Phẫu Thuật Tạo Hình (Tập 2): Phẫu Thuật Thẩm Mỹ – Neligan (Ấn bản 4)

SECTION I • Aesthetic Surgery of the Face
15 
Nasal analysis and anatomy
Rod J. Rohrich
SYNOPSIS
■ Surgery begins with a careful preoperative analysis utilizing
standardized measurements.
■ All tissues including bone, cartilage, and soft tissue may contribute to
any one measurement, e.g., nasal length.
■ Nasal anatomy is considered within the context of facial shape, facial
proportions, and the size and shape of adjacent structures.
■ Knowledge of nasal anatomy facilitates the use of an algorithmic
approach to surgery that increases the predictability of surgery.
■ A knowledge of blood supply increases the safety of the open
approach to rhinoplasty.
■ Any rhinoplastic problem can be analyzed by the component
structures and their relationship to one another.
Introduction
A thorough understanding of nasal anatomy enables the
practitioner to accurately perform reconstructive and aesthetic
rhinoplasty.1 Nasal surgery is recognized as one of the most
difficult procedures in plastic surgery, and accomplishing
predicable results is a challenging task for the surgeon. Rhi­
noplastic surgery can be approached with these points in
mind.
A discussion of nasal anatomy begins with a description of
the terms commonly used. These terms are the language that
describes nasal anatomy, shape, and form.
Surgery begins with a careful preoperative analysis utiliz­
ing standardized measurements. One must accurately describe
the deformity in order to establish an operative goal. Less
than hoped for results often occur as a direct result of failure
to recognize one or more features prior to surgery.2
All tissues including bone, cartilage, and soft tissue may
contribute to any one measurement, e.g., nasal length. This is
the main reason that understanding nasal anatomy is so criti­
cal to the performance of successful rhinoplasty surgery. Any
rhinoplastic problem can be analyzed by individual compo­
nents and their relationship to one another.3 Nasal anatomy
is considered within the context of facial shape, facial
proportions, and the size and shape of adjacent structures.4
The size and position of the chin, facial width, and facial
height, are examples of factors that may influence the opera­
tive goal.
A basic knowledge of blood supply increases the safety of
the open approach to rhinoplasty. This information is also
important to avoid injury to the angular artery during external
percutaneous osteotomy, and to avoid inadvertent intravas­
cular injections.5 Knowledge of nasal anatomy combined with
the ability to preoperatively analyze the nose facilitates the
use of an algorithmic approach to surgery that increases the
predictability of surgery.
The nose is described employing a standardized terminol­
ogy (Fig. 15.1). These terms allow standardized measurements
to be defined (Fig. 15.2). The nasolabial angle gives an
approximation of tip rotation relative to the Frankfort hori­
zontal plane, drawn through the external auditory canal to
the orbital rim. The nasofrontal angle is defined from the
glabella to radix to nasal tip. Normative values exist for these
measurements and vary according to gender (Fig. 15.3). The
normative values for tip projection, the distance from the alar
crease to the nasal tip, is calculated in three ways and described
later in the text. The tip-defining points seen on anterior view
are located where the lateral crurae begin to diverge. The
crurae themselves consist of three sections or parts, each with
its own curvature. The pyriform aperture, best visualized on
basal view, corresponds with the bony aperture of the maxilla
along the inferior nasal passage (Fig. 15.4).
The algorithm for preoperative assessment follows that
previously described.1 The relationship of the nose to the face
is first analyzed. The nose is thus considered in the context of
overall facial proportions for precise analysis. A simple tech­
nique for understanding facial proportions is using the fractal
technique of thirds: the upper, middle, and lower face vertical
heights are considered to be equal thirds. The lower face is
the distance from the alar base to the chin (menton). This is
further divided into thirds with the distance from the alar
base to lip crease (stomion) being one-third of this height.
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SECTION I
CHAPTER 15 • Nasal analysis and anatomy
of the nasal bones and upper vault, and points out asymme­
tries of the lower lateral cartilages.6
The dorsal aesthetic lines are determined by a line drawn
from the medial brow to the tip-defining points and should
be two gently diverging curves. These can be judged relative
to vertical lines drawn from the medial brows through the
lateral nostril (Fig. 15.7).
The distance between the alar bases is approximately equal
to intercanthal width. Alar shape is analyzed on frontal view
Frontal view allows nasal length to be analyzed relative to
lower facial proportions. One measurement suggests that the
distance from radix to tip-defining points is equal to the dis­
tance from stomion to menton (Fig. 15.5).
The nose is viewed from the frontal view (Fig. 15.6). A line
drawn from the glabella, radix through the middle lip and
chin helps to assess nasal deviation. The vertical line drawn
from the radix to the midline lip and chin analyzes several
structures. It helps to determine septal deviation, the position
Fig. 15.1  Standardized terminology of external nasal
landmarks exists that facilitates a discussion of
proportionate and disproportionate nasal aesthetics.
These landmarks, essentially reference points of nasal
topography, often relate directly to the shape and
relationship of underlying structures.
Radix
Keystone
area
Scroll
area
Alar
groove
Alar
cheek
groove
Alar
groove
Nostril
sill
Nostril
sill
Nostril
rim
Supratip
Tip
Lobule
Columella
Dorsal
hump
Nasal
dorsum
Infratip
lobule
Fig. 15.2  Angular measurements assess multiple factors such
as nasal length, alar base position, and lip aesthetics.
Nasofrontal
angle
Columellar–
labial angle
Horizontal
facial plane
Nasolabial
angle
Fig. 15.3  Tip projection, a critical
measurement in preoperative analysis, is
defined as the maximal distance from alar
base to the nasal tip.
Nasal
length
Tip
projection
Tip-
defining
points
Soft triangle
Caudal border lower
lateral cartilage
Weak
triangle
Cephalic
border
Nasal
tip
Columellar
lobular angle

419
Introduction
Radix is an important point that helps to define the naso­
frontal angle defined as the angle formed by the frontal bone
and a line drawn parallel to the nasal bone. If the nasofrontal
angle is positioned more anteriorly or superiorly than normal,
the nose appears elongated, and the tip projection will appear
less, while if the nasofrontal angle is more posterior and
inferior than normal, the nose will look shorter, and the tip
will appear to project more. The radix forms the cephalic end
for the measurement of nasal length, which is the distance
from the radix to the nasal tip. Normally, nasal length is equal
to the distance from stomion to menton (Fig. 15.11).
The nasal dorsum is then analyzed. The nasal dorsum lies
slightly behind a line drawn from the radix to the nasal tip,
more so in females than in males. The supratip break occurs
cephalad to the tip-defining points and 2–3 mm behind the
line from radix to nasal tip in women (Fig. 15.12). A slightly
lower value is more desirable in males.
The nasolabial is then assessed. It is formed by a line drawn
through the anterior and posterior ends of the nostril and the
vertical facial plane. The nasolabial angle is usually 95–100°
in females and 90–95° in males (Fig. 15.13). This is slightly
different than the columellar–labial angle, which is formed by
the columella and the upper lip, an angle that is often influ­
enced by a prominent caudal septum, which gives the impres­
sion of increased tip rotation despite a normal nasolabial
angle.
Another determinant of tip rotation is the columellar–
lobular angle, formed at the junction of the columella and the
infratip lobule and represents the junction between the middle
and medial crura. The ideal columellar–lobular angle is 30–45°
in females.
The relationship between the ala and columella is assessed.
A line drawn through the long axis of the nostril should bisect
the oval formed by the nostril in lateral view (Fig. 15.14). A
and has a gull wing-shaped curve, defined by the curvature
of the lateral and middle crurae (Figs. 15.8 & 15.9).
The lateral view is then reviewed. As with the frontal view,
the nose is analyzed in the context of position and facial
proportions (Fig. 15.10). On lateral view, the alar base should
lie slightly anterior to the medial canthus. The upper lip is
slightly anterior to the lower lip; the lower lip is slightly
anterior to the chin. This analysis can reveal micro- or macro­
genia, as well as skeletal disharmonies including maxillary
retrusion with a retro-displaced alar base.
The nose itself is analyzed in lateral view beginning with
the position and depth of the nasal root at the nasofrontal
angle (radix). The radix lies at a point between the lash line
and supratarsal crease with the eyes in horizontal gaze. The
depth of the radix, or the nasion–medial canthal distance, is
approximately 15 mm.
Fig. 15.4  The lower lateral cartilages, comprising the lower third nasal vault, have
three defined segments. These segments are determined by where the lower lateral
cartilages display marked changes in curvature.
Lateral crus
Medial crus
Medial crus
Fig. 15.5  General guidelines exist to assess nasal aesthetics in relation to the rest
of the face. One guideline suggests that nasal length is equal to lower facial height.
M, menton; R, radix; S, stomium; T, tip.
R
T
S
M
Fig. 15.6  A line drawn from midline glabella to menton helps to assess nasal
symmetry. This simple method is one of the best means to analyze septal deviation
and the position of the nasal bones. It also emphasizes asymmetries of the maxilla
or mandible.

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CHAPTER 15 • Nasal analysis and anatomy
greater distance below the long axis may indicate a hanging
columella, and a greater distance above the long axis may
indicate retracted ala. This issue is reviewed more thoroughly
in Chapter 16.
Tip projection is then assessed. Tip projection is defined as
the distance from alar base to the nasal tip (see Fig. 15.13). If
50–60% of the tip lies anterior to the vertical line adjacent to
the most projecting part of the upper lip, tip projection is
considered normal. If it is >60%, the tip may be overproject­
ing. Inadequate tip projection is suggested by a value <50%.
Similar to the rule of thirds used to evaluate the nasal
proportions relative to the overall face, tip projection
is 0.67 of total nasal length as measured from radix to
Fig. 15.7  The dorsal aesthetic lines should be a gentle curve
from brow to tip.
Fig. 15.8  For measurements, especially angular values, to be reproducible, head
position is standardized. Here the Frankfort horizontal is shown: the line from the
external auditory canal to the orbital rim is parallel to the horizon.
Nasal horizontal
Frontal plane
tip-defining points. If the ratio is <0.67, there is inadequate tip
projection.
Basal view provides information regarding alar shape, tip
projection, and alar width. The base of the columella and alar
rims should form an equilateral triangle (see Fig. 15.14). The
infratip lobule is one-third of the distance from alar base to
tip. The alar base view also visualizes alar base width and
flaring. The alar rims on basal view should have a flare of
2 mm. Any asymmetries in alar shape are noted. This analysis
provides the information necessary to formulate a detailed
operative plan including the techniques required to meet the
surgical goals.
The technical maneuvers of open rhinoplasty are facilitated
by an understanding of the details of nasal anatomy. Blood
supply to the nasal tip is the one anatomical point of over­
whelming significance that has contributed most to the safety
of open rhinoplasty. Understanding the vascular supply of the
nose, and how to preserve its intricate network, enhances the
safety of the open approach in not only primary rhinoplasties,
but secondary and tertiary procedures as well.
Blood supply
The extensive collateral blood supply of the nose makes the
open approach a safe procedure. Local flaps and wide under­
mining are possible because the multiple vessels supplying
the nasal tip. Latex injection gives some indication of the
degree of collateralization encountered during rhinoplasty.
Both a branch of the internal carotid, the supratrochlear, and
a branch from the external carotid, the facial artery, give rise
to branches that cross the midline. These form a vascular
network that crosses the dorsum.
The supratrochlear branch gives rise to lateral nasal,
descending external nasal, and angular vessels (Fig. 15.15).
The supratrochlear artery gives rise to the angular vessel and
the lateral nasal and external nasal arteries (Fig. 15.16). These
course directly below the dermis, superficial to the intrinsic
nasal muscles.
The facial artery travels superiorly to connect with the
angular vessel. Along the way, inferior to the nose, it gives rise

Fig. 15.9  The width of the bony base relative to the alar
base is then assessed. (A) The bony base width should be
80% of the normal alar base width. (B) A normal alar base
width is equal to the intercanthal distance or the width of
one eye.
A
B
Fig. 15.10  With the head in the standardized position, nasal
length and tip projection are analyzed. A, alar base; M,
menton; R, radix; S, stomium; T, tip.
R
T
A
S
M
Fig. 15.11  A line drawn from radix to nasal tip helps to analyze
dorsal aesthetics. The dorsum is located behind this line, and the
steepest curve occurs just cephalad to the nasal tip. This supratip
break is determined by the relationship between tip projection and
septal and upper lateral (middle vault) height.
Nasofrontal angle
Supratip break
Columellar-labial angle
Tip defining points

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SECTION I
CHAPTER 15 • Nasal analysis and anatomy
to the superior labial artery. The sill artery is a small branch that
arises from the superior labial artery (Fig. 15.17). The superior
labial also gives rise to the philtral arteries, these providing the
main contribution to the ascending columellar arteries.
The columellar artery is transected during the external
nasal approach, but this has little effect because of the multiple
branches that perfuse the region of the nasal dome. There
likewise exist multiple arcades, which arise from both the
supratrochlear, as well as the facial arteries. The arcades are
transected during surgery that removes any part of the ala.
Again, extensive collateralization protects the remaining
medial and lateral areas of the nose.
Fig. 15.12  The nasolabial angle is shown on the left, and the
columellar–lobular angle is shown on the right. While less discussed, it
is important to remember that the nasolabial angle is determined by alar
base position as well as tip projection and nasal length. Maxillary
deficiency has a tremendous effect in determining the nasolabial angle.
The columellar–lobular angle is determined by fewer variables: it simply
represents the transition from medial to middle crura.
45º
Nasal horizontal
Frontal plane
95–100º
Fig. 15.13  Tip projection can be analyzed by three techniques, either relative to
the nostril or relative to nasal length. Here, two methods are shown.
A
B
1.0
A=50–60%
0.67
Fig. 15.14  Tip projection is determined here relative to nostril position. In
addition, basal view should reveal the nose as an equilateral triangle.
1/3
2/3
Two points are suggested by this anatomy. The first is that
dissection in the correct plane preserves the blood supply,
even in compromised nasal tips. The safety of the external
approach in secondary procedures is increased by dissection
directly above perichondrium. This way, the delicate subder­
mal plexus is spared further trauma that could compromise
blood supply. The second point is that the arteries of the nasal
vasculature are significant and should be cauterized if cut.
This must be done with care because imprecise cauterization
can injure adjacent vessels. One can draw an analogy of the
blood supply of the nose to that of any other aperture on the
face. The eye, nose, and mouth are each protected by a
dual blood supply that travels circumferentially around each
aperture. In the case of the eyelid, the facial and supratrochlear
give rise to the marginal arteries; the facial and angular con­
tribute to the superior and inferior labial vessels, and the
supratrochlear and facial arteries provide blood supply to the
skin around each nostril. In each instance, these blood vessels
are directly beneath dermis.
It is during subdermal dissection, as may occur during
excessive defatting of a nasal tip, that the delicate blood
supply is at risk and may result in skin necrosis. The lateral

423
Nerve supply
Fig. 15.15  Vascular supply to the nose. This is derived from branches of the
ophthalmic and facial arteries.
Arcades
Columellar
branches
Philtral
branches
Superior
labial artery
Facial artery
Angular artery
Lateral
nasal artery
Fig. 15.16  The blood supply to the nose arises from both the internal and external
carotid arteries. a., artery; m., muscle.
Angular a.
Lateral nasal a.
External nasal a.
Transverse nasalis m.
Depressor septi m.
Fig. 15.17  All major nasal arterial branches lie above the muscles and nasal
fascia. Dissection deep to this plane spares collateral blood supply during the open
rhinoplasty technique. a., artery.
Sill a.
Central and lateral
philtral a.
Superior labial a.
Facial a.
Angular a.
Columellar a.
nasal artery is one of the main sources of blood supply to
the nose; this vessel is at risk during wide lateral skin
undermining.
The venous drainage of the nose consists mainly of vessels
anastomosing with the facial vein, either through veins travel­
ing from the dorsum and lateral nasal wall, or via vessels
accompanying the philtral and superior labial vessels.
Nerve supply
The main sensory nerves to the nose are branches of the
infraorbital nerve and the external nasal nerve, both of which
are terminal branches of the trigeminal nerve.
Fig. 15.18  The infraorbital nerve travels through its canal and exits through the
foramen to supply much of the lateral nose and tip. Supratrochlear and ethmoidal
branches supply the superior nasal skin.
Infraorbital
nerve
Nasal branches
Fig. 15.19  Clinically, nerve block at the alar base leads to anesthesia of the nasal
alae, side walls, and tip. A dense confluence of branches from V2 is found at this
location. m., muscle.
Alar branch V2
Levator labii m.
The infraorbital nerve, exiting the foramen rotundum and
coursing through the maxillary sinus in its own canal, exits
the maxilla through the infraorbital foramen (Fig. 15.18). This
foramen generally lies 10–12 mm below the orbital rim,
although there is significant variation depending on factors
including the age of the individual. There are multiple
branches of this nerve, and these provide sensation to the alar
base, upper lip, and lateral nasal wall. The dense confluence
of sensory branches of V2 at the alar base makes local anes­
thesia possible with subdermal infiltration. Infiltration at the
alar base is an ideal point with which to anesthetize the nasal
tip (Fig. 15.19).
An important consideration is that the alar and sill arteries
are located in direct contact with the sensory branches of the
infraorbital nerve at this location and require care during
infiltration to prevent bleeding or intra-arterial injection.
Another approach to local block of the infraorbital nerve
includes direct infiltration at or within the foramen.

