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

248
P.C. Kim and D.H. Park
of the medial crura but also down to the pyriform
aperture along the distal margin of the lateral
crura (Fig. 21.13 ). The medial crura of lower lat-
eral cartilages are then separated from the colu-
mella skin using Metzenbaum scissors. Once
dissection of the lateral crura from the nasal skin
Yaw
Roll
Pitch
a
b
c
Fig. 21.9 Orthobar is a useful and objective tool for
adjusting rolling, yawing, and pitching. ( a ) Three-
dimensional orientation for maxillomandibular complex.
The pitch ( x-axis ) refers to the movement of maxilloman-
dibular complex up or down . The movement is done about
a horizontal axis. The yaw ( y-axis ) allows skull to move
toward the left or right while in operation. The movement
is done about a vertical axis. Roll ( z-axis ) is known as the
rising or dipping of maxillomandibular complex. The
movement is done about a horizontal axis stretching from
anterior nasal spine to posterior nasal spine. ( b , c )
Application of the orthobar

249
21 External Marginal Approach Rhinoplasty (EMA Rhinoplasty)
Fig. 21.10 A standard brief operation record form. Every patient is checked intraoperatively with the visualized dia-
gram. ( a ) For male. ( b ) For female
Name:
ID:
S/A
Dept:
Date.
Site
Diagnosis
Operation
Anesthesia
OPD/Adm
11
12
13
14
15
16
17
18
21
22
23
24
25
26
27
28
31 32
33
34
35
36
37
38
41
42
43
44
45
46
47
48
Daegu Catholic Medical Center, Korea
Operation Diagram – Dentofacial Surgery
a

250
P.C. Kim and D.H. Park
Name:
ID:
S/A
Dept:
Date.
Site
Diagnosis
Operation
Anesthesia
OPD/Adm
11
12
13
14
15
16
17
18
21
22
23
24
25
26
27
28
31 32
33
34
35
36
37
38
41
42
43
44
45
46
47
48
Daegu Catholic Medical Center, Korea
Operation Diagram – Dentofacial Surgery
b
Fig. 21.10 (continued)

251
21 External Marginal Approach Rhinoplasty (EMA Rhinoplasty)
is complete, the entire lower lateral cartilages can
then be presented through one nostril, allowing
uninterrupted manipulation under direct binocu-
lar vision (Fig. 21.14 ).
First, the footplate of the medial crura can be
manipulated. The upper lateral cartilages can
then be exposed with a peanut ball dissector and
nasal periosteal elevator.
Eventually nasal bone should be exposed on
the subperiosteal plane using the periosteal eleva-
tor for dorsal augmentation or humpectomy.
21.5.3 Assessment of Tip Projection
Decision of tip height for tip plasty is one of most
important factors of rhinoplasty. Reinforced col-
umellar suture is the fi rst step for tip plasty. If it is
suspected that there is a strong depressor septi
nasi, such as in the case of an arrow type of nose,
the depressor septi nasi muscle should be detached
from the medial crura using angled scissors. Care
must be taken not to perforate the membranous
septum at this point. Footplate work with sutures
is also important. In open rhinoplasty, additional
dissection is necessary for footplate work which
is basically available in extended marginal
approach rhinoplasty without an additional pro-
cedure. Some surgeons routinely use a columel-
lar strut with septal cartilages; however, from our
experience, most alar cartilage is strong enough
with columellar reinforced sutures using PDS
5-0. In weak alar cartilage, reinforced batten graft
or septal extension graft is a good solution for
reinforcing the nasal tip. However, mostly carved
cartilage grafts with reinforced columellar sutures
can be replaced by any technique for reinforced
nasal tip.
In tip plasty, several tip grafts or tip plasty can
be utilized. Intercrural and intracrural sutures
can be used in routine procedures using PDS 5-0
for tip plasty [ 8 ] . A cephalic trim can be used to
a
b
Fig. 21.11 Retromolar intubation. For simultaneous facial contouring surgery, retromolar intubation is useful. ( a )
Intubated tube was fi xed to IMF screw by wire with occlusion. ( b ) Retromolar intubation

252
P.C. Kim and D.H. Park
perform cephalic rotation or tip plasty in wide
alar cartilages (Fig. 21.15 ). A shield graft can be
used for tip plasty. However, due to the visible
edges of the shield graft on the nasal tip, carved
cartilage is preferable to shield graft (Fig. 21.16 ).
For a cephalic rotation procedure, a cephalic trim
and/or cephalic rotation suture can be used. A
cephalic rotation suture is anchored from the
midportion of the medial crura to the upper lat-
eral cartilages using PDS 4-0. For a cephalic
derotation procedure, a caudal extension suture
and derotation wing graft should be performed
(Figs. 21.17 and 21.18 ). A carved rib cartilage
graft (CRCG) can also be used for a tip plasty
a
b
c
d
Fig. 21.12 Submental intubation. It allows whole face
exposure for facial surgery. There is no interference on
face during operation. ( a ) Submental incisional area. ( b )
Cross-sectional view for understanding. ( c ) Intraoperative
facial exposure with submental intubation. ( d ) Submental
scar 1 year postoperatively

