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

457
The structural nasal layers
substance (Fig. 17.4). No patient can have a straight profile
line without adequate tip projection; that is its importance. Tip
projection is not a reflection of nasal base size but rather alar carti­
lage strength, a distinction that is not always understood.
Many noses have large lower nasal thirds; excess skin volume
is not the same as excessive tip projection.
Tip projection extremes are the easiest to identify. Nasal
tip position in Fig. 17.4A depends on bridge height; therefore,
tip projection will decrease when the dorsum is resected.
Conversely, the nasal tip in Fig. 17.4B depends not on bridge
height but on new projection provided by tip grafts (no
columellar strut). Inadequate tip projection cannot be ren­
dered adequate by bridge resection alone. The tip, the lower
nasal skin, and in many patients nearly the lower half of the
profile line depend on suspension of the skin sleeve by the
alar cartilages, which, like a “cap” anterior to the remaining
skeleton, maintain lower nasal tension. The alar cartilages
carry a larger responsibility for caudal nasal support than
may at first be evident. Inadequate projection must be identi­
fied preoperatively.
edge), the critical area of the internal nasal valves, depends
on the width of the bony vault and the height and width of
the middle vault roof.6 Resection of the middle vault roof
during hump reduction removes this most critical anterior
stabilizing force on the upper lateral cartilages, which fall
medially and produce a characteristic “inverted-V” deformity
and obstructive narrowing at the internal valves. Middle
vault collapse virtually always occurs when the cartilagi­
nous roof has been resected, whether or not osteotomy has
been performed, but may not be visible if the overlying soft
tissues are sufficiently thick; however, when the nasal skin
is thin, the deformity can be impressive (Fig. 17.3). To avoid
middle vault collapse and internal valvular incompetence,
the surgeon should plan to reconstruct the normal forces
by a substantial dorsal graft or by spreader grafts,7,8 which
provide the same degree of functional mean nasal airflow
improvement as documented by a level II outcome study
(see below).8
Middle and lower cartilaginous vaults
The upper lateral cartilages are supported caudally by their
relationship to the cephalic margins of the lateral crura in the
region of the so-called “scroll”; radical alar cartilage resection
can compromise middle vault support and may leave an
external deformity typified by deepening and lengthening of
the alar creases. I resect the upper lateral cartilages submuco­
sally only when failure to do so would allow them to prolapse
into the airway or when necessary to shorten the nose.
The point of intersection of the upper and lower lateral
cartilages creates the “watershed” area between the internal
and external nasal valves, and aggressive surgery in this area
also affects external valvular competence, particularly in
patients whose alar cartilage lateral crura are cephalically
rotated.9,10 Compared with caudal support by the lower lateral
cartilages, however, anterior support provided by the intact
cartilaginous roof is more profound and more critical to
airway function.
Dorsum and tip
Tip projection is the intrinsic ability of the alar cartilages to
support the tip lobule independent of dorsal height and
depends on alar cartilage middle crural size, shape, and
Fig. 17.3  Resection of the middle vault
roof, especially when the middle third is
narrow (A) produces the so-called
“inverted-V” deformity and internal
valvular incompetence (B). Spreader or
dorsal grafts are functionally equally
effective corrections (C).
A
B
C
Fig. 17.4  Examples of inadequate (A) and adequate (B) tip projection, which can
be defined by the relationship of the alar cartilages to the septal angle; tip grafts
increased projection without struts or internal sutures.
A
B

458
SECTION I
CHAPTER 17 • Closed technique rhinoplasty
Four common anatomic variants
that predispose to unfavorable results
(Table 17.1)
A great deal can be learned about primary rhinoplasty by
observing the deformities of secondary rhinoplasty patients
and by examining one’s own unsatisfactory results. A ret­
rospective study of 150 consecutive secondary rhinoplasty
and 50 primary rhinoplasty patients suggests that only
four anatomic variants in the primary nose particularly
predispose to unfavorable rhinoplasty results: low radix/
low dorsum, narrow middle vault, inadequate tip projection,
and alar cartilage malposition.11 Each contributes to one of
only three deformity patterns seen in secondary rhinoplasty
patients: deformities from soft-tissue contraction, deformities
from skeletal contraction, and deformities from imbalance
(Box 17.1).
Low radix or low dorsum
Low radix or low dorsum begins caudal to the level of the
upper lash margin with the patient’s eyes in primary gaze;
this variant was present in 93% of the secondary patients and
32% of the primary patients in the series.11 First described by
Sheen, the low radix is one of several primary causes of nasal
imbalance: an upper nose that seems too small for its lower
nasal component.12 When the radix begins lower than the
upper lash margin, dorsal length is therefore shorter and so
nasal base size appears larger. The classic imbalance may take
the form of the depression or notch in the upper nasal third,
or a low, straight dorsum may accompany a large nasal base.
The surgeon often hears: “The tip of my nose sticks out too
far”. The surgical dilemma is as follows: If the surgeon reduces
the nasal dorsum, the patient’s preoperative skeletal and skin
sleeve maldistribution will worsen: the lower nose will appear
even larger. The surgeon fortunately has two other choices:
either limit tip reduction, or raise the dorsum segmentally or
entirely to balance the nasal base. Variations of the latter
option are generally safer because they require less contrac­
tion of the thicker nasal base tissues. Failure to recognize the
Table 17.1  Core anatomical variants, consequences, and treatments
Anatomy
Threats
Treatment
Associated secondary pattern
Inadequate tip Projection
Supratip deformity
Tip grafts
Deformities from soft-tissue collapse
Low radix/low dorsum
Nasal imbalance
Radix/dorsal grafts
Deformities from imbalance
Narrow middle vault (Congenital
or from roof resection)
Internal valvular obstruction
Spreader grafts
Deformities from skeletal collapse
Malposition
External valvular obstruction (congenial
malposition–cephalic rotation– or
excessive lateral crural resection)
Reposition lateral crus
or support
collapsing segment
Deformities from skeletal collapse
BOX 17.1  Patterns of secondary deformities
Deformities from soft-tissue contraction
Deformities from skeletal contraction
Deformities from imbalance
Fig. 17.5  Same patient as 17.4. Postoperative photographs are at 15 months.
Narrow middle vault (A) treated with spreader grafts. Many of these patients have
preoperative internal valvular incompetence and will develop increased airway
obstruction after resection of the cartilaginous roof.
A
B
low radix or low dorsum leads to the secondary pattern
“deformity from imbalance”. (see Table 17.1).
Narrow middle vault
A narrow middle vault (Fig. 17.5) is arbitrarily defined as any
upper cartilaginous vault that is at least 25% narrower than
the upper or lower nasal third (present in 87% of the second­
ary patients and 38% of the primary patients in this series).
This variant was described by Sheen in conjunction with short
nasal bones13 but has been discussed subsequently by that
author and others11,14–16 as a trait that places the patient at
special risk for internal valvular obstruction, which can exist
preoperatively or may be produced by dorsal resection. Descrip­
tions of valvular collapse had appeared earlier in the rhino­
plasty literature17–19 but the missing puzzle piece had been the
link between resection of the cartilaginous roof and postop­
erative internal valvular collapse, a phenomenon previously
attributed to traumatic or surgical avulsion of the upper
lateral cartilages from the nasal bones. Resection of even
2 mm of the cartilaginous roof during hump removal ablates
the stabilizing confluence that braces the middle vault, which
can now collapse toward the anterior septal edge, restricting
airflow at the internal valves and producing a characteristic
“inverted-V” deformity. Rhinomanometric studies indicate
that valvular obstruction is 4 times more common than pure
septal obstruction in primary rhinoplasty patients and 12

459
The structural nasal layers
but distinct entities: (1) intrinsic anterior supporting strength
supplied by the alar cartilages and (2) skin sleeve volume and
distribution in the lower nasal third. Inadequately projecting
nasal tips often appear to “hang” from the septal angle (see
Fig. 17.4A). Because an inadequately projecting tip owes its
position to dorsal height and not to tip cartilage support, the
surgeon must employ some tip-strengthening method to
increase middle crural length and create that support. Interest­
ingly, rhinoplasty pioneer Jacques Joseph instinctively solved
the problem of inadequate tip resection in his patients by
limiting bridge resection and leaving a dorsal convexity.26
Failure to recognize inadequate tip projection causes dorsal
over-resection, supratip deformity, and “deformity from soft-
tissue contraction” (see Table 17.1).
Alar cartilage malposition
“Alar cartilage malposition” describes cephalically rotated
lateral crura whose long axes run toward the medial canthi
instead of toward the lateral canthi, the position most com­
monly depicted in texts (Fig. 17.6A). This anatomic variation
was first recognized by Sheen27 as an aesthetic deformity that
produced a round or boxy tip lobule with characteristic
“parentheses” on frontal view. Initially believed to be a rare
variant, malposition is present in approximately 50% of
primary patients and 80% of secondary patients.28 Malposi­
tion also has two additional ramifications that are not aesthetic.
First, the abnormal cephalic position of the lateral crura places
them at special risk if an intercartilaginous incision is made
at its normal intranasal location.10 This maneuver will transect
the entire rotated lateral crus instead of only splitting the
intended cephalic portion. Most malpositioned lateral crura
do not provide adequate external valvular support, and so
malposition is not only associated with boxy or ball tips but
also the leading cause of external valvular incompetence.20
The secondary deformity is characteristic.
The adequate treatment of cephalic rotation of the lateral
crura requires resection and replacement of these structures,
relocation of the lateral crura to support the external valves,
or supporting the areas of external valvular collapse with
autogenous grafts (Fig. 17.6B,C).29 Approximately 50% of
patients presenting with external valvular obstruction have
alar cartilage malposition. Correction of external valvular
incompetence doubles mean nasal airflow in most patients
times more common in secondary patients; reconstruction
of incompetent, internal valves by dorsal or spreader graft
doubles nasal airflow in most patients.8,20 Some surgeons use
“spreader flaps” instead,14 redundant or unresected upper
lateral cartilages that are turned medially and fixed to the
septal edge by sutures. Although spreader flaps have become
a popular technique, no airway measurements have yet been
performed that show them to be superior, inferior, or equal to
spreader grafts.
Cartilaginous roof resection and failure to recognize mal­
position (below) contribute to the secondary pattern “defor­
mity from skeletal contraction”. (see Table 17.1).
Inadequate tip projection
A tip with inadequate projection is defined as any tip that
does not project to the level of the anterior septal angle (see
Fig. 17.4A). Inadequate tip projection was present in 80% of
the secondary patients and 31% of the primary patients in the
reported series.11 Despite its importance, the term “tip projec­
tion” has been used to connote different things by different
authors. Some surgeons assess tip projection by measuring
the distance of the most projecting point of the tip from a facial
parameter,21,22 and others by the relative proportion of the
nasal base segments anterior and posterior to the upper lip23,24
or the relative lengths of the nasal base and upper lip.25
Although these definitions apply in some cases, there are
patients whose nasal bases are large but whose tip cartilages
are nevertheless poorly projecting (i.e., reflecting a dispropor­
tionate amount of lower nasal skin, not excessive cartilage
size). In these individuals, tip projection may be inaccurately
assessed as “adequate” or even “excessive”, even though the
alar cartilages still lack the substance required to create a
straight bridge line.
An alternative functional definition of tip projection is the
relationship of the tip lobule to the anterior septal angle. Alar
cartilages sufficiently strong to support the tip to the level of
the septal angle are “adequately projecting” (see Fig. 17.4B);
alar cartilages too weak to do so are “inadequately projecting”
(see Fig. 17.4A). The practical value of this definition lies in
its ability to define treatment: adequately projecting tips do
not need increased support, whereas inadequately projecting
tips do. Further, by defining tip projection relative to the septal
angle, the surgeon can distinguish between two associated
Fig. 17.6  Patient with alar cartilage
malposition, a low, straight dorsum,
narrow middle vault, and inadequate tip
projection (A) preoperatively and (B)
after primary rhinoplasty; the dorsum
and tip have been over-resected. The
soft tissues cannot adapt. That
phenomenon would be impossible to
see by open rhinoplasty. (C) After
dorsal, spreader, tip, and alar wall
grafts. Postoperative airflow will triple or
quadruple with this reconstruction.
A
B
C

460
SECTION I
CHAPTER 17 • Closed technique rhinoplasty
The effect of rhinoplasty on the airway
Traditional concepts and clinical observations
For many years, the following concepts provided the basis for
analysis of the obstructed nose:
1. The bony and cartilaginous septal partition, deformed
by congenital anomalies or trauma, may obstruct the
nasal airway.
2. Compensatory hypertrophy of the contralateral inferior
turbinate frequently occurs, explaining why both
airways are obstructed.
Although many patients with obstructed nasal airways
undoubtedly improve after septoplasty with or without inferior
turbinectomy, not all do. Adding to the frustration of patient
and surgeon are three other common observations: (1) there
is often a poor correlation between a patient’s symptoms and
the apparent site of clinical septal or turbinate obstruction18–21;
(2) patients frequently breathe better (preoperatively and even
postoperatively) on the “narrower” side (ipsilateral to the
(2.5 times for primary patients; 4.0 times for secondary
patients).8 Cartilaginous roof resection and failure to recognize
malposition (below) contribute to the secondary pattern
“deformity from skeletal contraction” (see Table 17.1).
None of these four anatomical variants (low radix or low
dorsum, narrow middle vault, inadequate tip projection, and
alar cartilage malposition) always requires treatment. For
example, the low radix must always be assessed relative to
nasal base size: if the base is small, a low radix may create the
best balance. But they do supply cautionary notes. At least
one of these four anatomic traits was present in each of the
150 secondary patients in the reported series.11 Some 78% of
the secondary patients and 58% of the primary patients had
three or all four of the traits. The most common grouping in
both primary and secondary patients is the triad of low radix,
narrow middle vault, and inadequate tip projection (40% and
28%, respectively) (Fig. 17.7). The second most common
grouping is the association of all four anatomic traits (27% of
secondary and 28% of primary patients). None of these ana­
tomic variants is adequately treated by classic reduction rhi­
noplasty, emphasizing the importance of careful preoperative
diagnosis.
Fig. 17.7  The most common grouping of the four anatomic variants that predispose to unfavorable results: low radix, narrow middle vault, and inadequate tip projection.
Another particular trap is the nearly straight dorsum, so easy to over-resect. (A,B) Preoperative and 1 year postoperative frontal views. (C,D) Preoperative and 1 year
postoperative lateral views. (E,F) Preoperative and 1 year postoperative inferior views. (G) Schematic of the surgical correction: maxillary augmentation, dorsal and
conservative lateral crural reductions; radix, spreader, and tip grafts. Airflow has doubled. The dorsum is straight, the tip projecting, and the columella remains normally
narrow.
A
B
C
D
E
F
G