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CHAPTER 15 • Nasal analysis and anatomy
The second main sensory nerve supply to the nose is via
the external nasal branch of the V1. This arises from the
anterior ethmoidal branch of the frontal nerve and exits
through a small foramen in the midportion of the nasal bone.
The placement of local anesthetic at this location and at the
alar base will result in near-complete anesthesia of the nasal
skin.
Intrinsic and extrinsic nasal
musculature
The intrinsic muscles of the nose are the nasalis and its lower
portion, which is known as the dilator naris or as the levator
alae. The external muscles of the nose are the procerus, the
orbicularis, the depressor septi, and the levator labii alaeque
nasi. The importance of the nasal muscles is frequently under­
stated. They are important for animation, but intrinsic muscles
are also important to maintain a patent nasal airway.
The transverse part of the nasalis muscle inserts into the
edge of the upper lateral cartilage (Fig. 15.20). Contraction of
this muscle splays the upper lateral cartilage, increasing nasal
airflow. A front view emphasizes the relationship of the
transverse part of the nasalis muscle to the upper lateral
cartilage.
Two muscles control the position of the alar rim. The small
levator alae and the levator labii muscles flare the nostril rim
with contraction. Moreover, tonic contraction of these muscles
contributes to patency of the external nasal valve. One sees a
loss of function of these muscles with facial nerve paralysis
that results in collapse of the external nasal valve. Similarly,
the internal nasal valve is compromised by loss of function of
the transverse part of the nasalis muscle. The origin and inser­
tion of each of these muscles determines their contribution to
nasal airflow. Another situation that may result in diminished
nasal airflow is ablation of the alar rim, with loss of the eleva­
tor alae muscle.
Both the thickness of alar skin and tonic contraction of this
small, fine muscle are important in maintaining alar rim shape
and position. Cartilage grafts provide static support to substi­
tute for loss of these muscles from any cause.
There is some debate whether the levator labii is separate
from the levator alae – hence the frequent name “levator labii
alaeque nasi”. However, careful dissection shows that these
muscles are distinct (Fig. 15.21). The levator alae muscle
Fig. 15.20  Nasal muscles can be intrinsic or extrinsic. Both are important as a
dynamic means of providing nasal airway patency. Airflow can be diminished by
inadvertent injury to these muscles, especially the transverse nasalis; middle vault
disturbances are common in Bell’s palsy. m., muscle.
Nasalis m., transverse part
Nasalis m., vertical part
Upper lateral cartilage
Fig. 15.21  As seen in this dissection, nasal muscles may run together and
intertwine. This is important physiologically, as contraction of groups of muscles
usually occurs rather than contraction of one isolated muscle. Flaring of the nostrils
to increase nasal airflow is accomplished by contraction of the levator alae,
transverse nasalis, and orbicularis oris muscles. m., muscle; n., nerve.
Nasalis m. transverse part
Levator alae m.
Orbicularis oculi m.
Levator alae m.
Levator labii m.
Facial n. buccal branch
Fig. 15.22  The depressor septi muscle, beneath orbicularis oris muscle, may
cause the transverse upper lip crease. This muscle insert into the caudal septum.
m., muscle.
Inter-alar ligament
Depressor septi m.
Orbicularis oris m.
Sub-alar space
originates at the upper maxilla along the nasal bone. The
levator labii muscle (m.) arises from along the orbital rim and
lies beneath orbicularis oris muscle.
The levator alae m. elevates the ala and increases the area
of the external valve, as well as serving as a muscle of expres­
sion. The levator labii muscle primarily elevates the lip during
smiling and increases oral aperture size. The levator anguli
m. described in the section on facial muscles is termed the
“caninus”; however, this is a misnomer, at least from a func­
tional point of view. It is the levator labii m. that exposes the
canine, whereas the levator anguli m. controls vertical com­
missure position.
The depressor septi has its origin at the caudal septum. Its
insertion is the orbicularis muscle of the upper lip and is part
of the lip elevator complex (Fig. 15.22). The presence of the
depressor septi muscle is occasionally accompanied by a
transverse upper lip crease in some individuals. Denervation
of this muscle will diminish this crease, albeit at the expense
of increasing central upper lip height.
The intrinsic and extrinsic nasal muscles are interrelated
such that they usually contract as units of two or more
muscles. Therefore, the term “muscle of expression” is not
entirely accurate, since one muscle may be expressive and
functional, as is the case of the levator alae muscle. Muscles

425
Nasal bones, cartilages, and septum
stable with all soft tissue removed (sub-alar space). Usually,
submuscular fat lies in this space. However, with all the
adipose tissue and muscles removed, the alae are still stable
in their anterior posterior position. This one point stresses the
importance of the nasal septum in providing support for the
entire nose.
Nasal bones, cartilages, and septum
The upper third of the nose is a bony pyramid formed by the
nasal bones and the frontal process of the maxilla. This con­
stitutes the upper nasal vault (Fig. 15.25).
The paired upper lateral cartilages form the middle third
of the nose. They are triangular in shape and attach to the
nasal bones cranially and to the nasal septum dorsally. At
their most superior extent, they are overlapped by the nasal
bones for 4–5 mm in the so-called “keystone area”, normally
the widest part of the nasal dorsum (Fig. 15.26).
The importance of the relationship of the upper lateral
cartilages to the nasal septum is that an “I-beam” structure
is formed (Fig. 15.27). This provides stability for the middle
third of the nose so that collapse and subsequent airway
constriction does not occur.8 At the same time, lateral motion
of the upper lateral cartilages can occur, with contraction
of the transverse part of the nasalis muscle. Function­
ally, this attachment of the upper lateral cartilages to the
nasal dorsum is the framework of the internal nasal valve
(Fig. 15.28).
The anatomical relationship between the septum and upper
lateral cartilages (Fig. 15.29) explains why removing upper
lateral cartilage or overzealous septal trimming can result in
airway collapse.9 If this occurs, recreating the “I-beam” con­
struction with a spreader graft restores patency of the internal
nasal valve. This will be covered in Chapters 16–18.
The upper lateral cartilages are not in contact with the
maxillary bone. However, at the pyriform rim, these cartilages
are held in place by a membrane that encompasses them
as well as the edge of the nasal bone and lower lateral
cartilage.
Fig. 15.23  Ligaments, as condensations of deep fascia, exist throughout the nose.
These ligaments are released during rhinoplasty, highlighting the importance of
knowing their anatomic location as well as the importance of reconstructing them
with the various suturing techniques.
Dome
Middle crus
Inter-alar
ligament
Fig. 15.24  Cartilaginous framework. The cartilages are connected to each other,
the upper lateral cartilages, and the septum by fibrous tissue and ligaments.
Upper lateral
Lower lateral
Elastic fibers
Pyriform abutment
Pyriform
ligament
Inter-alar ligament
Fig. 15.25  The three nasal vaults—upper, middle, and lower—are shown with
their corresponding anatomical structures. The upper vault is formed by the nasal
bones, the middle vault by the upper lateral cartilages, and the lower vault by the
lower lateral cartilages. Upper lateral cartilage lies deep to both the nasal bone and
lower lateral cartilage.
Tip-defining point
Nasal septum
Lower lateral cartilage
(Alar cartilage)
Upper lateral cartilage
Nasal bone
are also part of static support nasal position; such is the case
with the alar rim and alar base. Inadvertent injury to an
intrinsic muscle, such as the transverse part of the nasalis,
may destabilize the upper lateral cartilages and contribute to
decreased nasal airflow.
Nasal ligaments
Ligaments are another part of static support.7 There are fibrous
connections between the upper portion of the lateral crura
and the lower portion of the upper lateral cartilage. Fibrous
connections also stabilize the medial crura to the distal
septum. Dorsally, the alar domes are interconnected by a
superficial ligament in the superficial fascia and by the inter-
alar ligament proper, often referred to as “Pitanguy’s liga­
ment” (Figs. 15.23 & 15.24). The inter-alar ligament stabilizes
the lower lateral cartilages at the level of the medial–middle
crura junction. Its disruption can lead to widening and distor­
tion of the nasal tip. For this reason, one can see why inter­
domal sutures are necessary after open rhinoplasty, where
these structures are frequently divided.
While muscles and ligaments are important for nasal
support, dissections demonstrate that the alar base position is

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CHAPTER 15 • Nasal analysis and anatomy
Fig. 15.26  Diagrams of the cartilaginous and bony nose and septum.
Sella turcica
Sphenoid sinus
Vomer
Crest of palatine bone
Crest of maxillary bone
Perpendicular plate of ethmoid bone
Anterior septal
angle
Anterior nasal spine
Premaxilla bone
Nasal bones
Nasal bone
Upper lateral cartilage
Upper lateral cartilage
Piriform aperture
Lateral crus
Medial crus
Septum
Anterior nasal spine
Maxillary crest
Lower lateral cartilage
Quadrangular septal cartilage
Fig. 15.27  Upper lateral cartilage constitutes the middle nasal vault. Transverse
nasalis inserts onto the edge of upper lateral cartilage such that muscular
contraction enables increased nasal airflow. Either disruption of the relationship of
the upper lateral cartilage to the septum, or paralysis of the nasal musculature, can
lead to diminished middle vault patency.
Septum beneath nasal
bone and upper
lateral cartilage
Lower lateral cartilage
Upper lateral cartilage
(reflected)

427
Nasal bones, cartilages, and septum
Fig. 15.28  Cartilaginous framework showing the location of
internal and external valves.
Internal valve
External valve
Fig. 15.29  The critical relationship of septum to the upper lateral cartilage can not
be stressed enough. This “T” configuration of cartilage to septum prevents middle
vault collapse. The narrowed middle vault after rhinoplasty is pathognomic of
disruption of this critical anatomy.
Septum
Upper lateral
cartilage
Fig. 15.30  The lower lateral cartilages, along with skin, subcutaneous tissue, and
the diminutive elevator alae muscle, constitute the external nasal valve. Their
height, width, shape, and contour determine the aesthetics of the nasal tip.
Medial
Lateral
Middle
Accessory
cartilage
The lower third of the nose is defined by the lower lateral
cartilages, which have three components: a medial, middle,
and lateral crura (Fig. 15.30). The upper portion of the lateral
crura interconnect with the upper lateral cartilages at the
so-called “scroll area”.
The lower lateral cartilages lie in a more prominent posi­
tion than the upper lateral cartilages. Consequently, they have
a greater impact on surface anatomy, with their upper border
defining the nasal dome and the most anterior portion deter­
mining the tip-defining points (see Fig. 15.25). Functionally,
the lower lateral cartilages support the external nasal valve
(see Fig. 15.28).
The edges of the lower lateral cartilages are visible when
there is little subcutaneous tissue, enabling one to assess
the anatomy before surgery. The lower lateral cartilages do
not lie parallel to the alar rim, but rather angle along an
oblique path towards the maxillary bone. The amount of
angulation contributes significantly to subtle differences in
the external shape of the nasal tip: angulation along an axis
toward the lateral canthus of the eye is considered normal,
whereas a more cephalic orientation with angulation toward
the medial canthus contributes to the so-called “parentheses
deformity”.
The pyriform ligament is a fibrous membrane that encases
the nasal cartilages (Fig. 15.31). As such, the cartilages can
function as a unit, each adding stability to the other.10 In this
way, the inferior (caudal) border of the upper lateral cartilage
stabilizes the lower lateral cartilage.
The nasal septum is the principle support structure for the
nose. It is comprised of hyaline cartilage and bone; a cross-
section reveals the varying thickness and translucency of
these regions. The junction of the anterior septum with the
caudal border is defined as the septal angle (Figs. 15.32 &
15.33).

428
SECTION I
CHAPTER 15 • Nasal analysis and anatomy
Fig. 15.31  Cartilages are attached to bone, nasal and maxillary, to increase their
stability. The pyriform membrane is one mechanism that exists to stabilize these
cartilages to the pyriform rim.
Upper lateral cartilage
Nasal bone
Lower lateral cartilage
Pyriform ligament
Fig. 15.32  The dorsal and caudal septum is noted, their junction occurring at the
septal angle.
Anterior septum
Caudal septum
Septal angle
Upper lateral cartilage
(retracted)
Lower lateral cartilage
(retracted)
Fig. 15.33  Other methods for assessing tip projection. (A,B) A second method the authors use to help access tip projection is by comparing it to the alar base width
– they should be equal. (C) When comparing the ratio of the nasal length (radix-to-tip, RT) to the tip projection (alar base-to-tip), the ideal tip projection is 0.67 × RT.
A
1.0
0.67
B
A=B
The mucosa overlying the perichondrium of the septum is
highly vascularized and receives its blood supply from pri­
marily from the labial, sphenopalatine, and ethmoidal arteries
(Fig. 15.34). The dense area of vascularity in the anterior
septum is referred to as Kiesselbach’s area and is a likely area
of epistaxis. If one stays in the subperichondrial plane during
septal dissection, there is less chance of significant bleeding.
The principle intranasal structures are the superior, middle,
and inferior turbinates, which are essentially bony structures
covered by thickened mucosa. The mucosa removes particu­
late matter, warms and humidifies the incoming air, and regu­
lates airflow by undergoing a normal cycle of expansion and
contraction (Fig. 15.35).
The turbinates are likewise highly vascular. The inferior
turbinate has the greatest impact on airway resistance and,
therefore, it is commonly reduced in size in order to improve
nasal airflow. It is important clinically to understand that
vessel diameter increases in the posterior turbinate, and that
posterior resection can therefore risk significant bleeding.
Submucosal dissection, and removal of bone alone, is another
practical method of avoiding bleeding during turbinate
resection.
The nose is thus created by a number of structures built
upon the scaffold of maxillary and frontal bone. Its three-
dimensional structure is able to be analyzed with knowledge
of these structures and their relationship to one another.