253
21 External Marginal Approach Rhinoplasty (EMA Rhinoplasty)
and derotation procedure for lengthening a short
nose (Figs. 21.19 and 21.20 ).
21.6
Osteotomies: Medial
and Lateral
The authors preferred nasal osteotomy that is low
to high approach (Fig. 21.21 ). Internal approach
is used more than external approach due to hav-
ing more experience in internal approach. Not
every widened dorsum may be corrected by
lateral osteotomy. In some patients, a low and
widened dorsum can be corrected by dorsal
a
b
Fig. 21.13 Incision design in EMA rhinoplasty ( a ) blue
dotted line is design for incisino ( b ) another view of inf-
racartilaginous incision
a
b
Fig. 21.14 Exposure of nasal framework in EMA rhino-
plasty. ( a ) Exposed nasal framework in EMA rhinoplasty.
( b ) Lower lateral cartilage and upper lateral cartilage can
be exposed from external marginal approach

254
P.C. Kim and D.H. Park
Fig. 21.15 Cephalic trim. Cephalic trim and approximation of two lower lateral cartilages with sutures allow cephalic
rotation of nasal tip
Fig. 21.16 Shield graft.
Shield graft has visible edge
on nasal tip and de fi cient
volume for nasal tip

255
21 External Marginal Approach Rhinoplasty (EMA Rhinoplasty)
augmentation with a diced rib cartilage graft
which automatically makes a slender dorsum.
21.7
Dorsal Reduction if Indicated
Humpectomy may cause open roof deformity,
so lateral osteotomy to close open roof is impor-
tant
to
prevent
postoperative
deformity.
Humpectomy (Fig. 21.22 ) should be very pre-
cise; sometimes endoscopic-assisted humpec-
tomy is bene fi cial.
If the nose has a minor hump, the hump may
be gone after tip plasty. Therefore, tip plasty
should be followed by nasal bone surgeries such
as humpectomy and/or rasping, and lateral or
medial osteotomy for correction of deviated nasal
bone. Humpectomy is not a procedure often used
in my population series. Tip enhancement can
make rasping procedures than real humpectomy
(Figs. 21.23 and 21.24 ).
21.7.1 Septal and Turbinate Surgery
if Indicated
21.7.1.1 Turbinoplasty
Turbinate out-fracture is a simple choice for wid-
ening of the nasal cavity. A Boies elevator can
make a microfracture on the inferior concha and
widen the nasal cavity (Fig. 21.25 ).
21.7.1.2 Submucosal Resection (SMR)
Submucosal dissection is a relatively easy
pro cedure using a modi fi ed Killian incision
(Fig. 21.26 ). Although a modi fi ed Killian incision
can be used for submucosal resection. Submucosal
resection should not be a routine procedure in the
a
b
Fig. 21.17 Caudal extension suture. Caudal extension
suture between upper and lower lateral cartilage is for
caudally lengthening of nasal tip. upturned nose in mild
degree ( a ). When lower lateral cartilage is pulled out,
upper lateral and lower lateral cartilage can be sutured
together ( b )

256
P.C. Kim and D.H. Park
a
b
Fig. 21.18 Derotation wing graft. Derotation wing graft
is graft between upper and lower lateral cartilage in both
side like wing for derotation (caudal rotation of nasal tip).
When lower lateral cartilage is pulled out, derotation wing
graft can be applied ( a ) another view of derotation wing
graft ( b )

257
21 External Marginal Approach Rhinoplasty (EMA Rhinoplasty)
correction of a deviated nose. Submucosal resec-
tion can weaken the septum due to resected carti-
lages and can contribute to several complications
like septal perforation, saddle nose, and septal
hematoma [ 9 ] . Moreover, turbinoplasty can
replace the role of SMR, and turbinoplasty can
contribute to the release of nasal obstruction. I do
not routinely use septal cartilage after submucosal
resection. The preferred cartilage is carved costal
cartilage for tip graft on the nose. Therefore, sub-
mucosal resection is merely my last step, or mini-
mal procedure, in corrective rhinoplasty.
21.7.2 Establishment of Final
Tip Projection
Final tip projection is checked with the pro fi le
template intraoperatively (Fig. 21.27 ). If the
height of the tip plasty is insuf fi cient according to
the pro fi le template analysis, another onlay graft
can be considered. Onlay graft can be added with
PDS 5-0 on the cartilage graft for nasal tip.
21.7.2.1 Dorsal Augmentation
if Indicated
See Chap . 36 .
21.7.2.2 Final Tip Cartilage Positioning
and Shaping
After tip projection and dorsal augmentation if
indicated are established, fi nal tip cartilage posi-
tioning and shaping should be considered. If
cephalic rotation of the tip is necessary after tip
a
b
Fig. 21.19 Carved rib cartilage graft (CRCG). ( a ) How
to harvest CRCG. ( b ) Carved cartilage graft can be formed
by the curved knife in carving instrument
DRCG
Derotation wing graft
DRCG
Fig. 21.20 Application of CRCG – short nose correc-
tion. For correction of short nose, CRCG can be applied
on nasal tip for caudal rotation of the nasal tip. Diced rib
cartilage graft (DRCG) and derotation wing graft are
shown on the illustrations