461
The effect of rhinoplasty on the airway
Adding to the confusion is the absence of consensus in the
literature about whether rhinoplasty itself impairs airflow,
which is surprising in view of the number of patients who
have postoperative airway obstruction. In fact, the second
most common cause for malpractice litigation after rhino­
plasty is unrelieved or new nasal airway obstruction (M.
Gorney, pers comm, March 2000).
Results of an airway outcome
study in 600 patients
To help resolve some of these conflicting clinical observations
and to provide quantitative measurements of the relative
increases in nasal airflow after functional septal or valvular
surgery, an ongoing study of 600 consecutive patients under­
going surgery for airway obstruction was undertaken between
1991 and 2008.8,59 Patients with septal perforation, atopic
patients, and patients requiring turbinectomy were excluded.
The diagnosis of septal obstruction or valvular incompetence
was made by observation of the nasal airway and nasal
sidewall movement with and without a nasal speculum
during quiet and forced inspiration. When a flaccid or collaps­
ible valve was supported during inspiration by a cotton-tipped
applicator, the patient could usually appreciate an immediate
improvement in nasal airflow, thus directing the surgeon
toward appropriate operative treatment. Septoplasty and
valvular reconstruction by cartilage or bone grafts were per­
formed as indicated. Anterior, active, mask rhinomanometry
was performed according to the method of Mertz et al.42,60–62
That study comprised 600 patients: 78% women and 22%
men; 36% primary rhinoplasties and 64% secondary rhino­
plasties (median follow-up 14.3 months, mean 27 months).
The longer-term data of 362 patients observed for a minimum
of 12 months (median 29 months) supported the numbers in
the entire group.
The data may be summarized as follows:
1. Septal and valvular surgery corrected the airway
obstruction in more than 95% of patients in a single
operation.
2. Although septoplasty improved airflow ipsilateral to the
obstruction, there was no significant improvement in
total (geometric mean) nasal airflow after septoplasty
alone.
3. Internal valvular reconstruction by dorsal or spreader
grafts doubled nasal airflow.
4. Spreader grafts and dorsal grafts were equally effective
in supporting the internal nasal valves.
5. External valvular reconstruction doubled mean nasal
airflow.
6. The largest postoperative improvement was seen in
patients after correction of both internal and external
valvular incompetence (more than four times
preoperative values).
7. Septoplasty in addition to valvular reconstruction did
not significantly improve nasal airflow over the results
obtained by valvular reconstruction alone, even in
patients observed more than 100 months
postoperatively.
8. These results were produced without performing
inferior turbinectomy in any of the patients.
septal deviation); and (3) many patients who have undergone
prior successful septoplasty and turbinectomy or who have
straight, unoperated nasal septa still complain of airway
obstruction.
These apparently inconsistent observations are more
understandable if the reader considers airway size to be the
product of at least four factors: (1) mucosal sensitivity to the
environment or hereditary factors; (2) inferior turbinate
hypertrophy from many causes; (3) septal deviation; and (4)
position and stability of the lateral nasal wall during the
dynamic process of ventilation.8,9,20 Thus, any congenital or
acquired weakness or instability of the upper or lower lateral
cartilages or their investing soft tissues (which compose the
internal and external nasal valves, respectively), along with
septal and inferior turbinate size and position, becomes a
factor that may profoundly influence the ability to draw
adequate volumes of air through the nose.
The internal nasal valve is formed by the articulation of the
caudal and anterior (or dorsal) edges of the upper lateral
cartilages with the anterior septal edge (Fig. 17.8); the external
nasal valve is composed of the cutaneous and skeletal support
of the mobile alar wall (the alar cartilage lateral crura with
their associated external and vestibular skin coverings). The
watershed area between the valves occurs at the transverse
portion of the alar crease and at the articulation of the caudal
edge of the upper lateral cartilages with the alar cartilage
lateral crura.
Until recently, efforts to correlate nasal airflow with clinical
symptoms had yielded equivocal conclusions. There was
argument on both clinical and rhinomanometric grounds that
septoplasty either did or did not improve nasal airflow.30–34
For such a commonly and easily diagnosed clinical problem
as septal deviation, one would expect to find more unanimity
in clinical series. These observations were clouded further by
the fact that some 80% of nasal septa in the population at large
are “deviated” and by imprecision in distinguishing internal
from external valvular incompetence. Nevertheless, mount­
ing clinical evidence indicates that obstruction at either set of
valves may profoundly obstruct the airway, even in the
absence of septal deviation.35–58
Fig. 17.8  The nasal valves. The internal valves are formed by the articulation of the
upper lateral cartilages with the anterior (dorsal) septal edge; the external valves are
formed by the alar cartilage lateral crura and their associated investing soft-tissue
cover.
Internal valve
External valve

462
SECTION I
CHAPTER 17 • Closed technique rhinoplasty
Resection of nasal lining, alar cartilage malposition, exces­
sive alar wedge resection, and inadequate or excessive nasal
shortening may also obstruct the airway.
Patient selection
Fallacies of planning: two false assumptions
that lead to unsatisfactory results
Two principles underlie the logic of reduction rhinoplasty,
neither of which is always valid:
■ FALSE ASSUMPTION NUMBER ONE: The nasal soft-
tissue cover has the infinite ability to contract to the
shape of any underlying skeleton.
If the nose is only being reduced, the entire surgical result
depends on whether this assumption is true. The nasal skin
sleeve contracts according to its quality, thickness, and preop­
erative distribution, and not necessarily to the shape of the
surgically reduced skeleton. The vectors of skin sleeve contrac­
tion are related to, but independent of, the volume and contour
of the underlying skeleton; the end stage of these vectors is the
classic shape of supratip deformity (see Fig. 17.1). If this
assumption were always true, supratip deformity would never
occur and augmentation would never correct it.65 Inability to
judge soft-tissue contour and movement is one of the largest
handicaps to the surgeon performing open rhinoplasty.
■ FALSE ASSUMPTION NUMBER TWO: Alterations in the
nasal skeleton produce purely regional changes.
The classic application of this assumption is the common
strategy in which the surgeon plans to resect all nasal dorsum
anterior to a straight line drawn from the nasal radix to the
point of the tip (Fig. 17.9). Underlying this strategy is the
assumption that dorsal reduction affects bridge height alone.
Changes in the nasal skeleton are not independent, however,
but rather have global effects outside their areas. Resection of
the nasal bridge affects nasal width and length, apparent nasal
base size, middle vault support, alar rim contour, and colu­
mellar position. Similarly, alar cartilage reduction can affect
tip support and projection, nasal length, alar rim contour, and
external valvular support. These structural interdependencies
9. In those patients with lateralized symptoms, the septum
was contralateral to the more obstructed side in 45% of
cases.
10. Of the 384 secondary rhinoplasty patients, 94% had
previously undergone an adequate septoplasty but were
still symptomatically obstructed. Within this group,
valvular reconstruction alone corrected the airway in
97% after one operative procedure.
11. When primary and secondary rhinoplasty patients were
stratified, the improvement in primary patients equaled
or exceeded the improvement achieved in secondary
rhinoplasty patients in six of the eight obstructed sites
examined.
12. Valvular obstruction was 4 times more common than
pure septal obstruction in primary rhinoplasty patients
and 12 times more common than pure septal obstruction
in secondary rhinoplasty patients.
13. When the entire 600-patient group was stratified, the
greatest improvement was observed in those patients
observed more than 12 months, supporting the view
that the airway continues to enlarge as edema resolves.
14. By measuring airflow during quiet and forced
inspiration, sidewall stiffness could be quantified and
shown to increase following valvular reconstruction by
dorsal, spreader, or alar wall grafts.
15. A decrease in nasal airflow was not obligatory, even in
patients with preoperative airway obstruction.
In conclusion, current rhinomanometric data support the
concept that lateral nasal wall movement caudal to the bony
arch (containing both the internal and external valves) consti­
tutes a cause of airway obstruction equal to or greater than
septal deviation in most rhinoplasty patients. By visualizing
the airway as a structure in which the septal partition forms
one side and the mobile lateral nasal wall forms the other, and
in which the turbinates and mucosa function as additional
dynamic structures, the inconsistencies in prior clinical obser­
vations become easier to explain. Inspired airflow passes
through the nose at 15–65 km/h, the latter equivalent to gale
force winds.63 The size of any nasal airway thus depends not
only on the position and configuration of the septum and
turbinates but also on the stability and competence of the
nasal valves under significant transmural pressures. The
observation that patients often breathe worse on the side
contralateral to the septal obstruction (45% of our patients
with lateralized obstructions) can therefore be explained
through valvular incompetence. In patients with septal devia­
tion and valvular incompetence, the side with the greater
airflow and greater transmural pressure (i.e., the side contra­
lateral to the septal deviation) will collapse first and therefore
become more symptomatic.
This study did not answer the question of where turbinates
fit into the hierarchy of nasal obstructions. In atopic individu­
als with gross turbinate hypertrophy or polyps, turbinectomy
is unquestionably valuable.64 However, the mean nasal airflow
improvements listed above were achieved without turbinec­
tomy, even in a population of patients with secondary defor­
mities, valvular incompetence, prior intranasal scars, webs, or
vestibular atresia, suggesting that turbinate obstruction in
many patients may be largely reactive or secondary and that
radical turbinectomy may not often be necessary if septal and
valvular factors have been addressed properly.
Fig. 17.9  The common “straight line” strategy used to plan rhinoplasty. The
assumptions implicit here are that the skin sleeve will contract infinitely and
uniformly to any skeletal size and shape, and that dorsal and tip resections will
affect only those structures. The ideas are all very logical; they are just not true.

463
Patient selection
For any patient older than 14 years, the author prefers to
interview and examine the patient alone (in minors after
parental permission), before involving the family, spouse, or
others of significance in the discussion. Although some pro­
tective family members or spouses initially object to this
policy, it is important to establish an individual relationship
with the patient and to hear his or her concerns and com­
plaints free of outside influences. Excessively protective
family members who try to dominate the conversation and
the surgical plan can be signs of immaturity in the patient or
boundaryless behavior in the family, all of which can compli­
cate the surgical relationship. An excessively controlling
family member invariably distracts the patient and can make
it impossible for the surgeon to obtain a good history or
establish a personal connection with the patient. Childhood
abuse and neglect are not only common in our society but also
in plastic surgery patients because both affect body image.
This topic is explored more fully in Vol. 1, chapter 3.
When the patient has had prior surgery, it is important to
obtain a careful chronology and, if possible, photographs that
reflect the preoperative appearance. Such pictures provide
information about the prior surgeon’s goal and how the
current deformities may have occurred and place the patient’s
original objectives in current perspective. For the younger
surgeon, a comparison of preoperative photographs to out­
comes is invaluable and teaches an enormous amount about
the consistencies and variabilities of nasal skeletal and soft-
tissue responses to surgery. Be particularly wary if the original
nose was normal: straight, symmetrical, and without airway
problems, and the patient knew it: the surgeon must fully
explore the motivation for the original surgery and determine
whether body shame or body dysmorphic disorder exists.
Inquire about the airway first to avoid becoming distracted
by the patient’s aesthetic considerations. Patients become
used to a poor airway. Many have never breathed normally;
others have lost their basis for comparison after trauma or
previous surgery and have forgotten how much better their
airways used to be. Ask about periodic or cyclic airway
obstruction; which airway is worse; any nasal trauma history;
seasonal allergies that obstruct the airway; clear rhinitis; epi­
sodes of suppurative sinusitis; snoring, epistaxis, and sinus
headache, frequent nose blowing; and what non-surgical
remedies the patient has previously tried. Not infrequently,
secondary rhinoplasty patients with poor airways chronically
self-medicate with steroid or vasoconstrictive sprays that
must be eliminated before surgery. Also important are the
patient’s work environment and a history of tobacco or alcohol
consumption (either of which may cause nasal congestion)
and, more important now than in previous years, cocaine use.
Finally, inquire about any nasal areas that the patient does not
wish altered and, if appropriate, whether a change in ethnic
appearance is desired.
Differences in primary and
secondary candidates
Primary and secondary rhinoplasty patients differ in three
characteristic ways. First, the secondary patient’s scarred,
contracted soft tissues will not tolerate aggressive dissection,
multiple incisions, wound closure under tension, or tight
dressings. Open rhinoplasty confers a significant hazard in
the secondary or tertiary nose, despite the enthusiastic
are not just regional. Recognizing them is necessary to preop­
erative planning, interpretation of intraoperative nasal
appearance, postoperative success, and the correction of sec­
ondary deformities (Table 17.2).
The interview
Although rhinoplasty presents unique difficulties for the
surgeon, it is difficult for the patients as well. Those surgeons
who have seen secondary rhinoplasty candidates devastated
by the results of one or more prior operations should imme­
diately recognize the importance of a safe and biologically
sound surgical plan and of an accurate understanding between
patient and surgeon of the aesthetic goals and the realities of
the surgical problem – that is, what is possible and what is
not.
Making the interview more difficult is the prevalent mis­
conception that many patients hold about their nasal deformi­
ties and therefore about the corrective plan. Many patients do
not recognize that a simple nasal reduction may not achieve
their goals. Patients without airway obstruction do not appre­
ciate the importance of maintaining nasal function, and most
do not realize that routine dorsal and tip reduction will jeop­
ardize the airway.
The patient must therefore be guided to understand that
every rhinoplasty is a compromise between the patient’s
preferred aesthetic goals and the limitations that a predeter­
mined preoperative skeletal and soft-tissue configuration
imposes. Donor materials vary in quantity, character, and
composition, determining their usefulness.66 Finally, many
preoperative noses already have some desirable features;
patient and surgeon should be careful not to destroy them.
It is important to elicit the patient’s goals in the greatest
possible detail and to prioritize them. Is the major issue bridge
height, tip projection, nasal length, asymmetry, or airway?
How long has the sense of deformity existed? This latter ques­
tion is more critical in older than in younger patients: the
60-year-old patient who has disliked her nasal shape for 40
years may tolerate a larger change than will one who has been
troubled for only 5 years and who may be noticing only signs
of recent aging.
Table 17.2  Common nasal structural interrelationships: what
does what
Nasal
structure
Location of effect
Possible surgical
maneuvers
Dorsum
Length, base size,
nostril contour
Columellar position,
middle vault
(internal valves)
Reduce/augment
Place spreader
grafts
Upper lateral
cartilages
Nasal length
Resect
Caudal septum
Length, subnasale
contour, lip carriage
Resect, augment,
augment maxillary
arch
Alar cartilages
Columellar contour,
tip projection
External valves
Resect, relocate,
augment