429
Nasal bones, cartilages, and septum
Fig. 15.34  The nasal septum consists of cartilage attached to nasal bone, maxilla,
vomer, and ethmoid. It is highly vascularized, having multiple blood supplies.
Septum is the key support structure of the nose, with cartilages and ligaments
attached and suspended from it. This cross-section also shows the proximity of the
sphenoid sinus, and superiorly located cribriform plate, to the posterior ethmoid
bone. Removing ethmoid bone with a twisting motion can inadvertently damage
either of these structures.
Nasal bone
Septal branches of
sphenopalatine artery
Branches of anterior
ethmoidal artery
Anterior ethmoidal
artery
Superior labial
artery
Fig. 15.35  The superior, middle, and inferior turbinates.
Middle turbinate
Superior turbinate
Inferior turbinate
References
1. Menick FJ. Nasal reconstruction. Plast Reconstr Surg. 2010;125:138e–
150e. An excellent overall review article of nasal anatomy and physiology.
2. Courtiss EH, Goldwyn RM. The effects of nasal surgery on airflow.
Plast Reconstr Surg. 1983;72:9–21. This clinical paper describes the four
anatomical structures that determine nasal airflow, important for
approaching any patient who presents with the complaint of nasal
obstruction.
3. Han SK, Lee DG, Kim JB, et al. An anatomic study of the nasal tip
supporting structures. Ann Plast Surg. 2004;52:134–139. The authors
describe the micro- and macroscopic anatomy of the supporting structures
of the nasal tip and the relevance of this anatomy to nasal tip surgery.
4. Sheen JH. Spreader graft: a method of reconstructing the roof of the
mid nasal vault following rhinoplasty. Plast Reconstr Surg.
1984;73:230–239. The classic paper that details the anatomy of the middle
nasal vault, crucial for prevention of mid-vault collapse after rhinoplasty.
5. Rohrich RJ, Muzaffar AR, Gunter JP. Nasal tip blood supply:
confirming the safety of the transcolumellar incision in rhinoplasty.
Plast Reconstr Surg. 2000;106:1640–1641. The arterial blood supply to
the nasal tip is discussed. This anatomical study is important with the
emergence of open rhinoplasty technique as a preferred method for
rhinoplastic surgery.
6. Constantian MB. The boxy nasal tip, the ball tip, the alar cartilage
malposition variations on a theme – a study in 200 consecutive
primary and secondary rhinoplasty patients. Plast Reconstr Surg.
2005;116:268–281.
7. Rohrich RJ, Hoxworth RE, Thornton JF, et al. The pyriform
ligament. Plast Reconstr Surg. 2008;121:277–281.
8. Byrd HS, Salomon J, Flood J. Correction of the crooked nose. Plast
Reconstr Surg. 1998;102:2148–2157.
9. Rohrich RJ, Muzaffar AR, Janis JE. Component dorsal hump
reduction: the importance of maintaining dorsal aesthetic lines in
rhinoplasty. Plast Reconstr Surg. 2004;114:1298–1308.
10. Pitanguy I. Surgical importance of a dermatocartilaginous ligament
in bulbous noses. Plast Reconstr Surg. 1965;36:247–253.

SECTION I • Aesthetic Surgery of the Face
16 
Open technique rhinoplasty
Rod J. Rohrich and Jamil Ahmad
SYNOPSIS
■ Accurate preoperative analysis and clinical diagnosis set the foundation
for successful primary open rhinoplasty.
■ Open rhinoplasty allows anatomic exposure, identification, and
correction of nasal deformities.
■ Component dorsal hump reduction and reconstitution of the dorsum
allow accurate and incremental reduction of the nasal dorsum while
preventing problems with internal valve collapse or dorsal irregularities.
■ Nasal tip suturing techniques allow control of definition without
damaging the osteocartilaginous framework and compromising
support.
■ Knowledge of the normal course of recovery and potential
complications is key to managing patient expectations in the
postoperative period.
Access the bonus content for this chapter online at

Introduction
Rhinoplasty remains one of the most commonly performed
aesthetic surgical procedures in plastic surgery with over
218 000 performed in 2015 in the USA.1 The trend over the past
25 years in rhinoplasty has shifted away from ablative tech­
niques involving excessive reduction of the osteocartilaginous
framework to conserving the native anatomy with cartilage
sparing, augmentation of deficient areas, and suture tech­
niques to correct contour deformities and restore structural
support. Emphasis on preoperative analysis and clinical
diagnosis, refinements in techniques, and the popularization
of the open approach in rhinoplasty (Box 16.1)2–4 have
advanced the understanding of nasal anatomy and nasal
surgery, leading to more predictable and consistent aesthetic
and functional outcomes.
Success in primary rhinoplasty is predicated on comprehen­
sive perioperative care of the patient. Accurate preoperative
analysis and clinical diagnosis, identification of both the
patient’s expectations and the surgeon’s goals, and a thorough
review of the plan of care and expected postoperative recovery
will form the foundation for a successful experience for both
patient and surgeon. Intraoperatively, adequate anatomic
exposure of the nasal deformity, preservation and restoration
of the normal anatomy, correction of the deformity using
incremental control, maintenance and restoration of the nasal
airway, and recognition of the dynamic interplays between the
multiple maneuvers lead to excellence in execution. Finally,
care and reassurance during postoperative recovery will lead
to increased patient satisfaction.
Basic science/disease process
A thorough knowledge of nasal anatomy and understanding
of nasal airflow and physiology are the foundations for suc­
cessful aesthetic and functional rhinoplasty. Nasal anatomy
is covered in detail in the Chapter 15, and nasal airflow and
physiology is covered in depth in the Chapter 18. Deformities
of the external and internal nose can be congenital or acquired,
and may be secondary to soft-tissue and/or osteocartilagi­
nous abnormalities, leading to aesthetic and/or functional
consequences.
Diagnosis/patient presentation
Consultation
The initial consultation for rhinoplasty serves as an opportu­
nity for the surgeon to obtain the patient’s nasal history and
perform a nasal examination. In addition, the surgeon should
solicit the expectations of the patient. If the patient is a suitable
candidate for rhinoplasty, informed consent should be obtained
and preoperative instructions are given, along with a general
overview of postoperative care. Each patient should receive an
information sheet containing this information (Fig. 16.1).
  Access video content for this chapter online at expertconsult.com

430.e1
Historical perspective
Historical perspective
The first recorded treatment of nasal injuries dates back to
approximately 3000 BC on the Egyptian surgical papyrus.5–9
Translated by Edwin Smith and later by James H. Breasted,5,6
this document contained descriptions of the diagnosis and
treatment of three nasal fractures. Reconstructive surgery for
nasal deformities is described as early as 600 BC.10,11 In India,
facial mutilation, especially of the nose, was practiced on
adulterers, thieves, and other criminals as a method of humili­
ation and stigmatization. In northern India, Sushruta, a
member of a lowly priestly class, described techniques to
transfer forehead and cheek skin to reconstruct the nose.9 In
the 14th century, descriptions of nasal reconstruction again
appear after a long period of quiescence during the Dark
Ages, as the Renaissance brought forth advances in science
and medicine. In Italy, Branca practiced the Indian methods
for nasal reconstruction.12 His son modified these techniques
by utilizing a delayed pedicled skin flap from the arm. This
technique came to be known as the Italian method and was
later reported by Benedetti,13 predating Gaspare Taglicozzi’s
description in 1597. In the early 19th century, Carl von Graefe
modified the Italian method by using a skin graft from the
arm instead of a delayed pedicled skin flap. In 1845, another
German, Johann Friedrich Dieffenbach, described external
excisions of nasal soft tissue and cartilage to reduce exces­
sively large noses.14 Dieffenbach was one of the first to describe
nasal surgery for aesthetic improvement of the nose.8,9 John
Orlando Roe, an American otolaryngologist, is credited with
describing the first aesthetic rhinoplasty and introduced the
endonasal approach.15,16 In 1887, Roe published The deformity
termed “pug nose” and its correction, by a simple operation, and
in 1891, The correction of angular deformities of the nose by a
subcutaneous operation. Roe’s descriptions precede those of
Jacques Joseph, a German orthopedic surgeon often regarded
as the father of modern rhinoplasty, by 11 years.15 In 1898,
Joseph published his experience with reduction rhinoplasty
using external excisions similar to Dieffenbach. Joseph’s first
report of the endonasal approach was in 1905.15 However,
Joseph is often regarded as the father of modern rhinoplasty
given his contribution to the analysis, classification, and repair
of various nasal deformities.9 In the first half of the 20th
century, the emergence of plastic surgery as a specialty was
spurred forward by experience gained reconstructing devas­
tating war injuries. The second half of the 20th century saw
significant contributions to the rhinoplasty literature enhanc­
ing preoperative assessment and diagnosis, management of
the nasal airway, cartilage grafting techniques and popular­
ization of the open approach to rhinoplasty.

431
Diagnosis/patient presentation
Nasal examination
Nasal examination includes both external nasal analysis (Box
16.2)3,4 and internal nasal exam (Box 16.3). In addition, facial
analysis plays a key role in achieving facial harmony after
rhinoplasty.22 External nasal examination provides informa­
tion about the underlying osteocartilaginous framework.23
Nasal skin is typically thinner and more mobile superiorly
and thicker around the nasal tip.24,25 Skin is thinnest over the
osteocartilaginous junction and thickest over the nasion and
supratip area. Nasal skin characteristics such as thick seba­
ceous or thin skin will influence the outcome and recovery
following rhinoplasty. Patients with thick nasal skin are prone
to prolonged postoperative edema and scar formation, requir­
ing a longer recovery. Manipulation of the osteocartilaginous
framework will be less evident in patients with thick nasal
skin, while subtle changes will be visible in patients with thin
skin. Thick skin will limit the degree of definition that can be
achieved during rhinoplasty. Systematic nasal analysis is
important to identify deformities, evaluate anatomical rela­
tionships, and establish goals for surgery.3,4 This is covered in
depth in the Chapter 15.
Prior to performing internal nasal examination, external
evaluation of the nasal airway should be performed. In particu­
lar, collapse of the external nasal valve on deep inspiration and
a Cottle test should be performed. Internal nasal examination
is aided with the use of a nasal speculum. If mucosal edema
is present, the use of oxymetazoline nasal spray facilitates
mucosal constriction. Internal valve narrowing or collapse
with inspiration should be noted. Inferior turbinate hypertro­
phy, which typically occurs on the side opposite septal devia­
tion, should be noted. Septal deformities including deviation,
tilt, spurs, and perforations are identified. The quality and the
quantity of available septal cartilage are assessed as this is
the primary source of autogenous graft material. To assess for
the presence of septal cartilage in the secondary rhinoplasty
patient, a cotton-tipped applicator is inserted into one nostril
and moved along the septum from the floor of the nasal cavity
towards the dorsum while feeling for a step-off. Presence of a
step-off may indicate previous septal cartilage harvest and
necessitate the discussion of possible harvest of ear or costal
cartilage. The presence of nasal polyps or tumors may require
further investigation and treatment.
Imaging
Standardized photography is obtained for every patient pre­
senting for rhinoplasty and includes frontal, lateral, oblique,
and basal views of the patient.19,26 These are a critical compo­
nent of the medical record for preoperative planning and
evaluation of postoperative results. It is useful to review
photographs with the patient to identify areas of concern that
can be addressed with surgery and deformities that may
persist after surgery including notches, grooves, and irregu­
larities. In addition, facial disproportions and asymmetries
should be pointed out to the patient as these may require
additional surgery to address.
The use of computer imaging in aesthetic surgery is becom­
ing increasingly common.19,26 These techniques allow the
surgeon to simulate the proposed nasal changes and enable
the patient to view and analyze them before surgery. This may
alleviate anxiety and allow the patient to participate in the
Nasal history
During the nasal history, the surgeon should obtain informa­
tion on the patient’s medical and emotional suitability to
undergo rhinoplasty. In addition to reviewing the patient’s
past medical history, the patient should be asked specifically
about a history of allergic disorders, including hay fever and
asthma, and other problems including vasomotor rhinitis and
sinusitis.17 These conditions should be well controlled prior to
rhinoplasty. However, exacerbations of these conditions may
occur in the postoperative period and may persist for several
weeks to months; the patient should be informed about this
before surgery. Nasal obstruction is usually found in patients
with a long history of allergic rhinitis secondary to inferior
turbinate hypertrophy.18 Engorgement of the inferior turbi­
nates causes these symptoms to be worse at night. Patients
with allergies or asthma associated with nasal obstruction
may also have nasal polyps. Prior nasal trauma and surgeries
including rhinoplasty, septal reconstruction/septoplasty, and
sinus surgery should be noted. Smoking, alcohol consump­
tion, and use of illicit drugs, in particular cocaine, can com­
promise outcomes. Medications including acetylsalicylic acid,
non-steroidal anti-inflammatory drugs, fish oil, and certain
herbal supplements may cause increased risk of bleeding19
and postoperative ecchymosis.
As with other aesthetic procedures, assessment of the
emotional stability of the patient is critical when evaluating
the patient seeking rhinoplasty.20–22 Motivating factors should
be identified and the surgeon must differentiate between
healthy and unhealthy reasons for seeking rhinoplasty. Feel­
ings of inadequacy, immaturity, family conflicts, divorce, and
other major life changes may be unhealthy motivating factors
behind the patient seeking aesthetic surgery. Poor postopera­
tive patient satisfaction is often based on emotional dissatis­
faction as opposed to technical failure, and this can be avoided
by preoperative identification these unhealthy motivating
factors.19
BOX 16.1  Advantages and disadvantages of the open approach
Advantages
Binocular visualization
Evaluation of complete deformity without distortion
Precise diagnosis and correction of deformities
Allows use of both hands
More options with original tissues and cartilage grafts
Direct control of bleeding with electrocautery
Suture stabilization of grafts (invisible and visible)
Disadvantages
External nasal incision (transcolumellar scar)
Prolonged operative time
Protracted nasal tip edema
Columellar incision separation
Delayed wound healing

432
SECTION I
CHAPTER 16 • Open technique rhinoplasty
Expectations
Identifying the patient’s expectations preoperatively is a
key component to postoperative patient satisfaction and
successful rhinoplasty.19 The patient should list specific
concerns about his or her nasal appearance and/or func­
tion. Common concerns include asymmetry, tip deformities,
planning process. Imaging or other predictive tools can dem­
onstrate the limitations of the procedure and help to establish
realistic expectations. All images that are viewed are only a
representation of the result that could be achieved through
the proposed surgery. Imaging is used as an educational tool
to benefit the patient and should not be presented as a guar­
antee of the result.
Fig. 16.1  Patient
information sheet and
informed consent for
rhinoplasty.

