FIGURE 52.9 A. Tip-to-length ratio. B. Tip projection. C. Tip projection to alar base width.
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FIGURE 52.10 Alar-columellar relationship.
Regardless of which method one uses to analyze the patient’s nose, the idea is to have a specific and
detailed operative plan for the procedure prior to entering the operating room.
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Treatment Plan
Many nasal surgeries are in fact a combination of procedures for both aesthetic and functional conditions.
Aesthetic rhinoplasty unless traceable to documented trauma is seldom covered by insurance, while
functional septorhinoplasty or rhinoplasty performed for correction of deformity secondary to
documented trauma or disease may be covered by insurance. Prior approval and contemporaneous
records are often required for coverage. The combined case, coding and billing, for the covered aspect of
the procedure is often computed by timing the portion of the case that is functional in nature. Most
surgeons performing aesthetic rhinoplasty require out-of-pocket payment in full for the procedure in
advance of the operation.
Common functional procedures:
Septoplasty/submucous resection
Septorhinoplasty
Reconstruction of the internal nasal valve
Reconstruction of the external nasal valve
Nasal turbinate modification
Anterior turbinectomy
Submucous resection of the inferior turbinate
Out fracture of the inferior nasal turbinates
Bipolar cautery of the inferior nasal turbinates
Endoscopic polypectomy
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Medical Treatment
Medical treatment is used in conjunction with surgical treatment or when mechanical airway obstruction
is ruled out and includes the following:
Systemic antihistamines and decongestants
Topical vasoconstrictor, steroid, and antihistamine sprays
Allergic desensitization
Medication changes; avoidance of medications known to contribute to nasal congestion
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Surgical Treatment
Anesthesia
Managed anesthesia care
Popular in past years when closed, rapid, and often “cookie-cutter” rhinoplasties were
performed
Requires expertise and experience in sedative of anesthesia by both the anesthesiologist and the
surgeon.
Not recommended except for very minor revisions
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General
Allows the surgeon the time needed to perform the individualized operation that each patient
requires.
Ensures that the patient is comfortable throughout the operation
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Approach: Considerations
Closed Rhinoplasty
No external scar
Limited undermining
Less postoperative edema
Faster recovery
Less operative time
Difficult to assess and visualize anatomic variations and therefore make an appropriate operative
plan
More difficult to teach this technique because it does not allow simultaneous visualization by the
surgeon and residents or students
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Open Rhinoplasty
Three-dimensional binocular visualization
Simultaneous visualization by the surgeon, residents, and students
More accurate assessment of anatomic variations
Requires wider dissection
More postoperative edema particularly at the tip
Exposure takes more time
Possible longer recovery time
Columellar scar
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Operative Order
The question for operative order is tip then nose versus nose then tip.
In closed rhinoplasty, many surgeons would argue that “as goes the tip so goes the nose.” This is a
reasonable approach in closed rhinoplasty particularly when there is limited tip suturing and/or grafting.
In open rhinoplasty, many surgeons would recommend modification of the tip as the last step in the
procedure. Given modern rhinoplasty techniques with multiple tip sutures and grafts, the possibility of
disrupting the tip modifications during performance of the remaining portions of the rhinoplasty argues
for performing most of the tip modifications later in the procedure.
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Localization and Preparation
This can be done prior to washing the face with prep solution. Local anesthesia with epinephrine is ideal
to minimize intraoperative bleeding. Typically, 1% lidocaine with epinephrine or 1% lidocaine with
epinephrine mixed 50/50 with 0.25% Marcaine without epinephrine is used. Intranasal cottonoids soaked
in Afrin or epinephrine 1:1000 are used to decrease bleeding and to shrink the turbinates. The face wash
should be nontoxic to the eyes.
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Incisions and Patient Preparation
Options for incisions (Figure 52.11):
Transcolumellar stairstep with intranasal marginal incisions: standard for open rhinoplasty
Cartilage-splitting incision: often used in closed rhinoplasty
Intercartilaginous incision: often used in combination with marginal incision to “deliver” cartilage in
closed rhinoplasty
FIGURE 52.11 Incisions. The transcolumellar stairstep with intranasal marginal incisions (shown in red) is standard for open
rhinoplasty. The cartilage-splitting incision (shown in yellow) is often used in closed rhinoplasty. The intercartilaginous incision
(shown in green) is often used in combination with marginal incision to “deliver” cartilage in closed rhinoplasty.
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Marking
Outline the proposed transcolumellar incision using methylene blue pen (Figure 52.12). Methylene blue
tattoos strategically placed on either side of the proposed incisions can aid in the closure at the end of the
case.
FIGURE 52.12 Nasal anatomy and general operative plan outlined on skin.
Optional: Outline the nasal anatomy, including the outline of the upper lateral cartilages, the lower lateral
cartilages, and the nasal bones as well as outline the planned incisions and any proposed nasal dorsal
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reduction, proposed placement of grafts, and proposed modification of the lower lateral cartilages, as
well as the location of any planned osteotomies.
Trim the nasal vibrissae.
Use the local solution described above in a 10-cc syringe with a 25 gauge 1.5 inch needle to inject the nose
in the intended plane of dissection. When injecting the nasal septum, use a 3-cc syringe with a 20 gauge
1.5-inch needle thus providing better hydraulic advantage and making it easier to dissect the septal
mucoperichondrial flap from the cartilage.
Place Afrin-soaked cottonoids along the floor of the nose and in the middle meatus and against the roof
of the nose to constrict the mucosal vessels and reduce the size of the turbinates. In the past, cocaine in a
4% solution was commonly used because of it being both a vasoconstrictor and a topical anesthetic. It is
not necessary nor indicated to use cocaine when performing this operation under general anesthesia.
Prep and drape the patient’s face consistent with your institution’s approved method.
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Basic Open Rhinoplasty
Opening
Mark a transcolumellar stair-step incision (or an inverted V) across the narrowest portion of the
columella. We suggest that the stairs step “down” from the operator’s side of the table as it is a little
easier to see the opposite nares when making and elevating that portion of the columella flap. Use the tip
of a no. 11 scalpel blade to describe the central stair-step right angles. Use the flat of the blade to make the
remaining horizontal incision over the medial crura being careful to stay superficial so as not to injure the
cartilage, which is immediately under the skin. This incision will intersect at a right angle with a
superficial vertical incision that can be made with a no. 15 scalpel blade and that is located just cephalic to
the caudal roll of the medial crura. Again, this should be very superficial as this incision overlies the
medial crura. The columellar elevation begins in the midline using a no. 4 angled Converse scissors. The
elevation continues carefully over the medial crura, dissected as far toward the domes as possible.