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CHAPTER 17 • Closed technique rhinoplasty
deviation exists; because hump removal can unmask a high
septal curvature, the surgeon should be prepared to camou­
flage or correct the septal deflection with unilateral or asym­
metrically thick spreader grafts.14,68
Turbinates
Clinical and rhinomanometric data indicate that obstructing
turbinates are relatively low in the hierarchy of common
airway obstruction causes in primary and secondary patients.
Because turbinates warm and humidify inspired air, the
surgeon should plan conservative resections even in atopic
patients. Furthermore, histologic studies have shown that
turbinate hypertrophy secondary to septal deviation is char­
acterized by bony, not mucosal overgrowth.69 Therefore, most
patients who have had good septal and valvular reconstruc­
tion can be adequately treated by only turbinate crushing and
outfracture (or no treatment at all).70
External nose
Palpation of the external nose provides important information
about cartilaginous size and substance, bony vault length,
nasal sidewall stiffness (another assessment of valvular
support), and soft-tissue thickness. Tip lobular contour is
considered, as is the balance between nasal base size and
bridge height (see below). The patient is asked to discuss each
nasal area, whether or not it has been mentioned previously:
width, length, bridge contour, tip shape, nostril size, columel­
lar and upper lip position, and any asymmetries.
Between the external and internal examinations the surgeon can
make all necessary diagnoses so that the entire operative plan can
be written out preoperatively and followed. The only intraoperative
decisions are thus quantitative, not qualitative, and depend on graft
and soft-tissue substance and texture. Anatomy that cannot be
seen and that is not blocking the airway may be an interesting
anatomical curiosity, but finding it has no value to the patient.
Limit dissection only to those areas that require change.
Basic nasal aesthetics
On frontal view, the upper nose should be narrower than the
lower nose; symmetric, confluent, divergent lines should
connect the two; alar base and tip lobular width should
balance. On oblique view, there should be no regional discon­
tinuities, the supratip should be flat, and tip lobular mass
should fall below the levels of the peaks of the alar cartilage
domes. On lateral and oblique views, nasal length and base
size should balance each other. Ideal parameters have been
suggested.71–75 The practical difficulty in employing many of
these guidelines lies largely in the facts that skin sleeve
volume and distribution have already been predetermined
and that skin contractility is limited, not infinite. Furthermore,
ideal aesthetics do not apply to most patients, even most
Caucasians.75 If the surgeon had the latitude of reducing skin
volume, the size of the postoperative nose could be altered
more radically to a patient’s facial measurements, body
habitus, or other parameters. In practice, however, the surgeon
works within narrower limits. The airway should be patent
and stable on forced inspiration. Beyond these basics, the
details depend on the patient’s skeletal framework and soft-
tissue cover and their aesthetic goals. Rhinoplasty offers, as
contrary claims of its advocates. Biological laws are consistent.
Any surgeon who examines revision rhinoplasty patients will
see many who have had segmental columellar soft-tissue
losses, areas of secondary healing, prior skin grafts, or failure
to achieve adequate tip projection because the columellar
incision could not be closed. The logic that the worse the
deformity and scarring, the more surgeons should use open
rhinoplasty is faulty and defies surgical principles always
respected elsewhere in the body.
Second, graft donor sites may have already been harvested,
necessitating the use of more difficult (distorted septum or
concha), painful (costal), or frightening (calvarial) donor
sources. Third, the secondary rhinoplasty patient’s morale is
often more fragile. Having already invested money, time,
discomfort, and emotion in one or more unsuccessful proce­
dures, what secondary rhinoplasty patients fear most and
need least are additional disappointments. The surgeon must
construct a plan that is based on a clear understanding of
what is possible and founded on sound surgical and biologic
principles that maximize the airway and respect the patient’s
aesthetic goals.67
The preoperative examination
It is wise to make a habit of examining the internal nose first
so that this most critical functional area is not forgotten in the
discussion of aesthetics. More importantly, the surgeon must
avoid unintentionally decreasing postoperative nasal func­
tion; this occurs more often than is recognized, and poor
airways dominate the complaints of secondary rhinoplasty
patients. The internal nose should be examined without
manipulating the airway by asking the patient to breathe
deeply and observing areas of collapse or asymmetry in the
nasal sidewalls, high septal deviations, distortion of the colu­
mella, protrusion of the caudal septum, or alar rim collapse.
Valves
Sidewall collapse with inspiration at one or both of the nasal
valves is surprisingly common. It is important to determine
why valvular incompetence exists (e.g., prior surgery, intrinsic
weakness, or alar cartilage malposition). If sidewall collapse
occurs, occlude one nostril and ask the patient to compare
flow through the unobstructed airway with and without sup­
porting the collapsing area with a cotton-tipped applicator
soaked in 1% pontocaine hydrochloride for the patient’s
comfort. Patients with valvular incompetence will notice an
obvious and gratifying increase in airway size. The surgeon
may observe valvular collapse and substantial airway obstruc­
tion even in the patient with a straight, unoperated septum
and without turbinate hypertrophy. Here, septoplasty may be
indicated to harvest grafts but by itself will not open the
airway; the surgeon must also place appropriate valvular
grafts. Reconstruction of the internal and external valves can
triple or quadruple airflow in most rhinoplasty patients, even
when septoplasty is not simultaneously performed.8
Septum
The septum should be palpated for substance, contour, and
mucosal cover (indicating the sequelae of allergy, injury,
perforation, or chronic cocaine use). It is also important to
assess whether a “high” (i.e., toward the anterior edge) septal

465
Parameters of rhinoplasty planning
and the patient’s goals reasonable; patient and surgeon must
understand each other explicitly. Each operation is more dif­
ficult than the last.
Parameters of rhinoplasty planning
What limits the applicability of most proposed aesthetic ideals
is the character, volume, and distribution of the skin sleeve
and the limitations that they impose. Three soft-tissue param­
eters can be used to form any rhinoplasty plan,76,77 and they
will therefore apply to both primary and secondary patients.
Skin thickness and distribution
It may be intuitively obvious that skin thickness affects any
rhinoplasty plan, but so also does skin distribution. The pre­
operative large nasal base does not contract into a small nasal
base; rather, it contracts to a distorted large nasal base. Skin
quality therefore affects both reduction and augmentation.
Thicker skin requires more skeletal support and contracts
less well; the surgeon must thus be conservative in reduction
and will need more substantial grafts to produce a given
result (Fig. 17.10A,B). Thinner skin allows greater reduc­
tion but requires softer grafts to avoid surface distortions
(Fig. 17.10C,D).
Fig. 17.10 appears online only.
Tip lobular contour
Because the nasal base (the lower nasal third) has a more
complex topography than the simpler pyramidal bony and
upper cartilaginous vaults, and because the soft tissues are
always thicker in the caudal than in the cephalic nose, it
follows that the surgeon should select first those maneuvers
that provide the best nasal base contours. The poorly shaped
tip lobule has a poorly defined, low point of greatest tip
projection, a convex supratip, and a tip lobular mass that lies
cephalad to the point of greatest projection (Fig. 17.11A,B).
Ideal tip aesthetics (Fig. 17.11C,D) require a defined point of
greatest projection, a flat supratip, and a tip lobular mass that
falls below the point of greatest projection.
Tip lobular contour is important for two reasons. Simple
alar cartilage reduction cannot increase middle crural length
– the segment responsible for tip projection and optimal
contour – but only produces a smaller replica of the same
preoperative tip. To create an aesthetic lobule from a poorly
shaped configuration with a short middle crus, the surgeon
must effectively lengthen the middle crural alar cartilage
segment. I use tip grafts.
The balance between nasal
base size and bridge height
Dorsal reduction or augmentation profoundly affects the
apparent size of the preoperative nasal base.77 The higher
the dorsum, the smaller the nasal base appears (Fig. 17.12).
The reverse is also true: dorsal reduction increases apparent
nasal base size. This powerful illusion has its most important
practical application in (1) patients who believe that preopera­
tive nasal base size is excessive, in whom the aesthetic goal
may best be reached by a change in balance instead of only
size (Fig. 17.13A,B); and (2) patients whose soft tissues are
much as or more than any other aesthetic procedure, the pos­
sibility of individualizing an aesthetic goal.
Preoperative photographs
For consultation, formulation of an operative plan, and intra­
operative guidance, good photographs are imperative. The
patient’s photographs should be available before the immedi­
ate preoperative visit so that the operative plan on which
surgeon and patient have already agreed may be reviewed or
modified. Photographs should include full head and close-up
frontal views, both oblique views (which often differ, particu­
larly in patients with nasal asymmetry), both lateral views,
and an inferior view. Photographs are best taken with a portrait
focal length lens (90–105 mm) against a medium–dark back­
ground, lit so that symmetries and contours will be depicted
accurately. Camera-mounted flash units are inferior to studio
systems with umbrella lights or wall-mounted strobes to
provide backlighting and to illuminate the face and hair.
Setting goals with the patient
Because practical rhinoplasty strategies may differ from what
patients imagine, the patient must understand the logic of the
surgeon’s plan and prefer it to other reasonable alternatives.
Unless the surgeon only plans to reduce the nose, he or she
must help the patient understand the benefits of equilibrium
or conservative reduction; to this end, words like “balance”
and “proportion” often serve better than terms that signify
only size. It is best to be specific about the plan down to the
last graft and choice of donor sites; this candor places patient
and surgeon on the same side of the problem and also ensures
that minor postoperative imperfections are more likely to be
tolerated by the patient, who understood the necessity of each
surgical maneuver beforehand. Recognizing the rationale for
grafting is more difficult for primary than for secondary
patients; the latter, who have already seen the effects of reduc­
tion and disequilibrium on their nasal configurations and
airways, are often easier to convince.
Discussion of potential
complications and revisions
Patient and surgeon alike must remember that revisions may
be necessary – and almost predictable in some difficult con­
figurations if the best possible result is desired. Revisions are
frequently minor, but all patients should understand preop­
eratively what cannot be predicted and therefore not mistake
the uncontrollable for the uncontrolled. No revision should be
undertaken until the end of the first postoperative year; I
provide a written surgical plan to each of my preoperative
patients that includes percentage chances that revision may
be indicated for the best possible result. This is not risk man­
agement; it is patient education. Resolution of swelling and
stabilization of the final appearance take at least that long in
the primary nose and often longer in patients undergoing
secondary rhinoplasty. Nothing should be done until healing
is complete. The surgeon should control every possible
variable.
Who should perform the revision? To some degree, the answer
depends on the same factors involved in the prior rhinoplasty.
The surgeon’s model and proposed solution should be clear,

465.e1
Parameters of rhinoplasty planning
Fig. 17.10  (A,B) Patient with thick nasal skin in whom skeletal reduction must be more conservative and augmentations more
substantial. (C) Patient with thin nasal skin before rhinoplasty; (D) preoperative to secondary surgery; (E) 17 years after
reconstruction, in whom skeletal and graft imperfections are more likely.
A
B
C
D
E

465.e2
SECTION I
CHAPTER 17 • Closed technique rhinoplasty
Fig. 17.12  (A,B) The effect of bridge height on apparent nasal base size. Although both nasal bases (lower nasal thirds) are the same size, the nasal base on the right
appears larger because the dorsum and nasal root are lower. This illusion provides an important diagnostic and therapeutic tool. (C–F) Unbalanced nose, low radix, in each
case corrected by dorsal augmentation. Notice the apparent difference in nasal base size and balance, created primarily by the alteration in dorsal height. Tip grafts were
also performed.
A
B
C
D
E
F
Fig. 17.13  (A–D) Patients who believe that preoperative nasal base size is excessive, in whom the aesthetic goal may best be reached by a change in balance instead of
only size.
A
B
C
D

466
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CHAPTER 17 • Closed technique rhinoplasty
which therefore requires some method (suture fixation or
columellar strut) to support the medial crura so that a new
nasal tip can be made. The strut creates a rigid, often wider
columella and increases graft requirements, the latter particu­
larly critical in secondary patients, whose donor sites are
already depleted. Endonasal rhinoplasty is not a blind opera­
tion. Most procedures are performed under direct vision
with excellent access. The operative strategy, making skeletal
changes through limited incisions and judging progress by
feeling the surface, is precisely the same discipline required
in other common surgical procedures. Limited pocket dissec­
tion minimizes the need for graft fixation and simplifies some
procedures. Solid or crushed grafts can be used in ways that
would be tedious or impossible by the open approach,78
although some solutions have been described.79
As open rhinoplasty has become more popular, new,
complex secondary deformities are becoming common, some
that are difficult or impossible to create endonasally: notched,
irregular, or retracted alar rims; scarred, wide columellae; and
soft-tissue loss. Avoidable iatrogenic deformities that are
technique-dependent become the surgeon’s responsibility,
and are responsible for many unhappy patients.
If open rhinoplasty were superior for most surgeons, the
majority of current secondary deformities should have been
caused by the closed approach; most surgeons should be more
confident of performing the operation. Just the opposite has
occurred. Rhinoplasty is not necessarily made easier by a
larger incision but rather by an accurate analysis of the surgi­
cal problem and adherence to a strategy that reflects the real
biologic processes at work. Almost all secondary deformities
result from inaccurate recognition of anatomic variants, tissue
characteristics, or functional/structural interrelationships and
almost none because the surgeon could not see well enough.
The decision to operate
Before agreeing to operate on a patient, the surgeon must be
able to answer each of the following questions affirmatively:
1. Can I see the deformity? This question eliminates
delusional patients or those with minimal defects that
may not be surgically correctable.
thick and poorly contractile and who therefore may be more
successfully treated by minimizing reduction and augment­
ing instead (Fig. 17.13C,D), a paradoxical principle that most
patients and many surgeons have to see to believe.
Figs. 17.12 & 17.13 appear online only.
Why this author still prefers
endonasal rhinoplasty
Endonasal rhinoplasty is an operation designed around
changes in the skin surface. The skeleton is only a means to
that end. Critical indicators such as skin sleeve movement,
balance changes, and the effects of reduction and augmenta­
tion all depend on an ability to see the undisturbed nasal
surface accurately. This is the anatomy that the patient sees
and that determines the success of the surgical result; this is
the right-brain part of the operation. Even more important is
the fact that the nasal soft tissues create half the nasal shape:
without being able to assess the skin surface accurately, the
surgeon forfeits half of the information that is available to
make the operation a success. Although not new, open rhino­
plasty has enjoyed its resurgence in the past three decades
because of the frustration that many surgeons experienced in
performing the newer augmentation techniques through the
endonasal approach. Reinforcing this stimulus is the tradi­
tional respect that all surgeons have for anatomy and exposure.
The advocates of open rhinoplasty properly note that binocu­
lar vision is possible, that anatomic points obscured by the
skin sleeve can be uncovered, that certain techniques can be
performed more easily, and that the scar itself is ordinarily
imperceptible.
All of these arguments are valid. Open rhinoplasty does,
however, impose its own constraints on surgeon and patient.
The dissection is slower and postoperative morbidity is
higher. Poor scars occasionally do occur. Moreover, the open
approach has not diminished the incidence or severity of
secondary problems; in fact, they have become more severe
over the last three decades, particularly deformities around
the nasal base, which can be most aggressively treated through
the open approach. By separating columellar skin from the
medial crura, the surgeon loses tip stability and projection,
Fig. 17.11  Poorly shaped tip lobules (A,B) and well-shaped tip lobules (C,D). The poorly shaped tip lobule requires both a volume and configurational change; both are
determined by middle crural length.
A
B
C
D