258
P.C. Kim and D.H. Park
plasty, cephalic rotation suture is bene fi cial
(Fig. 21.28 ). If caudal rotation of tip is necessary,
derotation graft or onlay graft on the caudal side
of the nasal tip can be added. If there is any tip
asymmetry, adjusting asymmetry with suturing
or repositioning of lateral or medial crus by par-
tial excision should be considered (Fig. 21.29 ).
21.7.2.3 Final Inspection
with Pro fi le Templates
Before closure, fi nal inspection with the pro fi le
template is a very important work. Sophisticated
theoretical facial analysis of frontonasal angle,
nasolabial angle is important. It is very dif fi cult to
check every angle for each patient during the oper-
ation, and it is not realistic. Therefore, I developed
a proposed pro fi le template for preoperative plan-
ning, intraoperative check, and postoperative eval-
uation for resorption or any change. So the last
step of rhinoplasty before closure is inspection
with the pro fi le template. This procedure is very
objective for achieving the fi nal goal (Fig. 21.30 ).
21.7.3 Wound Closure
and Splinting Technique
Suture-repair all incisions and dress nose appro-
priately.
Fig. 21.21 Low to high osteotomy. Low to high osteot-
omy does not affect inferior nasal turbinate, so narrowing of
osteotomized nasal bone does not affect nasal obstruction
Fig. 21.22 Humpectomy.
Humpectomy in external
marginal approach should be
very precise

259
21 External Marginal Approach Rhinoplasty (EMA Rhinoplasty)
(O)
(X)
Fig. 21.23 Rasping procedures after tip enhancement.
For correction of hump nose, immediate humpectomy
before tip plasty can cause mistake of adjusting tip height
with tip plasty. So tip plasty should be followed by correc-
tion of nasal hump which can be mostly changed into
rasping procedures instead of humpectomy
a
b
Fig. 21.24 ( a ) Preoperative 24-year-old male. ( b ) Postoperative following humpectomy with good correction

260
P.C. Kim and D.H. Park
21.8
Special Considerations
21.8.1 Endoscopic-Assisted
Rhinoplasty
The approach to corrective rhinoplasty is an
almost blind technique. Even the extended mar-
ginal approach, which provides direct ocular
vision, does not permit good observation of the
nasal bone. Therefore, to obtain a better result
with extreme precision, endoscopic-assisted rhi-
noplasty is useful especially in humpectomy,
corrective rhinoplasty, or septoplasty. The nasal
endoscopic instrument is initially used for a care-
ful and detailed diagnosis of the possible anoma-
lies of the deviated septum and the deviated nasal
bone. The surgeon holds the endoscope with the
left hand and evaluates any deformities or abnor-
malities of the dorsum. The cutting, rasping, and
chiseling instruments are held in the right hand.
The endoscope is a straight Stryker tube (camera:
Stryker No.97050224, Light source: X6000
No.04B030134, USA), 4.5 mm in diameter with
a
b
Fig. 21.25 Turbinate
out-fracture. ( a ) A Boies
elevator is a convenient
instrument for turbinate
out-fracture. ( b ) Mechanism
of turbinate out-fracture

261
21 External Marginal Approach Rhinoplasty (EMA Rhinoplasty)
a 30-angled tip (Fig. 21.31 ). The author has used
mostly endoscopic scissors, rasps, and chisels
that can remove or fl atten any hypertrophic callus
or overlying bony fragment of the nasal hump
with endoscopy (Fig. 21.32 ).
Any tissue that has been removed from the
nose (upper lateral cartilage, hump, nasal bone,
septal excess) is carefully preserved in a cup
fi lled with saline solution. The complementary
resections are performed and monitored by
watching an LCD screen to obtain good adjust-
ment of the nasal skeleton, both its bony and the
cartilaginous framework (Fig. 21.33 ).
21.8.2 Combined Adjuvant Aesthetic
Bone Surgery
Rhinoplasty can be achieved with another adju-
vant operation simultaneously. Paranasal aug-
mentation or genioplasty are typical examples of
simultaneous procedures. Also, submental intu-
bation (Fig. 21.34 ) allows us to perform orthog-
nathic surgery and rhinoplasty simultaneously.
1. Genioplasty (Fig. 21.35 )
Genioplasty should be considered in rhino-
plasty for proper pro fi loplasty. Otherwise
expectation of patient may not be achieved.
2. Orthognathic surgery (Fig. 21.36 )
b
a
Fig. 21.26 Submucosal resection (SMR). ( a ) Modi fi ed
Killian incision for SMR. ( b ) Harvest area in SMR. 10 mm
width of septal L-strut should be left
Fig. 21.27 Pro fi le template
on postoperative nasal pro fi le.
Inspection with nasal pro fi le
template is an objective
method for determining fi nal
tip projection in rhinoplasty

262
P.C. Kim and D.H. Park
Fig. 21.28 Cephalic rotation
suture. Cephalic rotation
suture with PDS 4-0 is hooked
up between fi xed upper lateral
cartilage and mobile lower
lateral cartilage. When knot is
made for the cephalic rotation
suture, lower lateral cartilage
moves cephalically
Fig. 21.29 Correction of
nasal tip asymmetry.
Repositioning with resection
of medial crus can adjust
nasal tip asymmetry
Fig. 21.30 Final inspection
with pro fi le template. Final
inspection with pro fi le
template before closure in
rhinoplasty is important for
achievement of fi nal goal