Everting the left alar rim with a double hook and your middle finger identify the caudal border of the
lateral crus and make an incision from just medial to the pyriform up over the dome with care not to
violate the soft triangle and joined this incision with the previously made columellar vertical incision. The
double hook will have to be moved toward the dome straddling the area of the dome and pushing with
the middle finger to see the caudal margin of the alar cartilage. With the assistant retracting the caudal
edge of the now exposed lateral crus, use the Converse no. 4 scissors to identify the plane immediately
above the perichondrium. In a primary rhinoplasty, you should now be able to use a Q-stick to continue
the dissection in this plane with gentle pushing action exposing all of the lateral crus up to and including
the domes. Any remaining attachments of the columella flap overlying the dome can be severed with the
scissors. Repeating this on the opposite side should allow the dorsal flap to be completely elevated to the
level of the upper lateral cartilages. A Q-stick to be used to continue the dissection in this plane over the
dorsum of the nose to approximately the level of the nasal bones. The dissection can be completed using a
curved Joseph-Peck scissors spreading and elevating just enough to insert an Aufricht retractor. It is
important to only elevate enough to allow whatever modifications are planned but not so much as to
decrease tissue attachments to the bone thus making it potentially unstable after osteotomies. Staying in
this relatively avascular plane immediately above the cartilage and bone will give you good exposure
with minimal bleeding (Figure 52.13). At this time, any individual bleeding vessels can be cauterized.
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FIGURE 52.13 Skin elevated.
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Modifying the Dorsum
In this case, we will modify the bony dorsum followed by modification of the cartilaginous dorsum. After
elevating the periosteum from the nasal bones using a Joseph elevator, a pull rasp is used to take the
dorsum down to the desired height. Incremental reduction and frequent checking with the skin redraped
and a wet index finger will help to avoid overcorrection. Orientation of the rasp head in exactly the right
plane both horizontal and vertical by stabilization through the skin with the operator’s nondominant
hand will ensure even takedown of the nasal bones. When proper bony height is achieved, attention is
turned to separate the dorsal septum from the medial aspect of the paired upper lateral cartilages.
The cartilaginous reduction is begun by exposure of the junction of the upper lateral cartilages with the
dorsal nasal septum by means of the creation of a superior Cottle tunnel. The caudal septal angle is
exposed with scissors and a mucoperichondrial elevation is begun on one side of the dorsal septum
(Figure 52.14). Care is taken to be directly on the glistening bluish cartilage. A mucoperichondrium flap is
elevated along the dorsum of the nasal septum using a Cottle elevator. This tunnel is dissected in the
cephalic direction at the junction of the septum with the upper lateral cartilage to and just beyond the
junction of the perpendicular plate of the ethmoid bone with the undersurface of the nasal bone. By
sweeping the mucoperichondrium laterally using the Cottle elevator, the junction of the dorsal septum
and medial upper lateral cartilage is defined (Figure 52.15). If a no. 15 scalpel can be placed within the
tunnel with its flat surface on the exposed dorsal septum and with the blade oriented dorsally and with
the skin protected by the Aufricht retractor, then the upper lateral cartilage can be sharply separated from
the dorsal septum from the junction with the nasal bone to its most caudal attachment. Repeating this
process on the opposite side will now expose the dorsal septum as well as the medial aspect of the right
and left upper lateral cartilages. Each of these structures can be independently trimmed or manipulated
at this time. If carefully done, the mucoperichondrium remains intact without communication to the nasal
cavity. The dorsal septum can be lowered using angled scissors or a scalpel. The upper lateral cartilages
can be trimmed as well or scored and enfolded on themselves to make auto spreader flaps or maintained
for resuturing to the dorsal septum. Note that the cartilaginous dorsum can be lowered first followed by
lowering the dorsal bone en bloc using an osteotome.
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FIGURE 52.14 Anterior superior septal angle.
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FIGURE 52.15 Elevating superior Cottle tunnels.
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Septoplasty, Caudal Septal Modification, or Septal Cartilage Harvesting
If the caudal septum is to be modified to shorten the nose or modify the columella labial angle,
mucoperichondrium will need to be elevated from that portion that is to be resected beginning dorsally at
the septal angle where previous superior Cottle tunnels were made. At this point, it is a good idea to
again inject local anesthetic into the plane of dissection on both sides of the septum. Once exposed on
both sides, the caudal septum can be modified with scissors or scalpel. If there is a need for septal
cartilage grafting or there is deviation of the quadrangular cartilage that is to be corrected, a complete
mucoperichondrial elevation on one side is necessary. In general, the first side to be elevated is that side
opposite the operator. The elevation can be done with a Cottle or a Freer elevator being careful to be in
the relatively avascular plane directly over the cartilage. If only a small piece of cartilage is necessary,
then a limited elevation can be performed. If there is need for more graft material, complete elevation is
necessary. At this point, it is important to ensure that a minimum of 1 cm of dorsal and caudal septum is
preserved as an L-shaped strut to support the nasal structure. The more that can be left, the stronger the
nasal structure. If the continuity of this L-shaped strut is accidentally interrupted, it must be repaired and
reinforced with cartilage or polydioxanone suture plate gussets. The cartilage to be harvested or removed
can be outlined on the surface of the quadrangular cartilage in methyl and blue pen. A curved septal
knife can then be used to incise along the outlined cartilage dorsally and caudally. A Cottle elevator can
then be used to carefully elevate the opposite side through these incisions only elevating the opposite side
over the cartilage that is to be removed. Once the opposite side is elevated, the remaining incisions can be
completed with scissors, scalpel, Ballenger swivel knife, and elevator without perforating the
mucoperichondrium. It is important to remember the shape of the quadrangular cartilage particularly
where it abuts the junction of the vomer and the perpendicular plate of the ethmoid. There is usually a
significant tongue of cartilage in this area that can provide important additional material for grafting. At
this point, any additional deviation of either the perpendicular plate of the ethmoid, the vomer or the
maxillary crest can be dealt with using a Jantzen-Middleton rongeur. The airway should now be assessed
for patency, and when indicated out-fracture of the inferior turbinate, Dennis bipolar cautery of the
inferior turbinate or anterior turbinectomy can be done. The flap should be inspected for perforations but
unless they are large and/or they communicate with a perforation on the opposite flap at the same level
repair is not necessary.