433
Treatment surgical technique
Informed consent
Prior to surgery, informed consent should be obtained follow­
ing discussion about the surgery, alternative treatments, and
disclosure of risks. The patient should be made aware of the
possibility of additional surgery in the event of a complication
or the need for revisionary surgery and his or her financial
responsibilities if this situation were to arise.19
Patient selection
After completion of a detailed nasal history and examination,
and the patient’s concerns and expectations have been dis­
cussed, the surgeon can decide if the patient is a good candi­
date for rhinoplasty. In general, the ideal candidate for surgery
has legitimate concerns and realistic expectations, is secure
and well informed, and understands the limitations of surgery.
The acronym SYLVIA has been used to describe the ideal
patient: Secure, Young, Listens, Verbal, Intelligent, and
Attractive. The poor candidate for surgery has excessive
concerns about minimal deformities and unrealistic expecta­
tions, is insecure and poorly informed, and fails to recognize
the limitations of surgery. The acronym SIMON has been used
to describe this patient: Single, Immature, Male, Overly
expectant, and Narcissistic traits.20,27 These patients are likely
to be unsatisfied following surgery regardless of the aesthetic
improvement. They should be approached with caution and
in most cases should not be operated on.
Treatment surgical technique
Anesthesia and preoperative management
(Video 16.1 )
It is our preference to perform primary open rhinoplasty
under general endotracheal anesthesia. Following induction
and intubation with a Mallinkrodt endotracheal tube, a moist
throat pack is placed to prevent intragastric blood leading to
postoperative nausea and vomiting. The patient is positioned
biased towards the side of the operating room table that the
surgeon is on and, also, so that their head is slightly past the
head of the operating room table allowing moderate hyperex­
tension of the neck improving visualization for the surgeon.
Prior to sterile prep, the nose and septum are infiltrated
with approximately 10 ml 1% lidocaine with 1 : 100 000 epi­
nephrine. Injection in the submucoperichondrial plane of the
nasal septum is performed followed by infiltration of the soft-
tissue envelope. Injection of the highly vascular areas of the
BOX 16.2  Systematic nasal analysis
Frontal view
Facial proportions
Skin type/quality – Fitzpatrick type, thin or thick, sebaceous
Symmetry and nasal deviation – midline, C-, reverse C-, or
S-shaped deviation
Bony vault – narrow or wide, asymmetrical, short or long nasal
bones
Midvault – narrow or wide, collapse, inverted-V deformity
Dorsal aesthetic lines – straight, symmetrical or asymmetrical, well
or ill defined, narrow or wide
Nasal tip – ideal/bulbous/boxy/pinched, supratip, tip-defining points,
infratip lobule
Alar rims – gull shaped, facets, notching, retraction
Alar base – width
Upper lip – long or short, dynamic depressor septi nasi muscles,
upper lip crease
Lateral view
Nasofrontal angle – acute or obtuse, high or low radix
Nasal length – long or short
Dorsum – smooth, hump, scooped out
Supratip – break, fullness, pollybeak
Tip projection – over- or underprojected
Tip rotation – over- or underrotated
Alar–columellar relationship – hanging or retracted alae, hanging or
retracted columella
Periapical hypoplasia – maxillary or soft-tissue deficiency
Lip–chin relationship – normal, deficient
Basal view
Nasal projection – over- or underprojected, columellar–lobular ratio
Nostril – symmetrical or asymmetrical, long or short
Columella – septal tilt, flaring of medial crura
Alar base – width
Alar flaring
BOX 16.3  Internal nasal examination
External valve – collapse
Internal valve – narrowing, collapse
Mucosa – edema, irritation
Inferior turbinates – hypertrophy
Septum – deviation, tilt, spurs, perforation, cartilage
Masses – polyps, tumors
dorsum irregularities, and nasal airway obstruction. The
patient should attempt to rank these concerns in order of
importance. Taking all of this into account, the surgeon has
to determine if the patient’s expectations are realistic and can
be met adequately. Most patients have realistic expectations
for surgery and can understand the limitations of rhinoplasty
with adequate discussion and review of photographs with the
surgeon. Reviewing photographs with the patient allows the
patient to appreciate different views of their face and nose
which can help them identify specific areas of concern for
the surgeon to address. A patient that focuses on minor or
uncorrectable problems or has unrealistic expectations despite
extensive discussion will likely be disappointed following
surgery regardless of the aesthetic improvement; it is better
to avoid operating on these patients.

434
SECTION I
CHAPTER 16 • Open technique rhinoplasty
placed within the alar rim, a separate incision is started at the
caudal border of the lateral crura and connected with the
medial incision, caudal to the middle crus (Fig. 16.3).
The lower edge of the lateral crus can be palpated after the
ala has been everted to assure precise infracartilaginous inci­
sion placement. Fine dissecting scissors are used to elevate the
nasal skin in a supraperichondrial plane starting from the
columellar incision in a superior direction to the nasal tip.
Next, dissection is started over the lateral crus and continued
in a medial direction connecting the supraperichondrial dis­
section planes over the middle crus. Dissection to elevate the
nasal skin in the supraperichondrial plane is carried to just
superior to the keystone area. A Joseph elevator is then used
to elevate nasal skin in a subperiosteal plane off of nasal bones
to radix. This dissection over the nasal bones is only performed
in the central area to allow for bony dorsal hump reduction
while the lateral soft tissue and periosteal attachments of
the bony sidewall should not be disrupted, as they provide
nose including the columella, tip, dorsum, lateral sidewalls,
alar base, and along the caudal margin of the lower lateral
cartilages is important for hemostasis. If inferior turbinate
surgery is anticipated, the anterior head of the inferior tur­
binates are also injected. Oxymetazoline-soaked cottonoid
pledgets are inserted into the nasal cavities. One drop of
methylene blue is instilled in the oxymetazoline to differenti­
ate this from the local anesthesia and prevent inadvertent
injection. Typically, two or three cottonoid pledgets are placed
in each nasal cavity. Comparable hemostasis can be obtained
using lidocaine with oxymetazoline while avoiding the use of
a controlled substance with potential cardiac effects as seen
with cocaine.28,29
A headlight is worn to assist in visualization of the internal
nasal structures. The entire face and neck are prepped sterilely,
which allows for intraoperative assessment of the nose in
relation to rest of the face.
Incisions and approach
Adequate exposure during primary open rhinoplasty is best
obtained using a transcolumellar incision with infracartilagi­
nous extensions. Several transcolumellar incisions are com­
monly used including stair-step, inverted-V, and transverse
incisions. Blood supply to the nasal tip is preserved with the
transcolumellar incision provided that extensive subdermal
defatting of the nasal tip or extensive alar base resections
above the alar grooves are not performed.30,31 We prefer to use
a stair-step incision, which camouflages the scar, provides
landmarks for accurate closure, and prevents linear scar
contracture. Broken-line transcolumellar incisions may lead to
better scar formation and less notching.32
The stair-step transcolumellar incision is made at the nar­
rowest part of the columella, which is typically at its midpor­
tion (Fig. 16.2). A no.15 blade scalpel is used to superficially
incise the skin, avoiding damage to the underlying medial
crura. The incision is carried into the nasal vestibule and then
continued along the caudal border of the medial crus towards
the middle crus of the lower lateral cartilage. After everting
the ala using external digital pressure against a double hook
Fig. 16.2  Transcolumellar stair-step incision.
Fig. 16.3  Transcolumellar stair-step incision with infracartilaginous extensions.
Infracartilaginous
Transcolumellar

435
Treatment surgical technique
necessary stability to the bony vault after percutaneous oste­
otomies have been performed.33
Component dorsal hump reduction and
dorsal reconstitution
An aesthetically pleasing nasal dorsum is critical to a success­
ful result after rhinoplasty. Dorsal hump reduction without
careful attention to the anatomic and physiologic functions of
the nasal dorsum and internal nasal valve can lead to irregu­
larities of the nasal dorsum, excessive narrowing of the
midvault, the inverted-V deformity, and under-resection or
over-resection of the osteocartilaginous hump.34–39 We prefer
a graduated approach using component dorsal hump reduc­
tion (Box 16.4) over earlier techniques of composite dorsal
hump reduction.34–39 This incremental reduction of the osteo­
cartilaginous structures of the nasal dorsum offers increased
control and reproducibility over composite dorsal hump
reduction performed with an osteotome.
The nasal dorsum is initially modified prior to addressing
the nasal tip, which establishes balance between the dorsum
and tip essential to achieving the optimal aesthetic result.34–39
Component dorsal hump reduction is performed using five
essential steps: (1) separation of the upper lateral cartilage
from the septum; (2) incremental reduction of the septum
BOX 16.4  Component dorsal hump reduction
1. Separation of the upper lateral cartilage from the septum
2. Incremental reduction of the septum proper
3. Incremental dorsal bony reduction (using a rasp)
4. Verification by palpation
5. Final modifications, if indicated (spreader grafts, suturing
techniques, osteotomies)
Fig. 16.4  Nasal dorsum.
Keystone area
proper; (3) incremental dorsal bony reduction (using a rasp);
(4) verification by palpation; and (5) final modifications, if indi­
cated (spreader grafts, suturing techniques, osteotomies).34–37
After dorsal undermining of the nasal soft tissues has
been carried over the central aspect of the bony vault, the
lower lateral cartilages are separated from each other and the
septum by taking down the interdomal suspensory ligament.
The creation of bilateral submucoperichondrial tunnels along
the dorsal septum is essential prior to component dorsal hump
reduction. This allows extramucosal resection of the osteocar­
tilaginous components of the dorsal hump, preventing late
cicatricial narrowing of the internal nasal valve and webbing
of the vestibule causing potential nasal airway obstruction.
The perichondrium is scored at the nasal septal angle with
a No.15 blade scalpel, and then using a Cottle elevator, dis­
section in a submucoperichondrial plane is performed from
caudal to cephalad along the dorsal septum until the nasal
bones are reached. Once in the correct plane, there should be
little resistance elevating the mucoperichondrium off of the
septal cartilage. The upper lateral cartilages are separated
from the septum sharply using a No.15 blade scalpel. By
incising along the surface of the septal cartilage to separate
the upper lateral cartilages, the transverse projections of
the T-shaped dorsal septum are kept attached to the upper
lateral cartilages (Fig. 16.4). This helps to minimize the need
for spreader grafts to maintain the internal valve. Following
this, angled septal scissors are used to incrementally reduce
the septal cartilage. This cartilage is saved and can be used
later for grafts, including as a columellar strut graft if large
enough.40 Preservation of the upper lateral cartilages during
dorsal reduction of the cartilaginous septum is important in
achieving smooth dorsal aesthetic lines, while equal resection
of the septum and upper lateral cartilages results in rounding
of the dorsum, and excessive resection of the upper lateral
cartilages results in the inverted-V deformity. A down-biting
diamond rasp is used to incrementally reduce the bony
dorsum. Rasping should proceed along left and right dorsal

436
SECTION I
CHAPTER 16 • Open technique rhinoplasty
three-point dorsal palpation test avoiding over-resection of
the dorsum.34–37
Upper lateral cartilage tension spanning sutures are used
to reapproximate the upper lateral cartilages to the septum to
reconstitute the integrity of the nasal dorsum (Fig. 16.5).34,36,37
In some cases, the upper lateral cartilages can also be used as
autospreader flaps, maintaining the patency of the internal
valves and contour of the dorsal aesthetic lines. Spreader
grafts are indicated in primary rhinoplasty to recreate the
dorsal aesthetic lines, widen the midvault, or correct the devi­
ated nose (Fig. 16.6).34–37,39,41 They may be fashioned from
harvested septal cartilage and are typically 5–6 mm in height
and 30–32 mm in length. They can be placed either unilater­
ally or bilaterally parallel to the dorsal septum. If indicated
for improvement of the dorsal aesthetic lines, they can be
aesthetic lines and then centrally, employing short excursions
of the rasp for maximal control. Care is taken to avoid avuls­
ing the attachments of the upper lateral cartilages from the
undersurface of the nasal bones. If a large reduction of the
bony dorsum is required, a guarded 8-mm osteotome can be
used. The osteotomy should start at the caudal aspect of the
nasal bones and is directed towards the radix. A rasp is used
for final adjustments. In some circumstances, reduction of
the upper lateral cartilages is indicated. Over-resection must
be avoided to prevent internal valve collapse or long-term
dorsal irregularities. Patients with short nasal bones and a
high and narrow osteocartilaginous framework are at higher
risk for these problems.34 Most importantly, after each incre­
mental modification of the dorsum, the nasal skin is replaced
and the contour of the nasal dorsum is assessed using the
Fig. 16.5  Upper lateral
cartilage tension spanning
sutures.
A
2-4mm
B
Fig. 16.6  Dorsal spreader grafts.
Spreader grafts

437
Treatment surgical technique
mucoperichondrial attachments to the septum, especially
the deviated part; (3) straightening of the septum, and if
necessary septal reconstruction, while maintaining a 10 mm
or wider caudal and dorsal L-strut; (4) correction of any
caudal septal deviation after the posterior septum has been
reconstructed; (5) correction of dorsal septal deviations with
cartilage grafting and/or scoring techniques; (6) restoration
of long-term support with buttressing caudal septal batten or
dorsal nasal spreader grafts; (7) if necessary, submucous resec­
tion of hypertrophied inferior turbinates; and (8) precisely
planned and executed external percutaneous osteotomies.43–45
As opposed to septoplasty, where the septal cartilage is
scored in an attempt to straighten it, or submucosal resection,
where the majority of the septum is removed other than the
L-strut, septal reconstruction differs in that only the portion
of the septum causing airway obstruction is removed, with
the idea that native cartilage is preserved. It is of critical
importance to preserve an L-strut of septal cartilage for struc­
tural integrity. The technique for septal reconstruction is
similar to that for septal cartilage harvest and is discussed
later in this chapter.
Inferior outfracture/limited submucous resection
The turbinates exist as three or four bilateral extensions from
the lateral nasal cavity. The inferior turbinate consists of
highly vascular mucoperiosteum covering a thin semicircular
conchal bone.47 It is involved in regulation of filtration and
humidification of inspired air. In combination with the inter­
nal nasal valve, the anterior extent of the inferior turbinate
can be responsible for up to two-thirds of the upper airway
resistance.17,48 Posteriorly, the inferior turbinate diverges away
from the nasal septum, allowing for reduced upper airway
resistance in this area.17,49
Inferior turbinoplasty is performed in patients with nasal
airway obstruction secondary to inferior turbinate hypertro­
phy that is refractory to medical management. We prefer a
more conservative surgical approach to correct inferior turbi­
nate hypertrophy, as we have found it to be effective with low
morbidity.50 Overly aggressive surgical management may be
complicated by bleeding, mucosal crusting and desiccation,
ciliary dysfunction, chronic infection, malodorous nasal
drainage, or atrophic rhinitis.17 In most cases, inferior turbino­
plasty with outfracture of the inferior turbinate and, in some
cases, limited submucous resection, is adequate to achieve
significant improvement (Fig. 16.7).50
After removal of the previously placed oxymetazoline-
soaked cottonoid pledgets, the inferior turbinates are inspected
after vasoconstriction of the overlying mucosa has occurred.
In cases of inferior turbinate mucosal hypertrophy, a long
Vienna speculum is used to outfracture the inferior turbi­
nates.50 In cases of inferior turbinate bony hypertrophy, limited
submucous resection of the inferior turbinate is indicated.50
Outfracture is performed so that the entire inferior turbinate
is microfractured laterally to open the nasal cavity. Limited
submucous resection is performed using needle point electro­
cautery to incise the inferior border of the anterior 1–2 cm of
the inferior turbinate down to the conchal bone. A Cottle eleva­
tor is used to develop a medially based submucoperichondrial
flap to expose the portion of the conchal bone to be resected.
Takahashi forceps are used to sharply resect the bone from the
anterior third of the turbinate. The mucoperichondrial flap is
visible, placed at or above the plane of the dorsal septum; and
if only indicated to improve function of the internal nasal
valve, they can be invisible, placed below the plane of the
dorsal septum. Additionally, an extended spreader graft with
its caudal extent projecting below the caudal septum can be
used to lengthen the short nose.42 Spreader grafts are secured
to the septum using 5-0 polydioxanone (PDS) horizontal mat­
tress sutures. Overuse of spreader grafts in primary rhino­
plasty can lead to excessive width of the midvault.34–37
Following reconstitution of the cartilaginous midvault,
percutaneous osteotomies are performed to correct widened
or asymmetrical nasal bones, or close the open roof deformity
if present after dorsal reduction.34–37 Osteotomies will be dis­
cussed later in this chapter.
The nasal airway
Proper identification of causative factors of nasal airway
obstruction is key to successful treatment. Nasal airway
obstruction can have both medically and surgically correct­
able causes. Common surgically correctable causes include
nasoseptal deviation, internal or external valve dysfunction,
and inferior turbinate hypertrophy.17 Management of issues
related to the nasal airway are covered in detail in Chapter
18. However, septal reconstruction and inferior turbinoplasty/
submucous resection are discussed here, as they are com­
monly performed during primary open rhinoplasty in the
patient with nasal airway obstruction secondary to septal
deviation or inferior turbinate hypertrophy, respectively.
Septal reconstruction
Septal deviation can involve deviation of the septal cartilage,
perpendicular plate of the ethmoid bone, or vomer away from
the midline, and can cause obstruction of one or both of the
nasal airways, along with external deviation of the nose. In
our experience, nasal deviations can be classified into three
basic types: caudal septal deviations, concave dorsal deformi­
ties, and concave/convex dorsal deformities (Box 16.5).43–45
Septal tilt is the most common type, where the quadrangular
cartilage and perpendicular plate of the ethmoid are straight
but the quadrangular cartilage is tilted to one side of the
maxillary crest internally.46 Hypertrophy of the inferior turbi­
nate contralateral to the side of internal deviation is usually
present. Correction of septal deviation is key to improving
nasal airflow and correcting the deviated nose.
The following principles are used to correct nasal deviation
and perform septal reconstruction: (1) exposure of all devi­
ated structures through the open approach; (2) release of all
BOX 16.5  Classification of nasal deviations
I. Caudal septal deviation
a. Straight septal tilt
b. Concave deformity (C-shaped)
c. S-shaped deformity
II. Concave dorsal deformity
a. C-shaped dorsal deformity
b. Reverse C-shaped dorsal deformity
III. Concave/convex dorsal deformity (S-shaped)

