Phẫu Thuật Tai Mũi Họng Và Phẫu Thuật Đầu Cổ

780
Section 9
Plastic and Reconstructive Surgery
tion of the pterygoid plate just medial and posterior to
the maxillary tuberosity. Thus, when marking the fl aps,
the surgeon should remember that the Z-plasties are
not two dimensional and that the angles do not need
to be at 60 degrees each because fl ap design is based
on the anatomy of the palate, not the geometry of the
Z-plasty.
The lateral limbs of the incisions on the oral side
and at the level of hamulus are extended to allow
advancement of the fl aps (see Fig. 83-11B). This inci-
sion can be extended around the maxillary tuberosity
as a short backcut when necessary. For limited soft
palate clefts, only the soft palate incisions and fl aps are
elevated without the need for hard palate releasing
incisions.
The left myomucosal fl ap (oral) is posteriorly based.
The muscle is dissected from the nasal mucosa with
scissors, and the levator muscle is carefully preserved.
The palatal muscles are separated from the aponeurosis
and from the medial side of the superior constrictor to
mobilize the fl ap for rotation. Once the oral fl aps are
raised, the nasal Z fl aps are incised. On the left, the ante-
riorly based fl ap (nasal) is elevated as a mucosal fl ap. On
the right, the posteriorly based (nasal) fl ap is elevated
with the muscle. Each lateral limb incision ends just
medial to the eustachian tube orifi ce (torus).
The left anteriorly based (nasal) mucosal fl ap is
incised from the uvula along the dissected edge of the
cleft muscle to the left torus. The right posteriorly based
(nasal) mucosal-muscle fl ap is created by an incision
from the posterior hard palate to near the torus while
taking care to include velar cleft muscle in the fl ap.
However, the mucosal incision on this fl ap is not
extended completely up to the torus to facilitate subse-
quent closure.
The nasal side is closed by fi rst transposing the left
nasal mucosal (anteriorly based) fl ap transversely to the
distal portion of the right nasal incision stepwise from
the distal to the proximal aspects to the posterior hard
palate nasal mucoperiosteum until the end of the fl ap
reaches near the right torus. When tension is present,
avoidance of the natural inclination to sew the distal tip
of the fl ap to its ultimate location fi rst helps protect the
fragile tip of the fl ap. Next, the right myomucosal fl ap
is transposed until the tip of the fl ap reaches the oppo-
site superior constrictor muscle at the torus (see Fig.
83-11C). This fl ap is sutured to the nasal mucosal fl ap
anteriorly. The muscle of the posteriorly based oral
myomucosal fl ap on the left side is then secured to the
right tonsillar pillar. The right anteriorly based mucosal
fl ap is sutured in stepwise manner across to the oral
mucosa on the opposite side.
Retention sutures through the muscle of the poste-
riorly based right-sided nasal fl ap may be placed through
the base of the oral fl ap on the opposite side to relieve
tension. Mucoperiosteal fl aps (when present) are
brought into the horizontal plane and sutured. Usually,
no bone is exposed and no raw nasal area on the soft
palate is left to contract and shorten the palate.
Postoperative care includes a liquid diet and place-
ment of arm restraints for approximately 2 weeks to
Table 83-3
COMMON SPEECH ABNORMALITIES
SEEN IN PATIENTS WITH
CLEFT PALATE
Hypernasality: Failure of the palate to separate the oral
and nasal cavities during non-nasal consonant
production. Oral phonemes substituted by nasal sounds
(m, n, ng)
Hyponasality: Reduction of the nasal airfl ow that occurs
with the nasal consonants /m/, /n/, and /ng/. Usually
not present with velopharyngeal insuffi ciency but may be
noted when large adenoid or posterior nasal airway
obstruction is present with an incompetent
velopharyngeal valve
Cul-de-sac resonance: Air enters the nasal cavity but
cannot escape because of anterior nasal blockage.
Muffl ed sound quality
Nasal emission: Airfl ow normal with nasal consonants;
abnormal with plosives, fricatives, and affricates.
Determined with mirror testing. May be audible or
inaudible
Nasal snort, /s/ phoneme, and other fricatives: In a
patient with an initially closed velopharyngeal valve, as
intraoral pressure increases, air escapes from the nose
Stops glottal: Plosive consonant produced by vocal fold
valving
Chronic hoarseness: Vocal hyperfunction secondary to
compensation at the laryngeal level
allow adequate mucosal healing. Careful follow-up and
regular visits with a speech pathologist are important.
CLEFT PALATE, MIDDLE EAR,
AND SPEECH
Speech characteristics associated with a cleft palate
include abnormal nasal resonance, abnormal nasal
airfl ow and altered laryngeal voice quality, nasal or
facial grimace, and atypical consonant production
(Table 83-3). In patients with clefts, abnormal nasal
resonance is typically manifested as hypernasality sec-
ondary to VPI. Inadequate nasal resonance (hyponasal-
ity) may also occur as result of obstruction. Hypernasality
and hyponasality can occur together (mixed nasality).
Altered laryngeal voice quality commonly includes
hoarseness and reduced volume. Nasal or facial grimace
is an unconscious compensation mechanism to inhibit
airfl ow through the nose. As a result of these issues and
other factors, there is a risk of articulation disorders
and other speech abnormalities.
Chronic Otitis Media
The cleft palate population has a high incidence of
mild to moderate hearing loss. Early onset of otitis
media with effusion (OME) is a universal fi nding in
infants with unrepaired cleft palates, and the pathology
is causally related to an inherent defect in the opening

Chapter 83
Cleft Lip and Palate: Comprehensive Treatment and Technique
781
mechanism of the eustachian tube that results in per-
sistent collapse of the tubal lumen.27,28 Treatment of this
condition requires evacuation of the effusion and inser-
tion of ventilation tubes. In children with a cleft lip and
palate, present and persistent OME should be addressed
at the time of lip repair, which usually takes place at
around 3 months of age. In children with a cleft palate
only, persistent OME should be addressed when diag-
nosed, in a separate procedure, and should not wait for
palate repair. In the author’s opinion (A.G.), long-term
tubes (T tubes) should be used when possible. This
option may not be available in a very small ear. In both
groups, ears need to be reevaluated shortly before
palate repair and regular tubes replaced with long-term
ventilation tubes at the time of palate repair. After suc-
cessful palate repair, most children with a cleft lip and
palate will not be scheduled for another surgical proce-
dure for several years. The shorter retaining period and
high extrusion rate of regular tubes make them less
than ideal in many instances. Even after palate repair,
eustachian tube function remains defi cient in a large
percentage of these children, and ear problems (infec-
tions, hearing loss, or both) are most prevalent in the
4- to 6-year-old age group. Ear problems persist at a
substantial level until the age of 12 years, and children
with a cleft lip and palate have a prolonged recovery
and a substantial incidence of late sequelae.28 T tubes
are retained longer and will therefore obviate the need
for repeated tube insertion, which presents additional
unnecessary anesthesia risk for the child, as well as
increases the cost of care substantially in the fi rst 5 years
of the child’s life. Evaluation of the ear and hearing
should be undertaken every 6 months.
Submucous Cleft Palate
A submucous cleft palate is a microform or incomplete
version of a complete cleft of the embryologic second-
ary palate. It is characterized by the presence of a bifi d
uvula, a translucent midline known as the zona pellu-
cida (caused by diastasis of the soft palate muscles),
and lack of a posterior nasal spine causing palpable
notching of the posterior hard palate. A submucous
cleft palate may be asymptomatic throughout life or
become symptomatic after adenoidectomy, as well as
after natural involution of the adenoid tissue. It is
important to inspect the uvula carefully and palpate the
posterior hard palate before an adenoidectomy. When
considering adenoidectomy in any patient, if the poste-
rior palatal spine cannot be palpated and a midline
notch is present, partial (anterior) adenoidectomy
should be considered. In general, submucous cleft
palates are repaired only when they cause symptomatic
speech abnormalities.
VELOPHARYNGEAL INCOMPETENCE
The secondary palate is composed of a hard (bone)
palate anteriorly and a soft palate or “velum” posteri-
orly. Within the soft palate, the levator veli palatini
muscle forms a dynamic sling that elevates the velum
toward the posterior pharyngeal wall during the pro-
duction of certain sounds. Other muscle groups within
the velum, the tonsillar pillar region, and the pharyn-
geal walls also affect the quality of resonance during
speech formation. The combination of the soft palate
and pharyngeal wall musculature jointly forms what is
described as the velopharyngeal valve mechanism (Fig.
83-12). This mechanism functions as a sphincter valve
for regulating airfl ow between the oral and nasal cavi-
ties to create a combination of orally based and nasally
based sounds.
Children born with a cleft palate have, by defi ni-
tion, a malformation that has a dramatic impact on the
anatomic components of the velopharyngeal valve
mechanism. Specifi cally, clefting of the secondary palate
causes division of the musculature of the velum into
separate muscle bellies with abnormal insertions along
the posterior edge of the hard palate (see Fig. 83-12).
VPI is a major functional concern for patients with a
cleft. Regardless of the repair type, the incidence of VPI
Figure 83-12. Anatomy of the
palate and velopharyngeal valve
mechanism. A, Normal anatomy.
B, Unilateral cleft of the primary
and secondary palate with associ-
ated anatomic abnormalities.
Normal Anatomy
A
B
Ptergoid hamulus and tensor
palatini muscle
Muscles of the Velopharyngeal Sphincter
Palatoglossus muscle
Levator veli palatini muscle
Pterygomandibular raphe and
superior constrictor muscle
Palatopharyngeus muscle
Unilateral Cleft Palate

782
Section 9
Plastic and Reconstructive Surgery
after primary palate repair varies in studies from 5% to
higher than 50%.1,2,29,30
VPI is defi ned as inadequate closure of the naso-
pharyngeal airway port during speech production. The
exact cause of VPI after successful cleft palate repair is
a complex problem that remains diffi cult to defi ne
completely. Incomplete surgical repair of the muscula-
ture is one cause of VPI, but even muscles that have
been appropriately realigned and reconstituted may fail
to heal normally or function properly. In addition, it
must be considered that the repaired cleft palate is only
one factor contributing to velopharyngeal valve func-
tion and that other abnormalities related to oropharyn-
geal morphology, nerve innervation, lateral and
posterior pharyngeal wall motion, and nasal airway
dynamics may all contribute to velopharyngeal valve
dysfunction. For example, a short, scarred soft palate
that does not elevate well may be compensated by
recruitment and hypertrophy of muscular tissue within
the posterior pharyngeal wall (Passavant’s ridge).
Approximately 20% of children with VPI after pala-
toplasty will eventually require management involving
additional palatal surgery. Left untreated, nasal air
escape–related resonance problems will lead to other
speech abnormalities, namely, abnormal compensatory
articulation. These abnormal, compensatory misarticu-
lations further complicate problems with speech forma-
tion and decrease speech intelligibility in patients with
cleft palate–related VPI.
After the initial cleft palate repair, periodic evalua-
tions are important to assess the speech and language
development of each child. Typically, this involves a
standardized screening examination performed by a
speech and language pathologist as part of an annual
visit to the cleft palate team. Detailed studies that
include the use of videofl uoroscopy and nasopharyn-
goscopy may be indicated. Videofl uoroscopy is used to
radiographically examine the upper airway with the aid
of an oral contrast agent. This technique allows dynamic
testing of the velopharyngeal valve mechanism with
views of the musculature in action. In addition, details
of upper airway anatomy, including residual palatal fi s-
tulas, can be visualized and their contribution to speech
dysfunction evaluated during the study. For a videofl uo-
roscopy study to be of diagnostic value it must include
multiple views of the velopharyngeal valve mechanism,
and a speech pathologist must be present to administer
verbal testing in the radiology suite.
Nasopharyngoscopy allows direct visualization of
the upper airway and specifi cally the velopharyngeal
valve mechanism from the nasopharynx. This technique
avoids the radiation exposure associated with videofl uo-
roscopy but requires preparation of the nose with a
topical anesthetic, skillful maneuvering of the scope,
and a compliant patient. Once the endoscope is
inserted, observations of palatal function, airway mor-
phology, and pharyngeal wall motion are made while
the patient is verbally tested by the speech pathologist.
The opportunity for direct visualization of the velopha-
ryngeal valve mechanism in action during speech for-
mation provides information that is critical to clinical
decision making related to secondary palatal surgery in
cases of confi rmed or suspected VPI.
With videofl uoroscopy and nasoendoscopy, the
closure pattern of the palate is documented and should
be differentiated. The closure pattern may help deter-
mine the success of various secondary palatal proce-
dures designed to augment anatomic defi ciencies.
• The most common pattern of closure (55% of the
normal population) is coronal closure. It consists of
posterior movement of the soft palate to the posterior
pharyngeal wall with little movement from the lateral
walls. Approximately 45% of patients with VPI have
this pattern of closure.
• The sagittal closure pattern is seen in 10% to 15% of
the population. Primary closure is by lateral wall
movement without signifi cant anterior-to-posterior
closure. This pattern is seen in approximately 10% of
children with VPI.
• Circular closure includes lateral wall movement and
posterior movement of the soft palate. It occurs in
approximately 10% of the population and 20% of
children with VPI. Circular closure with Passavant’s
ridge includes lateral wall and soft palate movement,
as well as anterior movement of the posterior pharyn-
geal wall. This pattern is seen in 20% of the normal
population and in 25% of children with VPI.
Secondary palatal surgery in young children is indi-
cated when VPI is causing hypernasal speech on a consis-
tent basis and is related to the anatomic problem. The
exact timing of surgery for VPI remains controversial,
however, with recommendations ranging from 2.5 to
older than 5 years. In such a young age group, variables
such as the child’s language and articulation develop-
ment and lack of compliance during speech evaluation
compromise the diagnostic accuracy of preoperative
assessment. The decision to proceed with additional
surgery for VPI is not an isolated surgical judgment. The
authors believe that lack of palatal movement in the
anterior-posterior direction benefi ts most often from a
pharyngeal fl ap, and frequently the lack of lateral wall
motion is best treated by sphincter pharyngoplasty.
There is considerable variation in surgical technique for
each of these procedures, and each can be customized
to fi t the particular closure pattern of each patient.
TONSILLECTOMY AND ADENOIDECTOMY
IN CHILDREN WITH CLEFTS
The age group of children evaluated for VPI certainly
coincides with the period when enlargement of the
tonsils and adenoids is most common. This issue is not
well addressed in the literature and, if ignored, has a
tendency to disrupt the positive outcome of cleft palate
repair.
Severely enlarged tonsils can interfere with eleva-
tion and closure of the palate. Careful observation of
the tonsil–soft palate relationship during oropharyn-
geal examination, as well as nasoendoscopy, will dis-
close the impact of tonsil enlargement. A repeat

Chapter 83
Cleft Lip and Palate: Comprehensive Treatment and Technique
783
speech evaluation should be performed 6 to 8 weeks
after tonsillectomy and the presence and severity of VPI
reassessed.
Enlarged adenoids aid velopharyngeal closure.
After adenoidectomy, occult VPI suddenly becomes
overt and decompensated speech patterns can be
dramatic. VPI after adenoidectomy in the general popu-
lation occurs in less than 1% of cases. Of these, approxi-
mately one third can be observed to have fi ndings of
mild VPI before adenoidectomy. The risk for VPI after
adenoidectomy is increased in children with develop-
mental delay, generalized hypotonia, mental retarda-
tion, submucous cleft palate, family history of VPI, and
history of feeding problems in early childhood.
If a subsequent pharyngeal fl ap is not planned,
adenoidectomy in a child with a repaired or submucous
cleft palate or in a child with other risk factors as men-
tioned earlier should be limited to the anterior one half
of the adenoid tissue (closest to the choanae and torus)
while leaving the height and posterior one half of the
adenoid tissue intact for adequate velar closure. Ade-
noidectomy in this age group is frequently indicated for
recurrent or chronic sinonasal infections and for recur-
rent or chronic otitis media. One of the rare causes of
VPI is closure of the palate against asymmetrical adenoid
tissue, which can be adequately identifi ed only with
nasoendoscopy.
A major cause of obstructive sleep apnea in chil-
dren is adenotonsillar hypertrophy. Failure to recog-
nize the impact of adenotonsillar hypertrophy in a child
with sleep-disordered breathing, snoring, or mild apnea
can lead to severe obstructive sleep apnea after creation
of a pharyngeal fl ap to treat VPI. Performing an ade-
noidectomy after a pharyngeal fl ap is in place is diffi cult
and may carry a higher risk of bleeding. A moderately
enlarged mass of adenoid tissue can become severely
obstructive after a few months and interfere with the
function of a pharyngeal fl ap. When adenoidectomy is
required before treatment of VPI, appropriate surgical
planning may include removal of the obstructive
adenoid tissue at least 4 to 6 weeks before creation of a
pharyngeal fl ap.
Enlarged tonsils obstructing the view of the poste-
rior pillars may interfere with the elongation of fl aps
for pharyngoplasty. When necessary, conservative ton-
sillectomy (preservation of both the anterior and pos-
terior tonsil pillars) is planned before pharyngoplasty.
The lateral pharyngeal ports can become obstructed by
enlarged tonsils several months after a successful pha-
ryngeal fl ap procedure and cause speech disturbance,
obstructive sleep apnea, or both. Nasoendoscopy will
show this problem and tonsillectomy can alleviate it. It
should be noted that adenoidectomy and tonsillectomy
in patients with clefting is a controversial area and that
treatment plans must be individualized.
OPERATIVE TECHNIQUES FOR
VELOPHARYNGEAL INSUFFICIENCY
Contemporary surgical management of VPI generally
involves the use of two types of procedures: a pharyn-
geal fl ap and sphincter pharyngoplasty.1,2,29 The use of
autogenous or alloplastic implants for augmentation of
the posterior pharyngeal wall has been described but is
not a commonly used procedure. More recently, some
surgeons have advocated performance of a second pala-
toplasty operation in an attempt at palatal lengthening
in a patient with VPI. This may become an alternative
in some patients with short gaps posteriorly.
A superiorly based pharyngeal fl ap remains the
standard approach for surgical management of VPI.
Using 14F catheters for guidance, the technique advo-
cated by the authors limits the combined size of the
lateral ports to less than 20 mm2, the maximal velopha-
ryngeal port opening during clinically normal speech.
Surgical maneuvers are directed at recruiting tissue by
developing a superiorly based soft tissue fl ap from the
posterior pharyngeal wall (Fig. 83-13). The soft palate
is then divided along the midsagittal plane from the
junction of the hard and soft palate to the uvula, and
the fl ap from the posterior pharyngeal wall is inset
within the nasal layer of the soft palate. A superiorly
based fl ap may be covered with mucosal fl aps on both
the dorsal and ventral surfaces, thus increasing the
viability of the fl ap, reducing fl ap contracture, and
expediting mucosal healing. As a result, a large naso-
pharyngeal opening that cannot be completely closed
by the patient’s velopharyngeal valve mechanism is con-
verted into two (right and left) lateral pharyngeal ports.
Closure of these ports is easier for the patient to accom-
plish as long as adequate lateral pharyngeal wall motion
is present.
The high overall success rate and the fl exibility to
design the dimensions and position of the fl ap itself are
advantages of the superiorly based pharyngeal fl ap pro-
cedure. Disadvantages of the pharyngeal fl ap proce-
dure are primarily related to the possibility of nasal
obstruction, resulting in trapping of mucus and the
potential for exacerbation of obstructive sleep apnea.
Inferiorly based pharyngeal fl aps for the manage-
ment of VPI are rarely used and tend to cause down-
ward pull on the soft palate after healing and contracture
of the fl ap. The result may be a tethered palate with
decreased ability to elevate during the formation of
speech sounds. Moreover, should postoperative hemor-
rhage occur, an inferiorly based fl ap obscures the donor
site for access to the bleeding site, and to control the
bleeding, the fl ap may need to be sacrifi ced in some
instances. A superiorly based fl ap leaves the donor site
fully accessible.
Dynamic sphincter pharyngoplasty is another
option for the surgical management of VPI. The opera-
tive procedure involves the creation of two superiorly
based myomucosal fl aps that include each posterior
tonsil pillar (Fig. 83-14). Each fl ap is elevated with care
taken to include as much of the palatopharyngeal
muscle as possible. It may be diffi cult to raise fl aps in
patients with velocardiofacial syndrome, because the
internal carotid arteries may take a median course in
the posterior pharynx. The fl aps are then attached and
inset within a horizontal incision made high on the
posterior pharyngeal wall. These fl aps are designed to