467
Surgical technique
padded and the knees slightly flexed; the operating table is in
10–15° reverse Trendelenburg position to minimize bleeding.
After induction of general anesthesia, the nose is blocked with
a freshly prepared solution of 1% carbocaine with epinephrine
1 : 100 000 (I use carbocaine for its longer analgesic effect and
for its own vasoconstrictive properties). Infiltration begins at
the nasal root, along each lateral nasal wall, into the columella,
across the maxillary arch, and into the alar lobules to vaso­
constrict the branches of the primary supplying vessels
(angular, anterior ethmoidal, superior labial) and the relevant
nerves (anterior ethmoidal, infraorbital, infratrochlear). This
infiltration usually consumes about 7 mL of the anesthetic
solution, the rest of which is saved for the septal surgery.
Nasal vibrissae are shaved with a No.15 blade, and the nose
is thoroughly cleansed internally with a povidone–iodine
solution. Internal preparation of the nose should be fastidious:
the nasal lining is the real operative surface. For hemostasis
and anesthesia of the nasopalatine nerve, the internal nasal
and posterior nasal branches of the anterior ethmoidal nerve,
the internal nasal branch of the nasociliary nerve, and the
nasal branch of the anterior superior alveolar nerve, two
cotton packs soaked in 4% cocaine solution and squeezed dry
with sterile gauze are placed in each airway. Only 4 mL of 4%
tinted cocaine solution is made available for each patient
(160 mg), safely below the maximum allowable dosage
(200 mg). The patient’s face is prepared and draped.
Skeletonization
Skeletonization controls access to the underlying structures
and also influences skin sleeve movement; by limiting skele­
tonization, the surgeon can use the undissected soft tissues to
immobilize any cartilage grafts. Skeletonize widely over the
upper cartilaginous vault to shorten the nose; otherwise limit
skeletonization only to those areas that will be changed.
Technical details
The author ordinarily skeletonizes the nose through unilateral
or bilateral intercartilaginous incisions (Fig. 17.14), depending
on whether alar cartilage modification will be necessary. The
2. Can I personally fix it? This criterion will vary from
surgeon to surgeon and must be based on operative
experience and ease in correcting specific problems.
3. Can I manage the patient? A patient who is unacceptably
nervous, impossible to examine, or unwilling to comply
with preoperative and postoperative instructions is a
poor candidate, even if all other conditions are met.
4. If there is a complication, will the patient remain controllable
and cooperate with treatment? No patient enjoys a
complication, but there are those who, although
disappointed, quietly understand and will await the
proper time for revision. There are others who become
hysterical, angry, disruptive, or accusatory and want an
immediate correction. Patients whose emotions are so
poorly controlled are in no position to withstand the
additional trauma of surgery.
5. Does the patient accept the margin of error inherent in
surgery? This is the most important criterion. Some
patients (and even some surgeons) have unrealistically
optimistic opinions about the degree to which any
surgeon controls wound healing: the quality and
availability of building materials, the patient’s immune
competence, and the myriad other factors, currently
known and unknown, that influence surgical outcomes.
The patient’s willingness to accept the imperfection that
is inherent in surgery is a willingness to accept the
imperfection that is inherent in being human.
How to teach yourself rhinoplasty
Early in my career I began taking sequential, intraoperative
photographs after each critical step, and lateral views at the
beginning and end of the operations. These sequences have
become the foundation of my rhinoplasty understanding.
After surgery, there is ample time to examine each image and
decode what happened. Surgeons must develop individual
judgment; sequential photographs are the key.
Surgical technique
Rhinoplasty differs from operations that may be more easily
portrayed step-by-step in atlases. Intraoperative feedback is
both difficult and unconventional: perspective is limited; skin
volume and texture, skeletal structure, and graft material
produce constant variations among patients; strategies
required for similar deformities differ according to the ana­
tomic details or the patient’s desire; and the final postopera­
tive contour depends on soft-tissue and skeletal changes and
therefore, does not appear immediately. Surgical success will
be higher if the surgeon remembers the equilibrium model
and therefore interprets the intraoperative nasal appearance
as the product of reduction, disequilibrium, augmentation,
and skin sleeve movement. This section describes each opera­
tive step in the order in which the author ordinarily performs
it; depending on the specifics of nasal configuration and surgi­
cal plan, some steps may be omitted.
Routine order of surgical steps
The operation is routinely performed under general anesthe­
sia. The patient is placed supine with the arms and legs
Fig. 17.14  The intercartilaginous incision, which can be lengthened into a
transfixing incision if necessary, gives access to the dorsum, upper and lower
lateral cartilages, and the septal angle. Dorsal modification; upper and lower lateral
cartilage resection; and spreader, radix, dorsal, and lateral wall grafts can all be
performed through this excellent access point under direct vision.

468
SECTION I
CHAPTER 17 • Closed technique rhinoplasty
shortening, the incision can be carried toward the anterior
nasal spine.
Dorsal resection
Producing a straight dorsum from a convex one is not a simple
matter. The surgical plan must consider (1) radix position; (2)
dorsal height; and (3) adequacy of tip support. Dorsal resection
can affect nasal length, apparent nasal base size and width,
middle vault position, apparent columellar position, and
nostril contour. If the radix will be elevated, less dorsal resec­
tion is required (Fig. 17.16). Because resection of the bony and
cartilaginous vaults alters their dynamic anterior projection,
reduced support to the upper nasal skin allows the alar carti­
lages to rotate cephalad or caudad, depending on the preopera­
tive nasal configuration. Most noses shorten after dorsal
resection, but long noses, especially those in which a dorsal
convexity has occupied the caudal half, can lengthen after
dorsal resection. The surgeon should watch for these intra­
operative changes and adjust subsequent steps accordingly.
The surgeon must also observe the effect of dorsal resection on
middle vault support. If the cartilaginous roof is resected, the
middle vault eventually collapses. The surgeon must observe
the contour of the middle third to determine the presence of a
high septal deviation that may have been masked by a sym­
metric dorsum or that may have been worsened by dorsal
resection. These observations will guide the use of spreader
grafts and how they can be used to produce a symmetric result.
incision runs from the lateral end of the caudal reflection of
the upper lateral cartilage around the septal angle. With
Joseph scissors (Fig. 17.15) and then a broad Cottle periosteal
elevator, the soft tissues are elevated over the bony and upper
cartilaginous vaults only as necessary for access. It is impor­
tant for the surgeon to obtain smooth elevation of all soft
tissues to ensure good cover and avoid dermal injury. If no
transfixing incision is necessary, the intercartilaginous inci­
sion stops at the junction of the anterior and middle thirds
of the membranous septum; if the caudal septum requires
Fig. 17.15  The intercartilaginous skeletonizing incision begins at the apex and
proceeds laterally only as far as necessary. Dorsal access and visualization are
easiest for a right-handed surgeon through a left-sided incision, and vice versa. If
the surgeon does not need to shorten the upper or lower lateral cartilages, only a
single intercartilaginous incision is needed.
1
2
3
4
5
6
Fig. 17.16  (1) Primary rhinoplasty patient with low radix, narrow middle vault, and inadequate tip projection in which radix, spreader, and tip grafts are planned.
Preoperative appearance before the incision. (2) Nose after skeletonization. Note the difference in columellar position, nasal tip rotation, and apparent flattening of the dorsal
hump, all artifacts of skeletonization. (3) By elevating the radix skin with a fingertip, the surgeon can estimate the amount of dorsal reduction that is actually necessary,
assuming that radix augmentation will be performed. (4) Intercartilaginous incision; a similar incision is made on the patient’s left side. Both give access to the dorsum, the
septal angle, and the alar cartilage lateral crura. (5) Transfixing incision for access to the caudal septum. (6) Rasp used for roughening the nasal root so that radix grafts
will adhere.

Fig. 17.16, cont’d
10
11
12
13
14
15
16
17
18
19
20
21
7
8
9
(7) Fomon rasp for lowering the bony vault. (8) The bony vault is reduced by careful use of this down-cutting rasp. (9) After reduction of the bony
vault, the cartilaginous dorsum seems even higher, further demonstrating the importance of the low root on the apparent height of the nasal bridge. (10) The cartilaginous
roof is resected with a No.11 blade under direct vision. The knife tip has been broken to avoid perforating the nasal skin. (11) The appearance after dorsal resection. Notice
the nasal shortening that has occurred simply by dorsal reduction, as well as the change in columellar position and the relative new prominence of the alar cartilages.
(12) The section of dorsal roof that was resected. Because the radix will be raised, less dorsal resection is necessary. Only a 2-mm resection is needed to open the
cartilaginous roof and to destabilize the middle vault. (13) After resection of the cartilaginous roof, note the concavity in the upper cartilaginous vault, signifying instability
at the internal valves produced by the dorsal resection. (14) Caudal septal resection shortens the nose and brings the columella into better relationship with the alar rim.
The dimensions and shape of the resection should be altered according to the clinical case. (15) The alar cartilage lateral crus is dissected retrograde from the vestibular
lining. (16) In this patient, the cephalic 2–3 mm is resected, leaving 10 mm. (17) Incision through right mucoperichondrium 15 mm above the caudal end of the septum
to begin the septoplasty. (18) The Freer elevator has lifted mucoperichondrium from both sides of the septum in the area of planned resection; no dissection is performed
over the proposed dorsal and caudal struts. (19) A cut has been made 15 mm below the anterior edge of the septum, and a second one approximately 10 mm below that.
Killian septal forceps are retrieving the first segment of septal cartilage. (20) The first strip of septal cartilage has been removed, providing an excellent dorsal graft if
necessary. The septum is always resected in the same fashion. Dissection now proceeds toward the vomer to retrieve additional cartilage and bone and clear septal
obstructions. (21) Several 4-0 chromic mattress sutures repair the septal access incision.
Continued

23
24
25
26
27
28
29
30
31
32
33
34
35
(22) The septal angle is identified in the transfixing incision, and submucoperichondrial infiltration with local anesthetic facilitates development of
spreader graft tunnels. (23) Harvested septal cartilage is on the right of the Sheen grid; the resected dorsal roof is in the upper left corner. (24) The most suitable segment
of septal cartilage is trimmed and beveled to provide the main upper dorsal graft. (25) The prepared dorsal graft. A second layer of cartilage has been lightly crushed and
placed beneath the first at its cephalic end. Note that the main graft is longer than might be expected to provide continuity into the nasal dorsum; the distal end has been
beveled. (26) The dorsal graft is placed under direct vision through the right-sided intercartilaginous incision; all other incisions have been closed. (27) After placement of
the upper dorsal graft, the dorsum has been rendered straight by reduction of the upper and middle thirds and elevation of the root. Note the apparent reduction in nasal
base size. (28) Placement of the right spreader graft; the left-sided spreader graft has already been positioned. (29) Several lightly crushed grafts will recontour the tip
lobule. (30) An infracartilaginous access incision is made for tip graft placement. (31) Dissection is carried into the tip lobule (previously unviolated because of the
retrograde lateral crural dissection). The surgeon must dissect only in the areas that require augmentation but widely enough that the tip tissues will drape over the grafts.
(32) The first tip graft is placed, aiming toward the patient’s right alar dome. (33) After placement of the first tip graft; compare with (27). The tip is more angular and has
been elevated above the supratip; a defined point of greatest tip projection has been developed. (34) After placement of a second tip graft, the forces over the lobule are
more diffused; the tip looks less angular. (35) After placement of all tip grafts, the access incision is closed.
22
Fig. 17.16, cont’d

471
Surgical technique
Technical details
The author performs the dorsal resection under direct vision
using a sharp Fomon rasp. Resection of the dorsal border of
the septum is accomplished with a No.11 blade from which
the tip has been broken to avoid lacerating the contralateral
dorsal skin. Despite the fact that the rasp and blade permit
more conservative resections than saws or osteotomes, the
surgeon can still over-resect. The dorsum should feel and
appear perfectly smooth through the skin surface after dorsal
resection.
Nasal spine–caudal septum
Caudal septal resection may change the relationship of the
columella to nostril rim, nasal length, subnasale contour, and
upper lip carriage, an observation that can be confirmed by
recalling the appearance of the patient with septal collapse,
in whom a sharp subnasale and upper lip retrusion are
present even though the nasal spine remains uninjured and
unresected.
If the nasolabial angle and upper lip relationships are sat­
isfactory, no transfixing incision and no caudal septal or nasal
spine modifications are necessary. If columellar position is
satisfactory but the subnasale is full, a short incision can be
made in the posterior membranous septum and septal floor,
the nasal spine exposed and resected with a small rongeur.
If the columella is low but the nasolabial angle is satisfactory,
the caudal or membranous septum is resected, paralleling the
nostril rims and without shortening the nose. Finally, if the
columella is low or the nasolabial angle is acute, more caudal
septum and membranous septum is resected anteriorly than
posteriorly. Caudal septal and nasal spine resections are two
of the most straightforward areas of nasal reduction, in which
the intraoperative appearance is often extremely close to
postoperative contours. Nevertheless, transfixing incisions
should not be made unless some intervention at the caudal
septum is required.
Technical details
Be cautious about over-resection; 1 or 2 mm makes the differ­
ence between normal columellar position and retraction.
Alar cartilage resection
The aphorism, “as the tip goes, so goes the rhinoplasty”, may
account in part for the fact that the small, paired alar cartilages
have received exhaustive attention in the rhinoplasty litera­
ture. Countless techniques have been described to improve
alar cartilage contour, most of them constituting various pat­
terns and degrees of resection.80–88
As security with tip reconstruction has grown, the author’s
approach to the alar cartilages has become simpler: preserve
as much alar cartilage as possible, consistent with good aes­
thetics and external valvular support; interrupt the continuity
of the alar cartilage arch only if tip projection is excessive or
where the arch severely disturbs aesthetics (e.g., the “boxy” or
“ball” tip); and use cartilage grafts to restore equilibrium or to
improve tip contour.28,89 Simple observation and anthropomet­
ric measurements have repeatedly demonstrated that normal
alar cartilage lateral width is 10–12 mm; it is not reasonable to
expect that a 2-mm “rim strip” remnant will adequately
support the external valves or provide proper tip contour.
The alar cartilages may be altered in one area but not in
another. Reduction at the lateral genu decreases tip width;
reduction of the middle crus decreases tip lobular length, tip
projection, and inter-domal distance; lateral crural resection
decreases the convexity apparent on frontal and oblique views
but may weaken the external valves.
Technical details
In the majority of primary rhinoplasties in which only conser­
vative reductions of the cephalic lateral crura edges are
necessary, the cartilages are modified retrograde through
the intercartilaginous incisions; I rarely remove more than
2–3 mm. If the cartilages are distorted, they can be delivered
as bipedicle flaps by intercartilaginous and infracartilaginous
incisions. If only the arch needs interruption (e.g., to narrow
the tip or to resect a “knuckle” at the lateral genu), only that
portion of the alar cartilage should be exposed. Finally, if the
lateral crus or dome areas are so distorted that a simple reduc­
tion or tip grafting will not provide the intended result, the
distorting structures can be dissected free from the vestibular
and overlying skin and (1) resected and replaced after trim­
ming to create the flattest segment; (2) resected and replaced
by septal cartilage grafts; or (3) delivered as a medially based
flap rotated into the alar rims. Freeing the lateral crura, dome
resection, or division of the alar cartilage arch reduces tip
projection and so tip grafts are necessary to reconstruct the
lobule. Lining should never be resected to avoid vestibular
stenoses and iatrogenic airway obstruction.
Upper lateral cartilages and shortening the nose
Resection of the caudal ends of the upper lateral cartilages
used to be routine; in fact, this step is unnecessary unless
substantial nasal shortening is required.
A variety of interventions shorten the nose. In descending
order of their effect, they are dorsal resection, caudal septal
resection, resection of the cephalic edges of the alar cartilage
lateral crura, and resection of the anterocaudal ends of the
upper lateral cartilages. The posterior edges of the upper
lateral cartilages should be left to abut the lateral crura;
mucosa should never be resected.
Technical details
The caudal edge of the upper lateral cartilage can be drawn
downwards by a single hook in its lining, exposing the caudal
edge for submucosal resection with Joseph scissors.
Septoplasty, spreader graft tunnels
Septoplasty is performed to relieve an airway obstruction
from septal deflection and to provide graft material for the
reconstruction itself. It is important to inquire about a history
of prior trauma because unhealed septal fracture lines may
extend to the dorsal septal edge and therefore threaten dorsal
strut stability. The surgeon should perform the resection
through a Killian incision, not from the dorsal edge, and leave
15–20 mm of intact, undissected cartilage along the nasal
dorsum and 15 mm caudally to preserve stability and to
facilitate spreader graft placement. Recent trauma (within 3
months) is an indication to postpone the rhinoplasty until any
fractures have healed and until postoperative edema allows
accurate judgment of the aesthetic contours. If significant