438
SECTION I
CHAPTER 16 • Open technique rhinoplasty
mild loss of tip projection due to disruption of ligamentous
support and increased skin undermining.67 As such, we
commonly employ columellar strut graft and nasal tip sutur­
ing techniques to maintain nasal tip support during open
rhinoplasty.
Cephalic trim
Cephalic trim is commonly performed with the bulbous or
boxy tip (Fig. 16.14).68 Paradomal fullness is secondary to
prominence of the cephalic border of the middle and lateral
crura of the lower lateral cartilages. Cephalic trim of this area
reduces paradomal fullness and helps to define the tip and
narrow the distance between the tip-defining points. An alar
rim strip of at least 5–6 mm is preserved for adequate support
of the external valve. Cephalic trim should be used judiciously.
In some cases in which the quality of the lower lateral carti­
lages is poor, cephalic trim will further weaken the cartilages
despite preserving a 5–6 mm alar rim strip, leading to alar rim
collapse. In these cases, use of a lower lateral crural turnover
flap is a better option to improve tip definition while preserv­
ing structural support.69 Calipers should be used to accurately
measure the alar rim strip. The excised cartilage can also be
used as a source of autogenous grafts.
A lower lateral crural turnover flap is another useful tech­
nique to address paradomal fullness while providing addi­
tional support to the lower lateral cartilages.69 It is beneficial
for deformities, weakness, and collapse of the lower lateral
crura and can also be used to improve lower lateral crural
strength during tip reshaping. However, there must be suffi­
cient lower lateral crura to leave a 5 mm alar rim strip. It can
be used in combination with other external valve and alar rim
supporting techniques.
Columellar strut graft
An intercrural columellar strut graft is used to maintain or
increase nasal tip projection and aids in unifying the nasal
tip.70–72 It can be either floating or fixed (Fig. 16.15). A floating
columellar strut graft is used more commonly to maintain tip
projection and is positioned between the medial crura and
rests in the soft tissues 2–3 mm anterior to the anterior nasal
spine. A fixed columellar strut graft is used to increase tip
projection and is positioned between the medial crura and
rests on the maxilla. The columellar strut graft is typically
fashioned from septal cartilage to measure 3 × 25 mm. A double
hook is placed with a hook in the vestibular apex of each lower
lateral cartilage. Upward traction is placed, and scissors are
used to dissect a pocket between the medial crura down
towards the anterior nasal spine. A 2–3-mm pad of soft tissue
is preserved over the nasal spine to keep the graft from moving
back and forth over the nasal spine with lip movements.73 The
columellar strut graft is placed in the pocket. With the tip-
defining points held at the same level, a 5-0 PDS suture is used
to stabilize the medial crura to the columellar strut graft, fol­
lowed by several additional 5-0 PDS sutures to unify the nasal
tip complex. The columellar strut graft is then trimmed.
Nasal tip suturing techniques
Tip suturing techniques (Box 16.6) are used to further refine
the tip by controlling the subtle contours of the lower lateral
cartilages. Various authors have described their approaches to
replaced down over the cut edge of the conchal bone; no
suturing is necessary as this will adhere to the raw surface.
Replacement of the flap will avoid postoperative hemorrhage
or crusting.
The nasal tip
A graduated approach to nasal tip surgery requires a combi­
nation of techniques including the cephalic trim, the use of a
columellar strut graft, nasal tip suturing, and nasal tip graft­
ing. Application of these techniques will help to correct tip
deformities and improve tip shape while minimizing defor­
mities secondary to loss of support. In addition, compared
with the closed approach, the open approach may cause
Fig. 16.7  Inferior turbinate outfracture and submucous resection.
Resected lateral
mucosa and
lamina propria

438.e1
Treatment surgical technique
Harvesting autologous grafting material
The trend over the past 25 years in rhinoplasty has shifted
away from ablative techniques involving over-reducing the
osteocartilaginous framework to conserving the native
anatomy and augmentation of deficient areas to correct
contour deformities and restore structural support. As such,
certain situations require harvest of autologous cartilage for
graft material. Autologous grafts are preferential to homo­
grafts and alloplastic implants because of their high biocom­
patibility and low risk of infection and extrusion.51 Their
disadvantages include donor site morbidity, graft resorption,
and unavailability of sufficient quantities for graft material.41
Autologous cartilage grafts are most commonly obtained
from septal, ear, and costal cartilage. Other donor sites for
autologous grafts include calvarial and nasal bone, and the
olecranon process of the ulna.51 Concerns regarding donor site
morbidity, graft availability, and graft resorption will neces­
sitate the use of homologous or alloplastic implants.52 Recently,
temporal fascia grafts have found utility as an autologous
graft material in rhinoplasty for camouflage or as composite
grafts such as diced cartilage grafts wrapped in temporal
fascia. Temporal fascia can be harvested with minimal donor
site morbidity and an inconspicuous scar located in the tem­
poral scalp.53–55
Septal cartilage
Septal cartilage is the primary choice for autogenous grafts in
rhinoplasty. It can be used in all areas including tip grafts,
dorsal onlay grafts, columellar strut grafts, and nasal spreader
grafts.53 It is easily harvested, leaves minimal donor site
morbidity, and is available in the operative field. Septal carti­
lage harvest is performed as previously described for septal
reconstruction.
Open rhinoplasty allows for ease of septal cartilage harvest
with improved exposure and visualization. Septal cartilage
harvest is performed only after component dorsal hump
reduction is complete as it is essential to preserve a L-strut
that is at least 10 mm for nasal support. However, this width
will depend on the strength of the septal cartilage, and in
many instances a width of 15 mm or more may be required
to ensure long-term support. Dorsal reduction of the septum
after septal cartilage harvest may leave an L-strut that is too
narrow to provide adequate nasal support. Septal cartilage
harvest is performed after the lower and upper lateral carti­
lages have been separated from the quadrangular cartilage. A
No.15 blade scalpel is used to score the mucoperichondrium
of the septal angle, and then a Cottle elevator is used to
develop the submucoperichondrial pocket on both sides of
the septum (Fig. 16.8). Once in the correct plane, the denuded
septal cartilage has a gray-blue hue, the septal cartilage has a
gritty texture, and there should be little resistance elevating
the mucoperichondrium off of the septal cartilage until the
dissection reaches the osteocartilaginous junction between
the quadrangular cartilage and the vomer. Dissection of the
submucoperichondrial pocket is done towards the floor of
the nasal cavity to the maxillary crest and posteriorly to the
vomer (Fig. 16.9). During development of the submucoperi­
chondrial pockets, care is taken to avoid perforations of the
mucosa. Unilateral mucosal perforations generally do not
cause any problems. However, bilateral opposing mucosal
perforations should be repaired with 5-0 chromic gut sutures
to prevent formation of a septal perforation postoperatively.
A dorsal and caudal L-strut is created using a No.15 blade
scalpel to incise the septal cartilage parallel to the dorsal edge
of the septum from the perpendicular plate of the ethmoid
and is curved to parallel the caudal edge of the septum (Fig.
16.10). This incision is then continued posteriorly and parallel
to the caudal edge of the septum until the crest of the maxilla.
A Cottle elevator is then used to elevate the septal cartilage
from the maxillary crest and vomer liberating the septal car­
tilage. Any bony septal deviation of the perpendicular plate
of the ethmoid, vomer, or maxillary crest can be carefully
Fig. 16.8  Submucoperichondrial dissection.

438.e2
SECTION I
CHAPTER 16 • Open technique rhinoplasty
removed using Takahashi forceps. This septal cartilage is
placed in saline until it is needed. During septal cartilage
harvest, pressure on the L-strut must be avoided to prevent
its fracture. If this occurs, it should be repaired to restore
nasal support.56 After cartilage grafts have been fashioned,
any excess material should be replaced between the
mucoperichondrial flaps in case it is required in subsequent
procedures. The mucoperichondrial flaps can be sutured
together using a 5-0 chromic gut quilting suture and are bol­
stered by placement of Doyle splints to support the mucop­
erichondrial flaps and minimize dead space.
Ear cartilage
The ear can provide a significant amount of cartilage for rhi­
noplasty when septal cartilage has been depleted. It can be
used for tip grafts, dorsal onlay grafts, alar contour grafts, and
reconstruction of the lower lateral cartilages.53,57–59 However,
its flaccidity does not allow it to be used where rigid structural
support is necessary. Donor site morbidity and scarring is
minimal.53,57–59
An anterior or posterior approach can be used (Fig. 16.11).
Three milliliters of 1% lidocaine with 1 : 100 000 epinephrine
is injected for hemostasis and hydrodissection of the subperi­
chondrial plane overlying the conchal cartilage. An anterior
approach is performed by making an incision through the
anterior auricular skin, 3 mm inside the rim of the conchal
bowl using a No.15 blade scalpel. Fine dissecting scissors are
used to dissect the anterior auricular skin off of the conchal
cartilage in the subperichondrial plane. A No.15 blade scalpel
is used to incise through the conchal cartilage, again 3 mm
inside and parallel to the rim of the conchal bowl; this rim
maintains the structural integrity of the remaining ear carti­
lage. Fine dissecting scissors are again used to dissect the
posterior skin off of the posterior aspect of the conchal carti­
lage in the subperichondrial plane. Once the desired amount
of cartilage has been dissected away from the overlying
anterior and posterior auricular skin, it can be excised with a
No.15 blade scalpel. Hemostasis is obtained and the incision
is closed with a 5-0 plain gut running suture. A tie-over
petroleum gauze bolster, held in place with a 3-0 nylon suture
through the anterior and posterior auricular skin, is used to
obliterate dead space and prevent hematoma formation. This
is removed on postoperative day 7. A posterior approach is
performed by making a 3-cm posterior auricular skin incision
with a No.15 blade scalpel over the conchal bowl. Fine dis­
secting scissors are used to dissect the posterior auricular skin
Fig. 16.9  Submucoperichondrial flaps. Elevator used to
dissect mucoperichondiral flap in caphalad direction (1-2) then
swept inferiorly (3) and withdrawn (4).
1
2
3
4
Fig. 16.10  Septal L-strut.

438.e3
Treatment surgical technique
Fig. 16.11  Harvesting ear cartilage.
off of the conchal cartilage in the subperichondrial plane up
to the postauricular sulcus. The amount of cartilage required
is marked by passing a 25-gauge needle dipped in methylene
blue from anterior to posterior to tattoo the ear cartilage. A
3-mm rim of conchal bowl is preserved along with a small
buttress of cartilage superiorly at the root of the antihelix and
inferiorly at the incisura intertragica, preventing donor site
deformity. The outlined ear cartilage is then incised using a
No.15 blade scalpel, and fine dissecting scissors are again
used to dissect the anterior auricular skin off of the anterior
aspect of the conchal cartilage in the subperichondrial plane.
Once the desired amount of cartilage has been dissected away
from the anterior and posterior auricular skin, it is excised
with a No.15 blade scalpel. Hemostasis is obtained and the
incision is closed with a 5-0 plain gut running suture, followed
by placement of a tie-over petroleum gauze bolster as previ­
ously described.
Costal cartilage
Costal cartilage provides abundant autogenous graft material.
It can be used for tip grafts, columellar strut grafts, nasal
spreader grafts, alar cartilage grafts, and dorsal onlay grafts.
Given the size, amount, and intrinsic qualities, costal cartilage
lends itself well to use as a dorsal onlay graft and where
structural support is required. It can be carved into any shape.
However, allowing at least 30 min to pass prior to carving
allows initial warping to occur, minimizing late deformity.60
In addition, utilizing centrally over peripherally located car­
tilage may help to minimize late deformity.60,61 Some authors
advocate the use of internal stabilization of costal cartilage
grafts with Kirschner wire to prevent warping, but this can be
associated with long-term complications including extrusion
of the Kirschner wire.62
Various authors63–66 have described harvesting costal carti­
lage from different ribs, but it is our preference to harvest the
ninth rib because it is straight medially and provides 4–5 cm
of autogenous graft material (Fig. 16.12). The ninth rib is a
floating rib and can be located by palpation. A 2-cm incision
is made on the anterolateral aspect of the chest wall. Since the
skin overlying the rib is mobile in this area, a long segment
of rib can be harvested through this relatively small incision.
The perichondrium is lightly scored and is dissected away
from the underlying rib cartilage using both a dental elevator
and a Joseph elevator. When freeing the cartilage away from
the deep perichondrium, care is taken to avoid damaging the
parietal pleura and creating a pneumothorax. After the
amount of cartilage needed is determined, it is harvested by
incising through the rib using a No.15 blade scalpel. Slightly
more cartilage should be harvested than what is needed
because cartilage is lost secondary to carving. Hemostasis is
obtained, and the perichondrium is closed using 3-0 Vicryl.
The wound is closed in layers using 4-0 Vicryl followed by a
5-0 Monocryl intradermal suture. Injection of 0.25% bupiva­
caine into the donor site for postoperative pain control is
followed by application of SteriStrips.
If there is concern for pneumothorax during costal cartilage
harvest, the wound is filled with saline and positive pressure
ventilation can be performed by the anesthesia provider to
ensure that there are no gas bubbles escaping from the chest
cavity. If the parietal pleura has been violated, the tip of a red
rubber catheter is inserted into the defect and a 3-0 Vicryl
purse string suture is performed around the catheter. The
anesthesia provider performs a Valsalva maneuver while
suction is applied to the red rubber catheter. As the catheter
is withdrawn, the purse string suture is tied to seal the parietal
pleural defect, followed by wound closure. An upright chest
X-ray should be performed postoperatively to confirm resolu­
tion of the pneumothorax.

438.e4
SECTION I
CHAPTER 16 • Open technique rhinoplasty
Fig. 16.12  Harvesting costal cartilage.