784
Section 9
Plastic and Reconstructive Surgery
Figure 83-13. Superiorly based pharyngeal fl ap. A, Elevation of a myomucosal fl ap from the prevertebral fascia and division of the soft palate
tissues. B, Dissection of the oral, nasal, and muscular layers for insetting the fl ap. C, Sagittal view of soft palatal anatomy in preparation for
insetting the pharyngeal fl ap at the appropriate vertical height.
Post. pharyngeal wall mucosa
Prevertebral fascia
Adenoid tissue
Soft palate
Hard palate
C
Tongue depressor
Tongue
n
w
Tonsil
Ant. pilla
Post. pilla
A
B

Chapter 83
Cleft Lip and Palate: Comprehensive Treatment and Technique
785
be anastomosed either end to end (if short) or side to
side (overlap) (if long) (see Fig. 83-14).
The goal of this procedure is creation of a single
nasopharyngeal port (instead of the two ports of
the pharyngeal fl ap) that has a contractile ridge poste-
riorly to improve velopharyngeal valve function. Trans-
posed fl aps should be high in the nasopharynx, at the
level of the velopharyngeal closure. VPI may persist
if positioning is incorrect or narrowing is inadequate.
Ideally, at the completion of the procedure, the
fl aps should not be visible during oropharyngeal
examination.
The main advantage of sphincter pharyngoplasty
over a superiorly based fl ap is a lower rate of complica-
tions related to nasal airway obstruction, as described
earlier. Despite this theoretical advantage, there is no
convincing evidence that pharyngoplasty procedures
achieve superior outcomes in the resolution of VPI. In
addition, the use of a sphincter pharyngoplasty tech-
nique may be associated with increased scarring along
the tonsillar pillar region.
Some surgeons advocate the use of revision palato-
plasty instead of a pharyngeal fl ap or pharyngoplasty
procedure for the management of patients with VPI.
Specifi cally, either aggressive repositioning of the mus-
culature with a two-fl ap palatoplasty and intravelar
velarplasty or a Furlow double-opposing Z-plasty is
carried out to facilitate velopharyngeal valve closure.
The ideal patient for a revision Furlow procedure is a
child younger than 12 years with poor levator recon-
struction, a short palate with a gap of less than 10 mm,
and 50% to 75% lateral pharyngeal wall movement. An
older patient with a 5-mm or smaller gap and good
lateral wall movement may also be a good candidate.
Long-term speech results of revision Furlow procedures
are unavailable at present, but some surgeons strongly
advocate this technique. Thus, the exact choice for
each patient still remains controversial and is best
tailored according to each surgeon’s individual
experience.
PALATAL FISTULA REPAIR
Fistulas can occur in patients who undergo repair of
cleft palates. The recommended timing of closure
may vary signifi cantly and remains a controversial
topic.1,2,30-33 Some surgeons or speech pathologists may
advocate aggressive management with early closure of
any fi stula present after the initial palate repair. The
authors prefer to take a more long-range view of fi stulas
and delay surgery for several years whenever possible.
Fistulas that have a negative impact on speech may be
closed earlier.
In infants, closure of a small, nonfunctional fi stula
can generally be deferred until later in childhood. In
such cases, fi stula repair may be incorporated into any
future procedures such as pharyngeal surgery for VPI
or bone graft reconstruction of the cleft maxilla and
alveolus, as long as there is no functional speech or
feeding-related concerns. When a large (>5 mm) fi stula
is present, there is a greater likelihood that functional
impairment will be encountered, such as nasal air
Figure 83-13, cont’d D, Sagittal close-up view indicating the relationship between adenoid tissue and the pharyngeal fl ap. E, Insertion of
the fl ap with closure of the oral mucosa over the raw defect to decrease scarring.
Post. pharyngeal wall mucosa
Prevertebral fascia
Adenoid level
Level of elevation
Mucosal adenoid bed
D
E

786
Section 9
Plastic and Reconstructive Surgery
Figure 83-14. Sphincteroplasty. A, Incision in the posterior pharyngeal wall and the posterior tonsillar pillars. B, Elevation of the tonsillar
pillar–myomucosal fl aps. C, Approximation in the central pharyngeal area to customize the size of the central port. D, Sutured fl aps placed in
the posterior pharyngeal walls and posterior-lateral pharyngeal walls.
A
B
C
D
escape affecting speech, nasal refl ux of food and liquids,
and hygiene-related diffi culties. In clinical situations in
which signifi cant functional problems exist, earlier
closure of a persistent fi stula is indicated. As part of the
decision-making process, surgeons must weigh the ben-
efi ts of repair against the negative effects on subsequent
maxillary growth of a second palatal surgery involving
stripping of mucoperiosteum.
Another consideration in planning the exact timing
of closing a fi stula is the type of technique being used
for the repair. Closure of a fi stula with local fl aps or
repeat palatoplasty may be undertaken during infancy
and early childhood. On the other hand, in cases in
which the use of a tongue fl ap is considered, the child
must be old enough to cooperate with the perioperative
regimen.
Operations currently used for fi stula repair include
local palatal fl aps, modifi cations of the von Langenbeck
and two-fl ap palatoplasty techniques, palatoplasty with
incorporation of a pharyngeal fl ap, and the use of a
tongue fl ap. Other regional fl aps, including tongue,
buccal mucosa, buccinator myomucosal, temporalis
muscle, and vascularized tissue transfer, are used less
frequently.

Chapter 83
Cleft Lip and Palate: Comprehensive Treatment and Technique
787
Figure 83-15. A and B, Four-fl ap technique of advancing much-needed attached mucosa into the residual cleft of the primary palate with
simultaneous closure of the oral-nasal fi stula and placement a of cancellous iliac crest bone graft. (From Fonseca RJ: Davis Reconstructive Preprosthetic
OMS. Philadelphia, WB Saunders, 1995, p 996.)
A
B
When less than 4 mm in diameter, the fi stula may
be closed with an edge-based turnover fl ap for nasal
lining, followed by a large oral mucoperiosteal rotation
fl ap. In this manner, the nasal and oral suture lines are
staggered. In some hard palate fi stulas or large fi stulas,
dissection resembling palate repair with palatal muco-
periosteal fl ap elevation and separate nasal and oral
closure is necessary. Depending on the location, closure
of larger fi stulas is aided by fl aps from the buccal sulcus
or pharynx.
When a large fi stula is located within the anterior
two thirds of the hard palate, another excellent choice
for repair is an anteriorly based dorsal tongue fl ap.
First, turnover fl aps are developed to close the nasal
side of the palatal defect with multiple interrupted
sutures. Next, this technique calls for the development
of an anteriorly based tongue fl ap that is approximately
5 cm in length by one third to two thirds the width of
the tongue. The tongue fl ap is elevated along the
underlying musculature and then inset with multiple
mattress sutures for closure of the oral side. The recipi-
ent bed within the tongue is closed primarily. After the
initial surgery, the tongue fl ap is allowed to heal for
approximately 2 weeks. At that time the patient is
returned to the operating room. The fl ap is sectioned
and the stump at the donor site is freshened and inset
into the tongue. The use of laterally and posteriorly
based tongue fl aps has also been advocated. In our
opinion, an anteriorly based fl ap is better tolerated
by most patients and allows the greatest degree of
tongue mobility with less risk of tearing the fl ap from
its palatal insertion. Some surgeons use maxilloman-
dibular fi xation for 2 weeks while the fl ap becomes
vascularized.
MAXILLARY AND ALVEOLAR CLEFT
BONE GRAFTING
Approximately 75% of patients with clefts will have clefts
that involve the alveolus, maxilla, nasal fl oor, and piri-
form rim. The vast majority of surgeons advocate recon-
struction of this portion of the cleft during mixed
dentition before eruption of the permanent canine or
lateral incisor.1,2,34 This approach allows continuity of the
maxillary arch, support for the erupting teeth, recon-
struction of the congenital defect, support of the nasal
base, and closure of the residual cleft/fi stula. Frequently,
orthodontic maxillary expansion is required to match
the arch compatibility of the mandible before perform-
ing the grafting procedure. Such expansion is performed
by a skilled orthodontist over a period of several months
before surgery in a coordinated fashion.
The technique used by most surgeons involves
layered closure of the defect with a multiple-fl ap tech-
nique that mobilizes attached gingiva into the cleft
defect where the tooth/teeth will ideally erupt (Fig.
83-15). Both anterior vestibular and palatal fl aps are
necessary, because the defect courses from the piriform
rim to alveolus and back to the incisive foramen region.
Some patients may have a residual hard palatal fi stula
that can be repaired at the same time.
The iliac crest is the most common donor site for
bone graft reconstruction at the cleft site. Other sites
have also been recommended, but the best results con-
tinue to be achieved with cancellous bone procured
from the anterior iliac crest via a minimal 3- to 5-cm
incision posterior and lateral to the anterior iliac spine.
The cartilaginous cap of the iliac crest is directly incised
with a blade, and a small trapdoor is elevated medially.
Curettes are used to procure enough bone to fi ll the
defect. Although attempts have been made to use allo-
geneic bone products or synthetic material, outcomes
have been poor in comparison with autogenous iliac
crest.1,2,34
Watertight closure is desirable for the nasal side of
the closure, and resorbable sutures with tapered needles
are used throughout. This can be tested by using a bulb
syringe with irrigation in the naris. Defects are repaired
with horizontal mattress or interrupted suture tech-
niques. The bone graft taken from the iliac crest is then
placed in the site while remembering to fi ll the entire
defect up to the piriform rim rather than just at the
alveolus. The oral mucosa is then mobilized to close the
remaining oral cavity layer in a tension-free manner.

788
Section 9
Plastic and Reconstructive Surgery
Patients with bilateral clefts of the anterior palate
benefi t from placement of a postoperative acrylic splint
made before surgery for stabilization of the premaxil-
lary segment. The splint can be wired to orthodontic
mechanics or bonded with a dental bonding agent to
the teeth for several weeks during healing of the mucosal
tissue.
Patients are placed on a liquid diet for 2 weeks and
told to avoid using straws. Once the initial mucosal
healing is complete, the diet can be advanced slowly
over the next several weeks. The splint is removed when
the mucosal tissues are more completely healed. Patients
should brush their teeth, but not directly over the repair
sites. Gentle mouth rinses of saline or chlorhexidine
may be used to keep the dentition and oral cavity clean
as well.
CLEFT RHINOPLASTY
Congenital clefts that involve the lip, nose, and underly-
ing skeletal structure will cause a complex three-dimen-
sional deformity of the nasal complex that affects both
form and function. In the case of a complete unilateral
cleft, the typical nasal deformity is characterized by
splaying of the alar base, inferior displacement of the
alar rim, deviation of the nasal tip, and irregularity of
the caudal nasal septum.1,2,30 Abnormal fi brous inser-
tions exist between the lateral crus of the lower lateral
cartilage and the lateral piriform rim on the cleft side.
At the time of the initial lip repair procedure, maneu-
vers for primary nasal reconstruction include dissection
along the lower lateral cartilage to separate the overly-
ing skin from the cartilage and sharp release of the
fi brous insertions along the piriform rim so that the
nostril can be repositioned appropriately. Despite effec-
tive primary cleft lip and nasal repair during infancy,
most patients will demonstrate enough residual nasal
dysmorphology that secondary nasal surgery for correc-
tion of the cleft-associated malformation or improve-
ment in nasal airfl ow will be benefi cial later in life.
The timing of cleft nasal revision surgery also
remains controversial. Some surgeons take a more
aggressive approach and undertake extensive nasal
reconstruction during early childhood. Our philosophy
is to delay the defi nitive cleft rhinoplasty until the nasal
complex is close to mature size. When possible, early
nasal surgery should be performed after bone graft
reconstruction of the maxilla so that a stable bony foun-
dation along the piriform rim and nasal base exists
fi rst. If the patient’s reconstructive treatment plan also
requires maxillary advancement, nasal surgery should
be delayed until approximately 6 months after the
orthognathic procedure. This allows a more predict-
able outcome and long-lasting improvement in nasal
function and facial aesthetics. Early surgery is reserved
for individuals with severe airway or nasal airfl ow prob-
lems or children who endure psychosocial consequences
such as teasing at school.
Secondary cleft-nasal reconstruction will often
require dorsal reduction, lower lateral cartilage sculpt-
ing, cartilage grafting, and nasal osteotomies. Cartilage
grafting is a critical component of the fi nal nasal recon-
struction and is used for augmentation of the dysmor-
phic lower lateral cartilage and improvement of nasal
tip projection. Several different donor sites may be
used, including auricular cartilage, nasal septum, and
rib cartilage. Ear cartilage is most useful in situations
in which augmentation of hypoplastic cleft-side lower
lateral cartilage is required. Septal cartilage is most
easily accessible and provides an excellent scaffold for
repositioning of the lower lateral cartilage and improve-
ment of nasal tip symmetry and projection. Unfortu-
nately, patients may be scheduled for defi nitive nasal
reconstruction after having previously undergone septal
cartilage harvest and not have suffi cient quantity for a
second septal cartilage graft. In such cases, the use of
costochondral cartilage is another excellent option. Rib
cartilage provides adequate amounts of graft material
but requires a distant donor surgical site. We have
found this type of cartilage graft to provide excellent
strength for support of the nasal tip and alar complex.
These techniques are best carried out through an open
approach. A transcolumellar splitting incision is com-
bined with marginal incisions to provide wide access
and direct visualization of the nasal dorsum, upper and
lower lateral cartilage, and nasal septum.
A similar rationale is applied when considering the
timing of secondary nasal reconstruction in a patient
with a bilateral cleft lip, but the specifi c dysmorphology
addressed is somewhat different. Generally, nasal asym-
metry is less problematic, and the dysmorphology is
characterized by defi cient columellar length. Many sur-
geons have focused on secondary lengthening of the
columella through the use of banked forked fl aps or
columellar lengthening with soft tissue fl aps from the
fl oor of the nose and alar fl aps. Unfortunately, these
types of surgical procedures often result in a distorted
columellar-labial angle, excessive scars that extend onto
the nasal tip, and additional distortion of the broad
nasal tip. We fi nd that using septal cartilage strut grafts
attached to the caudal nasal septum and lower lateral
cartilage yields the most natural-looking results. The
objective is correction of the underlying cartilaginous
anatomy with stretching of the overlying soft tissue
envelope instead of direct surgical manipulation of the
columellar skin.
CLEFT ORTHOGNATHIC SURGERY
The technical details and integrated orthodontic-surgi-
cal treatment planning for orthognathic correction are
beyond the scope of this chapter, but the treatment
concepts warrant comment inasmuch as more than
35% of patients who undergo cleft repairs will benefi t
from orthognathic surgery to treat malocclusion.35,36
Most commonly, midface hypoplasia results in an
underbite that causes functional and aesthetic prob-
lems. Additionally, facial asymmetry is common in
patients who have previously undergone cleft repairs in
infancy. These procedures are performed at the end of
growth in the craniomaxillofacial skeleton, usually 14
to 16 years of age in girls and 16 to 18 years in boys. In