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Spreader Grafts and Flaps
Spreader grafts or flaps are useful to prophylactically maintain or to widen the internal valve area when a
narrow valve angle is contributing to obstructive symptoms 13,14 (Figure 52.16). Grafts are generally made
from harvested septum but may also be made from rib or auricular cartilage. They can also be used to
strengthen the dorsal septum as well as to help straighten dorsal septal deviations. They can be stabilized
with 30 gauge needles to allow them to be sutured in place flush with the dorsal septum with 5-0 PDS.
Excess medial upper lateral cartilage can be folded on itself and sutured in a similar manner.
FIGURE 52.16 A. Spreader grafts. B. Spreader flaps.
Open rhinoplasty allows you to see the nasal tip as it sits in vivo. It is beyond the scope of this chapter to
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provide a comprehensive compendium of all potential tip modifications. 7-9,15,16 The most common tip
modifications involve some form of cephalic lateral alar crural resection, intradome and interdome
suturing, and/or the placement of a columellar strut. In principle, as much supporting structure of the
alar cartilages as possible should be left in place. The alar cartilages should be assessed for their thickness
and strength. If the alar cartilages are of sufficient thickness and strength, a cephalic resection leaving an
uninterrupted 6 to 8 mm caudal strip of cartilage can be removed (Figure 52.17). If there is unwanted
cephalic fullness but the cartilages of questionable strength than the removed cephalic segment can be
slid into a pocket made between the nasal mucosa and the remaining caudal cartilage and sutured into
position to bolster the lateral alar crus. If there is too much convexity in the segment, the cephalic
cartilage can be inverted before being sewn into place thus counteracting the tendency for convexity). If
the domes are widely separated or are of unequal height, they can be adjusted by interdomal mattress
sutures of 5-0 PDS (Figure 52.18A). The individual domes can be narrowed and accentuated with
intradomal (transdomal) mattress sutures of 5-0 PDS (Figure 52.18B). Combination interdomal and
intradomal/transdomal sutures can be used to both narrow the individual domes and as well as the
interdome distance (Figure 52.18C). Further strengthening of the medial crura for maintenance of
projection or to increase projection can be accomplished by the insertion of a columellar strut (Figure
52.19). This can be fashioned from harvested septum and trimmed to be 0.5 cm in width and up to 3 cm
or more in length. A tunnel is made with scissors between the medial crura and extending to the nasal
spine. The pocket should be made as close to the width of the strut as possible. The strut can be placed in
the pocket against the nasal spine and while the assistant holds the domes at the appropriate level the
strut can be sewn in a through-and-through fashion to the medial crura with 5-0 PDS mattress sutures
with the knot placed internally between the crura.
After each maneuver, the skin should be redraped
and the contours carefully inspected and palpated with a wet gloved index finger.
FIGURE 52.17 Cephalic lateral crural resection.
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FIGURE 52.18 Dome sutures. A. Transdome suture. B. Intradome sutures. C. Transdome and intradome suture.
FIGURE 52.19 Columellar strut.
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Osteotomies
Generally, osteotomies are performed at this time for closing the open roof that is to say the gap between
the nasal bones created when the bony dorsum is reduced. 17 The path that the osteotomies will take will
depend upon the degree and length of the open roof as well as the desired change in the width of the base
of the nasal bones. Medial oblique osteotomies are first performed by insertion of a curve-guarded
osteotome at the junction of the septum and nasal bones at the most cephalic aspect of the open roof
(Figure 52.20). The osteotomy line is carried in oblique fashion away from the Keystone area for about 5
to 10 mm. This helps to control the position of the osteotomies preventing injury to the Keystone area or
the creation of a rocker deformity. Lateral osteotomies can be performed intranasally using a curve-
guarded osteotome after elevation of the periosteum overlying the nasal bone-cheek junction or using a
2 mm osteotome through an external percutaneous approach. The osteotomy is begun slightly higher on
the pyriform lip preserving a triangle of bone along the pyriform, the Webster triangle, where the lateral
most aspect of the alar cartilage anchor and provide stability to the nasal valve. If the bony bases are to be
narrowed, the osteotomies are carried from this position staying low on the nasal bones (low to low) to
the level of the previously made medial oblique osteotomy. Gentle inward digital pressure will green
stick fracture the remaining bridge of nasal bone between the end of the medial oblique and lateral
osteotomies. If narrowing of the nasal bony base is not indicated, then the osteotomy can curve in a more
dorsal direction, low to high, joining and closing the open roof directly (Figure 52.21). Lateral osteotomies
can also be performed using a percutaneous 2-mm osteotome. A small puncture is made through the skin
in the natural skin tension line, and then the osteotomy is made along the same lines as described for the
intranasal curved osteotome by walking the 2-mm osteotome along its desired path with gentle taps from
the mallet. An advantage of the 2-mm osteotome is that the periosteum is not elevated and therefore
remains intact on both the nasal and the facial side of the bone adding stability to that bony segment.
FIGURE 52.20 Medial oblique osteotomies.
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FIGURE 52.21 Osteotomies and the Webster triangle (blue). A. Low to high. B. Low to low.
The disadvantage is the necessity for an external puncture though experience has shown that these
punctures are virtually invisible once healed.
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Final Inspection and Closure
Throughout the procedure, the nose should be assessed by observation and comparison to the operative
plan. Palpation of the nose using a wet gloved index finger slid along the dorsum should reveal smooth
contours without defects. Any residual bony defects should be treated with further rasping using a
diamond rasp, while any cartilaginous irregularities should be smooth with a scalpel. Further options for
dealing with and “fine tuning” remaining problem areas will be dealt with later in this chapter.
Prior to closing the incisions, the nasal septal flaps are quilted using a 4-0 plain catgut suture passing it
back and forth from one side to the other through and through from the caudal septum as far posteriorly
as possible in several rows. This is the best way to prevent septal hematoma.
Intranasal incisions are closed with interrupted 5-0 chromic in the same way as in the closed rhinoplasty.
The transcolumellar incision is closed very carefully with interrupted 6-0 fast absorbing plain catgut
suture, which is then reinforced with skin glue. A careful and meticulous closure of the transcolumellar
incision should result in a virtually invisible scar once fully healed. If alar base modifications are planned,
they can be performed once the nasal incisions have been closed completely. Alar base modifications
include alar base narrowing, nostril size adjustments, alar flare reduction, alar hooding reduction, and
alar margin grafting to adjust the position of the alar position on both anterior-posterior and lateral
views. 12,18
When both nasal septal surgery and turbinate modification are done, a Doyle septal splint is placed in
each nostril and suture to the membranous columella with a 3-0 Prolene through-and-through suture.