263
21 External Marginal Approach Rhinoplasty (EMA Rhinoplasty)
If a patient with prognathism wants rhino-
plasty, simultaneous orthognathic surgery
should be considered. Without change of facial
proportion, balanced rhinoplasty cannot be
achieved.
3. Paranasal augmentation (Figs. 21.37 and 21.38 )
For patient with midfacial hypoplasia, parana-
sal augmentation should be considered.
4. Facial contouring surgery (Fig. 21.39 )
Facial contouring surgery is popular in Asian
countries, and simultaneous rhinoplasty is
preferred.
Fig. 21.31 Endoscopic
handpiece for rhinoplasty. It
has irrigation supply with light
source
a
b
c
d
Fig. 21.32 Endoscopic-assisted rhinoplasty. ( a ) Opera-
tion procedure with endoscopy in rhinoplasty. Endoscopic
scissors are useful to resect remnant cartilage or tissues.
( b ) Osteocartilaginous hump. ( c ) After humpectomy,
resected upper lateral cartilage with open roof can be
seen. ( d ) Closed open roof after lateral osteotomy

264
P.C. Kim and D.H. Park
Fig. 21.33 Whole setting
for endoscopic-assisted
rhinoplasty in operation
room
Fig. 21.34 Submental intubation allows whole face
exposure

265
21 External Marginal Approach Rhinoplasty (EMA Rhinoplasty)
a
b
Fig. 21.35 Genioplasty with rhinoplasty. ( a ) Preoperative patient. ( b ) For proper pro fi loplasty, genioplasty can be
considered together
Fig. 21.36 Orthognathic surgery with rhinoplasty. ( a ) Preoperative 21-year-old male. ( b ) Postoperative following
orthognathic surgery, rhinoplasty, and forehead augmentation with fat graft in one stage
a

266
P.C. Kim and D.H. Park
Fig. 21.37 Paranasal augmenta-
tion for illustration. Mandibular
bone graft can be used for
paranasal augmentation
b
Fig 21.36 (continued)

267
21 External Marginal Approach Rhinoplasty (EMA Rhinoplasty)
a
Fig. 21.38 ( a ) Preoperative 23-year-old male who has arrow nose and midface hypoplasia. ( b ) Postoperative following
rhinoplasty and paranasal augmentation with particulate mandibular bone graft

268
P.C. Kim and D.H. Park
b
Fig. 21.38 (continued)

269
21 External Marginal Approach Rhinoplasty (EMA Rhinoplasty)
a
Fig. 21.39 ( a ) Preoperative 32-year-old female. ( b ) Postoperative after rhinoplasty and facial contouring surgery
including zygoma reduction and mandible angle reduction

270
P.C. Kim and D.H. Park
b
Fig. 21.39 (continued)

271
21 External Marginal Approach Rhinoplasty (EMA Rhinoplasty)
21.9
Results and Case Analysis
Case 1: Polly Beak Nose
A 27-year-old male presented for his fi rst rhino-
plasty. The patient was unhappy with the hump
of his nose. According to our analysis, he also
had microgenia, and he agreed with undergoing
advancement genioplasty (Figs. 21.40 and
21.41 ).
Surgical Technique (Figs. 21.42 and 21.43 )
1. Genioplasty (4-mm advancement)
2. Infracartilaginous extension approach without
transcolumellar incision
3. Exposure of nasal framework
4. Exposure of nasal septum by modi fi ed Killian
approach and harvest of septal cartilage
5. Tip plasty – cephalic trim and intercrural and
intracrural sutures with PDS 5-0 for tip
enhancement
6. Application of diced septal cartilage graft to
correct low radix and appearance of slight
nasal hump
7. Minimal dorsal reduction with the rasp
instrument
8. Suture-repair all incisions
Outcome Analysis and Critique
In the patient, a more favorable nasal tip has
been made by reduction of the osseous bone,
and an attractive chin was achieved with simul-
taneous genioplasty. Tip plasty improved the
appropriate nasal tip enhancement, and the
severe hump became mild degree. So hump cor-
rection can replace humpectomy with mild rasp-
ing after tip plasty. In general, tip plasty should
be performed fi rst in this kind of situation. The
later view shows improved facial pro fi le
achieved
with
simultaneous
genioplasty
(Fig. 21.44 ).

272
P.C. Kim and D.H. Park
a
b
Fig. 21.40 Preoperative four series photo views. ( a ) Frontal. ( b ) Three quarters. ( c ) Left lateral. ( d ) High basal
c
d

273
21 External Marginal Approach Rhinoplasty (EMA Rhinoplasty)
a
Fig. 21.41 The patient’s facial analysis. ( a ) Frontal. ( b ) Pro fi le
b

274
P.C. Kim and D.H. Park
a
b
c
d
Fig. 21.42 Intraoperative procedures in rhinoplasty. ( a )
SMR was done before rhinoplasty, and ( b ) lower lateral
cartilages are exposed. ( c ) After humpectomy and tip
plasty, nasal root augmentation was done with DRCG. ( d )
Preoperative pro fi le template was applied on the immedi-
ate postoperative nose