Chapter 83
Cleft Lip and Palate: Comprehensive Treatment and Technique
789
be free of bias and should include team care that is
patient, family, and community oriented. Only in this
fashion can the overall treatment be optimally success-
ful. This type of care maximizes patients’ ability to grow
into adulthood and succeed in life without focusing on
their deformity.
Bone grafts
Figure 83-16. A Le Fort I osteotomy, bilateral sagittal splits, and
genioplasty osteotomies are shown for a patient with maxillary hypo-
plasia associated with early surgery required for a unilateral cleft lip
and palate. Onlay bone grafts may be helpful for improving facial
contour. (From Ruiz RL, Costello BJ, Turvey T: Orthognathic surgery in the
cleft patient. In Oral and Maxillofacial Surgery Clinics of North America:
Secondary Cleft Surgery. Philadelphia, WB Saunders, 2002, pp 491-507.)
PITFALLS
• Patients with syndromes, dysmorphology, and wide
palates are more prone to fi stulas.
• A common pitfall is to incompletely reconstruct the
musculature of the lip or palate.
• Another common pitfall occurs when the surgeon
leaves considerable dead space within the layers of
the repair. Placement of at least several sutures
through each of the layers is important in preventing
dead space.
• Careful wound care is necessary because some
bolsters used to help mold the nose may cause
pressure necrosis of the columella or nasal base if
placed too tightly or kept in place for too long.
• A common pitfall occurs when the surgeon fails to
mobilize enough muscle to create an active levator
sling that is posteriorly displaced.
• Failure to preserve the vascular pedicle may result in
necrosis of the tissues.
rare instances, midface advancement may be indicated
earlier. Coordinated care with a skilled orthodontist is
very important to achieve the optimal result and con-
sists of planning and several phases of orthodontic
therapy both before and after orthognathic surgery.
Usually, a Le Fort I osteotomy is indicated for
patients with maxillary hypoplasia and malocclusion. In
many cases, bilateral sagittal split osteotomies and geni-
oplasty are helpful in treating the malocclusion and
improving facial balance (Fig. 83-16). Traditional
orthognathic surgery is dependent on precise place-
ment of fi xation to ensure the optimal occlusion and
facial balance to avoid relapse. Recently, distraction
osteogenesis has been used in patients who require
exceptionally large advancement of the midface.37
Although the technique shows little or no improvement
over traditional osteotomy techniques in most patients,
it may be helpful in some patients who require larger
advancement.
CONCLUSIONS
Comprehensive care of patients with clefts requires an
interdisciplinary approach that demands precise surgi-
cal execution of the various procedures necessary to
correct cleft deformities, as well as frequent long-term
follow-up. Clinicians experienced in the comprehensive
interdisciplinary care of patients with clefts are best
equipped to deal with these concerns. Treatment of
patients with cleft and craniofacial deformities should
PEARLS
• Marking the key landmarks is important to obtain
the best result, and the temptation to keep
hypoplastic tissue should be discouraged.
• Nasoalveolar molding appliances may be helpful in
reapproximating the segments to allow easier
surgical repair, and they may improve the aesthetic
result of the lip and nose.
• A three-layered closure is the key to both functional
and aesthetic repair of the lip.
• Some nasal asymmetry is expected in wide unilateral
clefts, but this can be minimized by conservative
primary nasal reconstruction.
• Nasal bolsters or silicone nasal stents can be used
to help mold the nose in the postoperative period.
• Arm restraints may be used for the fi rst 2 weeks to
help avoid injury to the lip repair, but they should
be removed occasionally to allow range of motion
of the arms.
• Palate repair requires adequate mobilization of
tissues to allow the most tension-free closure
possible.
• Releasing the nasal and palatal periosteum, as well
as the tensor veli palatine muscle or Veau’s muscle,
is helpful in gaining additional mobilization.

790
Section 9
Plastic and Reconstructive Surgery
References
1. Posnick JC: The staging of cleft lip and palate reconstruction:
Infancy through adolescence. In Posnick JC (ed): Craniofacial
and Maxillofacial Surgery in Children and Young Adults.
Philadelphia, WB Saunders, 2000, pp 785-826.
2. Costello BJ, Ruiz RL: Cleft lip and palate: Comprehensive treat-
ment and primary repair. In Milaro M, Larsen PE, Waite PD,
Ghali G (eds): Peterson’s Oral and Maxillofacial Surgery. Hamil-
ton, Ontario, BC Decker, 2004, pp 839-858.
3. Tolarova MM, Cervenka J: Classifi cation and birth prevalence of
orofacial clefts. Am J Med Genet 75:126-137, 1998.
4. Cohen MM: Etiology and pathogenesis of orofacial clefting. Cleft
lip and palate: A physiological approach. Oral Maxillofac Clin
North Am 12:379-397, 2000.
5. Tessier P: Anatomical classifi cation of facial, cranio-facial, and
latero-facial clefts. J Maxillofac Surg 4:69-92, 1976.
6. Parameters for the evaluation and treatment of patients with
cleft lip/palate or other craniofacial anomalies. American Cleft
Palate–Craniofacial Association. March, 1993 Cleft Palate Cranio-
fac J 30(Suppl):S1-S16, 1993.
7. Cash C, Set P, Coleman N: The accuracy of antenatal ultrasound
in the detection of facial clefts in a low-risk screening population.
Ultrasound Obstet Gynecol 18:432-436, 2001.
8. Pretorius DH, House M, Nelson TR, Hollenbach KA: Evaluation
of normal and abnormal lips in fetuses: Comparison between
three- and two-dimensional sonography. AJR Am J Roentgenol
165:1233-1237, 1995.
9. Dorf DS, Curtin JW: Early cleft palate repair and speech outcome.
Plast Reconstr Surg 70:74-81, 1982.
10. Dorf DS, Curtin JW: Early cleft palate repair and speech outcome:
A ten year experience. In Bardach J, Morris HL (eds): Multidis-
ciplinary Management of Cleft Lip and Palate. Philadelphia, WB
Saunders, 1990, pp 341-348.
11. Copeland M: The effect of very early palatal repair on speech. Br
J Plast Surg 43:676-682, 1990.
12. Grayson BH, Cutting CB, Wood R: Preoperative columella length-
ening in bilateral cleft lip and palate. Plast Reconstr Surg 92:1422-
1423, 1993.
13. Grayson BH, Santiago PE, Brecht LE, et al: Presurgical nasoalveo-
lar molding in infants with cleft lip and palate. Cleft Palate Cra-
niofac J 36:486-498, 1999.
14. Ross RB, MacNamera MC: Effect of presurgical infant orthope-
dics on facial esthetics in complete bilateral cleft lip and palate.
Cleft Palate Craniofac J 31:410-411, 1994.
15. Grayson BH, Cutting CB, Wood R: Preoperative columella length-
ening in bilateral cleft lip and palate. Plast Reconstr Surg 92:1422-
1423, 1993.
16. Grayson BH, Santiago PE, Brecht LE, et al: Presurgical nasoalveo-
lar molding in infants with cleft lip and palate. Cleft Palate Cra-
niofac J 36:486-498, 1999.
17. Berkowitz S: The comparison of treatment results in complete
cleft lip/palate using conservative approach vs. Millard-Latham
PSOT procedure. Semin Orthod 1996;2:169-184.
18. Randall P, Graham WP: Lip adhesion in the repair of bilateral
cleft lip. In Grabb WC, Rosenstein SW, Bzoch KR (eds): Cleft Lip
and Palate. Boston, Little, Brown, 1971.
19. Pruzansky S: Pre-surgical orthopedics and bone grafting for
infants with cleft lip and palate: A dissent. Cleft Palate J 1:164-187,
1964.
20. Millard DR: Cleft Craft, vol 1. Boston, Little, Brown, 1976, pp
165-173.
21. Millard DR: A primary camoufl age of the unilateral harelip. In
Transactions of the International Congress of Plastic Surgeons.
Baltimore, Williams & Wilkins, 1957, pp 160-166.
22. McComb H: Primary correction of unilateral cleft lip nasal
deformity: A 10 year review. Plast Reconstr Surg 75:791-799,
1985.
23. Shaw WC, Asher-McDade C, Brattstrom V, et al: A six-center
international study of treatment outcome in patients with clefts
of the lip and palate. Part 5. General discussion and conclusions.
Cleft Palate Craniofac J 29:413-418, 1992.
24. Bardach J, Nosal P: Geometry of the two-fl ap palatoplasty. In
Bardach J, Salyer K (eds): Surgical Techniques in Cleft Lip and
Palate, 2nd ed. St Louis, Mosby–Year Book, 1991.
25. Furlow LT Jr: Cleft palate repair by double opposing Z-plasty.
Plast Reconstr Surg 78:724-738, 1986.
26. Randall P, LaRossa D, Solomon M, Cohen M: Experience with
the Furlow double-reversing Z-plasty for cleft palate repair. Plast
Reconstr Surg 77:569-576, 1986.
27. Doyle WJ, Cantekin EI, Bluestone CD: Eustachian tube function
in cleft palate children. Ann Otol Rhinol Laryngol 89(Suppl
68):34-40, 1980.
28. Sheahan P, Miller I, Sheahan JN, et al: Incidence and outcome
of middle ear disease in cleft lip and/or cleft palate. Int J Pediatr
Otorhinolaryngol 67:785-793, 2003.
29. Costello BJ, Ruiz RL, Turvey T: Surgical management of velopha-
ryngeal insuffi ciency in the cleft patient. In Oral and Maxillofa-
cial Surgery Clinics of North America: Secondary Cleft Surgery.
Philadelphia, WB Saunders, 2002, pp 539-51.
30. Ruiz RL, Costello BJ: Secondary cleft surgery. In Milaro M, Larsen
PE, Waite PD, Ghali G (eds): Peterson’s Oral and Maxillofa -
cial Surgery. Hamilton, Ontario, BC Decker, 2004, pp 871-
886.
31. Reid DAC: Fistulae in the hard palate following cleft palate
surgery. Br J Plast Surg 78:739-747, 1986.
32. Abyholm FE, Borchgrevink HH, Eskeland G: Palatal fi stulae fol-
lowing cleft palate surgery. Scand J Plast Reconstr Surg 13:295-
300, 1979.
33. Cohen SR, Kalinowski J, La Rossa D, et al: Cleft palate fi stulas: A
multivariate statistical analysis of prevalence, etiology, and surgi-
cal management. Plast Reconstr Surg 87:1041-1047, 1991.
34. Boyne PJ, Sands NR: Secondary bone grafting of residual alveolar
and palatal clefts. J Oral Surg 30:87-92, 1972.
35. Posnick JC, Tompson B: Cleft-orthognathic surgery. Complica-
tions and long-term results. Plast Reconstr Surg 96:255-266,
1995.
36. Ruiz RL, Costello BJ, Turvey T: Orthognathic surgery in the cleft
patient. In Oral and Maxillofacial Surgery Clinics of North
America: Secondary Cleft Surgery. Philadelphia, WB Saunders,
2002, pp 491-507.
37. Costello BJ, Ruiz RL: The role of distraction osteogenesis in
orthognathic surgery of the cleft patient. Selected Readings Oral
Maxillofac Surg 10:1-27, 2002.

Chapter 84
Otoplasty
Grant S. Gillman
Auricular characteristics are inherited as an autosomal
dominant trait with variable penetrance. Many of those
who are born with an auricular deformity are subject to
teasing and ridicule in childhood and become very self-
conscious of the appearance of their ears in adoles-
cence and adulthood. Surgical correction of prominent
or protuberant ears (Fig. 84-1) may yield very grati -
fying results with relatively simple surgery. Nonetheless,
correct analysis of the deformity preoperatively and a
well-designed and well-executed surgical plan are fun-
damental requirements for optimal patient satisfaction
and stable long-term results. With a good result, patients
will derive both psychological and cosmetic benefi t.
The purpose of corrective surgery is to re-establish
what are considered “normal contour lines” (Fig. 84-2)
of the external ear, as well as the relationship of the
external ear to the scalp.
PATIENT SELECTION
Patients will generally be in one of three categories:
• Absence of the antihelical fold (thereby unfurling the
upper half of the ear and increasing the auriculomas-
toid angle)
• A deep overly projected conchal bowl (increasing
lateral projection of the ear and the conchomastoid
angle)
• Both of the above (Fig. 84-3)
Any of these patients are considered appropriate for
otoplasty. As with all cosmetic procedures, the patient
must be psychologically stable, be well motivated, and
have realistic expectations about the surgical outcome.
It is important that the patient recognize that although
the goal is perfection, “improvement” with a natural
appearance and without complications is an acceptable
result.
The timing of the procedure is guided by the
patient’s own awareness of the deformity. By 5 years of
age, the auricle has achieved about 80% to 85% of adult
size, so it is preferable to wait until at least this age
before considering surgery. If the deformity is excep-
tionally emotionally disturbing to the child, the proce-
dure may be performed just before the child begins
school. There is no end point beyond which the surgery
could not be performed; however, as the ear cartilage
ages, it loses its fl exibility, thereby restricting the
response to surgical manipulation.
PREOPERATIVE PLANNING
Preoperative planning begins with an evaluation of the
deformity.1 First, one has to decide whether the problem
is due to absence of the antihelical fold, a deep conchal
bowl, or both. Simple observation will reveal whether
there is a weak or absent antihelical fold. In such cases,
gentle fi nger pressure on the helical rim to create an
antihelical fold and set the ear back should indicate
whether this corrects the problem suffi ciently or
whether there is still some protrusion contributed by
the depth of the conchal bowl. It is also important to
note right-left symmetry preoperatively. Frequently, the
two sides are asymmetric, and it is useful to point this
out to the patient and the patient’s family.
The surgical goals1-3 are
• A natural looking, pleasing appearance of the auricu-
lar correction
• Creation of an antihelical fold with smooth edges and
contour and without sharp edges, ridges, or unsightly
scarring
• Reasonable symmetry between the two ears
• An enduring, stable long-term result
• Minimal or no complications, with preservation of a
postauricular sulcus
791

792
Section 9
Plastic and Reconstructive Surgery
The position and site of the planned antihelical
fold is determined by gently furling the ear with fi ngers
on the helical rim until a pleasing natural antihelical
fold is apparent. Markings are made symmetrically on
either side of the fold to guide the site of later place-
ment of horizontal mattress sutures.
To gauge the amount of postauricular skin to be
removed, the ear is manually set back against the scalp
and the amount of redundant skin determined. An
ellipse is then marked on the posterior auricle to outline
the skin excision. The width of the ellipse is thus indi-
vidualized but generally measures 15 mm (±5 mm) at
its maximal width. Conservatism is warranted because
more skin can be excised incrementally at any time if
need be. The ellipse incorporates the postauricular
sulcus but is not centered on the sulcus—it is biased
toward the posterior auricular surface so that more skin
is removed from the ear than from the scalp. In addi-
tion, within about 5 to 7 mm of the lobular attachment
inferiorly or the helical root superiorly, the ellipse
curves onto the auricle so the scars will not extend
beyond the sulcus and risk being visible on a lateral
view.
The face, both ears, and the surrounding occipital
areas are prepared with an antiseptic solution and
draped into the sterile fi eld. The postauricular skin is
injected with 1% lidocaine with 1 : 100,000 epineph-
rine. A broad-spectrum antibiotic is administered intra-
venously before commencing surgery. If the ears are
asymmetric, the ear with the more signifi cant deformity
is usually done fi rst.
Figure 84-1. Typical patient with protuberant ears.
Helix
Superior crus
of antihelix
Inferior crus
of antihelix
Scapha
Antihelix
Anti-tragus
Lobule
External
auditory meatus
Tragus
Cavum
concha
Cymba
concha
Fossa
triangularis
Figure 84-2. Normal auricular anatomy.
Preoperative photodocumentation is mandatory
and should include an anterior full face view, a poste-
rior full head view, full right and left lateral views, and
close-up lateral views.
Reasonable surgical outcomes, as well as possible
complications, are discussed preoperatively (see later).
Ultimately, ears that do not attract attention to them-
selves will be the measure of success to the patient.
SURGICAL TECHNIQUES3-5
Otoplasty for protuberant ears in children is usually
performed under general anesthesia. In older children
and adults, local anesthesia with or without intravenous
sedation can be used.

Chapter 84
Otoplasty
793
The ear is retracted forward and the ellipse of post-
auricular skin is excised with a no. 15 blade as outlined
(Fig. 84-4). A strip of premastoid soft tissue is excised
with electrocautery to ultimately help create space for
the auricular setback. With wide two-pronged hooks or
Senn retractors placed in the lateral aspect of the inci-
sion, the remaining postauricular skin is undermined
out to the helical rim in a supraperichondrial plane.
At this point, aligning the wound incision margins
(folding the ear back) demonstrates the extent to which
the conchal bowl cartilage is interfering with the auricu-
lar setback. This maneuver also demonstrates how the
conchal cartilage pivots forward at the posterior margin
of the external auditory meatus as the ear is set back.
To prevent iatrogenic meatal stenosis, a vertically ori-
ented ellipse of conchal bowl cartilage is excised medi-
ally just behind the ear canal. The ellipse is about 1 to
1.5 cm in height and approximately 1 cm in maximal
width. Incremental excision allows additional removal
if need be. There is often some contact between the
posterior aspect of the conchal cartilage and the pre-
mastoid region as well that can impede satisfactory
setback of the ear. In this case one tangentially shaves
partial-thickness discs of cartilage from the posterior
aspect of the conchal cartilage behind the external
auditory canal to further facilitate retrodisplacement of
the ear. In addition to preventing inadvertent canal
stenosis, this addresses the overly deep protruding
conchal bowl as well.
Creation of an antihelical fold is the next step.
Markings on either side of the future antihelical fold
were made earlier. A no. 15 blade can be used to score
the cartilage posteriorly along the line of the fold so
that the “spring” of the cartilage is weakened. Incisional
approaches to creating an antihelical fold will tend
to create a sharp, unnatural-looking antihelical fold.
Scoring the cartilage to weaken the spring works better
together with the Mustardé sutures.
To ease placement of the cartilage-contouring hori-
zontal (Mustardé) sutures posteriorly, it is useful to ini-
tially place two temporary percutaneous contouring
sutures6 from the anterior (lateral) aspect of the auricle
to create and maintain an antihelical fold while the
Mustardé sutures are placed posteriorly. This allows the
surgeon to move the ear forward and back while placing
the Mustardé sutures without concern that these sutures
may loosen or become released. The anterior tempo-
rary contouring sutures (4-0 Prolene or silk on Keith
needles) are placed in horizontal mattress fashion
around the proposed antihelical fold, with both needles
passed from the side of the conchal bowl, through into
the wound posteriorly, and then back through the
auricular skin anteriorly close to the helical rim (Fig.
84-5). Two such temporary sutures are placed and then
tightened until a pleasing antihelical fold is created.
Attention is then turned posteriorly to placement
of the Mustardé sutures.7 Two to four 4-0 Mersilene (or
similar) sutures are placed through the full thickness of
the auricular cartilage in horizontal mattress fashion (as
described by Mustardé) (Fig. 84-6) around the neofold
and tightened as the anterior temporary sutures hold
the position of the fold. Care is taken to ensure that as
the Mustardé sutures are placed they do not penetrate
the skin anteriorly (Fig. 84-7) and that they are not
overtightened, which would create a fold with an unnat-
ural sharp edge. Slight overcorrection will help account
Absent antihelical
fold
Deep conchal
bowl
Figure 84-3. Auricular deformity commonly seen in an otoplasty
patient: an ill-defi ned antihelical fold and a deep conchal bowl.
Figure 84-4. Excision of a skin ellipse, as well as partial-thickness
“discs” of conchal cartilage to facilitate retrodisplacement of the
auricle.