The purpose of this splint is not to prevent septal hematoma but rather to provide insulation preventing
the formation of synechiae between the septum and the inferior turbinate. Finally, the nose is taped, and a
thermoplastic splint is applied (Figure 52.22).
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FIGURE 52.22 Thermoplastic splint.
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Basic Closed Rhinoplasty
Tip Delivery Method
A combination of a marginal incision along the caudal border of the lateral alar crus and an
intercartilaginous incision at the junction of the cephalic alar crus and the upper lateral cartilages and
continued with a transfixion incision at the caudal and cephalic margin of the medial alar crus will allow
the total delivery of the dome and lateral alar crura into the nostril for subsequent manipulation. This
maneuver is repeated on both sides and allows for increased visualization of the alar cartilages. The
bucket handle dissection of the cartilages can be stabilized for manipulation or trimming by passing the
handle of a Neivert double ball retractor beneath. The exposure of the domes can allow for moderate
manipulation in this area as well.
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Tip Cartilage-Splitting Method
An intracartilaginous incision is made at the point where the planned cephalic resection of the lateral alar
crus begins. It is carried through the nasal vestibular skin and through the cartilage. The vestibular skin
can then be dissected from the nasal side of the cephalic alar cartilage, which can then be separated from
its attachment to the upper lateral cartilage and removed.
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Dorsal Elevation and Reduction
Once the tip is modified, a curved Joseph-Peck scissors can then be used to elevate the nasal dorsum over
the cartilage and bone. The plane of dissection should be immediately superficial to the perichondrium
and periosteum. Care to stay in this plane will result in a relatively bloodless dissection. The dissection
should be wide enough to allow the insertion of a Aufricht retractor for visualization of the dorsum but
should be limited to only that needed to make the planned dorsal modifications. A Joseph elevator can
then be used to elevate the periosteum over the nasal bones to allow reduction by rasp or osteotome. If
the rasp is to be used the bony modification is done at this point followed by reduction of the
cartilaginous dorsum. If an osteotome is to be used to lower the bony dorsum, then modification of the
cartilaginous dorsum is done first. Many surgeons prefer the rasp, because it allows a more incremental
reduction of the dorsum and is less likely to result in accidental overcorrection. The cartilaginous
reduction is begun by exposure of the junction of the upper lateral cartilages with the dorsal nasal septum
by means of the creation of a superior Cottle tunnel. Through the previously made transfixion incision at
the junction of the caudal septum and medial alar crura a mucoperichondrium flap is elevated along the
dorsum of the nasal septum using a Cottle elevator. This tunnel is dissected in his cephalic direction at
the junction of the septum with the upper lateral cartilage to and just beyond the junction of the
perpendicular plate of the ethmoid bone with the undersurface of the nasal bone. By sweeping the
mucoperichondrium laterally using the Cottle elevator, the junction point is defined. A no. 15 scalpel can
then be placed within the tunnel with its flat surface on the exposed dorsal septum and with the blade
oriented dorsally and with the skin protected by the Aufricht retractor, the upper lateral cartilage can be
sharply separated from the dorsal septum from the junction with the nasal bone to its most caudal
attachment. Repeating this process on the opposite side will now expose the dorsal septum as well as the
medial aspect of the right and left upper lateral cartilages. Each of these structures can be independently
trimmed or manipulated at this time. If carefully done, the mucoperichondrium remains intact without
communication to the nasal cavity. The dorsal septum can be lowered using angled scissors or a scalpel.
The upper lateral cartilages can be trimmed or left in place for later use as auto spreader flaps.
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Septoplasty
If correction of septal deviations or harvesting of septal cartilage to use for grafting is indicated, then this
should be done at this time after the dorsal profile has been set. Using the previously made transfixion
incision, a mucopericondrial flap is elevated in the same manner as described for open rhinoplasty. In
closed rhinoplasty, where visualization is more difficult, an inferior Cottle tunnel can aid in the elevation
of the mucoperichondrial flap along the junction of the quadrangular cartilage and the Vomer. A Freer or
McKenty elevator is used to elevate the periosteum along the medial surface of the floor of the nose and
the lateral surface of the Vomer up to the attachments at the cartilage-Vomer junction. Scissors can then
be used to cut the attachments between the cartilage and the vomer from caudal to cephalic under direct
vision therefore minimizing the risk of flap perforation. Once exposed on one side, the modifications can
proceed as described for open rhinoplasty.
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Spreader Grafts and Flaps
These can be placed in a manner similar to that described in the open rhinoplasty section. Exposure is
more limited, and placement and fixation are more difficult in the closed rhinoplasty.
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Tip Modification
Tip modifications are considerably more difficult in the closed rhinoplasty though virtually any
modification done in the open setting can be done in the closed rhinoplasty. The authors encourage using
the open approach until the surgeon has gained considerable experience.
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Osteotomies
Osteotomies are also performed as described for open rhinoplasty.
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Final Inspection and Closure
The intranasal incisions are now closed with interrupted 5-0 chromic suture. The nasal dorsum is
cleansed with saline, dried, and then treated with Mastisol, and then Steri-Strips are placed in such a way
as to try to eliminate any dead space between the skin and the refined cartilage and bone. Finally, a
thermoplastic splint is applied. Routine nasal packing is not necessary. 19,20 A Doyle internal splint may be
desirable when both septoplasty and anterior turbinectomy are performed to prevent synechia.