275
21 External Marginal Approach Rhinoplasty (EMA Rhinoplasty)
ID:
Name:
S/A M/27
Dept: PS
G
OPD/Adm
Date.
Site
Diagnosis
Operation
10−05−24
Nose, Chin
NBF, Hump Nose
Rhinoplasty, Advance Genioplasty
Anesthesia
0.6cc
4mm adv.
11
12
13
14
15
16
17
18
21 22
23
24
25
26
27
28
31 32 33
34
35
36
37
38
41
42
43
44
45
46
47
48
Daegu Catholic Medical Center, Korea
Operation Diagram − Dentofacial Surgery
Fig. 21.43 Intraoperative diagram. Standard brief operation note is visualized with diagram. It is not only for rhino-
plasty but also for whole facial procedures (dentofacial surgery)

276
P.C. Kim and D.H. Park
a
b
c
d
Fig. 21.44 Postoperative four series photos. ( a ) Frontal. ( b ) Three quarters. ( c ) Left lateral. ( d ) High basal

277
21 External Marginal Approach Rhinoplasty (EMA Rhinoplasty)
Case 2: Bi fi d Nose
A 19-year-old female presented with microgenia,
no trauma history. The patient visited the clinic
with the chief complaints of nasal obstruction, bi fi d
nose, and hump deformity. She underwent genio-
plasty and rhinoplasty (Figs. 21.45 and 21.46 ).
Surgical Technique (Figs. 21.47 and 21.48 )
1. Genioplasty (6-mm advancement)
2. Infracartilaginous extension approach without
transcolumellar incision
3. Exposure of nasal framework
4. Exposure of nasal septum by modi fi ed Killian
approach and harvest of septal cartilage
5. Tip plasty – cephalic trim and intercrural and
intracrural sutures with PDS 5-0 for tip
enhancement
6. Application of diced septal cartilage graft to
correct low radix and appearance of slight
nasal hump
7. Minimal dorsal reduction with the rasp
instrument
8. Suture-repair all incisions
Outcome Analysis and Critique (Fig. 21.49 )
In this patient, simultaneous genioplasty was
performed, so more attractive pro fi le was
achieved. On basal view, bi fi d tip was well cor-
rected. Humpectomy was preplanned; however,
after tip enhancement, operation procedure
changed into rasping procedures instead of
humpectomy. She was quite satis fi ed with attrac-
tive pro fi le and has more con fi dence on her
face.

278
P.C. Kim and D.H. Park
c
a
b
d
Fig. 21.45 Preoperative four series photos. ( a ) Frontal. ( b ) Three quarters. ( c ) Left lateral. ( d ) High basal

279
21 External Marginal Approach Rhinoplasty (EMA Rhinoplasty)
a
b
c
Fig. 21.47 Intraoperative procedures in rhinoplasty. ( a )
After nasal frame was exposed, ( b ) cephalic trim was
done. ( c ) After tip plasty with shield graft, pro fi le tem-
plate was applied on the nose
a
b
Fig. 21.46 The patient’s facial analysis. ( a ) Frontal and
( b ) pro fi le views were analyzed

280
P.C. Kim and D.H. Park
ID:
Name:
S/A
M/27
Dept: PS
G
OPD/Adm
Date.
Site
Diagnosis
Operation
09−02−12
Nose, Chin
NBF, Hump Nose
Rhinoplasty, Advance Genioplasty
Anesthesia
0.5cc
6mm adv.
11
12
13
14
15
16
17
18
21
22
23
24
25
26
27
28
31 32
33
34
35
36
37
38
41
42
43
44
45
46
47
48
Daegu Catholic Medical Center, Korea
Operation Diagram − Dentofacial Surgery
Fig. 21.48 Standard brief operation note in diagram. It is not only for rhinoplasty but also for whole facial procedures
(dentofacial surgery)

281
21 External Marginal Approach Rhinoplasty (EMA Rhinoplasty)
a
b
c
d
Fig. 21.49 Postoperative four series photos. ( a ) Frontal, ( b ) three quarters, ( c ) left lateral, and ( d ) high basal

282
P.C. Kim and D.H. Park
Case 3: Wide Ala and Low Height of Dorsum
A 34-year-old male suffering from nasal obstruc-
tion from deviated nose and septum.Low height of
dorsum, and wide ala was corrected as follows
(Figs. 21.50 and 21.51 ) :
Surgical Technique (Figs. 21.52 and 21.53 )
1. Turbinate out-fracture with Boies elevator
2. Infracartilaginous extension approach without
transcolumellar incision
3. Exposure of nasal framework
4. Exposure of nasal septum by modi fi ed Killian
approach and harvest of septal cartilage while
correcting deviated septum
5. Bilateral osteotomy for correction of deviated
nasal bone
6. Tip plasty- cephalic trim and lateral crural
spanning suture. Intercrural and intracrural
sutures with PDS 5-0 for tip enhancement
7. Shield graft and infratip augmentation with
septal cartilage graft and cinching suture using
V-Y closure of oral mucosa
8. Diced rib cartilage graft (0.9 cc)
9. Suture-repair all incisions
Outcome Analysis and Critique
In this patient, a straighter and stronger nose has
been made by DRCG and a cinching suture with
tip plasty. From a functional aspect, nasal obstruc-
tion was released by correction of deviated nasal
bone and septum. Unfortunately, because the
patient declined forehead augmentation and pro-
truded lip correction by advancement and reduc-
tion genioplasty, complete pro fi le could not
achieved only the nasal pro fi le. The basal view
demonstrates improved tip triangularity. Tip pro-
jection could have also been enhanced by the
cinching suture with V-Y oral closure. No scar
was observed on the columella (Fig. 21.54 ).