794
Section 9
Plastic and Reconstructive Surgery
A
B
Temporary
contouring
suture site
Temporary
contouring suture,
untightened
Mustardé
suture site
conchal bowl cartilage to the premastoid fascia or peri-
osteum. One or two such sutures may be required. If
this suture is placed too far back on the cartilage or too
far forward on the mastoid, anterior rotation of the
conchal cartilage may be exaggerated and result in
some stenosis or compromise of the external auditory
canal. Care is thus taken to ensure that the suture passes
Figure
84-5. Placement
of
temporary “contouring sutures” to
temporarily secure the formation
of the proposed antihelical fold.
Figure 84-6. Mustardé horizontal mattress sutures as seen from
behind the ear.
Figure 84-7. Mustardé sutures—coronal view. The suture is placed
through the full thickness of the cartilage without penetrating the
anterior skin.
for some reprotrusion that often occurs with time. Once
the Mustardé sutures are secured, the temporary con-
touring sutures can be removed.
At this point the position of the ear is further
secured with setback sutures. Conchomastoid 4-0 Mer-
silene suture is placed from the posterior aspect of the

Chapter 84
Otoplasty
795
on the cartilage and the mastoid fascia are either at the
same anterior/posterior point or that the pass on the
mastoid side is slightly behind the point of purchase on
the cartilage.
If some protrusion of the superior pole of the ear
still remains, a similar type of setback suture may be
placed at a point on the cartilage superiorly in the
region of the triangular fossa back to the premastoid
soft tissue.
Once one is satisfi ed with the position of the ear,
the skin is closed with 5-0 plain or fast-absorbing gut
suture.
Finally, Xeroform gauze or cotton soaked in mineral
oil is contoured to the lateral surface of the ear and
placed in the postauricular sulcus as well. Fluffs are
then applied and a lightly compressive mastoid-type
dressing is secured. The dressing should not be so tight
that epidermolysis of the skin ensues.
POSTOPERATIVE MANAGEMENT
The dressing is removed on the fi fth to seventh postop-
erative day. Thereafter, the patient is asked to wear a
supportive headband at night for 2 to 3 weeks. Incisions
can be cleaned with a cotton swab soaked in fresh
hydrogen peroxide, and antibiotic ointment can be
gently applied to the postauricular incision. Pain medi-
cation is usually required only for the fi rst several days.
When instructing the parents or the patient, one must
advise them of the signs of possible complications at the
surgical site, which would probably be manifested as
increasing pain, discomfort, or erythema. Patients who
experience such signs should contact the surgeon as
soon as possible.
A typical patient, preoperatively and postopera-
tively, is presented in Figures 84-8 and 84-9.
COMPLICATIONS3
Early
Hematoma is signaled by an inordinate amount of pain,
especially unilateral. Treatment includes exploration of
the wound, hemostatic control, irrigation with an anti-
biotic solution, and closure. Untreated hematoma risks
secondary cartilage necrosis and a deformed ear.
Infection usually takes 3 to 4 days to become evident.
Unilateral severe pain disproportionate to the physical
fi ndings should raise suspicion. If cellulitis is present,
treatment with systemic broad-spectrum antibiotics
(covering gram-positive cocci and Pseudomonas) is war-
ranted in an effort to prevent progression to perichon-
dritis or chondritis, which can result in cartilage loss
and an auricular deformity. Treatment of the latter,
which fortunately is rare, requires surgical drainage and
débridement.
Constriction/stenosis of the external auditory canal
results from failure to excise the anterior portion of the
conchal cartilage or from over-rotation of the conchal
bowl with the setback sutures. Treatment requires exci-
sion of that portion of the cartilage.
A
B
Figure 84-8. Preoperative (A) and postoperative (B) photos of a
patient with a unilateral protuberant ear.
A
B
Figure 84-9. Preoperative (A) and postoperative (B) photos of a
patient with bilateral protuberant ears.

796
Section 9
Plastic and Reconstructive Surgery
Loss of the postauricular sulcus can result from
over-resection of skin. Proper preoperative planning
and incremental skin excision intraoperatively when
needed will avoid this problem.
An overly compressive dressing can lead to epider-
molysis/pressure necrosis of the auricular skin. Treat-
ment involves conservative wound care.
Late
Cosmetically unacceptable results include overcorrec-
tion, undercorrection, asymmetries, sharp unnatural
contours or ridges, and gross asymmetry. All these com-
plications are largely avoidable with proper preopera-
tive planning and intraoperative attention to detail.
Cartilage-cutting techniques (as opposed to the carti-
lage-contouring technique described herein) have a
higher overall rate of cosmetic irregularities.
Minor asymmetry is not uncommon and should be
discussed with the patient preoperatively as realistically
being possible and not indicative of an unacceptable
result. Gross asymmetry, on the other hand, is not
acceptable. Undercorrection of the middle third of the
ear as a result of untreated conchal protrusion creates
a convex appearance on frontal view and requires cor-
rection with excision of the anterior portion of the
conchal bowl and setback sutures. Undercorrection of
the superior or inferior pole of the ear will result in a
concave appearance on frontal view (the “telephone
deformity”) and may require secondary revision.
Some degree of reprotrusion or suture release at
the superior pole is not uncommon. Braided sutures
such as Mersilene for the Mustardé mattress sutures are
less likely to release than a monofi lament suture mate-
rial. Patients should be forewarned of this possibility. If
minor, the patient is still frequently suffi ciently pleased
with the overall result that no treatment is necessary.
If signifi cant deformity develops, revision may be
necessary.
Hypertrophic scarring/keloids can occur, but well-
planned incisions and tension-free closure may help
prevent this complication from developing. If hypertro-
phic scarring or keloids are noted early, intralesional
triamcinolone (Kenalog) injections every 3 to 4 weeks
may control the problem. Otherwise, excision and serial
steroid injections may be required.
• It is important to establish proper expectations
preoperatively, particularly with respect to the
potential for minor persisting asymmetry
postoperatively. Document and photodocument.
• The amount of skin excised should facilitate the
auricular setback but not obliterate the
postauricular sulcus.
• Mustardé sutures should be tightened to create a
smooth, natural-appearing antihelical fold.
• Setback sutures (conchomastoid and scaphoid) can
further assist in retrodisplacing the ear without
having to excise more skin or cartilage.
PITFALLS
• Failure to plan appropriately or establishing
inappropriate expectations is the precursor of most
complications.
• Overexcision of postauricular skin can lead to
overcorrection (and obliteration of the postauricular
sulcus), which can be more diffi cult to address than
undercorrection.
• Overtightening of the Mustardé sutures can create a
ridge-like appearance that is unnatural and
displeasing to the patient.
• Incomplete hemostasis at the time of closure can
predispose to hematoma, infection, and subsequent
cartilage necrosis.
• Unilateral severe or disproportionate pain may be
indicative of skin necrosis, hematoma, or infection
and requires prompt visual examination of the
patient.
References
1. Becker DG, Lai SS, Wise JB, Steiger JD: Analysis in otoplasty. Facial
Plast Surg Clin N Am 14:63-71, 2006.
2. Nuara MJ, Mobley SR: Nuances of otoplasty: A comprehensive
review of the past 20 years. Facial Plast Surg Clin N Am 14:89-102,
2006.
3. Adamson PA, Litner JA: Otoplasty technique. Facial Plast Surg Clin
N Am 14:79-87, 2006.
4. Ducic Y, Hilger PA: Effective step-by-step technique for the surgical
treatment of protruding ears. J Otolaryngol 28(2):59-64, 1999.
5. Cheney ML, Rounds M: Otoplasty. Facial Plast Surg Clin N Am
5:319-328, 1997.
6. Hilger P, Khosh MM, Nishioka G, Larrabee WF: Modifi cation of
the Mustardé otoplasty technique using temporary contouring
sutures. Plast Reconstr Surg 100:1585-1586, 1997.
7. Mustardé JC: Correction of prominent ears using simple mattress
sutures. Br J Plast Surg 16:170-178, 1963.
PEARLS
• Preoperative evaluation of the patient should
establish the cause of the deformity (absence of an
antihelical fold, a deep conchal bowl, or both),
which guides the operative plan.

Chapter 85
Reconstruction of Microtia
Robert F. Yellon
Auricular reconstruction for microtia is challenging, yet
rewarding. Many lessons about the limitations of surgery
may be learned as a surgeon acquires the skills and
judgment required for successful auricular reconstruc-
tion. For example, the competing goals of a well-
projected, detailed auricular graft and a thin, intact,
vascularized skin fl ap to show that detail must be accom-
modated through compromise. The limitations of
blood supply and tension on the skin fl ap must not be
exceeded to avoid the complications of fl ap loss and
infection, which may necessitate the creation of an
auricle with a thicker skin fl ap than would be ideal for
aesthetic purposes. Meticulous attention to detail and
atraumatic tissue handling are critical for achieving
excellent results, with the caveat that an auricle con-
structed by a surgeon may fail to rival that of normal
embryonic development.
Most cases of microtia are unilateral, with an 8 : 1
ratio of unilateral to bilateral cases. The majority of
patients are male. Microtia usually, but not always,
occurs in conjunction with aural atresia. In general,
reconstruction of the microtia is completed before
reconstruction of the aural atresia.
PATIENT SELECTION
The best chance for successful auricular cartilage graft-
ing is when the blood supply to the recipient site has
not been impaired by previous surgery and scarring.
Although some surgeons have advocated starting mi -
crotia reconstruction as early as 2 years of age, most
surgeons prefer to wait until the child is older. Recon-
struction may be started as early as 4 years of age
in a large boy with bilateral microtia. In contrast, for a
petite child with unilateral microtia, one may wait to
begin reconstruction at 7 years of age. The longer the
surgeons waits to begin, the more rib cartilage is avail-
able and the more cooperative children are because
they understand the surgical process. However, the
longer the surgeon waits to begin reconstruction, the
more psychological trauma may occur because of ridi-
cule from the other children and the longer the child
has to wait for possible reconstruction of aural atresia
with the associated limitations of maximal conductive
hearing loss. Nonetheless, the recent availability of the
bone-anchored hearing aid gives the surgeon a new
option for improving hearing at an age as early as 3
years with minimal impairment of the potential for
auricular cartilage grafting.1
Most patients with microtia are candidates for
reconstruction. Exceptions are those with previous
extensive surgery in the area of the auricle, burns,
tumors, or radiation in the area. Relative contraindica-
tions to reconstruction include highly uncooperative
children and those with very severe hemifacial microso-
mia. In the setting of severe hemifacial microsomia,
formal angiography may be required to ensure that the
blood supply from the superfi cial temporal and occipi-
tal arteries is adequate. No major surgery should be
performed if the blood supply is inadequate because of
congenital absence of the vessels. A small, minimally
projecting graft may be placed in the case of severe
hemifacial microsomia with slightly diminished blood
supply if one takes into consideration the limited capac-
ity of the recipient area to support a large graft.
PREOPERATIVE EVALUATION
At the initial consultation for an infant with microtia,
the focus should be on hearing function. Audiologic
testing of the normal ear should be undertaken with
determination of sound-fi eld response and otoacoustic
797

798
Section 9
Plastic and Reconstructive Surgery
emissions. If testing is inconclusive and for bilateral
cases, auditory brain stem response testing may be
required. Bone-anchored hearing aids are available and
worn as an external headband device for infants and
children who are too young for defi nitive reconstructive
surgery. Computed tomography of the temporal bones
is performed late in the fi rst year of life to determine
whether the child has adequate anatomy for con-
sideration of aural atresia reconstruction in the future.
Computed tomography is also important to detect the
occasional case of congenital cholesteatoma that
requires surgical removal at an early age. The child
is evaluated at 6- to 12-month intervals until it is de -
termined that that child is ready for defi nitive
reconstruction.
The parents must be made aware that the recon-
structed auricle will be a great improvement over the
microtic vestige but it will not be completely normal.
Realistic expectations are important. Photographs
depicting the various stages of surgery are valuable for
educating families. The timing of reconstructive surgery
is discussed, with most children beginning between
the ages of 4 and 7 years, as discussed earlier. The surgi-
cal process of staged procedures is explained, with
most children requiring four stages of reconstruc -
tion as described later. Two to 3 months is allowed for
healing between stages. Thus, the overall process may
be completed in about 1 year. Additional surgery for
scar revision or refi nement of cosmetic results may be
necessary. The possibility of bleeding, infection, pneu-
mothorax, fl ap loss, cartilage graft loss, scarring, and
poor cosmetic results must be discussed with the
parents.
The parents and child should be informed that
after each stage of reconstruction a mastoid dressing
will be worn for approximately 2 weeks. Tape will be
used to fi x the dressing to the child’s hair to make it
less likely that an uncooperative child will pull the dress-
ing off, which can lead to complications. The family
needs to know that the child will not like the frequent
dressing changes with pulling of the hair during tape
removal, but it will be worth the struggle in the long
run. A very short haircut is recommended.
A template of the normal ear (if present) is made
from x-ray fi lm and will be used to determine the dimen-
sions of the reconstructed auricle. The optimal position
of the reconstructed auricle is determined by the dis-
tance from the lateral canthus, the brow, and the posi-
tion of the normal ear. The axis of a normal auricle is
about 30 degrees from the vertical position, with the
superior aspect of the auricle being in a more posterior
position. With hemifacial microsomia, considerable
judgment is required to select the best position for the
new auricle because the two sides of the head and face
are not symmetrical.
SURGICAL APPROACHES
Most surgeons prefer grafting of costal cartilage for
auricular reconstruction and use the method of Brent
as described later.2 Alternatives include prefabricated
implants instead of cartilage and osseointegrated
implants for a clip-on prosthetic auricle.
Stage 1
Sculpting an auricle out of costal cartilage takes skill
and practice. Preoperative practice carving a block of
soap or soft wood is recommended. Prophylactic peri-
operative antimicrobials are administered before all
stages of microtia reconstruction. Figure 85-1 shows
grade 2 microtia with a well-formed lower auricle and
defi ciency of the upper two thirds of the auricle. For
harvest of costal cartilage, a curvilinear incision is made
along the lower medial border of the contralateral rib
cage because it has a more favorable curve for recon-
struction of the auricle. The upper portion of the rectus
abdominis muscle is dissected, preserved, and retracted
laterally to allow exposure of the intercostal muscles
and ribs. Preservation of the rectus abdominis muscle,
rather than transecting it, decreases the chance of
future chest wall deformity caused by a depression at
the rib harvest site.3 The two lowest fl oating ribs are
harvested along with the synchondrosis of the sixth and
seventh ribs (Fig. 85-2). With the fl oating ribs, cartilage
is harvested all the way laterally until the bony-cartilagi-
nous junction is reached. A suction drain is placed
through a separate incision.
Young children have a relative defi ciency of carti-
lage, and therefore pieces of cartilage are often stacked
up to provide adequate bulk and lateral projection for
details of the reconstructed auricle. In the occasional
teen or adult with a generous amount of rib cartilage,
the cartilage may be carved as a solid block, with ade-
quate thickness and projection and little or no stacking
required. This is called a closed or solid framework. In
younger children, the various pieces of cartilage are
Figure 85-1. Grade 2 microtia with defi ciency of the upper two
thirds of the auricle. The planned site of placement of an auricular
graft is marked.

