. Gubisch W (2006) Twenty- fi ve years experience with
extracorporeal septoplasty. Facial Plast Surg 22(4):
230–239
3. Bönisch M, Mink A (1999) Septum reconstruction
with PDS implant. HNO 47(6):546–550
4. Bönisch M, Mink A (2000) Healing process of carti-
lage attached to a polydioxanone implant. HNO 48(10):
743–746
5. Senyuva C, Yücel A, Aydin Y, Okur I, Güzel Z (1997)
Extracorporeal septoplasty combined with open rhino-
plasty. Aesthetic Plast Surg 21(4):233–239
6. Gubisch W, Constantinescu MA (1999) Re fi nements in
extracorporeal septoplasty. Plast Reconstr Surg
104(4):1131–1139, discussion 1140–1132
7. McKinney P (1996) An aesthetic dorsum. The CATS
graft. Cartilaginous autogenous thin septal. Clin Plast
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8. Vuyk HD (2000) A review of practical guidelines for
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DOI 10.1007/978-3-642-28053-5_21, © Springer-Verlag Berlin Heidelberg 2013
21
21.1
Introduction
Traditional open rhinoplasty produces a scar on
the columella of the nasal skin [ 1 ] . To avoid such
a scar yet obtain wide exposure of the nasal
framework, the bilateral marginal incisions are
extended from the base of the columella through
the distal margin of the domal cartilage to the
pyriform margin. Extended marginal approach
rhinoplasty is a technique modifying and picking
up the advantages of both the open and closed
rhinoplasty
techniques.
Extended
marginal
approach rhinoplasty allows visual exposure of
the nasal framework from the lower lateral carti-
lage to the distal portion of the nasal bone, and
the other advantage is that there is no scar on the
columella that results using the open technique.
Good
results
using
extended
marginal
approach rhinoplasty [ 2 ] , in particular, a nonvis-
ible scar, have drawn a strong mainstream shift in
patient demand toward this modi fi ed technique
and away from the traditional open rhinoplasty
technique. The fi rst generation is an open tech-
nique for general surgery which involves a big
incision and exposure of the whole area to resect
a malignant area [ 3, 4 ] . The second generation is
an endoscopic technique for general surgery
which involves a smaller incision and use of an
endoscopic camera instead of the visual eye to
see inside and perform the surgery. Endoscopic
brow lift, transconjunctival blepharoplasty, and
transumbilical mammoplasty are examples of
other mainstream techniques offering no visible
scar.
21.2
Advantages and Disadvantages
of EMA Rhinoplasty (Table 21.1 )
Open rhinoplasty has been very popular. Open
rhinoplasty supposedly has the great advantage
of giving the surgeon better vision and access.
However, it can result in a scar on columella. In
closed rhinoplasty, there is limited visual fi eld.
There are three advantages to closed rhinoplasty:
no visible scar, less swelling, and shortened oper-
ation time [ 2, 4, 5 ] . Not only the lower lateral car-
tilages but also the upper lateral cartilage and the
distal portion of the nasal bone are exposed in the
extended marginal approach. To obtain advan-
tages of both the open and closed techniques,
External Marginal Approach
Rhinoplasty (EMA Rhinoplasty)
Peter Chanwoo Kim and Dae Hwan Park
P. C. Kim , M.D., Ph.D., M.B.A.
Department of Plastic and Reconstructive Surgery ,
Daegu Catholic University Medical Center ,
3056-6 Daemyung 4-Dong , Namgu,
Daegu 705-034 , Korea
e-mail: psman007@gmail.com
D. H. Park , M.D., Ph.D., FACS ()
Department of Plastic and Reconstructive Surgery ,
Daegu Catholic University Medical Center ,
3056-6 Daemyung 4-Dong , Namgu,
Daegu 705-034 , Korea
Department of Plastic and Reconstructive Surgery ,
Catholic University of Daegu , Daegu , Korea
e-mail: dhpark@cu.ac.kr

242
P.C. Kim and D.H. Park
such as binocular visual fi eld, extended marginal
approach rhinoplasty should be considered.
Regarding the disadvantages, exposure of the
lower lateral cartilage is not symmetric. There
may be slight tilting of one nostril due to delivery
into one nostril, so maturity of skill is necessary
to make the tip symmetric (Fig. 21.1 ).
21.3
Indications and
Contraindications of EMA
Rhinoplasty
Most aesthetic and functional nasal problem can
be a candidate for EMA rhinoplasty. Primary rhi-
noplasty is a good indication, de fi nitely. Regarding
secondary or tertiary rhinoplasty, if the patient
has an existing columellar scar, extended mar-
ginal approach is not necessary.
21.3.1 Contraindications
1. Very small nostrils that do not allow two lower
lateral cartilages to be presented through one
nostril. Open rhinoplasty with transcolumellar
incisions is recommended in such patients
(Fig. 21.2 ).
2. Inverted V deformity of the upper lateral carti-
lages which is a little bit far to approach in
EMA rhinoplasty.
3. Existing columellar scar: if the patient has an
existing operative scar on the columella from
Table 21.1 Advantages and disadvantages of EMA rhinoplasty
Advantages
Open
Closed
EMA
Binocular vision
+


_
+


Wide operation fi eld
+
_
+
Shorter learning curve
+
_
+
Lower risk of valve collapse +
_


+
Decreased post-OP. swelling _
+
+
Short operative time
_
+
+
No visible scar
_
+
+
Fig. 21.1 Nasal tip exposure in EMA rhinoplasty. Nasal
tip is exposed to tilt to one side. So maturity of skill is
necessary to make the tip symmetric