283
21 External Marginal Approach Rhinoplasty (EMA Rhinoplasty)
a
b
c
d
Fig. 21.50 Preoperative four series photos. ( a ) Frontal, ( b ) three quarters, ( c ) left lateral, and ( d ) high basal

284
P.C. Kim and D.H. Park
a
b
Fig. 21.51 The patient’s facial analysis. ( a ) Frontal and ( b ) pro fi le were analyzed
a
b
c
d
Fig. 21.52 Intraoperative procedures in rhinoplasty. ( a ) After nasal frame was exposed, ( b ) tip plasty with shield graft
and infralobular graft was done. ( c ) After rib cartilage was harvested, ( d ) DRCG was inserted into the dorsum

285
21 External Marginal Approach Rhinoplasty (EMA Rhinoplasty)
ID:
Name:
S/A
M34
Dept: PS
G
OPD/Adm
Date.
Site
Diagnosis
Operation
09−01−29
Saddle Nose
Rhinoplasty with DRCG(0.9cc)
Rhinoplasty with DRCG, Retracted columella
Anesthesia
0.9cc
intraoral
11
12
13
14
15
16
17
18
21
22
23
24
25
26
27
28
31 32
33
34
35
36
37
38
41
42
43
44
45
46
47
48
Daegu Catholic Medical Center, Korea
Operation Diagram − Dentofacial Surgery
Fig. 21.53 Standard brief operation note is visualized with diagram. It is not only for rhinoplasty but also for whole
facial procedures (dentofacial surgery)

286
P.C. Kim and D.H. Park
a
b
c
d
Fig. 21.54 Postoperative four series photo. ( a ) Frontal, ( b ) three quarters, ( c ) left lateral, and ( d ) high basal

287
21 External Marginal Approach Rhinoplasty (EMA Rhinoplasty)
Case 4: Deviated Nose
A 36-year-old male came to visit my clinic to
correct deviated nose. According to the facial
analysis, subapical augmentation was necessary
for proper rhinoplasty, so subapical augmentation
was performed because he has hypoplastic pyri-
form aperture and anterior nasal spine and he
requested genioplasty (Figs. 21.55 and 21.56 ).
Surgical Technique (Figs. 21.57 and 21.58 )
1. Genioplasty to correct microgenia
2. V-Y closure for subapical augmentation
3. Turbinoplasty
4. Infracartilaginous extension approach without
transcolumellar incision
5. Exposure of nasal framework
6. Lateral osteotomy for correction of deviated
nasal bone
7. Rasping procedure
8. Tip plasty – cephalic trim and cephalic rotation
suture with PDS 5-0. Intercrural and intracru-
ral sutures with PDS 5-0 for tip enhancement
9. Suture-repair all incisions
Outcome Analysis and Critique
In this patient, a more favorable nose has been
made by lateral osteotomy and tip plasty with a
cephalic rotation suture. From a functional aspect,
nasal obstruction was released by correction of
deviated nasal bone and turbinoplasty. From a
subjective point of view, the patient was very
satis fi ed with the conversion from a concave face
to convex face with a favorable nose. Tip projec-
tion could have also been enhanced by tip plasty
with a cephalic rotation suture. No scar was
observed on the columella (Fig. 21.59 ).

288
P.C. Kim and D.H. Park
a
b
c
d
Fig. 21.55 Preoperative four series photos. ( a ) Frontal, ( b ) three quarters, ( c ) left lateral, and ( d ) high basal

289
21 External Marginal Approach Rhinoplasty (EMA Rhinoplasty)
a
b
Fig. 21.56 The patient’s facial analysis. ( a ) Frontal and ( b ) pro fi le were analyzed
a
b
c
d
Fig. 21.57 Intraoperative procedures in rhinoplasty. ( a ) After nasal frame was exposed, ( b ) tip plasty was done. ( c )
After V-Y closure for subapical augmentation, ( d ) pro fi le template was applied on the face

290
P.C. Kim and D.H. Park
ID:
Name:
S/A
M36
Dept: PS
G
OPD/Adm
Date.
Site
Diagnosis
Operation
08−11−C3
Nose, Chin
NBF, Hump Nose
Rhinoplasty, Advance Genioplasty
Anesthesia
4mm adv.
11
12
13
14
15
16
17
18
21
22
23
24
25
26
27
28
31 3233
34
35
36
37
38
41
42
43
44
45
46
47
48
Daegu Catholic Medical Center, Korea
Operation Diagram − Dentofacial Surgery
Fig. 21.58 Standard brief operation note in diagram. It is not only for rhinoplasty but also for whole facial procedures
(dentofacial surgery)