Chapter 85
Reconstruction of Microtia
799
carved and stacked with open spaces between the por-
tions. This is called an open framework. The perichon-
drium is harvested along with the ribs, with great care
taken to not enter the pleural space. The portion of rib
cartilage containing the synchondrosis is used as the
body or central portion of the framework. The helix is
created by attaching a long fl oating rib segment around
the perimeter of the body. This fl oating rib may be
trimmed to achieve the proper projection and contour.
The perichondrium and cartilage around the outer rim
of the helix can be scored with partial-thickness inci-
sions to “break the spring” so that the helical cartilage
can wrap around the body with less tension. The various
pieces of cartilage are attached via 4-0 clear nylon mat-
tress sutures with the knots tied on the deep side of the
graft, or superfi cially placed knots may later extrude
through the skin fl ap. Additional pieces of cartilage
may be stacked for creation of the antihelix and crura
(Fig. 85-3). Occasionally, if adequate cartilage is avail-
able, the tragus may be attached to the main auricular
cartilage graft with sutures during the fi rst stage of
reconstruction. The overall cartilage graft for the auricle
is fashioned to be 2 to 3 mm smaller than the template
from the opposite auricle. The additional 2 to 3 mm
will be provided by the overlying skin fl ap.
To create the recipient bed for the cartilage graft,
an incision is made anterior to the microtic vestige, and
a thin fl ap is created just deep to the subdermal plexus.
The fl ap is elevated for approximately 2 to 3 cm past
the position marked for the auricle to allow a loose
pocket without tension. This decreases the chance of
fl ap loss and improves the details seen in the graft as
the loose skin of the fl ap drapes into the depressions
between the prominent areas of the cartilage graft. Two
tiny suction drains are placed through separate inci-
sions. The wounds are closed and the suction drains are
activated. One drain is placed around the helix and the
second is placed in the space between the anterior and
posterior crura (Fig. 85-4). The microtic vestige is not
resected at this time because if there is partial loss of
the skin fl ap, the skin of the vestige may be used as a
graft to cover the defect. A sterile mastoid dressing is
placed. The drains are removed when the drainage has
tapered off.
Stage 2
After 8 to 12 weeks, if healing has been complete, the
second stage of microtia reconstruction may be under-
taken. If there have been areas of skin breakdown or
tenuous blood supply after any stage of microtia recon-
struction, it is wise to defer the next stage until healing
is complete.
Figure 85-5 shows the auricle of a child with initial
grade 3 microtia who has healed after the fi rst stage of
reconstruction with implantation of an auricular carti-
lage graft. The microtic lobule is too anterior and supe-
rior and needs to be transposed to a more posterior and
inferior position. The second stage of microtia recon-
struction is essentially a Z-plasty. The skin at the recipi-
ent site is elevated and transposed to the site where the
lobule had been. The cartilaginous reconstructed
auricle has developed a fi brous capsule around it, and
fl ap elevation should be performed in a plane outside
this capsule. The lobular and skin fl aps are elevated
suffi ciently to allow transposition and closure of the
wounds without tension. The microtic vestige is resected
Figure 85-2. The cartilaginous portions of the two lowest fl oating
ribs have been harvested along with all but the superior 4 mm of the
synchondrosis of the sixth and seventh ribs.
Figure 85-3. An open-type framework has been created from rib
cartilage segments. Note how the cartilage fragments have been
stacked to increase detail and lateral projection. Also note how the
surface details are separated to allow the skin fl ap to drape in between
the details or they will not be seen as separate entities.

800
Section 9
Plastic and Reconstructive Surgery
during the second stage of reconstruction. The lobular
fl ap is carefully thinned and beveled to allow a smooth
and natural transition from the helix of the cartilage
graft to the lobule. Resection of tissue and beveling the
lobule medially decrease the natural lateral rotation of
the lobule (Fig. 85-6). Insuffi cient thinning and bevel-
ing will result in a “stuck-on” appearance of the lobule.
No drains are required. The mastoid dressing and activ-
ity limitations are the same as described earlier.
Stage 3
After the second stage, an additional 2 to 3 months is
required for healing. The third stage of microtia recon-
struction involves elevation of the auricle, which is in a
pocket under the scalp. Elevation increases the lateral
projection of the auricle and defi nes the helix and
postauricular sulcus. Figure 85-7 shows the auricle of a
child who has completed the fi rst two stages of recon-
struction and is ready for elevation of the auricle. An
incision is made approximately 4 mm superior and pos-
terior to the reconstructed helix (Fig. 85-8). The inci-
sion is carried down to the plane of the temporalis
fascia. The auricle is elevated in this plane with a gener-
ous, undisturbed anterior pedicle left for the blood
supply. The excess skin attached to the auricular graft
is gently tacked down to the helical rim with 4-0 chromic
suture. Excessive tension on the helical skin is avoided
to prevent skin fl ap loss. The scalp is undermined via
the postauricular incision in posterior and superior
directions in the plane of the temporalis fascia (Fig.
85-9). Heavy sutures are used in a horizontal mattress
fashion to advance the elevated scalp in anterior and
inferior directions. Lighter sutures are used to further
advance the skin edges. The goal is to hide the free
edge of the scalp incision under the auricular cartilage
graft for cosmetic purposes and, at the same time,
decrease the size of the area requiring skin grafting on
the scalp medial to the auricle. A split-thickness skin
graft is harvested from the hip area or upper, inner
Figure 85-4. An auricular cartilage graft has been implanted and
the two suction drains have been activated. Note how one drain is
placed between the crura to drain that space.
Figure 85-5. Second stage of reconstruction for a child with grade
3 microtia. Incisions have been made and fl aps have been elevated
for Z-plasty.
Figure 85-6. Completed reconstruction of second stage microtia
with transposition of the lobule. Note how the lobule fl ap has been
tapered and beveled to provide a smooth transition from the lobule
to the rest of the auricle.

Chapter 85
Reconstruction of Microtia
801
wedge and packed into the postauricular area. The
ends of the sutures are tied over the bolster securing
the skin graft (Fig. 85-10). The mastoid dressing is
placed as described earlier. The bolster is removed in
the offi ce after 8 to 12 days.
Stage 4
The tragus may be attached to the main auricular car-
tilage graft during the fi rst stage of reconstruction if
adequate cartilage is available, as described previously.
If this was not possible, the fi nal stage of microtia recon-
struction is creation of the tragus and conchal bowl.
This stage is performed after 2 to 3 months have elapsed
for healing after the third stage. Two methods have
been described for creation of the tragus during the
fi nal stage. One method, originally described by Tanzer,4
involves creation of an anteriorly based fl ap in the area
of the future tragus (Fig. 85-11). This method may be
used for bilateral microtia reconstruction or when the
family does not want the normal ear to be operated on
in cases of unilateral microtia. A rectangular-shaped
piece of cartilage is harvested from the conchal area of
the auricular cartilage graft. The conchal area is care-
fully excavated and deepened while taking care to watch
out for the occasional superfi cial aberrant facial nerve.
The rectangular cartilage graft is placed at the base of
the anteriorly based fl ap (Fig. 85-12). The skin fl ap is
folded over the rectangular cartilage graft, and a 3-0
Figure 85-7. Auricle of a child who has completed the fi rst two
stages of reconstruction and is ready for elevation of the auricle.
Figure 85-8. For elevation of the auricle, an incision is made 4 mm
superior and posterior to the helical rim.
aspect of the arm. The skin graft is cut to the appropri-
ate size and shape. A few perforations are made in the
skin graft to allow drainage of blood and serous fl uid.
The skin graft is then sewn in place in the postauricular
area with 4-0 chromic suture. One end of all these
sutures is left long for later use in tying down the bolster
over the postauricular skin graft. An iodine-impreg-
nated bolster is fashioned in the shape of an orange
Figure 85-9. The scalp has been undermined in superior and pos-
terior directions and heavy mattress sutures have been placed to
advance the scalp fl ap in inferior and anterior directions. Such
advancement hides the scalp incision medial to the auricle and
decreases the size of the area requiring skin grafting.

802
Section 9
Plastic and Reconstructive Surgery
Figure 85-10. A wedge-shaped bolster has been tied in over the
postauricular skin graft to secure it.
Figure 85-11. A U-shaped incision is used for creation of the tragus
by the anteriorly based fl ap method.
Figure 85-12. A rectangular cartilage graft for the tragus has been
harvested from the conchal area of the reconstructed auricle and
placed at base of the anteriorly pedicled skin fl ap.
nylon mattress stitch is placed through all layers to
create the tragus (Fig. 85-13). A full-thickness skin graft
is placed in the conchal bowl. An iodine-impregnated
bolster is tied in place with sutures. The mastoid dress-
ing is placed and the bolster is removed in the offi ce
after 8 to 12 days. Figure 85-14 shows the fi nal result.
Another method of tragal reconstruction was
described by Brent2 and is used for unilateral cases of
microtia. The reconstructed auricle is usually fl atter
than the normal auricle. A chondrocutaneous graft is
harvested from the lateral posterior aspect of the concha
of the normal ear (Fig. 85-15). Harvesting of this graft
decreases the projection of the normal ear, which serves
to improve bilateral frontal symmetry of the auricles
(Fig. 85-16). A J-shaped incision is made at the site of
the planned tragus (Fig. 85-17). The skin in the conchal
area is elevated and some of the soft tissues are resected
by careful blunt and sharp dissection as described
earlier to deepen the conchal bowl. The surgeon must
be alert to the possibility of the occasional aberrant
facial nerve (Fig. 85-18). A full-thickness skin graft is
placed. The previously harvested chondrocutaneous
graft is placed into the J-shaped incision and fi xed in
place with a 3-0 nylon mattress suture. The graft is
placed in a manner that allows the composite graft to
be angled from a more anterior position medially and
a more posterior position laterally. This serves to create
a shadow in the conchal bowl that mimics an ear canal
(Fig. 85-19). A bolster is placed for 8 to 10 days, and
the mastoid dressing is placed as described previously.
The bolster is removed in the offi ce after 8 to 12 days
(Fig. 85-20).
Staging of Surgery for Bilateral Microtia
Auricular cartilage grafts for fi rst-stage microtia recon-
struction are performed as unilateral procedures

Chapter 85
Reconstruction of Microtia
803
Figure 85-13. The anteriorly based fl ap has been folded over the
rectangular cartilage graft and secured with a nylon mattress suture
to create the tragus.
Figure 85-14. Final result after completion of stage 4 of reconstruc-
tion with the anteriorly based fl ap method of tragal reconstruction.
Figure 85-15. Planned incisions for otoplasty and the chondrocu-
taneous graft that is harvested from the lateral posterior aspect of the
concha of the normal ear.
Figure 85-16. Otoplasty and harvest of the chondrocutaneous
composite graft are performed to decrease lateral projection of
normal auricle. This serves to improve frontal symmetry of the two
auricles. The composite graft will be used for tragal reconstruction.

804
Section 9
Plastic and Reconstructive Surgery
Figure 85-17. A second method of tragal reconstruction requires
a J-shaped incision at the site of the planned tragus.
Figure 85-18. The conchal bowl has been excavated after the skin
fl ap was elevated. Care is taken to avoid a possible aberrant facial
nerve during excavation.
Figure 85-19. The chondrocutaneous composite graft has been
positioned to create the posterior border of the tragus. The skin fl ap
has been draped into the conchal bowl. A full-thickness skin graft has
been sewn into the conchal bowl between the pedicled skin fl ap and
the composite graft. Note how the reconstructed tragus casts a shadow
that gives the appearance of an external auditory canal.
Figure 85-20. Final result after completion of four stages of micro-
tia reconstruction with a J-shaped incision and a chondrocutaneous
composite graft for tragal reconstruction.
because of the extensive nature of these surgeries.
Third-stage microtia reconstruction with auricular ele-
vation is also performed as a unilateral procedure
because the posterior scalp tissue can be advanced only
to one side at a time. Second-stage microtia reconstruc-
tion with lobule transposition and fourth-stage recon-
struction with creation of the tragus by the anteriorly
pedicled fl ap method may be performed bilaterally

Chapter 85
Reconstruction of Microtia
805
during the same anesthetic because of the more limited
areas involved in these stages.
Revision Surgery
Revision surgery may be performed to enlarge the size
of the postauricular sulcus with a full-thickness skin
graft. A scar band with partial obliteration of the sulcus
often occurs at the junction of the superior two thirds
and inferior third of the sulcus because of skin graft loss
secondary to limited blood supply in this area. A second
area that may require revision is the transition of the
lobule to the auricle. If the transition of the lobule to
the auricular graft is not smooth and the lobule has a
notched or “stuck-on” appearance, revision may be
needed.
POSTOPERATIVE MANAGEMENT
Most surgeons prefer to continue prophylactic periop-
erative antimicrobial agents for 10 days. It is critical to
fi x the mastoid dressing to a young child’s hair with
tape to avoid having the child remove the dressing.
Without taping to hair, young children will nearly always
remove their dressing, which can lead to complications
of infection, bleeding, and fl ap loss. The discomfort of
hair pulling during dressing changes is well worth the
avoidance of complications and preservation of good
results. The dressing is changed on postoperative days
1, 3, and 7, and it is removed after 14 days. Contact
sports are avoided for a total of 6 weeks.
PEARLS
• The surgeon should invariably choose to preserve
the blood supply to avoid complications when
balancing aesthetics versus blood supply.
• To minimize bleeding and to save time, bipolar
scissors are excellent for removing intercostal
muscles from the ribs. Retraction of the ribs with a
two-pronged skin hook improves exposure during
rib harvest.
• Small areas of fl ap loss usually respond to
antimicrobials and gentle local wound care.
• Reducing the lateral projection of the cartilage graft
to permit closure without tension allows healing of
moderately sized areas of fl ap loss.
PITFALLS
• Unless a bridge of approximately 4 mm of cartilage
is left in situ at the superior aspect of the
synchondrosis, the undesirable late chest wall
deformity of splaying out of the ribs may occur.2
• If the pleural space was entered but the visceral
pleura of the lung has not been violated, a red
rubber suction tube is placed while the
anesthesiologist provides positive pressure to
evacuate the pleural air. The catheter is withdrawn
and the wound is closed. No chest tube is required
unless the visceral pleura was violated.
• If the cut edges of the ribs remaining in the chest are
not beveled so that the edges are smooth, painful
irritation of the pleura and intercostal muscles may
result.
• If adequate space between the surface details of the
auricular graft is not provided, the skin will not
drape in between the details and the details will not
be seen as separate entities.
• Large areas of fl ap loss require a temporoparietal
pedicled fl ap with a full-thickness skin graft to
provide adequate blood supply and coverage.
• Unless Doppler or angiographic evaluation of the
superfi cial temporal and occipital arteries is used to
identify and preserve the vascular pedicle of the
temporoparietal fl ap,5 fl ap loss is more likely to
occur.
References
1. Priwin C, Stenfelt S, Granstrom G, et al: Bilateral bone-anchored
hearing aids (BAHAs): An audiometric evaluation. Laryngoscope
114:77-84, 2004.
2. Brent B: Technical advances in ear reconstruction with autoge-
nous rib cartilage grafts: Personal experience with 1200 cases. Plast
Reconstr Surg 104:319-334, discussion 335-338, 1999.
3. Eavey RD, Ryan DP: Refi nements in pediatric microtia reconstruc-
tion. Arch Otolaryngol Head Neck Surg 122:617-620, 1996.
4. Tanzer RC: Total reconstruction of the external ear. Plast Reconstr
Surg Transplant Bull 23:1-15, 1959.
5. Park C, Lew DH, Yoo WM: An analysis of 123 temporoparietal
fascial fl aps: Anatomic and clinical considerations in total auricular
reconstruction. Plast Reconstr Surg 104:1295-1306, 1999.

Chapter 86
Basic Rhinoplasty
Grant S. Gillman
Perhaps no other procedure combines the degree of
artistic and technical detail affecting both form and
function to the same extent as cosmetic rhinoplasty,
which is what makes it the most challenging, humbling,
and variable of all cosmetic procedures in facial plastic
surgery. No single procedure is suitable to all patients,
no single procedure is embraced by all surgeons, and
the goals or desired changes will vary from one indi-
vidual to the next.
Given the number of variables that come into play
with each patient, no two operations are ever exactly
the same. Each case is unique, and only through
thoughtful preoperative analysis,1-3 commitment to
technical detail, critical and honest evaluation of one’s
postoperative results, ongoing education, and years of
experience can the surgeon deliver consistent and pre-
dictable results. Finally, rhinoplasty surgery requires
not only an appreciation of the artistic but also an
awareness of the potential impact that changes may
impart on nasal function so that nasal airfl ow is pre-
served or improved but not compromised.
The goal of this chapter is to outline some of the
principles behind basic rhinoplasty maneuvers and the
most commonly requested changes—dorsal reduction,
tip refi nement, and changes (increase or decrease) in
nasal tip projection. In most cases, combinations of
procedures are carried out, and it is incumbent on the
rhinoplasty surgeon to understand the dynamic inter-
play4,5 between techniques to properly anticipate what
is necessary to help achieve the desired result.
PREOPERATIVE PLANNING
Preoperative evaluation begins by establishing the issues
that are of greatest concern to the patient to clarify what
the patient hopes to achieve through rhinoplasty
surgery. A complete medical history is obtained. In par-
ticular, a history of any previous nasal surgery is elicited
and medications reviewed. Any anticoagulant medica-
tions (including products containing warfarin [Couma-
din], aspirin, or ibuprofen and any herbal products)
should be discontinued 7 to 10 days before surgery to
minimize the likelihood of excessive or unnecessary
bleeding intraoperatively or postoperatively.
A thorough assessment1-3 of the nose follows, which
should include an evaluation of the nasal airway,
skin thickness, dorsal height, tip defi nition, rotation
and projection, alignment of the nose (straight versus
crooked), and identifi cation of any preoperative
asymmetry.
Based on the patient’s desires and fi ndings on phys-
ical examination, a surgical plan is developed. The
operation should be individualized according to the
deformity, characteristics of the patient’s tissues, and
the patient’s objectives. In this way a “game plan” unique
to the individual patient is formulated.
The operative plan is then discussed with the patient
and realistic expectations are set. The typical postopera-
tive course, as well as potential complications and their
relative frequency, are reviewed.
It is equally important to consider the limitations
imposed by the patient’s tissues and what may not be
achievable and to clearly convey this information to
the patient. The goal of surgery is to create a natural-
looking nose without the tell-tale signs of surgery—
one that harmonizes well with the other facial features.
A conservative change is always preferable to
overcorrection.
Preoperative photography must be done routinely
and should include full facial frontal, right and left
lateral, right and left oblique, and nasal base views.
Close-up views are optional in general but preferable in
cases in which there is obvious asymmetry preopera-
tively or a crooked nose.
807

808
Section 9
Plastic and Reconstructive Surgery
ANESTHESIA
Rhinoplasty can be carried out under deep intravenous
sedation or general anesthesia according to the prefer-
ence of the patient and surgeon. Because intraoperative
bleeding is inevitable, a general anesthetic provides
maximal airway protection against aspiration and is
thus preferred in most circumstances. In either case,
the nose is also injected with 10 to 15 mL of 1% lido-
caine with 1:100,000 adrenaline and the mucosa is
decongested with oxymetazoline pledgets. The minimal
amount of infi ltrative anesthesia required to facilitate
hemostasis without overly distorting the nose is
recommended.
SURGICAL APPROACHES
Surgical approaches to rhinoplasty can be broadly clas-
sifi ed as endonasal or external. Endonasal approaches
to rhinoplasty are more diffi cult to learn and master
because of somewhat more limited visual access, and for
that reason most surgeons and certainly the less expe-
rienced are best served by the external approach for
maximal exposure of the surgical anatomy. Conse-
quently, only the external rhinoplasty approach will be
outlined herein.
The basic principles underlying design of the colu-
mellar incision in external rhinoplasty are intended to
minimize the chance of an unsightly conspicuous scar
across the columella.6 For this reason the incision is
irregularized rather than linear and placed across the
narrowest portion of the columella. A variety of inci-
sions are used (gull-wing, stair-step, inverted-V inci-
sions), but the basic rationale that underlies each of
them is the same. We prefer a fi ve-cornered, inverted
V transcolumellar incision because the angles of the
incision facilitate meticulous alignment at the end of
surgery, which helps better camoufl age the resulting
scar.
A fi ve-cornered inverted-V incision (Fig. 86-1) is
marked across the narrowest portion of the columella.
The transcolumellar incision is joined at a precise right
angle to bilateral “marginal” incisions—incisions made
along the lower (caudal) margin of the lower lateral
cartilage (LLC) (Fig. 86-2). Using a sharp wide two-
pronged double hook, the surgeon everts the alar rim
to expose the lower (caudal) border of the lateral crus
of the LLC. The incision is made with a no. 15 blade,
beginning laterally beneath the lateral crus (Fig. 86-3),
curving medially beneath the dome of the LLC, and
continuing alongside the lateral aspect of the columella
(Fig. 86-4) adjacent to the caudal margin of the medial
crus to meet the lateral extension of the previously
outlined transcolumellar incision. The transcolumellar
incision is made with a no. 15 blade while taking care
to stay superfi cial so that the underlying medial crura
are not inadvertently incised (Fig. 86-5).
Careful elevation of the columellar skin fl ap is
carried out with fi ne scissors by passing from the mar-
ginal incision on one side of the columella completely
through to the other side (Fig. 86-6). The scissors are
Figure 86-1. Five-cornered transcolumellar incision for an inverted-
V external approach.
A
B
Figure 86-2. A, Marginal incision outlined along the caudal margin
of the lateral crus. B, Marginal incision outlined along the caudal
margin of the medial crus and joining the transcolumellar incision
at a right angle.