472
SECTION I
CHAPTER 17 • Closed technique rhinoplasty
piece of septal cartilage, ideal for a dorsal graft. Dissection
continues posteriorly and caudally with the sharp end of a
Cottle perichondrial elevator. The septal cartilage in the
vomerine groove can often be dislodged by a bit of judicious
wiggling with a narrow osteotome. With an osteotome and
septal forceps, additional pieces of vomer or perpendicular
plate of the ethmoid can be removed if obstructing or if
additional graft material is needed, always working under
direct vision. In areas of severe deflection, tears in the muco­
perichondrial flaps may be unavoidable, but the surgeon
should nevertheless proceed cautiously and repair any tears.
Close the septal pocket with 4-0 chromic mattress sutures
(Fig. 17.17).
Turbinectomy
Partial inferior turbinectomy, defined as a trim of the anterior
edge sufficient to obtain 3 mm clearance to the septum or
nasal floor, is valuable adjunctive airway treatment if indi­
cated; like all nasal procedures, it has been overdone, and
rhinomanometric data suggest that aggressive turbinate treat­
ment is unnecessary in most patients if septal and valvular
causes have been adequately relieved. Turbinate crushing and
outfracture may suffice in patients whose turbinates contain
significant cystic bone and in whom adequate airway size can
be achieved without resection. When resection is necessary,
biopsy forceps allow smaller, more incremental changes than
angled scissors. The raw surfaces left will contract and epithe­
lize, further reducing the size of the remaining turbinate. Be
conservative: over-resection is not currently correctible.
Graft placement and wound closure
Close all but the contralateral intercartilaginous incision with
5-0 plain catgut sutures so that grafts position will be easier
to maintain.
Osteotomy
Osteotomy achieves two goals: reducing bony vault width
and closing the open nasal roof. Because the bony vault may
remain unopened after conservative dorsal resections, it is the
former of these two objectives that is probably more impor­
tant. Before performing any osteotomy, the surgeon should be
trauma has occurred, even in the distant past, it is preferable
to avoid simultaneous septoplasty and bilateral osteotomies
or to postpone osteotomy if the surgeon is not confident of
septal support. In practice, the need for bilateral osteotomies
in the severely traumatized nose is generally uncommon
because a unilateral osteotomy on the outfractured side
achieves better symmetry than bilateral osteotomies.
Technical details
If they are needed, spreader graft tunnels are performed
before septoplasty. Spreader graft tunnels are facilitated by
prior infiltration beneath the mucoperichondrium with local
anesthetic. By identifying the septal angle, the surgeon can
incise to cartilage beneath each mucoperichondrial flap and
develop the tunnels themselves with the sharp end of a Cottle
perichondrial elevator. Each tunnel must follow the dorsal
septal edge and should extend beneath the caudal edge of the
bony arch on each side, leaving a narrow mucoperichondrial
attachment along the top edge.
For septoplasty access, the initial mucoperichondrial
Killian incision is made 15 mm above (cephalad to) the caudal
septal edge; and, using first the sharp and later the blunt end
of a Freer elevator in one hand and a Frazier suction in the
other, dissection proceeds under the mucoperichondrial flap
onto the perpendicular plate of the ethmoid and over any
posterior bony obstructions. Once the first flap has been
developed, the sharp end of the elevator can score through
the septal cartilage at the site of the opening incision; dissec­
tion then proceeds on the second side. Elevation of the peri­
chondrium at the junction of septal cartilage and vomer is
particularly difficult because the periosteal and perichondrial
fibers are interlaced. The periosteal fibers are stronger, so
mucosal tears are less likely if the surgeon begins dissection
beneath the maxillary and vomerine mucoperiosteum and
works cephalad.
The first septal cut is made 15–20 mm below the dorsal
septal edge with angled Knight septal scissors, which cut
through septal cartilage and ethmoid; make sure that both
blades are within the mucoperichondrial flaps before making
the cut. A parallel cut is performed 8–10 mm inferiorly, and
using Killian septal forceps, the first graft, now free on three
sides, can be twisted so that the ethmoid fractures and allows
removal in one piece. This maneuver often provides an initial
graft 25–30 mm long containing the flattest, thickest, longest
Fig. 17.17  (A) Septal cartilage is not uniform in thickness, but broadens along its anterior edge, where it becomes confluent with the upper lateral cartilages and forms the
middle vault roof. (B) Any dorsal resection thicker than 2 mm interrupts this cartilaginous arch and removes the widened septal area, regardless of whether the mucosa is
intact. (C) The surgeon has now created a disequilibrium in which the upper lateral cartilages are no longer held apart by the spreading action of the intact roof. Even if the
internal valves were not incompetent preoperatively, they are now. (D) Spreader grafts recreate the former intact septal width and reconstitute competent internal valves.
Thus spreader grafts are indicated whenever the internal valves are incompetent preoperatively or when the surgeon resects an intact cartilaginous roof, unless the nasal
contour independently suggests a substantial dorsal graft (which duplicates the functional effect of spreader grafts).
A
B
C
D

473
Prioritizing the septal graft specimen for augmentation
The straightest, smoothest cartilage graft is used for the
nasal dorsum to reconstruct this most visible area covered by
thin soft tissues. If septum is available, it is used. Failing that,
I use rib cartilage for the dorsum.
The area of second priority is the nasal tip, for which septal,
ear, or rib cartilage work well. Tip graft requirements differ
along a spectrum. At the two extremes are the patient with a
thick, blunt lobule who desires the greatest postoperative
angularity (in whom an ethmoid buttress and several solid
cartilage grafts will be needed to define the angle of rotation),
and the thin-skinned patient whose well-shaped tip cartilages
require only augmentation of the cephalic lobule for refine­
ment. Technical variations help to optimize an insufficient
specimen (see below). Rib, ear, or septum each make excellent
spreader grafts. Other areas are less demanding: bone that
may be unsuitable elsewhere can be used instead for spreader
grafts, lateral wall grafts, or alar wall grafts, just as solid or
lightly crushed cartilage scraps can fill regional depressions.
Augmentation strategy: radix,
spreader, and tip grafts
Almost every rhinoplasty I perform follows one of only two
strategies: radix, spreader, and tip grafts; or dorsal and tip
graft, adding alar wall grafts for external valvular insuffi­
ciency. Because radix and dorsal grafts are the same graft in
different lengths, the surgeon need only master four graft
types to solve almost all rhinoplasty problems. While not easy,
these two strategies make the operation comprehensible and
manageable, even for occasional nasal surgeons.
These two operative patterns make better sense when the
surgeon considers the three patterns of secondary deformity
and the four anatomical variants (see Table 17.1). Radix and
dorsal grafts correct the imbalance pattern. Tip grafts correct
inadequate projection and supratip deformity, which com­
prise the soft-tissue collapse pattern. Spreader and alar wall
grafts support the internal and external valves, respectively,
the components of the skeletal collapse pattern.
The augmentation phase of any rhinoplasty re-establishes
the preoperative nasal equilibrium and alters contours in
ways that reduction alone cannot. In selecting each graft, the
surgeon should consider areas that may have needed aug­
mentation preoperatively and also those that may now need
grafts because of a disequilibrium that the surgeon has created
during by reduction (i.e., spreader grafts to support the inter­
nal valves after resection of the cartilaginous roof). The nose
that is equilibrated at the conclusion of the procedure is less
likely to change during healing and therefore gives the
surgeon greater control over the result.
Dorsum and radix
The key principle in all augmentation is to match the graft
material to the patient’s soft-tissue characteristics and to his
or her aesthetic goals. Unmodified rib cartilage is stiff, ear
cartilage is rubbery, and septal cartilage is the most “plastic”.
Thicker skin needs more augmentation to provide a given
result: thinner skin requires softer, well-contoured grafts that
do not show. At the nasal root, where the soft-tissue cover is
the thinnest and graft visibility or palpability is particularly
troublesome, the author layers lightly crushed grafts to fit the
defect: usually one longer graft that extends from the radix
sure that one is necessary. If the lower nasal third is already
appropriately wider than the bony vault, narrowing the upper
nose further may be counterproductive by making the nasal
base appear larger. If there is a high septal deviation, bilateral
osteotomies may create a newly asymmetric nose because one
nasal bone will move medially farther than the other. In the
elderly patient (in whom comminution of the nasal bones may
occur), the patient who wears heavy eyeglasses, or the patient
with nasal bones extending less than one-third the distance to
the septal angle (in whom middle vault width depends par­
tially on bony vault width), the surgeon may wish to omit
osteotomy. Finally, osteotomy may lengthen a long nose
further by reducing support beneath a large skin sleeve.
Technical details
The gentlest effective technique is preferable. A single lateral
osteotomy that begins intranasally, low at the pyriform aper­
ture, and ends higher toward the nasal root (at the attachment
of the nasal pyramid to the maxilla) is effective and the most
anatomically correct. Gentle digital pressure causes a green­
stick fracture at the remaining cephalic attachment and will
re-form the bony pyramid. I use a guarded osteotome facing
the button laterally to constantly assure correct orientation.
Alar wedge resection
Like every other preceding rhinoplasty step, reducing nostril
size used to be considered obligatory; it is not. With more
conservative dorsal resections, the degree of surgically devel­
oped nostril flare, and hence the need for alar wedge resection,
decreases. The surgeon should assess the proportion of tip
lobular size to nostril length, remembering that tip grafting (if
part of the preoperative plan) will increase tip lobular size and
improve nostril proportion. Because the alar rim has both
external and vestibular skin surfaces, the requirements of each
must be assessed and treated individually. If nostril size is
excessive, it is important to preserve a medial flap at the sill
to lessen the possibility of alar notching.90 Even with the
medial flap, excess resection of even 1 mm can notch the nasal
floor. Be conservative.
Technical details
An external incision made slightly outside the alar crease is
preferable in order not to destroy this important landmark, a
unique structure that simple skin repair does not reduplicate.
Accurate closure with 6-0 nylon suffices; 5-0 plain catgut is
used for the nasal floor. The non-absorbable sutures should
be removed by 5 days.
Prioritizing the septal graft
specimen for augmentation
One of the important preoperative unknowns in rhinoplasty
is the condition and quality of the graft material needed for
the reconstruction. The great appeal of alloplastics lies in their
predictability, at least on the day of surgery. This luxury does
not accrue to the surgeon using autografts; nevertheless, the
longevity and quality of an autogenous result still exceed
those of any alloplastic substance yet introduced: only auto­
grafts ensure a lifetime result.

474
SECTION I
CHAPTER 17 • Closed technique rhinoplasty
Tip grafting (Fig. 17.18)
The concept of grafting the primary tip or correcting supratip
deformity by augmentation rather than further reduction
began the evolutionary thinking from which the modern
rhinoplasty paradigm derived.91 Technical variations have
been described,91–106 but the principle remains the same. The
surgeon who uses tip grafts commonly finds that they not
only increase tip projection but also alter tip lobular and
nostril contour; increase lobular volume (reducing relative
nostril size); impart a different ethnic character; and enlarge
the nasal base, therefore changing the balance between dorsal
height and tip projection. The two most common graft designs
are the “shield” graft popularized by Sheen91,92 and the
cephalic transverse onlay graft, with or without a columellar
strut, popularized by Peck.106 The Sheen method effectively
lengthens the middle crural segment and therefore increases
tip projection; it is therefore an anatomical correction and my
favored technique.
The clinical problems that tip graft variations can solve
increase with experience, but the following generalities
apply:
1. Graft number and substance must suit the soft-tissue
cover and the patient’s aesthetic goals: more substantial
grafts are required beneath tissues that are thicker or
stiffer (e.g., scarred from prior rhinoplasties), and softer
grafts are needed under thinner skin to avoid surface
irregularities.
2. Tip angularity varies inversely with the number of
grafts used. The normal nasal tip is supported not by
the anterior presenting edge of a single rectangular or
shield-shaped cartilage but by the broad surfaces of the
two alar cartilage domes. A single, solid graft will
support only the tip at its single projecting end; in the
thin-skinned patient, this design produces an unnatural
artifact. The more grafts the surgeon places, the more
underlying support diffuses and the less angular the tip
becomes. To avoid graft visibility, the surgeon should
always use multiple tip grafts (Fig. 17.19).
toward the mid-dorsum, with a second, shorter graft fixed to
its cephalic end to fill the deepest part of the defect. Dorsal
and radix grafts are constructed similarly, the former being
only a longer version of the latter. The most common errors
are making dorsal and radix grafts too short, wide, or rigid;
at the cephalic end, neither usually exceeds 6–7 mm. Both
dorsal and radix grafts should feel perfect after insertion,
without palpable discontinuities or irregularities. If not,
remove and revise them. Most grafts are not sutured into
position but only fixed with the tape dressing. My current
dorsal graft revision rate is about 5%. With proper technical
attention, the augmented dorsum or radix can feel smooth
and unoperated; the grafts should be only barely palpable.
When any dorsum requires substantial augmentation, the
lateral walls may need onlay grafts to properly reconstruct the
upper vault pyramid.
Spreader grafts
Although septal cartilage provides the ideal spreader graft
(see Fig. 17.17C,D), strips of costal or conchal cartilage,
ethmoid, or vomer may be used instead. Their width should
provide confluence between the upper and lower nasal thirds
and they must span middle vault length from the bony arch
almost to the septal angle. After spreader grafts are placed,
caudal slippage can be avoided by a single 4-0 plain catgut
transfixing suture placed at the septal angle.
Lateral wall and columellar grafts
Cartilage provides the ideal lateral wall graft, split tangen­
tially or crushed to fit the defect. Where sufficient cartilage is
unavailable, ethmoid will correct asymmetries in the deviated
nose or mask the edges of a dorsal graft. Slivers of cartilage
that remain can provide “filler grafts” to correct columellar
notching from prior open rhinoplasty scars or retraction after
trauma or surgery. Augment the columella through a short
lateral incision in the membranous septum, anterior to the
medial crura so that the grafts provide adequate visible
augmentation.
Fig. 17.18  Changes in many nasal regions are “global”, not “regional”. The saddle nose should affect only supratip height, but it does much more. Patient preoperatively
(A) and after septal collapse (B). (C) Schematic of the surgical plan: rib cartilage maxillary augmentation, dorsal, caudal support, tip, and lateral wall grafts. All are
necessary to correct the protean, “global” effects of loss of septal support. (D) A 15-year postoperative view.
A
B
C
D