291
21 External Marginal Approach Rhinoplasty (EMA Rhinoplasty)
a
b
c
d
Fig. 21.59 Postoperative four series photo. ( a ) Frontal, ( b ) three quarters, ( c ) left lateral, and ( d ) high basal

292
P.C. Kim and D.H. Park
21.10 Complications
Overall, the results have been positive. A few
patients had have the following complications:
1. Tip asymmetry (Fig. 21.60 )
One of the disadvantages of EMA rhinoplasty
is that it is not easy to adjust tip symmetry in
beginners because nasal tip may be presented
tilted into one side of nostril. One of my fi rst
series in rhinoplasty suffered from nasal tip
asymmetry.
2. Nostril asymmetry (Fig. 21.61 )
Nostril asymmetry is not so rare complication.
Most of the patients accept mild degree of
asymmetry. However, noticeable nostril asym-
metry should be corrected.
a
b
Fig. 21.61 Nostril asymmetry. ( a ) Preoperative patient.
( b ) After cleft rhinoplasty, nostril asymmetry still exists
a
b
Fig. 21.60 Tip asymmetry. ( a ) Preoperative patient. ( b )
After tip plasty, nasal tip asymmetry was noticed

293
21 External Marginal Approach Rhinoplasty (EMA Rhinoplasty)
21.11 Discussion
Most publications on rhinoplasty by plastic sur-
geons have dealt with open rhinoplasty. Open rhi-
noplasty has great advantages such as binocular
vision and exposure of the nasal framework with-
out distortion [ 2, 6 ] . The transcolumellar incision
has, however, some major disadvantages. The
columellar artery is sacri fi ced in the transcolumel-
lar incision, so the lateral nasal arteries become
the main blood supply for the nasal tip [ 4 ] . In a
bulbous fatty tip, defatting is a mandatory proce-
dure in the nasal tip, and the lateral nasal artery
can be easily damaged. If both the lateral nasal
arteries are damaged in an open approach with
transcolumellar incision, the nasal tip can be com-
promised and become necrotic [ 3 ] . Even a hema-
toma on the nasal tip, which can compress both
lateral nasal arteries, may contribute to an unsta-
ble blood supply in the nasal tip which can ulti-
mately result in necrosis.
Other potential complications are related to
the columellar incision and/or scar. The horizon-
tal columellar incision is connected to the lateral
parallel columellar incision, and at the level of
this junction, a trapdoor scar or deformity may
occur. Constantian, who prefers the closed
approach, has criticized the open technique for its
potential complications after transcolumellar
incision. Open rhinoplasty without transcolumel-
lar incision eliminates the disadvantages of the
columellar scar and the disrupted circulation at
the nasal tip and is a valid alternative to the tradi-
tional approach [ 3 ] . Protracted edema of the nasal
tip may create the risk of development of a soft
tissue deformity or supra tip swelling which
would decrease in time.
In 1990, Guererosantos [ 4 ] proposed a modi fi -
cation of open rhinoplasty that utilized a bilateral
circumferential rim incision for dissecting the
cartilaginous vault, including the columella, from
the overlying skin. This proposed technique is a
circumferential incision, which is very different
from my technique. In conclusion, extended mar-
ginal approach rhinoplasty picks up the advan-
tages of both open and closed rhinoplasty. There
is no visible scar and no potential tip necrosis
from a sacri fi cing of the columellar artery, and
the approach involves no temporary columellar
closure when checking for immediate postopera-
tive change. Autologous graft is the best choice
of rhinoplasty with this modi fi ed extended endo-
nasal approach [ 10– 15 ] .
Acknowledgment We gratefully acknowledge and
thank Gemma Seung Jung Son (BA), medical illustrator
in our department, and Letitia An (B.Sc.), a good friend of
mine from New Zealand. Miss Gemma dedicated all the
illustrations in this article to make this chapter a work of
art as only she can do. Miss Letitia gave us continued and
tireless dedication to help make this chapter a high-quality
English publication. They were instrumental in transform-
ing this text from a dream to reality.
References
1. Baser B, Hiranandani N, Grewal DS (1989) External
rhinoplasty in the tropics. J Laryngol Otol 103:
1198
2. Sevin A, Sevin K, Erdogan B, Deren O, Adanali G
(2006) Open rhinoplasty without transcolumellar
incision. Ann Plast Surg 57(3):252–4. PubMed
PMID:16929188
3. Holmström H, Luzi F (1996) Open rhinoplasty with-
out transcolumellar incision. Plast Reconstr Surg
97(2):321–326. PubMed PMID: 8559814
4. Guerreosantos, J. Open rhinoplasty without skin-col-
umella incision . Plast. Reconstr. Surg. 85:955
5. Bravo FG, Schwarze HP (2008) Closed-open rhino-
plasty with extended lip dissection: anew concept and
classi fi cation of rhinoplasty. Plast Reconstr Surg
122(3):944–50. PubMed PMID: 18766064
6. Han SK, Woo HS, Kim WK (2002) Extended incision
in open-approach rhinoplasty for asians. Plast
Reconstr Surg 109(6):2087–96. PubMed PMID:
11994619
7. Peter Chanwoo Kim, Chang Hyung Oh, Yong Jig
Lee, Jeong Su Shim MD, Dae Hwan Park, (2009)
Measurement of Septal Cartilage Amount using
Sagittal view of facial bone CT. MJCUD (1)
67–70
8. Cárdenas-Camarena
L,
Guerrero
MT
(2002)
Improving nasal tip projection and de fi nition using
interdomal sutures and open approach without
transcolumellar incision. Aesthetic Plast Surg
26(3):161–6. PubMed PMID: 12140692
9. Peter Chanwoo Kim, Sang Soon Park, Yong Jig Lee,
(2011) Simultaneous Non-transcolumellar Incisioned