Chapter 86
Basic Rhinoplasty
809
then used to complete the transcolumellar incision and
release any soft tissue attachments of the fl ap for expo-
sure of the underlying medial crura (Fig. 86-7). A small
double skin hook is placed beneath the columellar skin
fl ap while a second such hook is placed beneath the
alar cartilage to provide delicate counter-retraction
(Fig. 86-8) as dissection of the skin–soft tissue envelope
is carried anteriorly over the dome of the LLC and later-
ally over the lateral crura in a relatively avascular plane
intimate to the overlying perichondrium. Precise and
deliberate dissection is required to avoid inadvertent
injury to or incision of the underlying cartilage.
Once the tip cartilage it exposed, it can be retracted
inferiorly by a sharp medium-width two-pronged hook
straddling the columella, with one hook beneath each
dome (Fig. 86-9). The skin–soft tissue envelope that has
already been elevated is retracted cephalically with a
wide sharp double-pronged skin hook. The anterior
septal angle (the most anterior and caudal point on the
Figure 86-3. Marginal incision below the lateral crus of the lower
lateral cartilage.
Figure 86-4. Marginal incision on the lateral aspect of the colu-
mella, below the medial crus of the lower lateral cartilage.
Figure 86-5. Trancolumellar incision.
Figure 86-6. Elevation of the columellar skin fl ap is facilitated by
fi rst undermining from the marginal incision on one side through to
the marginal incision of the opposite side.
Figure 86-7. Retraction of the columellar skin fl ap exposes the
underlying paired medial crura.

810
Section 9
Plastic and Reconstructive Surgery
dorsal cartilaginous septum) is identifi ed in the midline.
The dissection is then carried superiorly along the
dorsum in a plane intimate to the perichondrium over-
lying the dorsal septum to reveal the upper lateral car-
tilage (ULC) in the middle third of the nose (Fig. 86-10)
and ultimately the nasal bones in the upper third, where
one transitions to a subperiosteal plane. As the dissec-
tion moves cephalically, the best exposure is achieved
with the use of an Aufricht dorsal nasal retractor.
Dorsal Reduction/Profi le
Alignment/Osteotomies
The use of life-size photographs will allow one to take
precise measurements preoperatively to provide a more
accurate guide to the amount of cartilaginous or bony
reduction required intraoperatively. In general, the
preference in men is for a stronger profi le and a rela-
tively straight nasal profi le line from the nasion (root
of the nose) to the nasal tip. In women, a slightly
concave dorsal profi le line that is 1 to 2 mm below the
most anterior point of the projection of the nasal tip
will yield an aesthetically pleasing feminine profi le with
a slight supratip break. In either case, extreme over-
reduction or under-reduction is to be avoided.
Profi le reduction is best done incrementally to
arrive at the fi nal level in a graduated fashion. The bulk
of the reduction is carried out in the fi rst pass, with
fi ne-tuning and refi nement thereafter. In most patients
the osseocartilaginous hump is composed mostly of the
cartilaginous vault, with a smaller contribution coming
from the nasal bones themselves.
The cartilaginous dorsum is preferably reduced
before septoplasty (if planned) to prevent inadvertent
over-reduction of the dorsal septal strut that is to be
preserved, which might otherwise occur if submucous
resection of the septum is done before further reduc-
tion of the dorsal strut in the process of adjusting the
profi le. The cartilaginous reduction can be done with
either a knife (no. 15 or 11 blade) or angled Fomon
scissors (Fig. 86-11), with or without fi rst separating the
ULC from its attachment to the dorsal septum. If reduc-
tion of 3 mm or more is planned, submucosal separa-
tion of the ULC before dorsal reduction will preserve
the support provided by the nasal mucosa below the
ULC. When a smaller reduction is planned, it can gen-
erally be done without separating the ULC from its
septal attachment yet still remaining extramucosal (i.e.,
without violating the nasal mucosa). Once the cartilagi-
nous hump is removed, the height of the ULC relative
to the dorsal septum is inspected and its medial borders
lowered with a knife or fi ne scissors until they lie fl ush
or level with the dorsal septum.
Figure 86-8. Retraction of the lateral crus of the lower lateral car-
tilage enables elevation of the overlying skin in a relatively avascular
plane.
Figure 86-9. Retraction of the lower lateral cartilage caudally to
expose the anterior septal angle for dissection superiorly along the
nasal dorsum.
Figure 86-10. Complete exposure of the paired medial and lateral
crura of the lower lateral cartilage and the cartilaginous nasal
dorsum.

Chapter 86
Basic Rhinoplasty
811
The amount of bone to be removed is now defi ned
by the height of the dorsal septum just below the caudal
end of the nasal bones. Conservative reduction of the
bony hump is carried out initially so that incremental
refi nement can be carried out as needed. The bony
hump can be reduced with either nasal rasps or an
osteotome.7 Rasps allow more gradual reduction and
are therefore recommended for a smaller bony hump
and less experienced surgeons. For removal of a larger
hump, a Rubin osteotome (a fl at osteotome with a verti-
cal fi n to guide alignment and help keep the osteotomy
level) is seated at the caudal end of the nasal bones (Fig.
86-12) and advanced toward the radix on a line parallel
to the ideal dorsal line as the assistant strikes the back
end of the osteotome with a mallet. Slight undercorrec-
tion is preferred, followed by fi nal smoothing with a
fi ne sharp nasal rasp.
When a large bony hump has been removed, an
“open roof” deformity of the nasal bones is produced
that requires closure with lateral osteotomies to mobi-
lize and infracture the nasal bones. The osteotomies
will also serve to narrow the bony nasal pyramid. A large
open roof deformity may not need medial osteotomies,
but in many cases a short, fading medial oblique oste-
otomy will help establish a predictable, controlled loca-
tion for the backfracture of the lateral osteotomy.
Five to 10 minutes before the osteotomies are
carried out, the pathway of the proposed lateral osteot-
omies is reinjected with 1% lidocaine with 1:100,000
adrenaline to help minimize bleeding and therefore
postoperative bruising.
Medial osteotomies7 are carried out bilaterally with
a straight osteotome—2, 3, or 4 mm wide, depending
on the thickness of the nasal bones and the surgeon’s
preference. The osteotome is engaged at the cephalic
end of the open roof deformity at the junction of the
bony septum and nasal bone. As the assistant taps the
back end of the osteotome with a mallet, the osteotome
is advanced cephalically at fi rst and then fades obliquely
15 to 25 degrees off midline to join with the medial end
of the backfracture from the lateral osteotomy that
follows. For thinner, delicate or shorter nasal bones in
particular, medial osteotomies may not be necessary.
Lateral osteotomies are initiated through a stab
incision at the base of the piriform aperture, just above
the attachment of the inferior turbinate. Straddling the
piriform aperture with a small or medium-size specu-
lum will help bring the bone into relief and facilitate
accurate placement of the stab incision. Through that
incision a periosteal elevator is used to create a narrow
tunnel through the soft tissue along the line of the
proposed osteotomy to help diminish secondary soft
tissue trauma and bleeding from the osteotomy itself.
A 4-mm curved guarded osteotome (Fig. 86-13) is
initially directed laterally (as though aiming for the
ipsilateral lateral canthus) to engage the osteotome in
the ascending process of the maxilla. Once engaged,
the osteotome is then directed cephalically while making
certain to stay low in the nasofacial groove to avoid
creating a visible or palpable step deformity on the
bony nasal sidewall. Near the level of the infraorbital
rim below the medial canthus, the osteotome begins to
curve medially to meet the apex of the open roof defor-
mity or the cephalic end of the medial osteotomy. The
osteotome is then rotated medially to create a backfrac-
ture in the nasal bone for medialization and closure of
Figure 86-11. An angled (Fomon) scissors is used to reduce the
height of the cartilaginous dorsum (note that the upper lateral carti-
lage has been separated from its attachment to the dorsal septum).
Figure 86-12. A Rubin osteotome is positioned for reduction of
the bony dorsum. The incised portion of the cartilaginous dorsum to
be resected is seen above the level of the osteotome.
Figure 86-13. Curved right and left lateral osteotomes (above) and
a Rubin osteotome (below).

812
Section 9
Plastic and Reconstructive Surgery
In most cases, the goals of nasal tip surgery are the
same regardless of technique and include
• A natural looking, well-defi ned tip to address a broad
or bulbous nose.
• Tip rotation appropriate to gender to address a
drooping nasal tip (ideal nasolabial angle, 90 to 105
degrees in males and 100 to 115 degrees in
females).
• Tip projection appropriate to the height of the nasal
dorsum. In men, desirable tip projection creates a
fairly straight profi le from the root of the nose (the
nasion or radix) to the tip, whereas in women the tip
may project 1 to 2 mm above the level of the dorsum
to yield a more feminine profi le.
Nasal Tip Defi nition
As seen from the base of the nose, the ideal nasal tip
contour will be more triangular in shape than broad,
boxy, or trapezoidal. On a frontal view it should appear
as a nasal tip lobule with two distinct tip-defi ning points
closely approximating one another but without looking
“pinched.”
Enhancement of tip defi nition can be accomplished
with suture techniques (more conservative) or with car-
tilage excision (more aggressive) to shape the cartilage
at the lobular dome. The former is better suited to a
patient with very thin skin, a tip in need of more limited
refi nement, or a surgeon with less experience, whereas
the latter is best reserved for a patient with thicker skin
and a surgeon more familiar with the nuances of exci-
sional techniques.
A
B
Figure 86-14. Typical path of fading medial and lateral osteoto-
mies marked externally.
Figure 86-15. Preoperative and
postoperative lateral (A) and base
(B) views of a patient who under-
went only dorsal reduction and
lateral
osteotomies.
Note
the
deprojection of the nasal tip as
seen on the base view that results
from reducing the height of the
nasal dorsum.
the open roof deformity. The path of typical medial and
lateral osteotomies is seen in Figure 86-14. A patient
who underwent rhinoplasty with dorsal reduction and
lateral osteotomies only is seen in Figure 86-15.
Nasal Tip Surgery
The range of surgical techniques described in the surgi-
cal literature to modify the nasal tip is a refl ection of
the complexity of nasal tip surgery and the evolution
that has taken place to achieve better, enduring, and
more consistent and predictable results while diminish-
ing complication rates.

Chapter 86
Basic Rhinoplasty
813
1. Cephalic trim. Regardless of whether one is applying
suture modifi cation or excisional techniques at the
dome of the LLC, both are frequently used in con-
junction with a reduction in the overall height of the
lateral crus known as a cephalic trim (Fig. 86-16).
Volume reduction of the lateral crura will help
address a tip that appears too bulbous. A cephalic
trim is limited to the more medial aspect of the
lateral crus. Trimming the cartilage more laterally
does nothing to enhance defi nition more centrally
in the lobule and may unduly risk alar collapse by
compromising the strength and support that the
lateral crura provide to the nasal ala.
A minimum height of 6 to 7 mm of the lateral crus
should be preserved to ensure adequate alar support
and minimize the risk of alar collapse or retraction.
A no. 15 blade is used to incise the lateral crura, and
the cartilage to be removed is then dissected off the
underlying vestibular mucosa with either fi ne scis-
sors or the no. 15 blade. Care is taken to ensure that
the height of the remnant of the lateral crus is sym-
metrical on the two sides.
2. Tip suturing. One method to narrow a broad or
bulbous nasal tip uses permanent sutures8 to modify
the lower lateral crura at the tip (dome). This is a
very effective and conservative (nondestructive)
technique. By not actually excising any cartilage, one
avoids having any incisional edges in the tip and thus
diminishes the likelihood of visible irregularities.
A 5-0 monofi lament permanent suture is placed
as a horizontal mattress stitch spanning the alar
dome. The stitch is passed through cartilage only
(superfi cial to the vestibular mucosa underneath)
from a point medial to the dome; it exits the carti-
lage lateral to the dome and is then repassed back
through the cartilage several millimeters below the
fi rst pass in a lateral-to-medial direction (Fig. 86-17).
In this way the suture knot ends up between the two
medial crura. This is known as a transdomal suture.
As the suture is tightened, the domal angle is nar-
rowed, thus reducing the width of the nasal tip. The
same maneuver is executed bilaterally. At the knot,
one limb of the suture from each side is tied to that
of the opposite side to unite the two domes from
either side to one another (the interdomal suture).
This adds stability to the new tip complex, helps
ensure that the two tip-defi ning points rest at the
same level, and minimizes the likelihood that as the
nose heals, the effect of soft tissue contracture will
draw the two domes apart from one another and
lead to visible irregularities, asymmetry, or bossae
(knuckling) of the cartilage. Finally, any sharp or
prominent edges of the cartilage are shaved or
beveled as necessary to yield a smooth fi nal result.
An example of tip narrowing with transdomal and
interdomal sutures is seen in Figure 86-18.
3. Vertical dome division. Vertical dome division (VDD)
refers to an excisional technique that involves inter-
ruption of the integrity of the LLC from its cephalic
to its caudal border at or near the dome.9 It has also
been referred to as the mobile tripod technique10 or
vertical lobule division.11 With this technique a cephalic
trim is carried out in continuity with excision of
either a cephalically based triangle (Fig. 86-19) or a
wedge (Fig. 86-20) of cartilage at the chosen point
of “division.” The underlying vestibular mucosa is
always preserved.
Where the surgeon chooses to divide the cartilage
will vary with what the surgeon is trying to achieve
with respect to tip projection and tip rotation. Exci-
sion of a cephalically based triangle of cartilage (see
Fig. 86-19) lateral to the dome will tend to increase
both tip rotation and projection while simultane-
ously narrowing the tip. In such cases the medial
border of the excised triangle should be no more
than 2 to 3 mm lateral to the dome.9 Alternatively, a
wedge of cartilage can be excised right at the dome
(Fig. 86-20), thus shortening the medial and lateral
crura equally to effectively deproject and narrow the
nasal tip.
Figure 86-16. In a cephalic trim, the upper border (marked in
red) of the lateral crus is excised to help improve defi nition of the
nasal tip.
Figure 86-17. Bilateral horizontal mattress transdomal sutures will
narrow the domal angle and reduce tip width as they are tightened.
Suture ends from either side are then interlocked (interdomal
suture).