438.e5
Treatment surgical technique
Fig. 16.13  Harvest of temporal fascia.
Temporal fascia
The anterior limit of the incision is made in line with the
tragus (Fig. 16.13).53–55 A posteriorly pointing, V-shaped inci­
sion is used as this gives the widest exposure for the subcu­
taneous dissection. The incision is approximately 5 cm in
craniocaudal dimension and spans approximately 2.5 cm in
anteroposterior dimension. The skin of the scalp is infiltrated
with 5 ml of 1% lidocaine with epinephrine. The skin is incised
down through the temporoparietal fascia to expose the deep
temporal fascia. A needle tip electrocautery is used to dissect
the areolar tissues off the superficial surface of the deep
temporal fascia. An attempt should be made to harvest
the largest piece of temporal fascia possible. This involves
incising the temporal fascia close the temporalis muscle’s
attachments to the skull periosteum superiorly and posteri­
orly and where it begins to divide into deep and superficial
layers anteriorly. The temporal fascia should be harvested
inferiorly to the level of the ear. Although this area is about
8 × 6 cm in dimension, temporal fascia contracts significantly
and this generally yields a temporal fascia graft that is about
5 × 4 cm in dimension. The deep temporal fascia is incised
with the needle tip electrocautery and then swept off the
underlying temporalis muscle. Muscle fibers should not be
harvested with the temporal fascia graft. Hemostasis is
obtained, and the skin is closed in layers with 3-0 Vicryl
inverted deep dermal sutures followed by a running 4-0
chromic gut suture.

439
Treatment surgical technique
Fig. 16.15  Floating (A) and fixed (B) columellar strut grafts.
A
B
Fig. 16.14  Cephalic trim. Lateral and middle crura (A).
Lateral crus (B).
A
B
nasal tip suturing techniques.74–79 We commonly use four
primary suture techniques (Fig. 16.16).33,80–82 Medial crural
sutures are the first sutures placed and can be used to correct
medial crural asymmetries, to reduce flaring, and to control
the overall width of the columella.81,82 In addition, medial
crural suture techniques stabilize the columellar strut graft
and have been previously described. Interdomal sutures can
increase infratip columellar projection and definition or
further increase tip projection. A 5-0 PDS suture is placed
through the medial walls of the domes and tied to narrow the
interdomal distance. Transdomal sutures control dome asym­
metry. A 5-0 PDS horizontal mattress suture is placed from the
medial surface of the dome through to the lateral surface,
staying deep to the vestibular skin, and then back from lateral
to medial. A double surgeon’s knot is placed in the suture and
tightened until the desired angulation of the dome is achieved.
If narrowing of the distance between the tip-defining points
is required, one end of the suture is cut short and the other
left approximately 2 cm long (Fig. 16.17). Another transdomal
suture is performed on the opposite side, leaving one end of
the suture long. The long end is tied to the long suture end
on the opposite side. The knot is tightened until the desired
distance between the tip-defining points is achieved and then
tied. Intercrural septal sutures are used to alter tip rotation
(Fig. 16.18). Additionally, the lateral crural mattress suture has
been described to reduce the convexity and straighten the
lateral crus (Fig. 16.19).78 The area of maximal convexity of the
lateral crus is grasped with a forceps. A 5-0 PDS suture is
placed beginning at the caudal aspect of the lateral crus and
passed perpendicular to the length of the lateral crus on one
side of the forceps and then on the other side of the forceps
forming a mattress suture. The usual width of the mattress

440
SECTION I
CHAPTER 16 • Open technique rhinoplasty
BOX 16.6  Tip suturing techniques
Medial crural suture
Medial crural–columellar strut suture
Interdomal suture
Transdomal suture
Joined transdomal suture
Intercrural septal suture
Lateral crural mattress suture
Fig. 16.16  Nasal tip suturing techniques. Medial crural (A). Transdomal (B).
Interdomal (C).
A
B
C
Fig. 16.17  Joined transdomal sutures.
A
B
Fig. 16.18  Intercrural septal suture.

441
Treatment surgical technique
Fig. 16.19  Lateral crural mattress suture.
Fig. 16.20  Nasal tip
cartilage grafts. Supratip
(A). Infratip (B).
Anatomic (C).
A
B
C
suture is approximately 6–8 mm. The knot is tightened until
the convexity of the lateral crus disappears. The suture should
not penetrate the vestibular lining on the deep surface of the
lateral crus.
Nasal tip grafting techniques
Nasal tip grafts are used in primary rhinoplasty only if
adequate tip projection, definition, or symmetry cannot be
obtained by the use of the previously discussed techniques.81
Visible nasal tip grafts are used infrequently in primary rhi­
noplasty because of the potential for long-term resorption and
thinning of the overlying soft tissue leading to asymmetries
or excessive visibility requiring revision.83 When nasal tip
grafts are used, it is important that they have smooth, tapered
edges. If possible, invisible nasal tip grafts should be used
to diminish the risk of these long-term sequelae. Anatomic
cap grafts taken from the cephalic trim of the lower lateral
crus or morselized onlay grafts84 can be used to augment
the nasal tip or correct asymmetries.83 Nasal tip grafts of all
shapes and sizes have been described (Fig. 16.20).81 A shield
graft is placed adjacent to the caudal edges of the anterior
middle crura and extends into the tip. It is used to increase tip
projection and improve definition of the tip and the infratip
lobule.33,85,86 A shield graft is approximately 8 mm wide and
10–12 mm long. The width of the base of the graft is the same
as the distance between the caudal margins of the medial
crura. It is placed so that it extends 2–3 mm past the tip-
defining points and should be sutured with at least two 5-0
PDS sutures to the caudal margins of the dome and medial
crura. An onlay graft is placed horizontally over the alar
domes and is used to camouflage tip irregularities and can
provide increased tip projection.87,88 A 6–8 mm onlay graft is
sutured to the tip-defining points with two 5-0 PDS horizontal
mattress sutures with the knots tied on the underside of the
domes. An anatomic tip graft is a combination of the shield
and onlay grafts and reflects the surface anatomy of the ideal
tip.89 The upper part of the graft represents the area between
the domes, and the lower part represents the area between the
middle crura. In primary rhinoplasty, the anatomic tip graft
is reserved for the patient with inadequate tip projection or
thick skin.
The alar rims
The presence of deformities of the alar rims such as alar notch­
ing or retraction, facets of the soft tissue triangles, malposition
of the lateral crura, or functional problems including external
valve collapse may require the use of lateral crural horizontal
mattress sutures, lower lateral crural turnover flaps, alar
contour, or lateral crural strut grafts to correct.
Alar contour and extended alar contour grafts
Alar contour grafts are used as a simple and effective method
to correct and prevent alar notching or retraction, and facets
of the soft-tissue triangles, after correcting the tip deformity
(Fig. 16.21).90,91 Sharp dissection scissors are used to dissect a
subcutaneous pocket below the infracartilaginous incision
and parallel to the alar rim. The pocket should span the length
of the deformity and extend 3 mm to each side of it. An alar
contour graft is typically 4 × 10 mm but it may need to be
larger depending on the size of the deformity. In cases with
pre-existing alar notching at the caudal border of the lower

442
SECTION I
CHAPTER 16 • Open technique rhinoplasty
Fig. 16.21  Alar contour grafts.
lateral crus or where additional support of the position of the
lower lateral crus is required, extended alar contour grafts can
be used where the anterior aspect of the graft crosses the
infracartilaginous incision and is positioned between the deep
surface of the anterior aspect of the lateral crus and the ves­
tibular skin.90
Lateral crural strut grafts
Lateral crural strut grafts are used to support weak lateral
crura, prevent collapse of the external nasal valve, address
malposition of the lateral crura, or increase tip projection (Fig.
16.22).92 The vestibular skin is dissected from the deep surface
of the posterior two-thirds of the lateral crus. The lateral crus
is separated from the accessory cartilages. Sharp dissection
scissors are used to dissect a subcutaneous pocket below
adjacent to the accessory cartilages posteriorly to the pyriform
aperture. To correct malposition of the lateral crura, the pocket
is dissected below the infracartilaginous incision and parallel
to the alar rim. A 4 × 25 mm lateral crural strut graft is placed
in the pocket and rests on the pyriform aperture posteriorly.
The anterior aspect of the graft is placed deep to the lateral
crus and secured with two or three 5-0 PDS simple interrupted
sutures.
The alar–columellar relationship
The alar–columellar relationship demonstrated on the lateral
view is dictated by the relative positions of the alar rim and
the columella to a line drawn through the long axis of the
nostril (Fig. 16.23). The ideal distance from the long axis to
both the alar rim superiorly and the columella inferiorly is
1–2 mm.
Six classes of alar–columellar relationship have been
described.93 A class I relationship in which the distance from
the long axis to the columella is greater than 2 mm while the
distance from the long axis to the alar rim is 1–2 mm is known
as a hanging columella. Correction involves resection and
reapproximation of the membranous septum to reposition
the columella superiorly. It may also be necessary to resect
part of the caudal septum or medial crura if they contribute
to the hanging columella. A class II relationship is where the
distance from the long axis to the columella is 1–2 mm, while
the distance from the long axis to the alar rim is greater than
2 mm and is secondary to alar retraction. Correction may
involve caudal repositioning of the lateral crus, the use of alar
contour or lateral crural strut grafts, or composite grafts from
the septum or concha. A class III relationship is a combination
of both classes I and II and requires the use of techniques
described for both classes. A class IV relationship in which the
distance from the long axis to the columella is 1–2 mm while
the distance from the long axis to the alar rim less than 1 mm
is known as a hanging ala. Correction involves resection of
a horizontal ellipse of vestibular skin no more than 3 mm in
width to raise the hanging ala. A class V relationship in which
the distance from the long axis to the columella is less than
1 mm while the distance from the long axis to the alar rim
is 1–2 mm is secondary to columellar retraction. Correction
involves placing a contoured columellar strut graft between

Fig. 16.23  Alar–columellar
relationships. Class I (A). Class II
(B). Class III (C). Class IV (D). Class V
(E). Class VI (F).
A
B
C
A
A
B
C
B
A
B
C
C
A
B
C
D
A
B
C
E
A
B
C
F
Fig. 16.22  Lateral crural strut grafts.

444
SECTION I
CHAPTER 16 • Open technique rhinoplasty
lateral osteotomies during the final stages of the operation. A
2-mm incision is made in the nasofacial groove at the level of
the inferior orbital rim. A sharp 2-mm straight osteotome is
inserted through the incision and parallel to the surface of the
maxilla, down through the periosteum. A lateral subperiosteal
sweep to the bony nasofacial groove is performed to displace
the medial crura to push the columellar skin inferiorly. A
class VI relationship is a combination of both classes IV
and V and requires the use of techniques described for both
classes.
Percutaneous lateral nasal osteotomies
Nasal osteotomies are a key component to shape the bony
vault in rhinoplasty. Osteotomies are used to narrow a wide
bony vault, close an open roof deformity, or straighten devi­
ated nasal.94,95 The goals of nasal osteotomies are maintenance
or creation of smooth dorsal aesthetic lines and obtaining a
desirable width of the bony vault.94 Osteotomies can be clas­
sified by approach (external or internal), type (lateral, medial,
transverse, or a combination), and level (low-to-high, low-to-
low, or double level) (Fig. 16.24). A transition zone of decreased
bony thickness exists along the frontal processes of the maxilla
near its junction with the nasal bone, from the pyriform
aperture to the radix. This area of relatively thin bone allows
for consistent osteotomies and predictable fracture patterns.
Relative contraindications to the use of osteotomies during
rhinoplasty include patients with short nasal bones, elderly
patients with excessively thin nasal bones, those with rela­
tively thick nasal skin, and some non-Caucasian patients with
extremely low and broad noses.33,94–99
Various authors have described their experience using dif­
ferent approaches including intranasal, intraoral, and percu­
taneous and techniques.100–119 We prefer percutaneous lateral
discontinuous osteotomies because this technique results in a
more controlled fracture with less intranasal trauma while
minimizing morbidity including bleeding, ecchymosis, and
edema (Fig. 16.25).94,96–99 Although osteotomies can be per­
formed at any point during rhinoplasty, we typically perform
Fig. 16.24  Percutaneous discontinuous lateral nasal osteotomies. Low-to-high (A). Low-to-low (B). Double-level (C).
A
B
C
Fig. 16.25  Percutaneous discontinuous lateral nasal osteotomies.

445
Treatment surgical technique
upper lip. The upper gingivolabial sulcus incision is close
vertically to further elongate and enhance fullness to the
central upper lip.
Shaping the columella
The columella is central to the basal view of the nose. The
shape and contour of the lateral border of the columella is
crucial to nasal aesthetics and has been termed the basal
aesthetic lines, analogous to the dorsal aesthetic lines. The
basal aesthetic lines serve as a transition from the upper lip
to the nasal lobule and should ideally be symmetrical, smooth,
and slightly curved. Columellar deformities have been classi­
fied based on the underlying structural deformity (Box
16.7).122–125 The underlying structural deformity will dictate
the surgical treatment.
A common deformity of the columella is flaring of the
medial crural footplates. Five-step medial crural footplate
approximation is a useful technique to correct this (Fig.
16.27).122,125 This is performed in five steps: (1) the location and
the extent of the splayed footplates are marked by two sym­
metrical lines that parallel the columella along the inferior
medial portion of the nasal sill; (2) an excision of minimal
mucosa (1–2 mm) overlying the marked area of the medial
crural footplates is performed; (3) a 5-0 PDS horizontal mat­
tress, spanning suture is passed across the columella, securing
the medial crural footplates; (4) a second 4-0 chromic catgut
horizontal mattress suture is used to capture the soft-tissue
mass at the base of the columella; and (5) mucosal closure is
performed with 5-0 chromic catgut.
Alar base surgery
Alar base surgery is indicated for abnormalities including alar
flaring, nostril asymmetry, excessively large nostrils, elon­
gated alar sidewalls, widened alar base, large alae, and alar
asymmetry (Fig. 16.28).33,122 Alar flaring is the most common
problem requiring modification of the alar base. The relation­
ship between the alar and basal planes, alar base width, and
the nostril shape and size should be taken into consideration
when choosing the appropriate surgical technique. The ideal
configuration for alar base modification is when the alar plane
diverges laterally forming an acute angle of less than 90° with
the basal plane. When the alar and basal planes form a per­
pendicular or obtuse angle, alar base resections will cause a
disproportionately narrow alar base width, resulting in a
“bowling pin” appearance.41 With open rhinoplasty, alar base
resections should be keep inferior to the alar groove to avoid
damage to the lateral nasal arteries.30,31,122
Alar flaring
Alar flaring in the presence of normal nostril shape and sym­
metry is corrected by limiting excision to the alar lobule; the
incision is not continued into the vestibule.33,122 The incision
is not made directly in the alar–cheek groove but on the alar
lobule, within 1 mm of the groove allowing for an everted
closure with improved scarring. In addition, 1–2 mm of the
alar base is preserved preventing alar base notching. The
wound is closed with 6-0 black nylon suture on a PC-3 needle
using the “halving principle”, since the incision adjacent to
the alar–cheek groove is longer than the incision on the alar
surface.
the angular artery laterally and prevent its injury. The osteo­
tome is oriented so that only one edge is in direct contact with
the bone for improved accuracy. The discontinuous osteotomy
is performed from inferiorly, preserving the caudal aspect of
the frontal process of the maxilla at the pyriform aperture to
prevent collapse of the internal nasal valve, to the level of the
medial canthus superiorly, and then continued into a superior
oblique osteotomy medially. The osteotomy should not be
continued superior to the medial canthus to avoid a rocker
deformity due to the thicker bone present superior to this
level. A mallet is used to strike the osteotome with the end­
points being loss of resistance and change in sound. After the
osteotomies have been completed, the thumb and index finger
are used to exert gentle pressure to perform a greenstick
fracture of the nasal bones to reposition them in the desired
location. If more than gentle pressure is required, the osteo­
tome should be reinserted to ensure that there are no signifi­
cant areas of non-osteotomized bone between the discontinuous
perforations.
Closure
Prior to closure, the wound is irrigated with warm sterile
saline to remove debris that can cause deformity. Closure
of the incisions is begun by lining up the transcolumellar
stair-step incision in the midline and at the junction of the
columellar skin and nasal vestibule bilaterally. This incision
is closed with simple interrupted sutures using 6-0 black
nylon on a PC-3 needle. This closure must be meticulously
performed to prevent notching leading to a noticeable
columellar scar. The bilateral infracartilaginous incisions
are closed next with simple interrupted sutures using 5-0
chromic gut on a PC-3 needle. Sutures are not placed in
the infracartilaginous incision deep to the soft triangle to
prevent distortion of the soft triangle or webbing at the nasal
vestibule.
Depressor septi nasi muscle release
The depressor septi nasi muscles are small, paired muscles
attached to the medial crural footplates and interdigitating
with the orbicularis oris muscle fibers (type I) or originating
on the periosteum of the maxilla (type II).120,121 In some
patients, these muscles are diminutive or nonexistent (type
III). The action of the depressor septi nasi muscles creates or
accentuates the deformity characterized by descent of the
nasal tip, shortening of the upper lip, and a transverse crease
in the midphiltral area.120,121 If the patient has a tension tip that
with animation causes a foreshortened upper lip and decrease
in tip projection, the depressor septi nasi muscles are released
through the open approach and released from their attach­
ments to the medial crura and caudal septum. If the patient
has a tethered upper lip, an upper gingivolabial sulcus
approach is used as this will also provide lengthening of the
upper lip (Fig. 16.26). A horizontal incision between 8 and
10 mm centered on the frenulum is made in the upper gingi­
volabial sulcus using needle tip electrocautery. The depressor
septi muscles are dissected using needle tip electrocautery
and then released near their origin with the orbicularis oris
muscle or maxillary periosteum. The depressor septi nasi
muscles are then transposed and their cut ends are sutured
with 4-0 chromic gut suture providing fullness to the central