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Advanced Maneuvers
Advanced rhinoplasty maneuvers include the following:
Septal extension grafts
Onlay grafts
Rim grafts
Tip grafts
Dome grafts
Shield graft/infratip grafts
Supratip graft
Lateral crural strut grafts
Lateral crural spreader grafts
Tip diverging grafts
Tip width-control grafts
Lateral crural shaping sutures to increase external convexity or concavity
Through-and-through suturing to narrow the columellar base with or without footplate resection
Columella to septum anchoring sutures
Alar base excisions to decrease flare or narrow the base
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Revision Rhinoplasty
The principles for approaching revision rhinoplasty are the same as those for primary rhinoplasty: careful
analysis, diagnosis of the problem, and application of appropriate surgical maneuvers. Revision surgery
often involves reconstructive principles because the presenting anatomy is no longer standard. There will
be scar tissue encountered during dissection and distorted, missing, and possibly extra nasal tissue or
alloplastic implants discovered. Additional cartilage sources, including rib or ear cartilage and bone
sources including outer table of the calvarium may be necessary. The guiding principle of revision
surgery is that regardless of the deformity encountered, the revision surgeon must be prepared to use all
tools available to make the anatomical structures as normal as possible to achieve satisfactory appearance
and function. Revision rhinoplasty patients also require greater attention to the psychological aspects
involved, as these patients tend to be more anxious about repeating another surgery and risking another
disappointing outcome. It is important to obtain the operative records of previous surgeries whenever
possible. Bear in mind that not all operative reports are entirely accurate. Preoperative CT scans and
office-based nasoendoscopy when available can be helpful as can endoscopy in the OR just prior to the
procedure.
Common presenting deformities in revision rhinoplasty include a residual dorsal hump, an overprojected
nose, a crooked dorsum, a crooked and asymmetric tip, and an overdone “pinched” tip. Other common
problems encountered are an overresected dorsum (saddle nose deformity), alar retraction, dorsal
asymmetry, visual or palpable irregularities, and a widened dorsum. In addition, one may encounter
functional nasal obstruction that is either new or was not optimally dealt with in previous surgery. Given
the numerous possible deformities, addressing every problem is beyond the scope of this chapter. The
goal is to use whatever tools necessary to fix the problem and create a “normal” structural appearance
and normal function. Often, structures need to be reconstructed using strong normal cartilage, which can
include residual septal cartilage, previously placed grafts that have been removed during the revisional
surgery, rib cartilage, or ear cartilage. Variously prepared allograft materials have also found their way
into complex nasal revisional surgery. Extra care is needed in dissecting the skin flap from the underlying
skeleton as tenacious scar tissue may be encountered the dissection through which can lead to accidental
perforation of the skin flap. Dorsal humps may need to be shaved down using rasps or power burrs if
necessary. Repeat osteotomies can create better symmetry in nasal bones but may also lead to
comminution and instability. Crooked dorsal septal cartilage may need to be straightened and reinforced
using strong cartilage batten grafts applied to one or both sides. The tip can be reconstructed using a
variety of means, including grafts to reinforce or replace the lower lateral cartilages and tip grafts to
create a more normal looking symmetric tip. Suture can be used to achieve these goals and can also be
used to narrow a wide middle third (with care taken not to
create a functional problem in the internal
nasal valve). Revision septoplasty, anterior turbinate reduction, turbinate cautery, turbinate
out-fracture,
and internal nasal valve reconstruction using spreader grafts and/or lateral crural strut grafts may be
necessary to reconstruct functional airway problems.
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Complications
Bleeding
Septal hematoma
Infection
New or persistent obstruction
Scarring/skin loss
Aesthetic irregularities
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Patient Outcomes
Patient outcomes are critically important with any surgery. Measuring individual outcomes quality
depends on close and thorough follow-up for at least 1 year if not longer, asking patients questions about
their satisfaction with their results, excellent standardized photography at every patient visit, and
surgeon dedication to reviewing preoperative photographs and 1 year follow-up photographs in
conjunction with the surgical operative report to determine if the operative plan and postoperative
treatment were appropriate. 5,21 Many variables affect the result of rhinoplasty surgery, and it is
incumbent upon the surgeon to critically analyze his or her results and patient satisfaction to obtain the
most optimal outcomes. Objective patient-related outcome (PRO) scales have been developed; however,
the perfect qualitative validated scale remains elusive. PRO scales with acronyms such as SCHNOS,
NOSE, SNOT, RHINO, and Face-Q are available to the rhinoplasty surgeon but vary in their usefulness.
An ideal PRO scale should be validated, reproducible, and easy to administer. 22-27
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Questions
The patient is a 27-year-old man who presents to you with two complaints concerning his nose: dislike for
the appearance of his nose and nearly complete obstruction of his left nasal airway. He states that he has
broken his nose at least two times playing collegiate rugby. He was seen the first time in the ED where a
closed reduction was attempted after X-rays confirmed a fracture. He states that his nose has been
crooked ever since and that his nasal breathing, though problematic his whole life has been much worse
since that trauma. He did not seek medical attention after his second nasal trauma. He denies any known
inhalant allergies, takes no medication, denies using nasal sprays or having had any previous nasal
surgery other than the attempted reduction in the ED. When asked to be specific about his nasal
appearance, he states that he does not like the crookedness of his nose, nor is he happy with the
prominent dorsal hump. He is fine with the appearance of the tip of the nose. His family history is
unremarkable, as is his review of systems.
Focused nasal exam reveals a moderately large and projecting nose with a prominent nasal dorsal bony
and cartilaginous hump. The nose shows a significant C-shaped deformity concave to the right. He has a
narrow supratip and a wide and boxy tip. His skin is intermediate in thickness. His caudal septum
presents in his left nostril. He has marked septal deviation to the left with near total obstruction of the left
nasal airway. There is a significant spur of the junction of the quadrangular septal cartilage and the
vomer extending into the right nasal airway. He has significant enlargement of the right nasal turbinate
and moderate enlargement of the left. He has a sharply positive Cottle test on the right and minimal
improvement on the left. You devise a treatment plan, which you go over at length and in detail with the
patient.
1. You propose an open septorhinoplasty to be done in the hospital under a general anesthetic as an
outpatient. Which of the following statements is most accurate regarding the osteotomies in your
surgical plan?
a. He will require osteotomies to straighten his nose and correct the incompetent internal nasal
valve.
b. He will require osteotomies to close an open roof deformity and straighten the nose.
c. He will require osteotomies to narrow the nasal bases and straighten the nose.
d. He will require oseotomies to close an open roof deformity and straighten the nasal septum.
e. Low to high osteotomies would be ideal to correct the bony asymmetry.
2. You perform the septorhinoplasty using an open approach, transcolumellar stair-step incision. To
surgically treat the exam finding of a positive Cottle test, which of the following would you perform?
a. Quadrangular septal cartilage and bony septum excision
b. Bilateral inferior turbinate submucosal resection and outfracture
c. Cartilage spreader graft placement between the septum and upper lateral cartilage on the
right side
d. Cartilage spreader graft placement between the septum and upper lateral cartilage on the left
side
e. Cartilage lateral crural strut graft placement under each lower lateral crura
3. You perform the septorhinoplasty using an open approach, transcolumellar stair-step incision.
Given the marked septal deviation preoperatively, dissection around the deviation was difficult and
fractures within the septum from previous trauma presented difficulty in elevating the septal
mucoperichondrial flaps. Following completion of septal cartilaginous and bony resection, you note
perforations in the septal flaps on both sides. You decide that suture repair of the perforations are not
necessary for which of the following reasons?