814
Section 9
Plastic and Reconstructive Surgery
In either case, the two medial crura are then
sutured to one another several millimeters proximal
to the cut edge with 5-0 clear nylon mattress suture.
This will stabilize the medial crural complex as
natural scar contracture develops with healing and
thereby help prevent migration or twisting of the
cartilage, which might otherwise create visible irreg-
ularities. It is very important with VDD, especially in
patients with thinner skin, to trim or round off any
sharp or protruding edges of cartilage. Meticulous
attention to such fi ne detail is essential when using
this technique. An example of tip narrowing with
VDD using the technique illustrated in Figure 86-19
is seen in Figure 86-21.
Nasal Tip Rotation
Elevation or increased rotation of the nasal tip (to
address a drooping nose) may result from alterations to
the LLC or as a by-product of other maneuvers that do
not directly change the shape of the LLC. Some basic
techniques that facilitate an increase in tip rotation are
described.
1. Dorsal reduction. In patients in whom the dorsum is
quite high and overprojected preoperatively, reduc-
tion of the nasal dorsum will promote upward
rotation of the nasal tip. Whereas a more limited
reduction (2 to 3 mm) may not effect a very signifi -
cant change in nasal tip rotation, reductions of 4 mm
or greater will often result in secondary rotation of
the nasal tip.
2. Shortening the caudal septum. In patients with exces-
sive columellar show (>4 mm on lateral view), short-
ening the overly long caudal septum is another
effective means of promoting tip rotation. In such
cases, a dorsally (anterior) based triangular wedge of
cartilage is excised from the caudal end of the quad-
rangular cartilage together with the overlying septal
mucosa. The septum can be stabilized with forceps
in the nondominant hand while the cartilage is
excised with a no. 15 blade.
3. Transdomal/interdomal sutures. Transdomal and inter-
domal sutures,8 when applied as described earlier
and illustrated in Figure 86-17, will provide a conser-
vative and modest increase in tip rotation. A patient
in whom a transdomal and interdomal suture tech-
nique was used is shown in Figure 86-22.
Figure 86-18. Preoperative (left)
and postoperative (right) base views
of a nasal tip refi ned with trans-
domal and interdomal sutures.
Figure 86-19. A vertical dome division (outlined in red, in continu-
ity with a cephalic trim) carried out by excising a cephalically based
triangle of cartilage 2 to 3 mm lateral to the dome will narrow the
broad or boxy nasal tip while simultaneously increasing tip projec-
tion. The two medial crura are suture-united for stability of the medial
complex.
Figure 86-20. A vertical dome division (outlined in red, in continu-
ity with a cephalic trim) carried out by excising a wedge of cartilage
at the dome will reduce the medial and lateral crura equally. This will
narrow the broad or boxy nasal tip while simultaneously decreasing
tip projection. The two medial crura are suture-united for stability of
the medial complex.

Chapter 86
Basic Rhinoplasty
815
4. Vertical dome division. VDD, as described earlier, will
increase rotation when division of the lateral crura
is executed several millimeters (2 to 3 mm) lateral
to the dome (see Fig. 86-19).9 In essence, the medial
crura are thus lengthened at the expense of the
lateral crura when using this technique, thereby
increasing projection and rotation simultaneously.
5. Lateral crural overlay. With this technique, vertical
division of the lateral crura is carried out midway
along the lateral crus, and the two segments are
then overlapped and suture-fi xated. A lateral crural
overlay (also called a lateral crural fl ap) proce-
dure12,13 will rotate the tip upward while simultane-
ously deprojecting the tip (as the lateral crura are
effectively shortened). When tip deprojection is
desired together with tip rotation and the nasal tip
itself is already narrow and well defi ned, maneuvers
further out on the lateral crura that produce the
desired changes are preferable to maneuvers exe-
cuted at the dome itself so that tip features that are
already agreeable are not altered or disrupted.
It is helpful to fi rst undermine the vestibular
mucosa with fi ne scissors from beneath the lateral
crus at the area to be divided and overlapped. Divi-
sion of the cartilage is carried out with a no. 15
blade, and the two segments are then overlapped
and secured with a 5-0 or 6-0 PDS mattress suture
(Fig. 86-23). The greater the degree of rotation/
deprojection desired, the greater the extent of the
overlap.
Nasal Tip Projection
As is evident from the preceding sections on nasal tip
surgery, many of the very procedures that are used to
change either tip defi nition or tip rotation will have an
effect on tip projection as well. There are many differ-
ent options one may choose from to promote either an
increase or a decrease in tip projection, and for this
A
B
Figure 86-21. Preoperative (left)
and postoperative (right) base views
of the nasal tip refi ned via vertical
dome division with excision of a
cephalically based triangle of carti-
lage lateral to the dome.
Figure 86-22. Preoperative and
postoperative lateral (A) and base
(B) views of a patient who under-
went dorsal reduction and tip
modifi cation with transdomal and
interdomal sutures (in addition to
chin augmentation).

816
Section 9
Plastic and Reconstructive Surgery
degree of tip deprojection will result naturally as tip
support mechanisms are disrupted over the course
of the operation, whereas greater deprojection will
generally require some direct alteration of either the
medial or the lateral crura.
Maneuvers that diminish tip support and thus
deproject the nasal tip include signifi cant dorsal
reduction (described earlier; also see Fig. 86-15), sepa-
rating the attachment of the LLC from the ULC
(separation occurs as the scroll attachment of the
two is eliminated with a cephalic trim), or a full
transfi xion incision along the caudal septum. For each
of these maneuvers the degree of actual tip deprojec-
tion is limited. To make a full transfi xion incision, a
no. 15 blade is used to complete a through-and-
through incision from the vestibular mucosa on one
side of the caudal septum right through the vestibu-
lar mucosa on the opposite side. This severs the
attachment of the medial crural feet to the caudal
septum and thereby allows the tip to become retro-
displaced. Septocolumellar sutures (from the caudal
septum to the columella) are used to resecure the
tip in a new, deprojected position while at the same
time closing the transfi xion incision. Scar contrac-
ture will retrodisplace the tip toward the fi xed nasal
spine.
When more pronounced tip deprojection is
required, changes will need to be directly made to
the LLC. Shortening the lateral crura (the lateral
crural overlay,12,13 described earlier) will deproject
and rotate the nose (Fig. 86-24). Alternatively, one
could use exactly the same technical maneuver on
Figure 86-23. With a lateral crural overlay an incision is made in
the lateral crus (solid line). The cartilage medial to the incision is then
overlapped with and sutured to the cartilage lateral to the incision to
deproject and rotate the nasal tip. The area outlined in red illustrates
an example of an area to be overlapped.
A
B
Figure 86-24. Preoperative and
postoperative lateral (A) and base
(B) views of a patient who under-
went dorsal reduction, a complete
transfi xion incision, and lateral
crural overlay to facilitate nasal tip
deprojection and rotation.
reason the surgeon needs to always consider the broader
view of what one is trying to accomplish to select options
that are best suited to each given patient. Some of the
more commonly used techniques in tip projection are
outlined.
1. Deprojection. As is the case with tip rotation, tip
deprojection may occur directly as a result of altera-
tions made to the LLC or as a secondary by-product
of other maneuvers peripheral to the LLC. A smaller

Chapter 86
Basic Rhinoplasty
817
the medial crura to deproject and derotate (lengthen)
a short nose by incising and overlapping the medial
crural segments in a medial crural overlay.13 Finally,
one could also promote tip deprojection by shorten-
ing both the medial and lateral crura equally (which
generally should not change tip rotation) either by
combining the lateral and medial crural overlay13 or by
using the dome division technique (described earlier
under tip defi nition), which involves resection of a
wedge of cartilage right at the dome (see Fig. 86-19)
to effectively shorten both the medial and lateral
crura equally (Fig. 86-25).
2. Increasing tip projection. One of the more common
techniques to increase tip projection is the use of
transdomal/interdomal sutures (described earlier). The
advantage of this method is that it is conservative,
nondestructive, quick, and relatively easy to execute.
Narrowing of the tip will also result, as will some
modest tip rotation.
Another option is the use of vertical dome division
(described earlier). To increase tip projection, the
lateral crura are divided 2 to 3 mm lateral to the
dome (see Fig. 86-19), and the medial elements are
then brought together and suture-stabilized. What
results is augmentation of the length of the medial
crural complex at the expense of the lateral crura,
thus increasing tip projection. At the same time the
tip is narrowed and rotated cephalically. This tech-
nique requires fastidious attention to detail to reduce
the likelihood of visible irregularities, particularly in
a thinner-skinned patient. In these patients a thin tip
overlay graft of crushed cartilage can be used in addi-
tion to VDD as an added layer to smooth out the
surface of the cartilage at the tip.
With the exposure provided by the external
approach to rhinoplasty, a different alternative would
be to isolate the caudal septum between the two
medial crura and advance and resecure both medial
crura on the caudal septum. These options have
been referred to as projection control sutures14 or a
tongue-in-groove technique.15
Another means of augmenting tip projection is
with the use of a cartilage tip graft, usually harvested
and fashioned from septal or auricular cartilage. The
edges of the graft must be beveled and thinned to
minimize visibility, and the graft is then secured to
the domes of the lower lateral crura with 6-0 PDS
suture. This technique must also be used judiciously
in a thin-skinned patient lest the graft edges become
visible through the skin.
DRESSINGS AND POSTOPERATIVE
MANAGEMENT
If a septoplasty was performed concurrently, Doyle
splints may be secured intranasally to stabilize the
septum. Some surgeons prefer packing with Telfa,
Merocel sponges, or Vaseline gauze. All are acceptable.
Packs are generally removed in 24 to 48 hours, whereas
splints may stay in place from 4 to 7 days. Use of a pro-
phylactic antibiotic is recommended as long as nasal
packing remains in place.
A
B
Figure 86-25. Preoperative and
postoperative lateral (A) and base
(B) views of a patient who under-
went dorsal reduction, a complete
transfi xion incision, shortening of
the caudal septum, and vertical
dome division with excision of a
domal wedge to facilitate nasal tip
deprojection and rotation.

818
Section 9
Plastic and Reconstructive Surgery
If the ULC was separated from the dorsal septum
before reducing the height of the nasal bridge, it should
be resecured to the dorsal septum with a mattress 5-0
PDS suture. The marginal incisions are closed with
absorbable suture (5-0 chromic or plain catgut), and
the transcolumellar incision is closed with monofi la-
ment suture (6-0 nylon or Prolene). Meticulous realign-
ment of skin edges will be rewarded with a very faint,
well-camoufl aged inconspicuous scar. An external dress-
ing that consists of 1–2 -inch paper tape or Steri-Strips over
the skin and a moldable splint over the tape is then
applied.
Patients are advised to use saline spray frequently
to keep intranasal splints clean. The inside of the nostril
area and the transcolumellar incision should be cleaned
several times daily with cotton-tipped applicators soaked
in peroxide to remove dried blood and crust and then
coated with an antibiotic ointment to help keep the
tissue moist. Keeping the head elevated for the fi rst 48
to 72 hours helps avoid postoperative edema, and ice
packs or cool compresses are used over the eyes or a
regular basis.
The patient is seen for suture and splint removal 5
to 7 days postoperatively. They are instructed at that
time to avoid sunburn for 3 to 6 months with use of an
appropriate sunblock and to avoid wearing glasses
directly on the nose for the fi rst 4 to 6 weeks while the
edema continues to settle. Further follow-up appoint-
ments are usually made for 1, 3, 6, and 12 months
postoperatively and annually thereafter.
COMPLICATIONS16
Patient Dissatisfaction
Managing expectations preoperatively is essential to
minimizing the likelihood of having an unhappy
patient.17 Patients should be equally aware of the limita-
tions of surgery and their own unique anatomy, as well
as the diffi culty that can sometimes arise in matching
surgical outcomes to expectations. A patient who sets
realistic goals and thoroughly understands the risks
associated with rhinoplasty surgery will usually be a satis-
fi ed patient postoperatively.
Dorsal Over-reduction/Under-reduction
The use of life-size photographs from which one can
make preoperative measurements is a useful guide to
avoiding gross under- or over-reduction, particularly for
a less experienced surgeon. Under-reduction, if signifi -
cant, may require a revision procedure to further lower
the dorsum. Gross over-reduction, on the other hand,
will result in a “saddle” deformity18 and necessitates a
revision procedure to augment the dorsum, preferably
with cartilage grafting.
Pollybeak Deformity
Over-reduction of the bony dorsum or under-reduction
of the cartilaginous dorsum will result in a pollybeak
deformity19 in which the profi le line appears high from
the rhinion to the nasal tip. If caused by over-reduction
of the bones, dorsal augmentation in that area is
required. If secondary to under-resection of the carti-
laginous dorsum, additional reduction of that part of
the nasal bridge is then required.
Tip Asymmetry/Irregularities/Bossae
Meticulous attention to detail in planning and execut-
ing the surgery will help avoid such complications,20
especially in a thin-skinned patient because tip irregu-
larities are more likely to be camoufl aged in patients
with thicker skin. Nonetheless, scar contracture and
shrinking of the soft tissue envelope can result in either
asymmetry or visible irregularities despite vigilance of
the surgeon intraoperatively. In such cases, targeted
revision surgery (usually relatively minor) may be
warranted.
Alar Retraction/Alar Collapse
Both these complications are typically caused by overly
aggressive resection of the lateral crura and result in a
deformity with both aesthetic and functional implica-
tions. For this reason, preservation of at least 6 mm of
the height of the lateral crura is recommended. Both
retraction and collapse will require structural grafting
with cartilage (septal or auricular) to either replace or
reinforce the overly resected lateral crura.21,22
PEARLS
• Complete and thorough analysis is a vital prelude to
developing a successful surgical plan.
• Realistic goals must be established with the patient
because patients with unattainable expectations are
not good surgical candidates.
• Effort should be made to maintain dissection in
tissue planes intimate to the underlying cartilage
and bone to maximize the thickness of the soft
tissue cover, which will minimize unnecessary
bleeding and swelling.
• Conservatism is always warranted, and desirable
preoperative features should be preserved.
• Many alterations to the lower lateral cartilage affect
both tip projection and tip rotation.
PITFALLS
• Over-reduction of the nasal dorsum will produce an
unnatural, scooped appearance and give the nose a
telltale “surgical” look.
• Aggressive resection of tip cartilage will not yield
better nasal defi nition but will set the stage for
complications such as alar collapse or alar
retraction.
• One cannot overcome thick skin by resecting more
of the underlying cartilaginous support in search of
better refi nement.

Chapter 86
Basic Rhinoplasty
819
9. Simons RL: Vertical dome division techniques. Facial Plast Surg
Clin North Am 2:435-458, 1994.
10. Glasgold AI, Glasgold MJ, Rosenberg DB: The mobile tripod
technique: The key to nasal tip refi nement. Facial Plast Surg Clin
North Am 8:487-502, 2000.
11. Constantinides M, Liu ES, Miller PJ, Adamson PA: Vertical lobule
division in rhinoplasty: Maintaining an intact strip. Arch Facial
Plast Surg 3:258-263, 2001.
12. Kridel RW, Konior RJ: Controlled nasal tip rotation via the lateral
crural overlay technique. Arch Otolaryngol Head Neck Surg
117:411-415, 1991.
13. Soliemanzadeh P, Kridel RW: Nasal tip overprojection: Algorithm
of surgical deprojection techniques and introduction of medial
crural overlay. Arch Facial Plast Surg 7:374-380, 2005.
14. Tebbets JB (ed): Primary Rhinoplasty: A New Approach to the
Logic and the Techniques. St. Louis, CV Mosby, 1999, pp
342-350.
15. Kridel RW, Scott BA, Foda HMT: The tongue-in-groove tech-
nique in septorhinoplasty. Arch Facial Plast Surg 1:246-256,
1999.
16. Simons RL, Gallo JF: Rhinoplasty complications. Facial Plast Surg
Clin North Am 2:521-529, 1994.
17. Morehead JM: The dissatisfi ed patient. Facial Plast Surg Clin
North Am 8:549-552, 2000.
18. Alsarraf R, Murakami CS: The saddle nose deformity. Facial Plast
Surg Clin North Am 7:303-310, 1999.
19. Tardy ME, Kron TK, Younger R, Key M: The cartilaginous polly-
beak: Etiology, prevention and treatment. Facial Plast Surg 6:113-
120, 1989.
20. Perkins SW, Tardy ME: External columellar incisional approach
to revision of the lower third of the nose. Facial Plast Surg Clin
North Am 1:79-98, 1993.
21. Toriumi DM, Josen J, Weinberger M, Tardy ME: Use of alar
batten grafts for correction of nasal valve collapse. Arch Otolar-
yngol Head Neck Surg 123:802-808, 1997.
22. Gunter JP, Friedman RM: Lateral crural strut graft: Technique
and clinical applications in rhinoplasty. Plast Reconstr Surg
99:943-952, 1997.
References
1. Toriumi DM, Becker DG: Rhinoplasty analysis. In Toriumi DM,
Becker DG (eds): Rhinoplasty Dissection Manual. Philadelphia,
Lippincott Williams & Wilkins, 1999, pp 9-23.
2. Gunter JP, Hackney FL: Clinical assessment and facial analysis. In
Gunter JP, Rohrich RJ, Adams WP (eds): Dallas Rhinoplasty:
Nasal Surgery by the Masters. St. Louis, Quality Medical Publish-
ing, 2002, pp 53-71.
3. Byrd HS, Burt JD: Dimensional approach to rhinoplasty: Perfect-
ing the aesthetic balance between the nose and chin. In Gunter
JP, Rohrich RJ, Adams WP (eds): Dallas Rhinoplasty: Nasal
Surgery by the Masters. St. Louis, Quality Medical Publishing,
2002, pp 117-131.
4. Guyuron B: Dynamic interplays during rhinoplasty. Clin Plast
Surg 23:223-231, 1996.
5. Guyuron B: Dynamics in rhinoplasty. Plast Reconstr Surg
105:2257-2259, 2000.
6. Davis RE: Proper execution of the transcolumellar incision in
external rhinoplasty. Ear Nose Throat J 83:232-233, 2004.
7. Toriumi DM, Hecht DA: Skeletal modifi cations in rhinoplasty.
Facial Plast Surg Clin North Am 8:413-431, 2000.
8. Toriumi DM, Tardy ME: Cartilage suturing techniques for cor-
rection of nasal tip deformities. Op Tech Otolaryngol Head Neck
Surg 6:265-273, 1995.
• In patients with thin skin, inexact surgery at the tip-
defi ning points will lead to visible prominences or
bossae.
• Inattention to detail when closing the
transcolumellar incision will result in visible notching
or a wide unsightly scar.