475
Prioritizing the septal graft specimen for augmentation
Fig. 17.19  (A–F) A patient with all four anatomic variants that predispose to unfavorable results: low radix, inadequate tip projection, narrow middle vault, and alar
cartilage malposition, preoperatively and 1 year after surgery. (G) Schematic of the surgical correction: dorsal reduction; relocation of the alar cartilage lateral crura, radix,
spreader and tip grafts. Notice that radix augmentation has reduced apparent lower nasal size; tip grafts alter tip contour and maintain support in a previously long nose. The
columella remains normally narrow.
A
B
C
D
E
F
G
3. Tip symmetry is paradoxically easier to produce with
multiple grafts than with a single graft. Healing forces
contracting on six graft edges can rotate a single graft
and produce an asymmetric appearance. It is easier to
place at least two grafts, one angled toward the dome
on each side, to distribute forces and to recreate normal
anatomy. If the second graft still leaves a deficiency on
one side, the surgeon can add more for symmetry
without disturbing the first two pieces. Tip grafts are
fixed by the dressing.
4. Ethmoid or vomer “buttresses” prevent anterior graft
displacement. Augmentation in a lobule whose alar
cartilages are intact is different from augmentation in a
contracted postoperative lobule from which the alar
cartilages have been partially or completely removed.
The former case can be treated by selective
augmentation of the deficient areas with multiple
softened grafts.28,78 In the latter case, there is no
cartilage remnant to act as a “backstop” for any
grafts placed anterior to it and no remaining structure to
determine middle crural length and angle. Therefore, an
initial buttress graft, usually of ethmoid or vomer and
slightly smaller than the primary tip grafts,
should be inserted first to define the posterior edge of
the pocket and control the anterior position and angle
of the main grafts. The buttress graft creates an angle
of rotation and “tip-defining point” where none exists,
e.g., in supratip deformity. Other grafts can then be
placed anterior to it to fill out the lobular part. The
same strategy is effective in patients desiring substantial
tip projection.
Technical details
Tip grafts are placed through an infracartilaginous incision on
the side from which the surgeon operates. It is important to
dissect the recipient pocket adequately but not so liberally
that the grafts cannot create the required support and projec­
tion. Complete access incision closure is mandatory to mini­
mize infection; the grafts should be manipulated as little as
possible and rinsed in saline in an antibiotic solution before
insertion. The author now places tip grafts in almost every
patient, except for those whose preoperative tip aesthetics are
excellent (Fig. 17.20).

476
SECTION I
CHAPTER 17 • Closed technique rhinoplasty
must be applied precisely but not too tightly; the nasal tip skin
is at greatest risk. Particularly in patients whose tip lobules
have been expanded by grafts, tip color should be checked
frequently in the postoperative period and the tip sling cut
and nasal packs or splint removed as necessary. Even in the
primary rhinoplasty patient, nasal circulation is not inviolable.
Selection and use of additional graft
donor sites and other augmentation
materials
Although the nasal septum is the most “plastic” of the autog­
enous sources for nasal reconstruction, septal cartilage and
bone are not always present in adequate amounts even in the
primary rhinoplasty patient (i.e., where the septum may be
largely bony). Other autogenous sites are available; each has
its particular idiosyncrasies and optimal uses.
Conchal cartilage
Unmodified cartilage from the conchal floor supplies excellent
grafts for the nasal dorsum, lateral walls, tip, or internal valves.
Although many surgeons harvest conchal cartilage through
a postauricular incision, the anterior approach provides the
Routine postoperative care
Dressings
Assuming that septal or turbinate surgery has been performed,
the nose is packed with 7-cm strips of petrolatum gauze
impregnated with bacitracin/mupirocin ointment and layered
over No.18 suction catheters placed in the floor of each nasal
airway. Although patency may last only a few days, the tubes
do help equalize middle ear pressure and allow some airflow,
for which all patients (particularly those anxious about
packing) are grateful. Packing and tubes ordinarily remain for
7 days, by which time normal mucus production has returned
and the packs can be removed painlessly. The packing should
not overstuff the nose, which may dislodge repositioned nasal
bones. In the absence of septal resection or turbinectomy,
smaller packs can be used and need to remain for only 24–48 h.
I prescribe oral antibiotics appropriate for upper airway
organisms as prophylaxis against suppurative sinusitis while
packs are in place.
The nasal splint is fashioned from layers of 12 -inch paper
tape placed across the dorsum, tip, and cheeks so that cloth
tape of the same width, layered over it, does not touch the
skin itself. Several layers of moistened 2-inch plaster are cut
to fit and secured with another layer of cloth tape. The splint
Fig. 17.20  Preoperative (A,C,E) and
4-year postoperative (B,D,F)
photographs of a patient reconstructed
by dorsal reduction; vertical wedge
lateral genual resection; radix, spreader,
and multiple tip grafts. Note that tip
grafts have altered tip lobular shape
and changed the lobular/nostril ratio,
appearing to decrease nostril length (no
alar wedge resections were performed).
Tip lobular width still balances alar base
width. The columella remains narrow;
there are no iatrogenic deformities. (The
dorsal irregularity is a dermal nevus.)
A
B
C
D
E
F

477
The postoperative course
Alloplastics
Except in the single circumstance of maxillary augmentation
(described later), this author does not use alloplastic materi­
als for three reasons. First, literature reports share the same
characteristics: limited, incomplete follow-up of patients,
and complication rates defined only as infection or extru­
sion. Compared with autogenous materials for which infec­
tion, extrusion, and even resorption are rare, such data are
unconvincing. No alloplastic material has yet demonstrated
the success and complication rate that matches autogenous
grafts. Second, the rationale for use of alloplastic materials is
always their simplicity for patient and surgeon while avoiding
the pain and inconvenience of autogenous grafts. The latter
disadvantages are real but largely controllable by the sur­
geon’s experience; the former apply only in the perioperative
period. Whereas alloplastic materials offer the convenience of
not having to be harvested, they are decidedly inconvenient
if they become infected or extrude. Finally, the patient in
whom the surgeon most wishes to use alloplastic materials
is the one for whom they are least suitable, i.e., the tertiary
patient whose soft tissues are scarred and thin and whose
best donor sites have been exhausted. These are the patients
who are least likely to benefit from alloplastic materials
and whose tight, hypovascular beds will be least hospitable
to them.
Maxillary augmentation
Maxillary augmentation is my sole exception to using allo­
plastics in selected patients. Immobile and deep beneath the
thick soft tissues of the upper lip, Gore-Tex (1-mm SAM facial
implant brand of expanded polytetrafluoroethylene, WL Gore
& Associates, Flagstaff, AZ) can be rolled and placed through
a short incision in the nasal floor. Subperiosteal dissection
should be carried high across the maxillary arch tight against
the pyriform aperture; the implant must be carefully central­
ized, and good soft-tissue closure must be achieved. The
implant can be fashioned so that it augments primarily the
central lip or the perialar areas, depending on preoperative
lip configuration. Gore-Tex is pliable and therefore not notice­
able to most patients; the augmentation result appears to be
stable. Complications are low. In a current series of more than
425 patients over 22 years, only five Gore-Tex implants have
required removal (infection). Alloplastic maxillary augmenta­
tion should not be performed in patients who have undergone
cleft lip repair because of unacceptable late extrusion rates.
Use cartilage or bone grafts instead.
The postoperative course
As difficult as nasal surgery is acknowledged to be for
the surgeon, it is even more difficult for the patient, who
(particularly after primary rhinoplasty) does not know what
to expect; has high, perhaps even unrealistic expectations,
despite the surgeon’s preoperative counseling; and is fearful
of complications and anxious for a perfect result. Added to
the usual postoperative worries are the unsolicited opinions
of interested family members and friends who intensify the
patient’s worries by volunteering their opinions. The post­
operative course after rhinoplasty is complex and offers the
surgeon an opportunity to make a positive experience out
surgeon a better view of the quality and contour of the avail­
able cartilage. By either route, it is critical to preserve the
posterior conchal wall to avoid deforming the donor ear; even
so, substantial donor cartilage can be harvested. The ear
should be isolated from the nose during harvesting and gloves
and instruments changed prior to returning to the rhinoplasty
itself. Such appropriate technical points greatly decrease the
chance of introducing gram-negative organisms from the
external auditory canal into the nasal incisions. Conchal carti­
lage forms an excellent dorsal graft for deep, asymmetric
defects beneath a thick soft-tissue cover. The method of trim­
ming, rolling, and fixing the graft has been described by
Sheen.107 For shorter, shallower defects or under thinner soft-
tissue cover, crushed conchal cartilage is not ideal but can be
used as a compromise solution. Because of their rubbery
consistency and thickness, however, single pieces of solid
conchal cartilage will flatten and deform as the overlying soft
tissues compress them and so do not make good dorsal grafts.
Calvarial bone
The calvarial outer table supplies grafts well suited for the
reconstruction of long, shallow (2–3 mm), symmetric dorsal
defects beneath thin soft-tissue covers. These grafts must be
harvested with exceeding care because intracranial injuries
have been described.108,109 Some surgeons have been discour­
aged by the long-term results of calvarial bone, but the author
has used it frequently with only two (of 50) cases of partial
absorption in the supratip. Other surgeons have reported
similar success with even larger series.109 The grafts must be
harvested under low speed using an electric burr and cold
chisel, keeping the bone cool with saline irrigation to avoid
overheating. Bony union is the rule. Calvarial grafts need not
be immobilized by internal fixation if their position can be
maintained by limited dissection and splinting. Where the
soft tissues are distorted or the nasal base has collapsed, fixa­
tion at the root is necessary, a circumstance that is uncommon
in the primary patient unless septal collapse has occurred.
However, because of its utility in providing all graft needs, I
now use costal cartilage in preference to calvarial grafts.
Costal cartilage
Costal grafts, not commonly necessary in primary rhinoplasty,
are excellent for nasal reconstruction. Slices of costal cartilage
(either solid or crushed) can fill the maxillary arch, lateral
nasal walls, columella, or tip. The notoriety of rib grafts to
warp postoperatively can be avoided by observing their
internal stresses as grafts are shaped, and by noting that ribs
progressively calcify as patients age (especially beyond 40
years). The more calcification, the more the distorting peri­
chondrial forces are overcome. I always use the smallest rib
that will suffice (eighth, ninth, or tenth), so that less modifica­
tion and therefore less disruption of internal stresses occurs.
I no longer use threaded, longitudinal K-wires as internal
splints because one or even two wires have not been consis­
tently reliable; rib can pull away from the wires and deform
anyway.110 Sutured perichondrial/cartilage laminates con­
structed from matching anterior and posterior surfaces or
crushed slices of rib cartilage provide alternative and much
more consistently effective approaches.111 Laminates are
my preferred dorsal augmentation method unless very thin
perichondrial/cartilage slices suffice.

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CHAPTER 17 • Closed technique rhinoplasty
good physical therapy after hand surgery, at least 50%
of the patient’s happiness and as much as 90% of the
surgeon’s intraoperative and postoperative judgment
are determined by lengthy and conscientious follow-up.
Variations on the standard
Nasal deviation (Fig. 17.21)
The asymmetric nose is common and difficult to correct. In
the acute fracture when bony displacement is the primary
defect, closed reduction is effective. However, when the injury
has been primarily septal or cartilaginous, closed or even
open techniques in the acute situation are often incompletely
effective. The surgeon who diagnoses an asymmetric nose as
a bony problem alone when septal injury is a substantial
component will find that manipulation of the nasal bones or
attempts to “twist” the septum into its prior position are
incompletely successful and that the prevalence of residual
deformity is high.
In the healed deviated nose, the required techniques are
identical to those already discussed. Several specific principles
should be followed:
1. Asymmetric maneuvers must be done to an asymmetric
nose to achieve symmetry. The strategy for correcting
nasal deviation should consider the cephalic, middle,
and caudal nasal thirds individually. A nose may appear
asymmetric despite a symmetric bony vault. In such
cases, no treatment of the cephalic third may be
indicated, and the surgeon must devote greater
attention to the displaced cartilaginous parts. In general,
the bony vault is treated by no osteotomy or unilateral
osteotomy; the middle third by placement of
asymmetrically thick spreader grafts (wider on the side
that has collapsed further medially, with or without
onlay grafts) and/or onlay grafts for symmetry; and the
caudal third by resection of the septal angle and
submucosal caudal septal resection and replacement as
needed.
2. The strategy for achieving symmetry also depends on
whether the nasal dorsum is convex or concave. When
the deviated nose has a convex bridge, the hump is
often its most asymmetric part. By reducing bridge
height, the surgeon also removes the area of greatest
deflection and therefore makes a straighter nose even
before performing any other maneuvers. Conversely,
when the nasal dorsum is low and asymmetric relative
to a large nasal base, the surgeon can frequently achieve
more symmetry by camouflaging the deflection with a
straight dorsal graft or by aligning the anterior septal
edge with spreader grafts.112–117
3. Deflection of the septal angle is a frequent cause of
misalignment of the nasal base; resection of the septal
angle releases the soft tissues at the nasal tip, allowing
them to move toward the midline. However, septal
angle or dorsal resection sufficient to correct the
asymmetry may simultaneously produce a nasal bridge
that is now too low and therefore requires augmentation
to re-establish postoperative balance and middle vault
support. A deflected caudal septum/septal angle can
of what otherwise might be a negative one (or vice versa).
Surgeons who do not see their patients after the dressings are
removed are missing the chance to observe usual and unusual
postoperative courses and to develop the skills and experi­
ence that might otherwise lead to consistent postoperative
success.
The nasal splint and any remaining packing are removed
on postoperative day 7. Despite better symmetry, a straighter
bridge, or increased tip contour, many patients are worried 1
week after surgery and need repeated assurance that the nose
is still swollen. The airway, however, should be appreciably
better when packing is removed, an instant reward for the
patient after a week of bandages. By day 10, the nose has
begun to assume a much better shape, and most patients’
confidence builds from there. Patients should be seen as
needed during the first 2 weeks after surgery to clean the nose
of secretions that have accumulated around intranasal sutures,
to ensure that edema has not displaced the nasal bones, and
to educate the patient about changes to be expected over the
ensuing weeks and months. I see my patients every 3–4
months until the end of the first postoperative year and yearly
thereafter, if possible, adjusting for patients who travel from
a distance. Patient and surgeon always learn something from
each postoperative visit.
Some changes predictably occur during the postoperative
period. The degree of change (see above) depends on the
degree of disparity between preoperative and postoperative
skeletal volume, how well the interdependent skeletal areas
have been rebalanced, and how well the re-formed skeleton
supports the soft tissues. The bigger the disequilibrium, the
greater the postoperative change.
The following sequence occurs in most patients during the
first postoperative year:
1. The nose becomes longer and “deskeletonizes” as upper
lip edema abates, so that the nasolabial angle decreases
and the nostrils become less visible.
2. The nasal base rotates caudally, depending on skin
elasticity and the degree of skeletal support; the long
preoperative nose has the greatest tendency to elongate
postoperatively.
3. The profile assumes its final postoperative shape sooner
than the frontal view; the nose narrows for at least
12–18 months, particularly in the middle third. During
this time, the unsupported middle vault narrows and
demarcates from the caudal edges of the bony vault.
The nasal skin tries to assume its preoperative shape, a
characteristic that has particular implications for tip
grafting: the flatter, more contracted preoperative tip
will compress tip grafts and alter postoperative contour
more than the larger tip with a more pliable soft-tissue
cover, a phenomenon that the surgeon must take into
account intraoperatively.
4. Skeletal irregularities or asymmetries may appear (and
sometimes disappear).
5. Areas of underlying skeletal change or grafts may
become visible and suggest the need for revision;
conversely, early postoperative improvement may
become obscured by soft-tissue contraction and
thickening. As the surgeon becomes more experienced,
postoperative changes become more interpretable and
the surgeon’s advice becomes more reliable. As with