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a. Septal perforations always heal on their own and close secondarily.
b. The opposing perforations are anterior.
c. The opposing perforations are posterior.
d. The perforations will close with spreader graft placement.
e. The perforations on each side are not opposing.
4. The patient you just treated was happy with the results of his rhinoplasty and refers his 22-year-
old sister to you for revision rhinoplasty. She has no functional nasal concerns and her nasal history
and exam are unremarkable for any breathing disturbance. Her concern is a residual prominent nasal
dorsal hump, and she feels that her tip is still too projecting and too bulbous. Her primary
rhinoplasty surgery was 3 years ago. You receive a copy of her original operative report, and there is
no mention of septal cartilage harvest. You do a nasofacial analysis and find that her tip projection is
70% of her radix-to-tip length and her nasolabial angle is 100°. Your operative plan and consent
process should include which of the following?
a. Reduction of the bony and cartilaginous nasal dorsum and tip suturing to better define the
domes with no change to the nasal labial angle, tip deprojection, and septal cartilage harvest for
columellar strut grafting
b. Reduction of the bony and cartilaginous nasal dorsum and tip suturing to better define the
domes, increasing the nasal labial angle, tip deprojection
c. Reduction of the bony and cartilaginous nasal dorsum and tip suturing to better define the
domes with no change to the nasal labial angle, tip deprojection, septal cartilage harvest for
columellar strut grafting, and possible ear or rib cartilage graft harvest
d. Reduction of the bony and cartilaginous nasal dorsum and tip grafting to better define the
domes with no change to the nasal labial angle, tip deprojection, and septal cartilage harvest for
columellar strut grafting
e. Reduction of the bony and cartilaginous nasal dorsum and tip grafting to better define the
domes with no change to the nasal labial angle, tip deprojection, septal cartilage harvest for
columellar strut grafting, and possible ear or rib cartilage graft harvest
5. You perform revision rhinoplasty on the 22-year-old woman in the previous question in the
operating room under general anesthesia. Which of the following is not accurate regarding optimal
patient outcome assessment?
a. The patient should be followed for 1 year after surgery to assess the final result.
b. Standard photographs should be taken at only at the 1-year postoperative visit for
comparison.
c. Functional assessment should be made at each postoperative visit.
d. The patient should be asked directly about satisfaction with the procedure at each
postoperative visit.
e. Given the reproducible validity of objective patient reported outcomes scales, it is critically
important to use them with every patient.
1. Answer: b. Two indications for performing osteotomies are to straighten the nose and to close and
open roof deformity after the bony hump is rasped. As he has a C-shaped deformity and crooked
nose from his trauma, and because the plan would include rasping of the dorsal bony hump to
correct his dissatisfaction cosmetically, answer #2 would be most accurate. Osteotomies are not
performed to correct incompetent nasal valves or to straighten the septum. Low-to-high osteotomies
are used to prevent further narrowing of the nasal bone bases, not to correct nasal bone asymmetry.
2. Answer: c. A positive Cottle test reveals incompetent unilateral internal nasal valve or bilateral
internal nasal valves. In this case, the patient had relief of Cottle test on the right side only. Spreader
graft placement on the right side is indicated to open the angle of the internal nasal valve on the
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affected side. Surgery on the septum or turbinates will not treat the internal valve problem. Lateral
crural strut grafts are used to treat external nasal valve incompetence.
3. Answer: e. Perforation of one or both sides of the septal mucoperichondrium may occur during
septoplasty, especially when dissection is exceptionally difficult. Unilateral perforations do not
require suture closure. Perforations that are nonopposing will not heal with a persistent open
perforation. Tears in the mucosa that are opposing must be closed with suture on each side to
prevent a persistent open perforation that can lead to bleeding, crusting, whistling, and functional
airflow issues.
4. Answer: c. The patient’s concerns are residual hump deformity and an overprojected bulbous
nasal tip. The plan should include bony and cartilaginous hump reduction, tip suturing to better
define the domes of the tip and reduce bulbosity, and deprojection of the tip. Deprojection of the tip
will require columellar strut grafting to resupport the new position of the tip. A columellar strut graft
can be fashioned from septal, rib, or ear cartilage. Even though the previous operative report does
not mention previous septal cartilage harvest, operative reports are not always accurate. Therefore,
the operative plan and informed consent for all revision rhinoplasty patients should include the
possibility of ear or rib cartilage harvest.
5. Answer: b. Patients should be followed postoperatively for at least 1 year after rhinoplasty
surgery. Standard photographs should be taken at each postoperative visit throughout the year to
track and document the patient’s progress. Asking the patient about their satisfaction at all time
points, as well as surgeon assessment of both functional and aesthetic outcomes, is critical to evaluate
the overall results. Objective patient reported outcome scales can sometimes be useful in the
postoperative setting, but the scales available today may be difficult to administer and the perfect
validated scale remains elusive.
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References
Constantian, MB. Four common anatomic variants that predispose to unfavorable rhinoplasty results: a study based on 150 consecutive
secondary rhinoplasties. Plast Reconstr Surg. 2000;105:316.
Constantian, MB, Lin, CP. Why some patients are unhappy. Part 1. Relationship of preoperative nasal deformity to number of operations and
a history of abuse or neglect. Plast Reconstr Surg. 2014;134(4):823-835.
Constantian, MB, Lin, CP. Why some patients are unhappy. Part 2. Relationship of nasal shape and trauma history to surgical success. Plast
Reconstr Surg. 2014;134(4):836-851.References 2 and 3 are paired articles by Constantian and Lin that provide insight into the recognition of the body
dysmorphic patient. They should be read by anyone interested in rhinoplasty.
Heinberg, CE, Kern, EB. The Cottle sign: an aid in the physical diagnosis of nasal airflow disturbances. Rhinology. 1973;11:89-94.
Guyuron, B. Precision rhinoplasty. Part I: the role of life-size photographs and soft-tissue cephalometric analysis. Plast Reconstr Surg.