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Rhinoplasty in Nasal Bone Fracture : Analysis of 121
Cases. Korean Aesth Plast Surg 17(3):165–172
10. Yilmaz S, Ercocen AR, Can Z, et al (2001) Viability
of diced, crushed cartilage grafts and the effects of
Surgicel (oxidized regenerated cellulose) on cartilage
grafts. Plast Reconstr Surg 108:1054–1060; discus-
sion 1061–1052
11. Coskun BU, Seven H, Yigit O, et al (2005) Comparison
of diced cartilage graft wrapped in surgicell and diced
cartilage graft wrapped in fascia: an experimental
study. Laryngoscope 115:668–671
12. Calvert JW, Brenner K, DaCosta-Iyer M, et al (2006)
Histological analysis of human diced cartilage grafts.
Plast Reconstr Surg 118:230–236
13. Brenner KA, McConnell MP, Evans GR, et al (2006)
Survival of diced cartilage grafts: an experimental
study. Plast Reconstr Surg 117:105–115, Oly
1658–1659
14. Peer LA (1954) Extended use of diced cartilage grafts.
Plast Reconstr Surg14:178–185
15. Coster DJ, Galbraith JE (1980) Diced cartilage grafts to
correct enophthalmos. Br J Ophthalmol 64: 135–136

295
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_22, © Springer-Verlag Berlin Heidelberg 2013
22
22.1
Introduction
Closed rhinoplasty is the most frequent choice of
most experienced surgeons since it is a quick way
to approach the nasal structures. On the contrary,
the open rhinoplasty takes a longer time in dis-
section to expose the alar cartilages, but in this
way, all the structures of the nose are actually
seen without dif fi culty.
The closed technique is good for approaching
the nasal dorsum to resect the septum (SC) and
triangular cartilages (TC). The nasal bone can be
trimmed down, and the result is very accurate
with this technique. Also the recovery time is
shorter since there is less edema in the nasal tip.
But when it comes to the nasal tip (NT), with
resection of the alar cartilages (AC), it is often left
with asymmetries (Fig. 22.1 ) with this technique.
It is also a lot more dif fi cult to lift the nasal tip
with a strut graft put into the columella because
the columella is actually closed and the strut graft
could be frequently misplaced (Fig. 22.2 ).
However, the open rhinoplasty could be more
time-consuming and have prolonged edema of the
nasal tip, but the alar cartilages are exposed widely
(Fig. 22.3 ), and their resection can be quite precise
(Fig. 22.4 ). Suturing of these cartilages to change
the shape can be made, and the strut and tip grafts
can be sutured precisely in place (Fig. 22.4 ). This
is very important also in secondary or revisional
rhinoplasty, because the wide exposure enables
more access, thus more possibility to improve the
errors of the previous surgery.
22.2
Technique
The surgeon should have a precise knowledge of
what he wants to change in the nose he is going to
operate on. It is very important to clarify in con-
sultation prior to surgery what the patient wants
to change because sometimes our appreciation
may not be the same as that of the patient. The
surgeon must be acquainted with what the patient
wants and let him or her know of the real possi-
bilities of the outcome in his hands.
22.3
Preoperative Markings
The preoperative markings are important for
good results, in either technique, be it open or
closed. The line of the fracture of the maxillary
ramus should be marked to help the surgeon frac-
ture this bone to close the resection of the nasal
dorsum, be it with external or internal chisels.
The trimming of the nares should also be marked
if necessary. These are the only markings to use
for the closed procedure (Fig. 22.5 ).
The Controversy Between
Open and Closed Rhinoplasty
Arturo Grau
A. Grau , M.D.
Facial and Body Cosmetic Surgery ,
Multiclinica Medical Center , 5081 Poeta Carlos
Giménez c/Charles de Gaulle, Bo. Villa Morra ,
Asunción , Paraguay
e-mail: agrauestetica@hotmail.com

296
A. Grau
For the open technique, a “W” is performed in
the mid-third of the columella and also marks the
anterior rim of the alar cartilages. If fat resection
of the nasal tip is necessary, a round dotted mark-
ing is made in the skin of the nasal tip that will
help respect only the fat of the area that is needed
to “shrink” the tip. The rest of the markings are
the same as in the closed technique (Fig. 22.6 ).
22.4
Anesthesia
The anesthesia preferred by the author is local
(2% lidocaine with epinephrine) with sedation so
the patient does not feel any pain at all during the
in fi ltration of the anesthetic. On the other hand,
general anesthesia is also possible.
a
c
b
d
Fig. 22.1 ( a – d ) Asymmetries in the nasal tip (NT) due to irregular alar cartilage (AC) resection with closed
rhinoplasty