479
Variations on the standard
■ Bridge height is important. Most men prefer a straight (or
even convex) dorsal line to one that is concave with
retroussé.
■ Men want noses that “look male”; not too short, not too
narrow, and not too small.
■ Secondary male patients most often complain of a bridge
that is too low. Be conservative in resections.
■ Whereas some women say, “I don’t care how well I
breathe as long as my nose is pretty”, men expect
excellent postoperative airways.
Ethnic rhinoplasty
Beauty is subjective. There are patients whose private aesthet­
ics are quite specific, and patients who simply want the
surgeon to remove the bump and restore the airway. Every
patient deserves to have his or her aesthetic goals and personal
identity respected by the surgeon. In my view, therefore, there
is no such thing as “ethnic rhinoplasty”.
The point for the surgeon to remember, however, is that
some patients’ ethnic backgrounds shape their aesthetic goals
in one of two ways: either retaining ethnic characteristics or
changing them. But the surgeon must ask. One of the most
common motivations for secondary rhinoplasty is the loss of
a familial, ethnic, or personal nasal characteristic.
also be aligned by asymmetrically thick spreader grafts,
placing the thicker graft on the side toward which the
septal angle is deflected.
Rhinoplasty in men
Although the diagnostic and technical aspects of rhinoplasty
performed on men do not differ from those performed on
women, there are other differences. Men have larger frames,
heavier bones, thicker skin, and historically have been more
likely to involve themselves in contact sports and in work
with high physical demands.
Men are also judged to be most attractive when they best
represent their phenotype – that is, when they “look male”:
defined jaws, strong foreheads, and larger noses.75
It is also true that men can have turbulent postoperative
courses. In my previous survey of 1000 consecutive rhino­
plasty patients, men represented 30% of the disruptive or
needy patients and 40% of those with body dysmorphic
disorder, although men only represented 22% of that
population.118
This is not to say that men cannot be very good rhinoplasty
patients. However, the following generalities almost always
apply:
■ Men tolerate larger noses than women; that is, shape is
more important than size.
Fig. 17.21  Preoperative (A,C,E) and
2-year postoperative (B,D,F)
photographs of patient with symmetrical
nose treated with dorsal resection,
asymmetrically thick spreader grafts,
dorsal camouflage graft, and right lateral
wall graft. Columella is undamaged. No
new deformities, a consequence of
endonasal surgery.
A
B
C
D
E
F

480
SECTION I
CHAPTER 17 • Closed technique rhinoplasty
of tighten, making some intraoperative judgments more dif­
ficult and contraction to a reduced framework less probable.
Cartilages may have become more rigid, and many patients
believe that their tips have grown larger with time. Whether
this reflects actual cartilaginous growth, elongation or thin­
ning of soft tissues, or even absorption of the bony vault creat­
ing a new imbalance is not yet known. Tips that were
adequately projecting in prior years begin to hang from the
septal angle, causing an apparent curvature in the lower nose.
Rhinophyma
Rhinophyma (Fig. 17.22) is the perfect setting for real reduc­
tion rhinoplasty. Rhinophymatous noses really are too large,
distorted by sebaceous and vascular overgrowth, chronic
inflammation, exudates, and sometimes grotesque soft-tissue
excesses. The diseased tissues must be reduced, either by
tangential or direct excision. While the excised surface heals,
skin texture changes, sometimes becoming smoother and
sometimes becoming scarred, depending on excision depth.
Patients must be forewarned of the latter possibility, but few
object because the deformity is so significant and so inaccu­
rately associated ethanol abuse.
Three
principles
can
guide
the
surgeon
treating
rhinophyma:
1. Not every nose with rhinophyma was originally small
and straight. Before beginning the excision, try to
visualize the patient’s real underlying contour, and
obtain old photographs if possible (see Fig. 17.22A). The
objective is to reduce the nose but produce as little
scarring as possible. Compromise may be necessary.
2. Do not assume that every nose was well balanced
before it became diseased: some had dorsal humps and
low radices, some had inadequate tip projection, and
some were already too long. Your patient may need a
second rebalancing procedure (e.g., dorsal or tip grafts).
Skin excision cannot correct skeletal deformities.
3. Plan excisions according to the nasal planes and
aesthetic units to minimize distracting color and contour
discontinuities.131
The donor site-depleted patient
Although donor site depletion is more common in the second­
ary patient whose donor sites have previously been harvested,
even the primary rhinoplasty patient may be donor site
depleted if the septum is bony and yields minimal usable
cartilage (a circumstance somewhat more likely in the non-
white or post-traumatic nose). In one series,132,133 17% of the
primary rhinoplasty patients had nasal septa that were at least
75% bony and supplied insufficient donor material for the
patient’s requirements. A few principles are helpful in such
patients:
1. Internal valvular reconstruction can be accomplished by
either spreader grafts or dorsal grafts with equivalent
functional effects.
2. External valvular reconstruction can be accomplished by
battens of cartilage or bone that span the area of
collapse, or by composite skin/conchal cartilage grafts.
3. Tip reconstruction may be accomplished by selectively
grafting the skeletally deficient lobular parts using
crushed grafts in limited pockets.
The principles of forming and performing the surgical
plan, however, do not differ. The surgeon trying to correct a
low, broad dorsum and a large nasal base covered by thick
soft tissues faces the same imbalances and the same chal­
lenges regardless of the patient’s ethnic background. The
interaction with each patient sets the plan. It is only important
that all changes are intentional and reflect the patient’s aes­
thetic and ethnic sensibilities.
Cleft lip nasal deformity
Although patients who have undergone lip and nasal repair
in infancy (which may have involved only dissection of the
lower lateral cartilage on the cleft side) do not, strictly speak­
ing, constitute a “primary rhinoplasty deformity”, they often
require definitive corrections during the teen or early adult
years. The classic anatomic characteristics have been described
elsewhere.119–124
The septal, maxillary, nasal base, and alar cartilage abnor­
malities that typify the unilateral or bilateral cleft lip may be
managed by many of the methods designed for aesthetic
rhinoplasty. The deformity is always complex and must be
analyzed in terms of the symmetry of each nasal third, maxil­
lary arch contour, columellar support, septal obstruction,
valvular competence at the internal and (particularly) external
valves – especially on the cleft side, alar cartilage contour,
vestibular webbing or atresia, and tip support. What is fre­
quently characterized as a “short columella” may reflect
inadequate tip projection instead and is best managed by
increasing the tip projection without columellar lengthening.
Also commonly overlooked or unrecognized is cephalic rota­
tion of the alar cartilage lateral crus on the cleft side. Additional
techniques are required for deformities uncommon to the
usual primary rhinoplasty: maxillary augmentation, excision
of alar rim skin, correction of vestibular webbing, coronal
composite grafts, and creation or relocation of the alar crease.
The primary repair has frequently often constricted the nostril
on the cleft side and may have displaced the alar base medi­
ally. When the alar base is properly positioned, nostril stenosis
can be improved by axial or sagittal composite grafts from the
alar lobule or ear.125,126 When the nostril stenosis and alar base
malposition occur simultaneously, however, an inferiorly
based transposition flap lateral to alar base or a crescentic
island flap vascularized by subcutaneous and musculocuta­
neous perforators is effective.127,128
Older patients
Older, of course, is relative. Two important considerations for
the older patient are (1) how long dissatisfaction with the nose
has been present and (2) any structural characteristics that
may suggest alterations in the surgical plan.
It is therefore wise to inquire how long the patient has been
unhappy with his or her nasal shape. For some patients, it has
been since their teen years. These patients can tolerate more
significant changes. Alternatively, the patient whose unhap­
piness with his or her nasal shape is recent may simply be
noticing aging changes. The surgeon’s task in these cases is to
restore the nose, as far as possible, to its previous, more youth­
ful appearance.129,130
Older nasal bones are thinner and more brittle, and the
bony arch must be able to support eyeglasses. Soft tissues have
become atrophic and less elastic, and tend to wrinkle instead

481
Problems in the postoperative course
Iatrogenic airway obstruction
More common than any complication, and entirely prevent­
able, is a decrease in postoperative airway size, particularly
unfortunate if it is new and iatrogenic. Although attributed
by some authors to the use of an intercartilaginous access
incision or the narrowing effects of osteotomy,134,135 more
common causes are increased internal valvular incompetence
from resection of the middle vault roof and external valvular
incompetence from alar cartilage resection, particularly in
cases of cephalic rotation of the lateral crura. Airway obstruc­
tion from loss of skeletal support due to surgery may be
avoided by a preoperative evaluation that identifies short
nasal bones, narrow middle vault, or alar cartilage malposi­
tion, and establishing valvular competence in each patient.
Substantial dorsal or spreader grafts correct internal valvular
incompetence, with equal efficacy; collapsing external valves
can be stiffened by autogenous cartilage.134 Less commonly,
new airway obstruction may be caused by the inadvertent loss
of tip support (through septal collapse or excessive dorsal or
alar cartilage reduction), excessive alar wedge resection
(treated by composite grafts or local flaps), or resection of
nasal lining (which should never only be performed at the
4. Multiple staggered grafts (even tangentially split,
crushed ear cartilage) can form a smooth dorsum in
patients with adequate soft-tissue cover.
5. Single-unit dorsal grafts are still needed for dorsal
defects in thin-skinned patients; not all patients can be
treated with minimal donor material.
Problems in the postoperative course
Unlike other plastic surgical operations that are technically or
conceptually difficult, rhinoplasty has fewer of the complica­
tions that traditionally plague surgeons. Most rhinoplasty
surgeons never see lacrimal duct or extraocular muscle injury
after rhinoplasty; even septal perforation is relatively infre­
quent. Because of its very nature, however, most rhinoplasty
complications are directly related to an insufficiently complex
understanding of the structural interdependencies in the
nose, incorrect diagnosis, or technical difficulties, all of which
are under the surgeon’s control and can be decreased by plan­
ning and operative technique.
The following complications are listed in decreasing fre­
quency as they are recognized in patients seen in consultation.
A
E
Fig. 17.22  Preoperative (B,D,F) and postoperative (C,E,G) photographs of a patient with rhinophyma treated by shaving the external skin, spreader, radix grafts. The
original premorbid nose (A) is not always well proportioned.
B
C
D
F
G

482
SECTION I
CHAPTER 17 • Closed technique rhinoplasty
Surgeons who routinely assume that the wider dissection of
the open approach is superior in difficult secondary cases
should rethink their philosophy. Even the best open rhino­
plasty surgeons lose nasal tip or columellar skin – catastrophic
in cosmetic cases. The surgeon must always remember that
the surgical principles that apply everywhere in the body
apply to the nose.
Graft problems
Skeletal problems caused by grafts rank third only because
fewer surgeons augment than reduce. For those surgeons who
augment often, graft imperfections are the most common
reason for secondary revision. Dorsal grafts must be carefully
contoured and placed in pockets that limit their movement.
Similarly, tip grafts may produce unacceptable asymmetries
or visible edges. Graft visibility depends on the number and
substance of the augmentation material as well as the charac­
teristics of the soft-tissue cover. The surgeon who uses multiple
grafts will find tip symmetry easier to achieve and graft visibil­
ity less likely.
Intraoperative and postoperative hemorrhage
Even a few extra drops of blood can cloud the field or float
grafts out of position postoperatively. There are two patterns
of excessive intraoperative bleeding: constant slow, multifocal
bleeding starting at the first injection; or normal hemostasis
for 2–3 h, then multifocal bleeding, even from areas previ­
ously treated. Each requires different management.
The first pattern often indicates factor VIII deficiency; even
normal patients can acquire anti-factor VIII antibodies during
childbirth. The treatment is DDAVP (desmopressin acetate)
0.3 µg/kg, which has been used for hemophilia A, von Will­
ebrand’s disease, and diabetes insipidus. If the problem is
known, pretreatment begins 30 min preoperatively. Re-dosing
is not usually necessary. Uncommon side effects are headache,
nausea, and cramps.
The second pattern manifests as normal hemostasis for
2–3 h, then multifocal bleeding, even from areas previously
treated, and indicates a circulating fibrinolysin, commonly
seen following heart surgery, abruptio placentae, some
cancers, and antidepressants, now so commonly prescribed.
This pattern is treated with Amicar (aminocaproic acid), a
fibrinolysis inhibitor that inhibits plasminogen activators. The
clinical picture must be distinguished from disseminated
intravascular coagulation, of course rare during rhinoplasty.
Aminocaproic acid is given as a 4–6 g loading dose, followed
by 1 g intravenous hourly until discharge, and then 1 g p.o.,
q.i.d until the risk of hemorrhage has passed. Side effects are
headache, glomerular capillary thrombosis, bradycardia, and
hypotension. Because of the possibility of renal tubular clots,
pre-administration urinalysis is mandatory. Unfortunately,
the problem cannot be screened by routine bleeding studies:
prothrombin time (PT), partial thromboplastin time (PTT),
and platelets are normal in most cases; some patients, however,
do have a histories of previously undiagnosed hemorrhage.
The link to serotonin reuptake inhibitor antidepressants is
postulated to be platelet serotonin depletion, leading to
abnormal bleeding.138
It is theoretically ideal but impractical to have all patients
stop antidepressants for 2 weeks preoperatively. Consequently,
membranous septum to shorten the nose). Inadequate or
excessive shortening misdirects the air stream that should
flow posteriorly along the nasal floor. Patients with exces­
sively long noses often relieve their airway obstructions by
supporting their nasal tips; here, even osteotomy may be
counterproductive by decreasing skeletal volume.135 The over-
shortened nose can be improved by dorsal grafts, resection of
the posterior caudal septum, and coronally oriented compos­
ite grafts.125,136 Osteotomy has been indicted as a cause of
decreased postoperative airflow, although many authors have
now concluded that osteotomy rarely decreases nasal airflow,
partly because septal and valvular surgery is so effective in
secondary patients. The passion of many patients for “small”
noses and the aggressiveness of some osteotomy techniques,
however, can produce narrow pyriform apertures, in which
case excision of the lateral lips of the pyriform apertures
improves the patient’s symptoms. Finally, inadequate turbi­
nate resection may leave residual obstruction; more com­
monly, excessive turbinate resection produces a sense of
obstruction (presumably from loss of the normal baffling and
resistance functions), nasal dryness, and clear, persistent rhi­
nitis. Insufficient turbinate resection is easy to correct; exces­
sive resection and its sequelae have no current accepted and
effective treatment. An improvement in nasal appearance
should never decrease airway size; virtually all rhinoplasty
patients can maintain or improve function if the surgeon
remembers the functional interrelationships that exist and
plans the operation accordingly.
Skeletal problems
Irregularities or asymmetries may occur in any modified
skeletal structure; their visibility varies with the thickness of
the soft-tissue cover. Irregularities at the caudal edges of the
bony vault are often attributed to inadequate reduction but
more often represent middle vault collapse, which causes the
caudal end of the bony arch to stand out in relief; treatment
is spreader or dorsal grafts,6 not further bony resection.
A palpable or visible low point may appear in the midline
of the nasal bridge, either intraoperatively or postopera­
tively.137 This “mid-dorsal notch” has been interpreted as an
untidy resection of the cartilaginous dorsum but is actually a
soft-tissue phenomenon that occurs where the thinner, upper
nasal skin thickens in its transition to the supratip and there­
fore represents the cephalic end of the supratip deformity (or
the midpoint of the “inverted-V” deformity associated with
middle vault collapse) and indicates dorsal over-resection; it
should be treated by augmentation.
A new frontal asymmetry may develop when dorsal resec­
tion has uncovered a high septal deviation. The high septal
deviation can be camouflaged by splinting the anterior septal
edge with spreader grafts of unequal thickness, adding any
necessary onlay grafts for additional symmetry.
Soft-tissue problems
As much as graft quality, soft-tissue quality determines the
beauty of the final result. Skin that has been damaged by
previous surgeries may be unevenly thick, can be assumed to
be hypovascular, and may not adapt or cover a rebuilt under­
lying skeleton (which itself may be constructed of suboptimal
materials) evenly. Nasal circulation can never be taken lightly.