243
21 External Marginal Approach Rhinoplasty (EMA Rhinoplasty)
prior surgery, open rhinoplasty can sometimes
be recommended, with columellar scar revision.
4. For septal reconstruction due to septal per-
foration.
Open rhinoplasty can be chosen for these
issues.
21.4
Preoperative Planning
21.4.1 Preoperative Assessment
and Planning (Fig. 21.3 )
The surgeon must take the time to evaluate and
assess the patient’s face before rhinoplasty and
carefully discuss with the patient the proposed
postoperative changes. To reduce the risk of
Fig. 21.2 Very small nostril
Fig. 21.3 Standard photo 15 series. Fifteen photo series should be taken to every patient for precise facial analysis and
follow-up comparison

244
P.C. Kim and D.H. Park
patient dissatisfaction, the surgeon should explain
only realistic postoperative changes that can be
accomplished. In our dentofacial center, 15 mul-
tiple facial photos, three-dimensional computer
tomogram (3D CT), and a dental cast can be used
for the patient’s information and assessment.
Review of the 15 multiple-view photographs also
assists patients to more accurately describe, and
perhaps modify, their own expectations as to out-
come. Life-sized photos can help 2D facial aes-
thetic analysis for proposed pro fi le changes and
typical proportions of the face [ 7 ] . Life-sized 2D
photos are a good tool for preoperative analysis
to check face asymmetry or nasal/nostril asym-
metry before surgery, for intraoperative check,
and for postoperative comparison. Three-
dimensional CT is a good tool for detecting
hypertrophic turbinate, deviated septum, preex-
isting sinusitis, paranasal or maxillary hypopla-
sia, and correlation with the mandible. A dental
cast shows existence of dentoalveolar protrusion,
or teeth malalignment or malocclusion. Three-
dimensional software allows combined visualiza-
tion of skin and bone to understand which factors
contribute to facial contour (Fig. 21.4 ).
21.4.2 Facial Analysis
for Preoperative Planning
We must carefully and completely evaluate the
patient’s face even if the patient wants to undergo
only rhinoplasty. The patient’s facial ratio must be
considered. In preoperative planning, as mentioned
above, life-sized photos are used in our practice.
Using Peter’s analyzer (Fig. 21.5 ), the frontal, right
lateral, and high basal views provide the outline
for proposed postoperative changes (Fig. 21.6 ).
The pro fi le template can be picked up from the
pre- and postoperative pro fi le outline in the life-
sized photo (Fig. 21.7 ). Orthobars are composed of
vertical and horizontal bars with magni fi ed occlusal
plane (Fig. 21.8 ). The distance from the pupil to
the orthobar on the right and left sides indicates
facial asymmetry, and the orthobar can handle the
maxillomandibular complex in a vertical and hori-
zontal way precisely in frontal aspects. The ortho-
bar helps to control rolling (vertical bar) and
yawing (horizontal plane), and the pro fi le template
helps to check pitching in proposed pro fi loplasty
(Fig. 21.9 ). The proposed facial pro fi le and frontal
line nearly approached our goal.
Any other simultaneous adjuvant surgery must
be determined before proceeding with rhinoplasty.
Rhinoplasty is intimately correlated with chin sur-
gery. For example, if the patient has a small chin
with a big nose, we have to consider advancement
genioplasty with reduction rhinoplasty. If the
patient has a prognathic or retrognathic face, we
explain to the patient whether simultaneous
orthognathic correction with rhinoplasty would
be performed in a one stage. If the patient does not
feel comfortable with the simulated facial pro fi le
changes, we have to fully explain to the patient
the importance of facial ratio, and the potential for
postoperative dissatisfaction if there is harmony
imbalance. Otherwise, the patient would not be
satis fi ed with their cosmetic nasal results because
a disproportionate face ratio would still exist.
Every patient is checked intraoperatively with the
visualized diagram (Fig. 21.10 ).
Fig. 21.4 Combined skin and bone tissue using 3D soft-
ware for better analysis. 3D software allows visualization
of skin and bone three-dimensionally (Anatomage, USA)

245
21 External Marginal Approach Rhinoplasty (EMA Rhinoplasty)
21.5
Operative Technique
21.5.1 Anesthesia
1. Local anesthesia
Local solution with 1:100,000 epinephrine
mixed with 1% lidocaine allows rapid recov-
ery. Infraorbital nerve block can accomplish
regional anesthesia of the midfacial skin includ-
ing the cheek, the external lateral side of nose,
and the upper lip to anesthetize the anterior and
middle maxillary alveolar nerves, inferior
palpebral, lateral nasal, and superior labial with
insensibility. 5 cc is enough for external rhino-
plasty (2 mL for tip, 1 mL for dorsum, and
1 mL for each lateral side). For internal rhino-
plasty such as turbinoplasty and submucosal
resection, 4 mL can be additionally used.
2. Orotracheal intubation under general anesthesia
For longer operation time, general anesthesia
is appropriate. Usually tertiary rhinoplasty or
a
b
Fig. 21.5 Peter’s analyzer ruler. ( a ) The ruler is a convenient drawing tool including frontal, lateral, and basal outline
of forehead, nose, lips, and nostril for facial analysis. ( b ) Sequence of facial analysis

246
P.C. Kim and D.H. Park
a
b
Fig. 21.6 Two-dimensional life-sized facial analysis. ( a ) Frontal. ( b ) Lateral. 2D facial analysis is essential for not
only rhinoplasty but also facial cosmetic surgery
a
b
c
Fig. 21.7 Pro fi le template and life-sized photo. ( a ) Pro fi le template. ( b ) Pro fi le template can be picked up from the
life-sized photo. ( c ) Postoperative pro fi le template can be used during the operation