446
SECTION I
CHAPTER 16 • Open technique rhinoplasty
Alar flaring with modification of nostril shape
Alar flaring with nostril asymmetry or excessively large
nostrils requires a wedge excision of the alar lobule and
vestibule.33,122 The alar lobule incision is continued into the
vestibule allowing for reduction in the circumference of
the nostril opening while reducing alar flaring. The medial
incision is made so that a small medially based flap is
created to prevent notching at the nostril sill. The wound is
closed with 6-0 black nylon suture on a PC-3 needle start­
ing with realigning the nostril sill and then careful eversion
of the wound edges to avoid a depressed scar across the
nostril sill.
Fig. 16.26  Transoral dissection and transposition of depressor septi nasi muscle.
A
B
C
D
BOX 16.7  Classification of columellar deformities
I.
Caudal septum aberrancy and/or malposition of the anterior
nasal spine is primarily responsible for the columella distortion.
II.
Abnormal medial crura are primarily responsible for columellar
distortion. Premature flaring of the medial crura footplates
represents the most common cause.
IIIA. Soft-tissue excess is primarily responsible for columellar
distortion and may obstruct nasal inflow.
IIIB. Soft-tissue deficiency is primarily responsible for abnormal
columella.
IV.
A combination of septum, medial crura, and/or soft tissue is
responsible for columellar distortion.

447
Correction of specific deformities
Correction of specific deformities
Deviated nose with dorsal hump
Systematic analysis
The patient illustrated in this example had the following
complaints: (1) a dorsal hump, (2) a bulbous nasal tip, and (3)
deviation of the nose to the left (Fig. 16.29). On frontal view,
she has Fitzpatrick type IV thick skin and good facial propor­
tions. She has a reverse C-shaped dorsal septal deformity,
nasal deviation to left, the nasal base is wide, and the nasal
tip is bulbous with slight alar flaring (greater on the left). On
lateral and oblique views, the radix position is good, there is
a moderate dorsal hump about 4 mm, but tip projection and
nasal length are adequate. She has a short upper lip. On basal
view, there is a left caudal septal deviation, and a bulbous tip
and slight alar flaring are again demonstrated. Internal nasal
examination reveals pink mucosa with septal deflection to the
left.
Operative goals
1. Correct the nasal airway obstruction.
2. Reduce the dorsal hump.
Fig. 16.27  Five-step medial crural approximation suture.
A
B
Fig. 16.28  Alar base
surgery. Alar flaring
(A). Alar flaring with
modification of nostril
shape (B).
A
B
3. Correct the nasal deviation.
4. Correct and refine the bulbous nasal tip.
5. Narrow the wide nasal base.
6. Lengthen the short upper lip.
Surgical plan
1. Open approach with transcolumellar and
infracartilaginous incisions to expose nasal framework.
2. Component dorsal hump reduction to reduce
cartilaginous and bony dorsum 4 mm.
3. Expose nasal septum and perform septal reconstruction
with septal cartilage harvest to correct nasal airway
obstruction and provide material for cartilage grafts.
4. Perform 50% full-thickness inferior cuts into the
deviated L-strut and place figure-of-eight suture to
contralateral periosteum of anterior nasal spine with 5-0
PDS suture to correct septal deviation.
5. Place right spreader graft to prevent deviation of L-strut
and strengthen dorsal aesthetic lines.
6. Perform cephalic trim of bilateral lower lateral cartilages
retaining 5 mm alar rim strip to correct and refine
bulbous nasal tip.
7. Secure floating columellar strut graft with 5-0 PDS
medial crural–columellar strut sutures to support and
unify nasal tip.

448
SECTION I
CHAPTER 16 • Open technique rhinoplasty
nose, and (3) a poorly defined nasal tip (Fig. 16.30). On frontal
view, the patient has Fitzpatrick type II moderately thick skin
and good facial proportions. He has deviation of the nose to
the right, the nasal base is wide, and the nasal tip is poorly
defined with a wide angle of divergence and domal arch. On
lateral and oblique views, he has a moderate dorsal hump
and a dependent nasal tip with infratip lobule excess, giving
the appearance of poor tip projection. On basal view, the
poorly defined nasal tip is again apparent with a wide angle
of divergence. Internal nasal examination reveals a septal
deflection to the right.
Operative goals
1. Correct the nasal airway obstruction.
2. Reduce the dorsal hump.
3. Correct the nasal deviation.
4. Decrease nasal length by correcting infralobular excess.
5. Narrow the wide nasal base.
6. Correct and refine the nasal tip.
Surgical plan
1. Open approach with transcolumellar and
infracartilaginous incisions to expose nasal framework.
2. Component dorsal hump reduction to reduce
cartilaginous and bony dorsum 4 mm.
8. Perform graduated approach to nasal tip suturing with
medial crural–columellar strut and interdomal sutures
and place cap graft from cephalic trim to refine nasal
tip.
9. Perform percutaneous low-to-low lateral osteotomies to
reposition the bony nasal base.
10. Release and transpose depressor septi muscles through
upper lip gingivolabial incision.
Outcome
The patient is shown at 2-year follow-up. Frontal view reveals
a straight nose, improved dorsal aesthetic lines, and a refined
nasal tip. Lateral view shows a normal radix position, a
smooth, straight dorsum, a slight supratip break, and
improved nasal length. Tip projection is good. There is a
subtle increase in the upper lip length that enhances the tip–
lip relationship. Basal view again demonstrates an aesthetic
triangular nasal tip with an improved alar–columellar
relationship.
Long, wide nose with a drooping tip
and nasal airway obstruction
Systematic analysis
The patient illustrated in this example had the following
complaints: (1) nasal airway obstruction, (2) a long, drooping
Fig. 16.29  Preoperative (A,C,E) and postoperative (B,D,F) patient with deviated nose with dorsal hump. Gunter diagrams.
A
B
C
D
E
F

449
Postoperative care
A
B
C
D
E
F
3. Expose nasal septum and perform septal reconstruction
with septal cartilage harvest to correct nasal airway
obstruction and provide material for cartilage grafts.
4. Perform cephalic trim of bilateral lower lateral cartilages
retaining 5 mm alar rim strip to correct and refine
bulbous nasal tip.
5. Secure floating columellar strut graft with 5-0 PDS
medial crural–columellar strut sutures to support and
unify nasal tip.
6. Perform graduated approach to nasal tip suturing with
medial crural–columellar strut, transdomal, and
interdomal sutures to refine nasal tip.
7. Perform intercrural–septal suture to increase tip
projection and derotate nasal tip.
8. Infralobular onlay graft to improve nasal tip balance.
9. Perform percutaneous low-to-low lateral osteotomies to
narrow the bony nasal base.
Outcome
The patient is shown at 1-year follow-up. Frontal view reveals
a straight, narrower nose, improved dorsal aesthetic lines, and
a refined nasal tip. Lateral view shows a smooth, straight
dorsum, improved tip rotation and projection, and improved
balance between the nasal tip and dorsum. Basal view again
demonstrates improved nasal tip definition and an aesthetic
triangular nasal tip.
Postoperative care
Postoperative care begins preoperatively with a thorough
review of the plan of care and expected postoperative recov­
ery. The patient is provided with both oral and written detailed
postoperative instructions at the initial visit, establishing the
foundation for successful postoperative care. At each subse­
quent visit, including the day of surgery, postoperative
instructions are reviewed with the patient to reinforce and
clarify these details. This helps to improve patient under­
standing, involves the patient in their own care, and minimizes
patient anxiety. Dressings and wound care, medications,
activity restrictions, general instructions, and management of
complications are the core elements in postoperative care of
the rhinoplasty patient.126
Dressings and wound care
At the end of the procedure, edema is gently compressed from
soft tissues of the lobule, the nasal skin is cleansed with an
alcohol prep pad, Skin-Prep protective barrier wipe (Smith
& Nephew, Inc., St. Petersburg, FL) is applied followed by
Fig. 16.30  Preoperative (A,C,E) and
postoperative (B,D,F) patient with long, wide
nose with a drooping tip and nasal airway
obstruction. Gunter diagrams.
Continued

450
SECTION I
CHAPTER 16 • Open technique rhinoplasty
G
4mm reduction
Cap graft
Primary open
External percutaneous
osteotomy
H
Cap graft
Inferior F.T.
50% cut
Right spreader only
Figure-of-eight
suture
Fig. 16.30, cont’d  G) and H); Red = resection. Green = graft. Note graft material harvested from septum.

451
Outcomes, prognosis, complications
days, after which minimal analgesic medication should be
required. While using narcotics, the patient should also receive
stool softeners to prevent constipation as straining may pre­
cipitate postoperative bleeding.
Activity restrictions
During the initial 48 h following rhinoplasty, the patient
should keep their head elevated greater than 30° and gently
apply cold compresses to help decrease postoperative edema
and ecchymosis. Head elevation should be continued until
there is no longer edema in the morning. This is typically 7–10
days. The patient should avoid any straining, including
strenuous activity or heavy lifting, for 3 weeks. Trauma and
pressure on the nose, including wearing glasses, should be
avoided for 4 weeks.
General instructions
In addition to the previous postoperative instructions, the
patient is instructed to call the physician if they experience
fever (temperature greater than 38.5°C or 101.5°F), pain not
controlled with medication, or persistent nasal bleeding with
bright red blood or changing the nasal drip pad more fre­
quently than every 30 min.
Follow-up
The first follow-up appointment is at 1 week postoperatively,
where sutures and splints are typically removed. Typically,
the patient is seen again at 1 month, 3 months, 6 months, 1
year, and then every 1–2 years following surgery. Postopera­
tive photographs are taken at the 1-year follow-up appoint­
ment, and then yearly thereafter.
Outcomes, prognosis, complications
Outcomes
At this time, there are no standardized measures for assessing
the aesthetic or functional outcomes following rhinoplasty.
Various authors have proposed different methods including
image analysis, measurement tools, and computer programs,
to assess these outcomes.38,132–137
Following rhinoplasty, most patient dissatisfaction is seen
in the lower third of the nose including the nasal tip, followed
by the middle and upper thirds. Poor results in the lower
third typically arise from nasal tip asymmetries, notching
of the alae, and inadequate tip position. Common problems
in the middle third include supratip fullness or a pinched
supratip. Complaints in the upper third include excessive
reduction of the dorsum, internal valve collapse, asym­
metrical or ill-defined dorsal aesthetic lines, and other dorsal
irregularities.
Prognosis
Several studies have attempted to assess the impact of rhino­
plasty on the patient’s quality of life.138 Rhinoplasty has been
reported to significantly improve the quality of life for patients
following this procedure, regardless if the indication was
cosmetic or post-traumatic.139
14-inch Steri-Strips (3M, St. Paul, MN). SteriStrips are applied
starting at the supratip break, carefully contouring the soft
tissue to the underlying osteocartilaginous skeleton and then
continuing superiorly along the dorsum with SteriStrips of
progressively shorter length.
A Denver dorsal splint (Shippert Medical Technologies
Corporation, Centennial, CO) is shaped over a cylindrical
object with a diameter similar to the width of the osseous
base of the nose. This splint is applied over the superior
two-thirds of the dorsum, and the edges are compressed
medially to support the osteotomized nasal bones. The infe­
rior edge of this splint should be superior to the supratip
area. If septal reconstruction and/or inferior turbinoplasty
was performed, Doyle septal splints (Micromedics, Inc., St.
Paul, MN) are applied to avoid hematoma formation deep
to the mucoperichondrial flaps, support and stabilize the
structures, protect the septal mucosa, and prevent synechiae
formation between adjacent mucosal surfaces. These splints
are covered with antistaphylococcal antibiotic ointment,
inserted into each of the nasal cavities, and secured using a
3-0 nylon horizontal mattress suture through the membra­
nous septum, loosely tied to prevent ischemia of this delicate
tissue. Both Denver and Doyle splints are removed typically
on postoperative day 7, along with the columellar sutures.
If the patient has undergone extensive septal reconstruction,
the splints many be left in place for approximately 10–21
days. Alar base sutures are removed 7–10 days following
surgery.
A nasal drip pad is fashioned using 2 × 2 gauze and held in
place under the nose with paper tape secured to tape on the
cheeks. The tape on the cheeks helps to prevent skin macera­
tion secondary to frequent removal and reapplication of the
tape. The patient will gently clean the incisions with half-
strength hydrogen peroxide and apply antistaphylococcal
antibiotic ointment twice daily for 7 days.
Generally, most of the nasal swelling and ecchymosis will
resolve within 3–4 weeks following surgery; however, soft-
tissue edema, both external and internal, will take approxi­
mately 12 months to resolve and external subtle nasal
definition, and internal nasal airflow will continue to improve
over this period. In patients with thick skin, edema can take
even longer to resolve.
Medications
First- or second-generation cephalosporins are generally used
for perioperative antibiotic prophylaxis. The patient receives
preoperative prophylactic intravenous antibiotics in the
holding area 30 min prior to surgery. Several studies127–129
have shown no difference in infection rate with the use of
postoperative prophylactic antibiotics. We do not prescribe
any postoperative oral antibiotic prophylaxis.
A dose of corticosteroids is given intraoperatively for pre­
vention of postoperative nausea and vomiting. Intraopera­
tively, 8 mg intravenous dexamethasone is given. This can be
continued in the form of oral methylprednisolone (Medrol
Dosepak) for 6 days to minimize edema and ecchymosis.
Although the efficacy of high-dose corticosteroids remains
debatable, there is newer data that suggests their utility in
open rhinoplasty.130,131
Postoperative pain and discomfort is highly variable. In
general, oral narcotic analgesia may be required for several