Chapter 87
Nasal Reconstruction
Frederic W.-B. Deleyiannis and Jayakar V. Nayak
The nose is of critical aesthetic and functional signifi -
cance. Mastery of nasal reconstruction requires not only
a knowledge of fl aps and grafts but also an appreciation
of facial aesthetics and functional rhinoplasty. A skin
graft or local fl ap will close most nasal defects,
but without a comprehensive evaluation of the nasal
defect and the anticipated reconstructive outcome, re-
establishment of facial balance and nasal breathing can
be lost.
Nasal defects represent tissue loss, often the result
of tumor resection or trauma. To reconstruct a nasal
defect aesthetically and functionally, one must under-
stand the layers and volumes missing from the defect,
the nasal subunits involved, the cartilage support struc-
tures required, and the color and thickness of the
proper skin replacement. This chapter describes the
basic principles of nasal reconstruction as applied to
acquired nasal defects.
PATIENT SELECTION
It is critical to defi ne the extent and signifi cance of an
acquired nasal deformity to the patient. As in many
aspects of plastic surgery, congruence between what is
perceived by the patient and observed by the physician
is essential. Discrepancies in form or function are best
addressed before any consideration can be given to
surgical intervention. Smoking will increase the risk of
partial or total loss of a skin fl ap.1 This risk should be
discussed with the patient. The surgeon should insist
that the patient stop smoking at least 3 weeks before
surgery, and this should be documented in the patient’s
record. Preoperative counseling is also crucial to best
defi ne the anticipated cosmetic results and limitations.
This might include demonstrating certain procedures
to the patient by using a mirror and outlining schematic
fi gures of the intended surgery. If multiple, staged sur-
gical procedures are needed, the timing of the proce-
dures should be emphasized.
Because of the importance of the nose for body
image, most nasal defects are reconstructed. The
patient’s age is not generally a contraindication to nasal
reconstructive procedures. However, a patient’s general
medical condition, as well as the extent of the proce-
dure, may infl uence the decision for or against surgery.
Sometimes a nasal prosthesis is a valuable and recom-
mended option (Fig. 87-1). If the nasal defect is a result
of tumor resection, the pathology, as well as the need
and the timing of any adjuvant therapy (i.e., radiation
therapy), should be discussed in the context of tumor
surveillance, recurrence, and wound healing.
In children, reconstruction should be initiated and,
if possible, completed before they have attained school
age to avoid psychosocial repercussions.2 The recon-
structed nose, with skin, lining, and support, will grow
with the child. However, additional surgical procedures
to increase the nasal airway, to add cartilage grafts for
enhancement of projection or contour, and to revise
scars are expected.
PREOPERATIVE PLANNING
Analysis of the Defect by Adjacent and
Underlying Facial Structures
Extended nasal defects are those that extend beyond
the nose and involve the cheek, upper lip, underlying
maxilla, or any combination of these structures. Large
cheek and lip defects may require free tissue transfer
before nasal reconstruction (Fig. 87-2) to replace
missing volume and skin. Small defects of the medial
part of the cheek and upper lip can be repaired with
cheek advancement fl aps or nasolabial fl aps at the fi rst
stage. A foundation of skin and fat should exist or be
reconstructed along the region of the piriform aperture
(i.e., the nasal platform) to support the reconstructed
alar bases and columella and to position the new nose
anterior to the maxilla so that it does not extend beyond
821

822
Section 9
Plastic and Reconstructive Surgery
B
A
Figure 87-1. An 83-year-old man after total
rhinectomy before (A) and after (B) coverage
with a nasal prosthesis.
its normal borders and fl ow onto the cheek. Cheek
advancement fl aps can be used as a foundation for the
nasal base before median forehead fl ap reconstruction
and can be used for replacement of the nasal sidewall
(Fig. 87-3). The nasal platform and base should be in
harmony with the eyes (i.e., the width of the alar base
should approximate the intercanthal distance).
Analysis of the Defect by Nasal Subunits
The nose is often divided into subunits (Fig. 87-4) that
defi ne areas of dissimilar skin texture and depth.3-5
Borders between these areas are sites of shadow and
highlights. The convex subunits of the nose are the tip,
dorsum, alae, and columella. Application of the subunit
principle is practical mainly for reconstruction of the
convex subunits with fl aps, not for the concave sub-
units—the nasal sidewalls and soft triangles. As skin
fl aps heal, they contract secondary to the collagen and
myofi broblasts in the recipient bed. This contraction
pulls the fl ap centripetally (i.e., trapdoors) into the
convex shape of the unit that it covers. The subunit
principle is not suitable for repair with skin grafts
because skin grafts do not undergo trapdoor contrac-
tion. These grafts lie fl at and do not bulge with wound
contraction, probably because they lack a layer of sub-
cutaneous fat. If more than 50% of the subunit is
missing, the entire subunit (in particular, the tip or ala)
should be replaced with a fl ap.
The nose in a young child is smaller, fl atter, and
less defi ned than in an adult.6 The subunit borders are
less distinct, but even in children the subunit principle
can be used as a technique to hide scars and harness
fl ap contraction.
Analysis of the Defect by Nasal Layers
(Skin, Cartilage, and Mucosa)
Accurate analysis of the defect with regard to the com-
ponent layers of the nose is essential. In general, when
only skin is missing, reconstruction can be done reliably
with local fl aps, and if the underlying framework is
defi cient, cartilage grafts are needed. The diffi culty of
the reconstruction increases as the amount of nasal
lining diminishes.
The nose has three distinct zones of skin thickness
with differing degrees of subcutaneous fat, sebaceous
gland content, and mobility (Fig. 87-5).7,8 The skin of
zone I is nonsebaceous and mobile and covers the
upper dorsum and sidewalls of the nose. Zone II con-
tains thick, sebaceous, nonmobile skin and covers the
supratip area, tip, and alar lobules. Zone III skin is thin,
nonsebaceous, and fi xed to the underlying alar carti-
lage or fi brofatty structures of the alar margin, soft
tissue triangles, infratip lobule, and columella.
SURGICAL APPROACH
Reconstruction of the nose begins with an analysis of
the defect. With a diagnosis of the facial and nasal sub-
units involved and the nasal layers missing, one can now
evaluate the various reconstructive options and plan the
surgical approach.
Nasal Lining Options
Thin, vascular, and supple nasal lining remains the goal
in reconstruction. Thick, bulky fl aps, such as a nasola-
bial fl ap, will block the nasal airway.9 Cartilage grafts
placed on poorly perfused fl aps will necrose and
extrude. Lining fl aps that are highly vascular and thin
can be taken from multiple donor sites within the nose
(Fig. 87-6).9,10 Menick’s technique of performing a
folded forehead fl ap procedure in three stages offers a
new, refi ned method of replacing nasal lining, and
transfer of free fasciocutaneous fl aps enables recon-
struction of total or near-total defects.11,12
Turnover Flaps
Turnover fl aps are small fl aps of skin surrounding a
defect that are turned over like the pages of a book into
Text continued on p. 827.

Chapter 87
Nasal Reconstruction
823
A
C
D
B
E
Figure 87-2. Reconstruction of the cheek and nose with free tissue transfer. A, A 4-year-old girl with total loss of the medial aspect of her
left cheek (skin and underlying musculature) and heminose 1 year after an avulsion injury from a motor vehicle accident. B, Intraoperative
plan—scar to be excised and reconstructed with a scapular fl ap. The stippled region is the area to be augmented with partial de-epithelization
of the scapular fl ap. C, Cheek defect re-created. D, Design of the scapular fl ap. E, One year after reconstruction of the cheek with a scapular
fl ap.

824
Section 9
Plastic and Reconstructive Surgery
F
H
G
I
J
Figure 87-2, cont’d F, First-stage nasal reconstruction 16 months after cheek reconstruction. The nasal defect is re-created, and a nasal
template is designed from the contralateral side of the nose. G, First-stage nasal reconstruction. The nasal lining is created with turnover fl aps,
and conchal cartilage is used for alar and tip grafting. H, Forehead fl ap for cutaneous covering. I, Second-stage nasal reconstruction, 4 weeks
after the fi rst stage. The forehead fl ap is bipedicled, and the fl ap was thinned of frontalis muscle and subcutaneous tissue. J, Appearance after
division and inset of the forehead fl ap (after the third stage).

Chapter 87
Nasal Reconstruction
825
B
A
C
Figure 87-3. Reconstruction of the cheek and nose with a cheek
advancement fl ap. A, Cheek and nasal defect (skin zone I, lateral nasal
sidewall). B, Cheek fl ap. C, Appearance 19 months after surgery.
Alar lobule
Soft triangle
Tip
Dorsum
Figure 87-4. Nasal subunits. The surface of the nose can be seg-
mented into distinct anatomic regions that correspond to sites of
natural lines of shadow, curvature, and differing skin characteristics.
The convex subunits of the nose are the tip, dorsum, alae, and colu-
mella. (From Burget GC: Aesthetic restoration of the nose. Clin Plast Surg
12:463-480, 1985, with permission.)
Zone I
Zone II
Zone III
Zones of
skin thickness
Figure 87-5. Depiction of the three zones of nasal skin types.
(Reprinted from Burget GC: Modifi cation of the subunit principle for recon-
struction of nasal tip and dorsum defects [commentary]. Arch Facial Plast
Surg 1:16-18, 1999, with permission.)

826
Section 9
Plastic and Reconstructive Surgery
A
B
C
Figure
87-6. Nasal
lining.
Options for nasal lining include
(A) the turnover/turn-in fl ap, (B)
the septal mucoperichondrial fl ap,
and (C) the bipedicled fl ap inter-
position. (A and C, Reprinted with
permission from Burget GC: Aesthetic
reconstruction of the nose. In Mathes
SJ [ed]: Plastic Surgery, vol 2. Phila-
delphia, Elsevier, 2006, p 578; and B,
reprinted with permission from Burget
GC, Menick FJ: Nasal support and
lining: The marriage of beauty and
blood supply. Plast Reconstr Surg
84:189-202, 1989.)

Chapter 87
Nasal Reconstruction
827
the nasal airway. Because they are based on scar, their
blood supply can be tenuous and their length is limited.
If their blood supply appears inadequate at the time
of reconstruction, cartilage grafting should be done
secondarily.
Septal Mucoperichondrial Flaps:
Ipsilateral and Contralateral
An ipsilateral septal fl ap, based anteriorly on the septal
branch of the superior labial artery, has been described
by Burget and Menick.9 The fl ap pivots on an anterior-
inferior point near the nasal spine and folds outward
to provide lining for the nasal domes. The exposed
septal cartilage is either harvested as a graft or left to
remucosalize.
A contralateral septal fl ap can be harvested with or
without septal cartilage.9,13 This technique involves har-
vesting the contralateral septal mucoperichondrium
and swinging it like a trapdoor underneath the nasal
dorsum through a dorsal perforation in the septum.
The fl ap can reach the nasal sidewalls but not the alar
margins.
Bipedicled Lining Flaps
The nasal lining of the alar margin can be successfully
reconstructed with a bipedicled lining fl ap (Fig. 87-7).13
The fl ap is based medially on the septum and laterally
on the vestibule and is pulled down to the alar margin.
The secondary lining defect made above the alar margin
can be covered with a contralateral (or ipsilateral)
septal mucoperichondrial fl ap.
Menick’s Technique for Nasal Lining:
The Folded Forehead Flap, Skin Grafts, and
Three-Stage Nasal Reconstruction
To provide nasal lining, Menick has advocated folding
the forehead fl ap on itself and insetting it into the
defect (Fig. 87-8).11,12 At a second operation 3 weeks
later, the covering portion of the fl ap is separated from
the nasal lining portion of the fl ap and lifted entirely
off the nose. The nasal lining fl ap is now thinned by
removal of the frontalis muscle and excess subcutane-
ous tissue. Cartilage grafts are placed at this second
stage. The covering portion of the forehead fl ap is also
A
C
B
D
Figure 87-7. Superiorly based, two-stage nasolabial fl ap. A, Defect of the soft tissue triangle, frontal view. B, Oblique view. C, First stage: nasal
lining reconstructed with a bipedicled lining fl ap (retracted downward with the skin hook, refer also to Figure 87-6C) and septal cartilage used
to buttress the soft tissue triangle. D, Superiorly based nasolabial fl ap used for cutaneous coverage.

828
Section 9
Plastic and Reconstructive Surgery
F
E
G
Figure 87-7, cont’d E, Second stage: nasolabial fl ap divided and inset,
oblique view. F, Basal view. G, Appearance 1 week after the second stage,
frontal view.
thinned and then reattached to the nose. At a third
stage 3 weeks after the second stage, the pedicle is
divided. For large nasal defects, a full-thickness skin
graft can be sewn to the edges of the mucosal defect
and to the frontalis muscle layer of the forehead fl ap
in the fi rst stage. Wound healing and contracture are
not initiated until the subcutaneous and frontalis planes
are surgically injured. Therefore, the reconstructed
lining of the folded fl ap or skin graft remains supple
and soft until supported by the delayed placement of
cartilage grafts during the second stage. Reconstruction
in three stages with a folded forehead fl ap or a forehead
fl ap with a skin graft offers an excellent option for
reconstructing a nasal defect with missing internal nasal
lining.
Microvascular Free Tissue
Free tissue transfer of a fasciocutaneous fl ap, usually a
radial forearm free fl ap, can be done to reconstruct the
nasal lining vault for total or subtotal loss of the nose
(Fig. 87-9).14,15 However, a bulky free fl ap will obstruct
the nasal airway unless supported on the nasal septum.
When the anterior nasal septum is present, Burget and
Walton advocate rotating it forward as a septal pivot fl ap
(Fig. 87-10).16,17 This septal fl ap has the ability to support
the length and projection of the nose without obstruct-
ing the airway. The raw external surface of the free fl ap
is skin-grafted. At a second stage 5 to 6 weeks later, the
skin graft and subcutaneous fat of the free fl ap are
removed, and formal nasal reconstruction with carti-
lage grafting and a paramedian fl ap is carried out.
Without a septal pivot fl ap a single-paddle free fl ap
will collapse against the piriform aperture. For correc-
tion of this problem, a double-paddle radial forearm
free fl ap can be used to create double-vaulted nasal
lining and columellar lining.
Skeletal Support
As the local fl aps used for nasal reconstruction heal, the
collagen and myofi broblasts within the fl ap and wound
contract and pull the fl ap toward a center of centripetal
contraction. Grafts of cartilage and bone support the
skin fl aps from contraction and after a few months show
through the covering fl ap to give the reconstructed

Chapter 87
Nasal Reconstruction
829
A
E
B
F
D
C
Figure 87-8. Three-stage nasal reconstruction with a forehead fl ap. A, Alar defect, frontal view. B, Oblique view. C, First stage: design of a
folded forehead fl ap for nasal lining and cutaneous coverage. D, Immediate postoperative appearance. E, Second stage: fl ap divided along the
alar margin and nasal and cutaneous fl aps thinned of frontalis muscle and subcutaneous tissue. F, Conchal cartilage harvested.
nose a normal shape. Cartilage and bone from the
septum, the concha of the ear, or the ribs (sixth through
ninth ribs) are the best donor sites.18 Because the
septum is a possible growth center, the ear and costal
cartilage are better options for sources of cartilage
grafts in children. Grafts will survive only if placed on
a well-vascularized bed, such as that provided by septal
fl aps. With use of the folded forehead fl ap or micro-
vascular free fl aps, secondary placement of grafts is
preferred.
To provide midline nasal support, there are several
well-accepted options. A cantilevered bone graft can be
harvested either from the skull outer calvaria or from
rib as an osteochondral segment (Fig. 87-11).18 A sturdy
longitudinal segment can then be crafted to extend
from the nasion to the superior aspect of the nasal
lobule as an onlay or cantilevered graft. It can be
secured in place by suture to the underlying cartilagi-
nous dorsum or plated/wired to the frontal bone or
nasal bones as needed. Smaller segments of calvarial
bone, rib, or septal cartilage can be carved into longi-
tudinal struts for more limited reconstructions, such as
for the nasal sidewall.
For reconstruction of alar cartilage, strips of carti-
lage 4 to 5 mm in width and 1.5 to 2.0 cm long are
harvested from the concha of the ear, septum, or rib

830
Section 9
Plastic and Reconstructive Surgery
G
H
I
J
Figure 87-8, cont’d G, Conchal cartilage graft to the ala. H, Third stage: division of the forehead pedicle and fl ap inset. I, Appearance 4
months after pedicle division, frontal view. J, Oblique view.
(Fig. 87-12). To make an arch, one weakens or scores
the cartilage in the area destined to be the lateral genu,
and the cartilage is bent into a curve with one or two
spanning mattress sutures. The intrinsic curves of
conchal cartilage make it ideal for alar batten grafts, but
conchal cartilage may be too weak to support a scarred
nasal skin envelope. Septal and costal cartilage is stiffer
than conchal cartilage and will better tolerate the com-
pressive force of a contracted skin envelope. A separate
cartilage graft should be used to brace the soft tissue
triangle.
Nasal Skin Coverage
The size of the defect and the zone of nasal skin thick-
ness can serve as a useful guide for selecting the appro-
priate skin cover. Because the skin of zone I is mobile,
local rotation advancement fl aps or primary closure can
successfully reconstruct small defects (<1.5 cm). Zone
II contains thick, sebaceous, nonmobile skin. The only
donor skin that matches zone II is the remaining skin
of zone II (i.e., transposed with a bilobed fl ap) or the
forehead skin with its dense subcutaneous fat. Zone III
skin is thin, nonsebaceous, and fi xed to the underlying
alar cartilage or fi brofatty structures. Composite grafts
from the ear (<1.5 cm) and preauricular full-thickness
skin grafts can blend well in zone III.
For large defects (>1.5 cm), a paramedian forehead
fl ap is the preferred coverage for all zones. Columellar
defects present a reconstructive challenge. A distal
extension of the forehead fl ap provides an optimal solu-
tion when the columellar defect is a missing element of
a larger defect. Other options, in particular for isolated
columellar defects, include superiorly or inferiorly
based nasolabial fl aps.
Full-Thickness Skin Grafts
Because the skin of the upper two thirds of the nose
(zone I) is thin with few sebaceous units, full-thickness
skin grafts blend well in this area. Possible sites of
harvest include the preauricular area, postauricular