1988;81:489-499.First in a set of two articles showing the methodology used by Guyuron as a master rhinoplastic surgeon to obtain consistently good
results,
Mehta, U, Mazhar, K, Frankel, AS. Accuracy of preoperative computer imaging in rhinoplasty. Arch Facial Plast Surg. 2010;12(6):394-398.
Daniel, RK. Rhinoplasty: creating an aesthetic tip. Plast Reconstr Surg. 1987;
80:775.
Rohrich, RJ, Adams, WP Jr, Deuber, MA. Graduated approach to tip refinement and projection. In: Gunter, JP , Rohrich, R , Adams , eds.
Dallas Rhinoplasty: Nasal Surgery by the Masters. St Louis, MO: Quality Medical Publishing; 2002:333.
Toriumi, D. New concepts in nasal tip contouring. Arch Facial Plast Surg. 2006;8:156-185.
Byrd, HS, Hobar, PC. Rhinoplasty: a practical guide for surgical planning. Plast Reconstr Surg. 1993;91:642-654.Describes Byrd’s method for
mathematically analyzing nasal anatomic relationships based on measurements of a particular population judged as having attractive noses.
Chauhan, N, Alexander, AJ, Sepehr, A, Adamson, PA. Patient complaints with primary versus revision rhinoplasty: analysis and practice
implications. Aesthet Surg J. 2011;31:775.
Gunter, JP, Hackney, FL. Clinical assessment and facial analysis. In: Gunter, JP , Rohrich, RJ , Adams, WP Jr , eds. Dallas Rhinoplasty: Nasal
Surgery by the Masters. St Louis, MO: Quality Medical Publishing; 2002:53.
Rohrich, RJ, Hollier, LH. Use of spreader grafts in the external approach to rhinoplasty. Clin Plast Surg. 1996;23(2):255-262.
Sheen, JH. Spreader graft: a method of reconstructing the roof of the middle nasal vault following rhinoplasty. Plast Reconstr Surg.
1984;73(2):230-239.An early presentation of spreader grafts by their inventor.
Adamson, PA, Funk, E. Nasal tip dynamics. Facial Plast Surg Clin North Am. 2009;17:29-40.
Hewell, TS, Tardy, ME. Nasal tip refinement. Facial Plast Surg. 1984;1:87.
Sullivan, PK, Harshbarger, RJ, Oneal, RM. Nasal osteotomies. In: Gunter, JP , Rohrich, RJ , Adams, WP Jr , eds. Dallas Rhinoplasty: Nasal
Surgery by the Masters. St Louis, MO: Quality Medical Publishing; 2002:595.
Gunter, JP, Rohrich, RJ, Friedman, RM, et al. Importance of the alar-columellar relationship. In: Gunter, JP , Rohrich, RJ , Adams, WP Jr , eds.
Dallas Rhinoplasty: Nasal Surgery by the Masters. St Louis, MO: Quality Medical Publishing; 2002:105.
Guyuron, B. Is packing after septorhinoplasty necessary? A randomized study. Plast Reconstr Surg. 1989;84(1):41-44.
Mansfield, CJ, Peterson, MB. Toxic shock syndrome: associated with nasal packing. Clin Pediatr (Phila). 1989;28:443-445.
Guyuron, B. Precision rhinoplasty. Part II: prediction. Plast Reconstr Surg. 1988;81:500-505.Second in a set of two articles showing the methodology
used by Guyuron as a master rhinoplastic surgeon to obtain consistently good results,
Klassen, AF, Cano, SJ, East, CA, et al. Development and psychometric evaluation of the FACE-Q scales for patients undergoing rhinoplasty.
JAMA Facial Plast Surg. 2016;18(1):27-35.
Kosowski, TR, McCarthy, C, Reavey, PL, et al. A systematic review of patient-
reported outcome measures after facial cosmetic surgery
and/or nonsurgical facial rejuvenation. Plast Reconstr Surg. 2009;123(6):1819-1827.
Menger, DJ, Richard, W, Swart, KM, et al. Does functional septorhinoplasty provide improvement of the nasal passage in validated patient-
reported outcome measures? ORL J Otorhinolaryngol Relat Spec. 2015;77(3):123-131.
Rhee, JS, Sullivan, CD, Frank, DO, et al. A systemic review of patient-reported nasal obstruction scores: defining normative and symptomatic
ranges in surgical patients. JAMA Facial Plast Surg. 2014;16(3):219-225.
Schwitzer, JA, Sher, SR, Fan, KL, et al. Assessing patient reported satisfaction with appearance and quality of life following rhinoplasty using
the FACE-Q appraisal scales. Plast Reconstr Surg. 2015;135(5):830e-837e.
Stewart, MG, Witsell, DL, Smith, TL, et al. Development and validation of the Nasal Obstruction Symptom Evaluation (NOSE) scale.
Otolaryngol Head Neck Surg. 2004;130(2):157-163.One of the first validated patient-reported outcome measured instruments for functional
septorhinoplasty.
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C H A P T E R 5 3
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Otoplasty
Arin K. Greene
Key Points
Ear anomalies can be characterized by having excess structures, deficient parts, or adequate
components that need to be rearranged.
Ear molding may correct some anomalies during the neonatal period.
Most otoplasty procedures are best performed ≥3 years old when most ear growth is completed.
Otoplasty should aim to achieve symmetry on frontal view.
Simple otoplasty techniques are considered before more complicated reconstructive procedures.
About 50% of newborns have an auricular deformity that persists in 33% by 1 month old 1 ; as many as
84% of deformities continue to improve over the first year of life. 2 An exception is prominent ears, which
increase from birth to 1 year old, suggesting that postnatal deformation can contribute to this condition
(e.g., infant sleep position may push the ear outward). 1,2 Half of children have a bilateral deformity, and
when deformity is unilateral, the right and left sides are affected equally. 1 No difference in the
prevalence or type of ear deformity exists among males and females. 1 A helical anomaly/constricted ear
is the most common disorder at birth (15%). 1 Vaginal delivery and increased birth weight increase the
risk of ear anomalies, likely due to forces on the ear causing deformations. 1
Otoplasty is used to reconstruct several types of ear abnormalities. The primary morbidity of an ear
deformity is psychosocial. Ear anomalies do not affect hearing and thus insurance companies often do not
cover the procedure. Correction of some deformities (e.g., cryptotia) can facilitate the use of eyeglasses. In
the pediatric population, ear anomalies can be particularly worrisome for families because they often
have to pay for the procedure, and they are subjecting their child to general anesthesia for a “cosmetic”
problem. Consequently, surgeons treating ear anomalies should be well trained on the subject and ensure
that patients and families have reasonable expectations.