452
SECTION I
CHAPTER 16 • Open technique rhinoplasty
BOX 16.8  Complications
Anosmia
Arteriovenous fistula
Bleeding (ecchymosis, epistaxis, hematoma)
Deformities and deviation
Epiphora
Infection (cellulitis, abscess, granulomas, toxic shock syndrome)
Intracranial injury
Nasal airway obstruction (external valve collapse, internal valve
collapse, septal deviation, synechiae, vestibular stenosis)
Nasal cyst formation
Nasolacrimal apparatus injury
Prolonged edema
Scarring
Septal perforation
be gently placed in the affected nostril. If bleeding continues,
the Doyle splints should be removed and the nasal cavity
should be irrigated with saline and suctioned to remove blood
clots and crusting to allow identification of the origin of the
bleeding. Silver nitrate can be used to cauterize the offending
area, followed by anterior nasal packing. If bleeding remains
refractory, posterior nasal packing should be considered along
with hospital admission for observation. In less than 1% of
patients, major epistaxis occurs and should be addressed in
the operating room with exploration and cauterization. Infe­
rior turbinate resection is usually the source. If all of the above
measures fail, consultation for angiographic embolization
should be obtained.
Hematoma is another common bleeding complication fol­
lowing rhinoplasty. Regardless of the location, all hematomas
should be drained following rhinoplasty. Hematomas deep to
the skin will cause fibrosis, leading to scarring and contour
deformities affecting the final nasal appearance. Septal hema­
tomas can lead to septal perforations or necrosis of septal
cartilage leading to a saddle-nose deformity. A septal hema­
toma appears as an ecchymotic septal mass that resembles
a “blackberry” on physical examination. Hematomas can
usually be drained in the office with appropriate lighting.
Following drainage, the area should be packed with 14 -inch
ribbon gauze to prevent recurrence. This should be removed
the following day and the area should be reinspected.
Infection
Although infections are rare following rhinoplasty, diligent
physical examination to identify early signs of infection allow
early initiation of treatment to prevent serious complications
such as tissue necrosis, toxic shock syndrome, and cavernous
sinus thrombosis. In the event of an infection, internal nasal
splints, or packing may need to be removed.
Mild cellulitis usually responds to cephalosporins. If infec­
tion has developed where a course of postoperative prophy­
lactic antibiotics have been prescribed, treatment with a
different antibiotic such as a fluoroquinolone should be
started. In the event that cellulitis is refractory to these anti­
biotics, consideration of methicillin-resistant Staphylococcus
aureus should be given and empirical antibiotic treatment
with levofloxacin, sulfamethoxazole/trimethoprim, or mino­
cycline should be started based on local antibiotic-resistance
patterns. In cases of severe cellulitis, the patient may need to
be admitted for intravenous antibiotics. Abscesses are usually
found at the nasal dorsum, nasal tip, and the septum. Any
abscess identified should be drained and irrigated, and puru­
lent material should be cultured to guide antibiotic therapy.
Toxic shock syndrome has been described after rhinoplasty
with the use of both nasal packing146,147 and internal nasal
splints.148 It is an acute, multisystem disease caused by
release of exotoxins from Staphylococcus aureus or Streptococ­
cus pyogenes causing excessive activation of inflammatory
cells and release of inflammatory cytokines, often resulting
in tissue damage and organ dysfunction.149 Patients can
present with fever, a diffuse macular erythroderma rash,
desquamation, nausea, vomiting, diarrhea, tachycardia, and
hypotension.132 Removal of nasal packing or internal nasal
splints, administration of intravenous antibiotics supportive
care, and intensive care unit monitoring are indicated in this
rare event.
Complications
The reported incidence of significant complications following
rhinoplasty ranges from 1.7% to 18%.140–145 Common compli­
cations following rhinoplasty include bleeding, infection,
prolonged edema, deformities and deviation, and nasal
airway obstruction (Box 16.8).126,145
Bleeding
Patients who are at risk for bleeding complications include
those with hypertension, a family history of bleeding
diatheses, and those taking aspirin and other non-steroidal
anti-inflammatories. Hypertension should be well controlled
perioperatively. Patients should be instructed about which
antihypertensive medications to take the morning of surgery.
There should be good communication with the anesthesia
provider regarding intraoperative blood pressure control.
Patients with intraoperative hypertension may benefit from
placement of a Catapress-TTS-2 (0.2 mg clonidine transdermal
therapeutic system) (Boehringer Ingelheim Pharmaceuticals,
Inc., Ridgefield, CT) for prevention of transient postoperative
hypertension. Patients with a family history of bleeding
diatheses should have preoperative laboratory investigations
that may include prothrombin time, partial thromboplastin
time, and platelet count. Aspirin and other non-steroidal anti-
inflammatories should be stopped 10 days prior to surgery
and avoided for 2 weeks after.
Epistaxis is one of the most common complications follow­
ing rhinoplasty.3,126,145 It is usually mild and originates from
the incisions or areas of mucosal trauma. Head elevation
greater than 60°, oxymetazoline nasal spray into the affected
nostril, and gentle pressure for 15 min is usually enough to
stop any mild epistaxis. These measures may be attempted
twice by the patient; however, if bleeding persists, the patient
should be seen immediately. Oxymetazoline nasal spray may
be used again, and anterior nasal packing with saline moist­
ened ribbon gauze or Surgicel (Ethicon, San Angelo, TX)
lubricated with antistaphylococcal antibiotic ointment should

453
Secondary procedures
examination should be performed to identify the cause. If it
is secondary to edema, a 7–14 day course of a corticosteroid
nasal spray can be used, but topical vasoconstrictors should
not be used for more than 7 days because of rebound conges­
tion following cessation of these medications. If an anatomical
cause of obstruction is identified such as internal nasal valve
collapse or synechiae, surgical treatment will be required but
should be delayed for at least 1 year to allow for complete
resolution of edema and maturation of scar tissue.
Secondary procedures
Although it is difficult to determine an exact revision rate
following primary open rhinoplasty, a recent survey of plastic
surgeons and otolaryngologists revealed that 58% of those
surveyed cited their revision rate as less than 5% while another
33% reported their revision rate was 6–10%.150 This survey
also revealed that the open approach was preferred by 73%,
compared with 20% preferring the closed approach for revi­
sion rhinoplasty. It has been over 25 years since the benefits
of the opening approach for secondary rhinoplasty were
described.151 Revision or secondary rhinoplasty poses a sig­
nificant challenge due to the complex nature of the problems
causing the anatomical deformity or functional abnormality,
alteration of native nasal anatomy, presence of scarring, and
depletion of autogenous cartilage needed for grafting. Many
advances in concepts and techniques to address these
problems encountered during secondary rhinoplasty have
undoubtedly been made possible by the adaptation of the
open approach.151 Secondary rhinoplasty is covered in detail
in Chapter 19.
Prolonged edema
Soft-tissue edema in the early postoperative period is largely
prevented by preoperative patient education about postopera­
tive care and recovery, perioperative corticosteroid use, head
elevation, taping, and application of cold compresses. Most
edema will resolve within 4 weeks.
Late soft-tissue edema persists several months to more
than a year postoperatively and represents scar remodeling.
It can be seen in situations such as secondary rhinoplasty or
patients with thick skin. Patients should be reassured that it
will resolve on its own. In certain circumstances where exces­
sive scarring threatens to cause loss of definition such as in
the supratip area or radix, corticosteroid injection may be
indicated to decrease the production of scar tissue.126,145 An
injection of 3–5 mg of triamcinolone acetate (10 mg/ml)
mixed with 2% lidocaine in a 1 : 1 ratio is given into the supra­
tip area with a 27-gauge needle. Care is taken to avoid
superficial injection that can lead to dermal atrophy resulting
in contour deformities and visibility of the underlying osteo­
cartilaginous framework or hypopigmentation. Depending
on the clinical scenario, injections may be administered as
early as 1 week postoperatively and repeated at 4- and 8-week
intervals. Corticosteroid injections should be used judiciously
to avoid complications.
Deformities and deviation
Deformities may be identified in the postoperative period.
Mild deformities should be observed. If they persist beyond
1 year, surgical treatment is required. Significant deformities
should be corrected as soon as they are identified to avoid
patient dissatisfaction.
Deviations are managed similar to deformities. Mild devia­
tion may be corrected using nasal molding techniques.126,145
The patient is instructed to apply controlled pressure using
their thumb along the nasal sidewall 3–4 times per day for 4–6
weeks postoperatively. If the deviation is significant or persists
beyond 1 year, surgical treatment is required.
Nasal airway obstruction
Following rhinoplasty, most patients experience transient
nasal airway obstruction secondary to edema. This typically
resolves over 3–4 months as edema subsides. When significant
nasal airway obstruction persists after 6 weeks, internal nasal
Bonus content for this chapter can be found online at

Historical perspective
Harvesting autologous grafting material
Temporal fascia
Fig. 16.8 Submucoperichondrial dissection.
Fig. 16.9 Submucoperichondrial flaps.
Fig. 16.10 Septal L-strut.
Fig. 16.11 Harvesting ear cartilage.
Fig. 16.12 Harvesting costal cartilage.
Fig. 16.13 Harvest of temporal fascia.
17. Howard BK, Rohrich RJ. Understanding the nasal airway:
principles and practice. Plast Reconstr Surg. 2002;109:1128–1146.
35. Rohrich RJ, Muzaffar AR, Janis JE. Component dorsal hump
reduction: the importance of maintaining dorsal aesthetic lines in
rhinoplasty. Plast Reconstr Surg. 2004;114:1298–1308. Dorsal hump
reduction may result in dorsal irregularities caused by uneven resection,
over-resection or under-resection of the osseocartilaginous hump, the
inverted-V deformity, excessive narrowing of the midvault, and collapse
of the internal valve. The authors present a technique for component
dorsal hump reduction that allows a graduated approach to the correction
of the nasal dorsum by emphasizing the integrity of the upper lateral
cartilages when performing dorsal reduction.
37. Roostaeian J, Unger JG, Lee MR, et al. Reconstitution of the nasal
dorsum following component dorsal reduction in primary
rhinoplasty. Plast Reconstr Surg. 2014;133:509–518. Following
component dorsal hump reduction, reconstitution of the nasal dorsum is
performed to create smooth and symmetrical dorsal aesthetic lines.
Preservation of the upper lateral cartilages during component dorsal
hump reduction avoids the routine use of spreader grafts in primary
rhinoplasty while preventing deformities including the inverted-V
deformity and function problems including internal valve collapse.
Variations of upper lateral cartilage tension spanning sutures used to
reconstitute the dorsum are reviewed.
43. Rohrich RJ, Gunter JP, Deuber MA, et al. The deviated nose:
optimizing results using a simplified classification and algorithmic
approach. Plast Reconstr Surg. 2002;110:1509–1523. The deviated nose
frequently causes both functional and aesthetic problems. The authors
present a classification and approach to the deviated nose that relies on
Access the complete reference list online at

454
SECTION I
CHAPTER 16 • Open technique rhinoplasty
accurate preoperative planning and precise intraoperative execution of
corrective measures to return the nasal dorsum to midline, restore dorsal
aesthetic lines, and maintain airway patency. An operative algorithm is
described that emphasizes simplicity and reproducibility.
44. Constantine FC, Ahmad J, Geissler P, et al. Simplifying the
management of caudal septal deviation in rhinoplasty. Plast
Reconstr Surg. 2014;134:379e–388e.
73. Gunter JP, Landecker A, Cochran CS. Frequently used grafts in
rhinoplasty: nomenclature and analysis. Plast Reconstr Surg.
2006;118:14e–29e.
81. Ghavami A, Janis JE, Acikel C, et al. Tip shaping in primary
rhinoplasty: an algorithmic approach. Plast Reconstr Surg.
2008;122:1229–1241. Underprojection and lack of tip definition often
co-exist. Techniques that improve both nasal tip refinement and
projection are closely interrelated. The authors present a simplified
algorithmic approach to creating aesthetic nasal tip shape and projection
in primary rhinoplasty to aid the rhinoplasty surgeon in reducing the
inherent unpredictability of combined techniques and improving
long-term aesthetic outcomes.
91. Rohrich RJ, Raniere J Jr, Ha RY. The alar contour graft: correction
and prevention of alar rim deformities in rhinoplasty. Plast
Reconstr Surg. 2002;109:2495–2505.
97. Rohrich RJ, Krueger JK, Adams WP Jr, et al. Achieving consistency
in the lateral nasal osteotomy during rhinoplasty: an external
perforated technique. Plast Reconstr Surg. 2001;108:2122–2130. The
lateral nasal osteotomy is an integral element in rhinoplasty. The authors
present a reproducible and predictable technique for the lateral nasal
osteotomy and discuss the role of the external perforated osteotomy
technique in reproducing consistent results in rhinoplasty with minimal
postoperative complications.
151. Rohrich RJ, Lee MR. External approach for secondary rhinoplasty:
advances over the past 25 years. Plast Reconstr Surg.
2013;131:404–416.

454.e1
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SECTION I
CHAPTER 16 • Open technique rhinoplasty
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2013;131:404–416.

SECTION I • Aesthetic Surgery of the Face
Closed technique rhinoplasty
17 
Mark B. Constantian
SYNOPSIS
■ Nasal deformities are not limitless or lawless but follow patterns
– therefore their solutions follow patterns.
■ The most common motivation for secondary surgery is an iatrogenic
deformity from prior rhinoplasty.
■ All key planning decisions can be made preoperatively from the nasal
surface. Each anatomical point translates directly to a diagnosis and
then to a surgical step: the entire rhinoplasty strategy can be set
before surgery.
■ Only four common anatomical variants determine rhinoplasty success:
(1) low radix or low dorsum; (2) inadequate tip projection; (3) narrow
middle vault; (4) alar cartilage malposition.
■ Reconstruction of both internal and external valvular incompetence
triples or quadruples airflow in most patients without concomitant
septoplasty or turbinectomy.
■ The great majority of primary nasal deformities can be corrected with
only one of two operative strategies: radix, spreader, and tip grafts; or
dorsal and tip grafts. Alar wall grafts are occasionally needed. Thus the
surgeon need only learn four techniques to perform most rhinoplasties.
■ Reconstruct anatomically, never forgetting function and always
considering the patient’s own aesthetic.
■ Most intraoperative and postoperative problems are under the
surgeon’s control.
■ Effective patient selection is mandatory.
Introduction
Rhinoplasty is uniquely difficult and uniquely rewarding
surgery, but some excellent surgeons stop performing rhino­
plasty because they lose confidence in their abilities or
abandon it after unsuccessful attempts to produce desired
results. This need not be the case. The goal of this chapter is
to outline a system of understanding and treating nasal
deformities that is based on functional analysis, knowledge
of critical anatomical variants, soft-tissue and skeletal behav­
ior, and a surgical philosophy that emphasizes safety and
function, and that relies on only four techniques that always
work if performed correctly.
The anatomy and science necessary
for surgical success
Why is rhinoplasty difficult?
The advocates of open rhinoplasty argue that open rhinoplasty
is easier than the endonasal approach because the surgeon has
good binocular vision and can see and modify the nasal
anatomy. If that is true, why are so many open rhinoplasties
unsuccessful?
Surgeons trying to perform endonasal rhinoplasty must
recognize that it is not the same as open rhinoplasty performed
through a keyhole. The mindset is different, just like it is
between liposuction and abdominoplasty. In fact, endonasal
rhinoplasty is easier in several ways:
1. Dissection is limited only to those areas that are going
to be changed, limiting patient morbidity and the
possibility of introducing new deformities.
2. Fewer techniques need to be mastered – I only use four.
Internal sutures and struts are not required.
3. Most importantly, the surgeon sees better through the
endonasal approach. Half of nasal shape is imparted by
the skin, which adds its own variability to the outcome:
that is why there is supratip deformity (Fig. 17.1). The
surgeon who chooses the open approach therefore
forfeits all surface feedback – 50% of the intraoperative
information that the nose can provide. The open
rhinoplasty surgeon sees the skeleton very well, but the
skin not at all. The closed rhinoplasty surgeon sees and
benefits from both.
It is therefore more accurate to say that rhinoplasty is difficult
because the nasal soft tissues have limited contractility; the
nasal regions are structurally and functionally interrelated,