The ears are particularly tolerant of asymmetry because of their lateral position over the temporal bones.
The full appearance of the ears cannot be appreciated on frontal view. To compare the ears, an individual
must look at one ear first and then change positions to see the contralateral side. Consequently, it is most
important to have the ears as symmetrical as possible on frontal view. Because most ear anomalies cause
a “cosmetic” problem, patients and families can be focused on minor asymmetries. It is important that
families understand that asymmetries between the ears are common in the general population 3,4 and that
there will be some asymmetry following the procedure.
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Diagnosis
Diagnosis of an ear anomaly is made by physical examination. Ear abnormalities can be broadly
separated into malformations (absence of part of the ear) or deformations (fully developed ear but
misshapen). The surgeon should be able to identify the abnormality and list reconstructive options. I
approach the management of ear anomalies by dividing them into three categories:
Excess components—treated by excision
Deficient parts—managed by addition of tissues
Adequate structures that are malformed—treated by rearrangement of tissues
The surgeon must understand normal ear anatomy and can use the contralateral ear, if normal, as a guide
(Figure 53.1). The axis of the ear is angled approximately 20° more posterior than a vertical line. The top
of the helix is at the level of the eyebrow and the lobule is at the base of the columella. The height of the
ear is 6.5 (±1) cm, and its width is 4.0 (±0.5 cm). 5,6 It is located one ear length (6–7 cm) posterior to the
lateral canthus. Although several measurements for abnormal protrusion from the mastoid have been
described, I use greater than 18 mm at the top of the helix and 21 mm at the midhelix. 3
FIGURE 53.1 Ear anatomy.
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Nonoperative Treatment
A window exists during the neonatal period when the ear can be molded. 7 Because some anomalies
improve during the first week of life, molding should not be initiated until at least 1 week old to allow for
possible spontaneous correction. 8 Ideally, molding is started between 1 and 3 weeks old when maternal
estrogens in the child facilitate cartilage manipulation. The ear can be molded using wire and tape or a
commercially available system (Figure 53.2). 8,9 Unfortunately, patients often are referred after the
window to mold their ears has passed. At 6 weeks old, estrogens in the child equal that of an adult and if
ear molding is initiated after this time, patients are likely to have a poor response. 9 If the mother is
breast-feeding, initiation of ear molding can be attempted up to 8 to 10 weeks old. After 12 weeks old, ear
molding is not effective. 9 The ear deformity that is most amenable to molding is a prominent ear. The
antihelical fold is recreated to set back the ear. A mildly constricted ear with overhanging helical cartilage
can be improved by lifting the helical cartilage into better alignment. A Stahl deformity can be corrected
by flattening the abnormal crus.
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FIGURE 53.2 Ear molding. A. Two methods of ear molding. Wire and tape (left) and a commercially available system (right).
B. Before (left) and after (right) molding of a prominent ear deformity. C. Before (left) and after (right) molding of a mildly
constricted ear.
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Timing of Operative Treatment
The primary indication for otoplasty is to improve the patient’s self-esteem. Cryptotia and
moderate/severe constricted ears can inhibit the ability to wear eyeglasses. Timing of intervention falls
into three categories: infancy, 3 to 4 years old, and late childhood or adolescence. Simple excisions of
excess structures can be performed during infancy with local anesthesia. Parents having children with
preauricular cartilage remnants usually are eager to remove them as soon as possible. Most are small and
able to be excised using local anesthesia in the office, as early as 4 to 6 weeks old. After 12 months old,
however, it is difficult to restrain an awake child and I will perform the procedure in the operating room
with sedation or wait until the child is old enough to cooperate in the clinic. If a child has an ear
deformity that cannot be corrected simply using local anesthesia, then I prefer general anesthesia.
Because long-term memory and self-esteem begin to form at approximately 4 year old, many parents
decide to correct an ear anomaly when the child is between 3 and 4 years old. At this time, the ear has
achieved 85% of its size and the risk of scar limiting ear growth is reduced. 6,10 Most ear growth is
completed by 6 years old. 6,10 Although data have shown that operating on ears before 3 years old does
not inhibit growth, 11 I prefer to wait until at least 3 years old because (1) the ear is larger to facilitate the
procedure and (2) it is not urgent to intervene before this time because memory and self-esteem have not
yet formed. An advantage of early intervention is that children tolerate the procedure more favorably
than older patients who are more anxious about the operation and are busier with activities such as
sports and school.
If an individual has a mild deformity that he/she may not want to have improved, then it is prudent to
wait until they are older to determine if they become bothered by it. Some families choose to wait to
correct a significant ear anomaly until the child is old enough to participate in the decision to have the
procedure. Children between 5 and 8 years old typically are bothered by a deformity, but fear of the
operation outweighs their desire to improve their appearance. At 9 to 10 years old, the child’s interest in
correcting the anomaly begins to outweigh the anxiety about the operation. Girls typically present later
than boys, because they are better able to camouflage their deformity with hair. Males often will grow
their hair long to hide their ear.
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Prominent Ear
Approximately 5% of the population has a prominent ear caused by an absent or weak antihelical fold
and/or overgrown concha (Figure 53.3). 1,2 Most patients will require recreation of the antihelical fold and
setback of the concha. Rarely, a patient will have a normal antihelix and only require a procedure on the
concha. Similarly, an individual may have a normal concha and only require formation of the antihelical
fold. The prominence of the auricle can be evaluated by considering the upper, middle, and lower thirds
of the ear. Although all patients will need to have the upper and/or middle third of the ear setback, 25%
of patients in my practice will benefit from having their lobule setback as well. Three-fourths of patients
in my experience undergo bilateral setback otoplasty, whereas one-fourth of individuals have
prominence of only one ear.
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FIGURE 53.3 Otoplasty for a prominent ear. A. Preoperative view illustrating the absence of the antihelical fold and overgrown
conchal bowl. B. Postoperative appearance.
Although setback otoplasty is a clean case, I give one dose of intraoperative antibiotics because I am
placing permanent foreign bodies (merseline sutures) and exposing cartilage. I do not prescribe
postoperative antibiotics. After the patient is under general anesthesia, I measure the distance of the ears
to the mastoid from the most prominent part of the superior helix and from the midhelix at the level of
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