483
Problems in the postoperative course
The surgeon should plan incisions to provide necessary access
and minimize the amount of dissection.
Infection
Bacterial infection is mercifully rare after rhinoplasty and
septal surgery141–149 but has become more common with the
emergence and increasing prevalence of methicillin-resistant
Staphylococcus aureus as a community-acquired pathogen.150
Many surgeons use antibiotics while postoperative packing is
in place, although their absolute necessity has not been estab­
lished. Toxic shock syndrome, cavernous sinus and nasofrontal
abscess, and even endocarditis are extremely rare but have
been reported. Limited but especially troublesome infections
occur infrequently in areas of tissue compromise, with exces­
sive manipulation, or where conchal cartilage grafts have
been placed carrying Gram-negative organisms from the
external auditory canals.
Septal collapse
Loss of cartilaginous support has protean effects because the
intact septal partition is necessary for normal bridge contour,
nasal length, base support, middle vault (and internal valvu­
lar) competence, and upper lip carriage. The required recon­
struction is therefore predictably complex. The surgeon may
minimize the possibility of septal collapse by identifying
those patients with unhealed or unstable septal fractures and
by leaving a minimum 15 mm width of undissected septal
cartilage and mucoperichondrium along the dorsum to avoid
jeopardizing septal support if unexpected, unhealed fracture
lines are encountered.
Red nose
The “post-rhinoplasty red nose” is a cutaneous manifestation
of postoperative circulatory readjustment and is displayed
varyingly in patients; many never develop this condition,
whereas others develop it after the first rhinoplasty. At par­
ticular risk are patients whose scarred or immature tips have
been expanded by grafts. Patients with facial telangiectases
develop red noses more frequently; most improve spontane­
ously during the first postoperative year. When the condition
persists, laser treatment is simple and effective.
Nasal tip discoloration cannot be ignored. Even when the
access wound has not been closed under tension, internal
pressures caused by grafts, packing, postoperative edema,
and taping may render a carefully placed dressing too tight.
Remove the tape sling if tip color is not perfectly normal. Even
at 24 h, graft position will not be lost.
Other complications
Lacrimal duct injury (presumably from lateral osteotomy)
was described in a 1968 series,151 in which the incidence of
lacrimal obstruction in a 27-patient group was 78%; later
studies have confirmed this rare possibility.152,153 Reports have
also appeared of orbital floor and extraocular muscle injury
after osteotomy. Such events are unlikely if the surgeon knows
and controls osteotome position. Cerebrospinal fluid rhinor­
rhea, cavernous sinus thrombosis, meningitis, permanent
anosmia, recurrent intradermal cysts, and blindness after
corticosteroid injection for supratip deformity have been
reported but are fortunately uncommon.154–159
I order a urinalysis to rule out microscopic hematuria so that,
Amicar can be given safely during surgery if the need arises.
Rare patients classically re-bleed between postoperative
days 5 and 10. At particular risk are patients who have
taken antidepressants, herbals, or vitamins that interfere
with platelet function. The surgeon’s major task is to elicit
cooperation from the frightened patient and family; as occurs
so often in upper gastrointestinal hemorrhage, the calmed
patient frequently stops bleeding. The surgeon should see
the patient personally, remove packs, suction the airway, and
identify the site of bleeding. When bleeding does not stop,
reinsertion of an absorbent pack soaked in phenylephrine
hydrochloride is necessary. The need for posterior packs
fortunately occurs less frequently, but the surgeon should be
familiar and comfortable with their use before the occasion
arises.
Septal perforation
Perforations occasionally occur after difficult septoplasties
but can be minimized by cautious dissection over the vomer,
by repairing tears in the mucoperichondrial flaps, and by
placing 1-mm silicone splints on each side of the septal parti­
tion before the nose is packed.
Even with these precautions, the occasional septal perfora­
tion may be unavoidable and is usually asymptomatic. Small
perforations may cause a curious whistling; larger ones cause
crusting, epistaxis, and rhinitis as the turbulent airflow spins
through the perforated mucosa. Epistaxis frequently reflects
an area of exposed septal cartilage or bone. Repairing septal
perforations is difficult; recurrence after local or even distant
flaps in the largest series is still high. In symptomatic perfora­
tions, it is often preferable to identify and eliminate areas of
exposed septal skeleton and repair the mucoperichondrial
flaps to obtain a perforation with a healed, stable surface. If
symptoms can be alleviated in this manner, closing the perfo­
ration itself is not usually necessary.
Rhinitis
Temporary rhinitis may occur for several weeks postopera­
tively, particularly when an obstructed airway has been
improved. Persistent rhinitis, however, is uncommon unless
excessive turbinectomy has been performed. The proponents
of turbinectomy minimize this sequela,139,140 but it is a trouble­
some entity for which there is yet no consistently effective
treatment.
Circulatory problems
Circulatory complications are extremely uncommon after
closed rhinoplasty. During primary endonasal rhinoplasty, the
surgeon can make intercartilaginous and infracartilaginous
incisions with or without alar wedge resections without fear
of circulatory compromise as long as the incisions are not
made longer than is necessary, skeletonization is appropri­
ately limited, the dermis is not thinned, and packs and dress­
ings are not placed tightly. Differentiation of the tip lobule
from the dorsum (the desirable “supratip break”) reflects
not overcorrection of the cartilaginous dorsum but rather
adequate dorsal height and tip projection. If these factors are
absent, the surgeon cannot produce a supratip depression by
excessively tight taping, dermal sutures, or steroid injections.

484
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CHAPTER 17 • Closed technique rhinoplasty
own. Alternatively, the surgeon evaluating someone else’s
unhappy patient need not overcome disappointment with
the current result but has less information about the original
deformity, the patient’s tissue idiosyncrasies and donor mate­
rial, the procedures themselves, and the patient’s personality
and goals. Particularly when a patient is angry with the
prior surgeon, it is imperative that the secondary surgeon
has confidence that the patient (1) has realistic surgical goals
and understands what is needed to achieve them and (2)
appreciates that the original operating surgeon was doing
his or her best to produce the patient’s original goals. Until
these criteria can be satisfied, the surgeon is wise to delay
surgery.
The decision to reoperate
The patient counseled properly before surgery knows that
resolution of swelling takes time and that the final appearance
may not stabilize until the end of the first postoperative year
or later. In practice, waiting for the final outcome is a bigger
challenge for some patients (and surgeons) than for others.
Accordingly, the surgeon should withhold the decision to
reoperate for at least 1 year, until the postoperative result has
stabilized. In some patients or after multiple surgeries, even
more time may be necessary. The nature and degree of revi­
sion, and who should perform it, depend on the same factors
involved in the prior rhinoplasty. Patient and surgeon must
understand each other explicitly because secondary surgery
itself is often geometrically more difficult than the primary
operation. Regardless of the overt indications, patient and
surgeon must not abandon the priorities of safety, function,
and aesthetics, in that order. Rhinoplasty does not own its
reputation by accident.
Secondary rhinoplasty
Space does not permit the discussion of endonasal secondary
rhinoplasty. The author’s analysis and techniques are avail­
able elsewhere.186 The most common problems requiring
secondary rhinoplasty are iatrogenic or uncorrected airway
obstruction; failure to recognize the critical anatomical vari­
ants described earlier (low radix or low dorsum, inadequate
tip projection, narrow middle vault, or alar cartilage malposi­
tion); supratip deformity; problems of length or balance;
problems resulting from nasal implants; technical problems
related to grafting; intolerable loss of identifiable racial, famil­
ial, or personal characteristics189; or deformities caused by
previous open rhinoplasty.
Why primary and secondary rhinoplasty
are the same operation
There are surgeons who will perform primary rhinoplasty but
not revisions. That is understandable, but for the surgeon who
has learned rhinoplasty phenomenology, anatomical variants,
principles of balance, grafting techniques, and airway man­
agement, the two operations can be viewed as only variations
on a surgical theme. If the surgeon is economical in incisions,
maintains or establishes equilibrium, removes or repositions
deforming parts, maximizes functional support, and uses
Serious but rare (0.02% in a pooled series of 12 672 cases)
complications have been reported after calvarial bone graft
harvesting: hemiparesis; hemiplegia (in a patient with platelet
disorder); epidural hematoma; subdural infection; dural,
brain, or sagittal sinus lacerations; aphasia; persistent
speech defect; and temporal hemianopia. Adverse events are
extremely rare in the hands of surgeons experienced with
proper bone harvesting technique.108
Alloplastics placed during rhinoplasty have their own
litany of postoperative problems. The reader is encouraged to
become familiar with these misadventures before assuming
that alloplastic reconstructions are inherently less trouble­
some than autogenous materials.160–169
The unhappy patient
In a perfect world, the relationship between the surgeon and
the aesthetic surgery patient would be even more favorable
than in other medical encounters. Although it may be optimal
for patient and surgeon to like each other, this is not always
necessary or possible for the frightened cancer patient or the
intoxicated emergency department patient. In the elective
cosmetic case, everything should be different.
Differences do exist in aesthetic surgery, but perhaps not as
expected. Where the risks and complications are as real as in
non-elective procedures and where the emotional investment
may be even greater, patients expect more than passable
outcomes without complications. Patients desire excellent
results, even “perfect” results, from procedures that are tech­
nically difficult, that change appearance, and that have pro­
found ramifications for that complex part of the human
psyche that we call “body image”. In aesthetic surgery, it is
important for patient and surgeon to like each other.
The surgeon–patient relationship is always tested when
things do not go as planned. It is these circumstances that
measure the surgeon’s equanimity and test the degree to
which “informed consent” has been obtained. It is here that
the patient must understand the difference between the
uncontrolled and the uncontrollable. The patient is often
seeing a “problem” that they cannot necessarily identify but
that well-meaning but uninformed friends or family members
have interpreted instead. In a sound relationship with the
surgeon, education and reassurance will support the patient
until the problem resolves or until it can be corrected.
There is a special group of patients who seem impossible
to satisfy, are depressed and demanding of surgeon and staff,
and are inconsolable when the result does not meet their
expectations.170–188 Recent research indicates that many of
these patients have histories of childhood abuse or neglect
that create body shame – very different from body dissatisfac­
tion.187,188 These patients form the interface between plastic
surgical practices and the body dysmorphic disorder patients
described in the mental health literature. They are detailed in
Vol.1, chapter 3.
The identity of the prior surgeon also creates distinct differ­
ences in management. The surgeon evaluating his or her own
unhappy patient has the advantage of knowing the operative
circumstances, the characteristics of the donor material, and
the patient’s personality, but has the disadvantage of having
to manage both the patient’s disappointment and his or her

485
Secondary rhinoplasty
deformities most commonly produced by the open approach
are those involving the anatomical parts encountered first
during surgical exposure (the columella, alar cartilages, and
alar rims) or by those procedures that can be performed more
easily or more aggressively through the open approach (e.g.,
columellar struts and alar cartilage suturing).
Some secondary deformities are easier to correct than
others. The nose previously operated through the open
approach contains more scar and permanent sutures, making
the dissection difficult and the resection of uncorrectable
deformities tedious. Struts may have widened the columella
but not produced adequate tip projection; the struts will have
to be interrupted or removed and tip projection produced by
more anatomic methods. The surgeon should assume that the
nasal circulation has been irreversibly damaged and proceed
cautiously. In some cases, the secondary surgeon is operating
under skin that may behave as if it had been irradiated. For
this reason, the curious strategy of some surgeons to treat the
severely damaged tertiary nose by a wide, aggressive, open
dissection runs counter to surgical principles followed every­
where else in the body and would be hard to defend if soft-
tissue loss occurs; I have seen many such cases, even from the
best technicians. The surgeon who performs both open and
closed rhinoplasty in different circumstances would therefore
be wise to consider performing the open approach on the
primary, unscarred nose, and the closed approach for the
scarred, hypovascular, damaged nose, rather than the other
way around.191
As is so true of all aesthetic procedures, the relationship
between patient and surgeon is paramount because perfection
is difficult and elusive and because rhinoplasty changes facial
appearance. Following the principle that Osler enunciated
on treating his famous patient, Walt Whitman: “A doctor
does not treat typhoid fever, but he treats the man with
typhoid, and it is the man with his peculiarities – his bodily
idiosyncrasies – we have to consider”.192 Perhaps even more
than other plastic surgical operations, rhinoplasty is brain
surgery.
grafts to create balance, contour, and structure, there is really
no difference between primary and secondary rhinoplasty
except the donor sites.
The secret to good secondary rhinoplasty is good primary rhino­
plasty – not only performing but understanding the operation
and the genesis of its various postoperative shapes. Because
secondary shapes are not limitless but form patterns (see
Table 17.1), the solutions form patterns (see Tables 17.1 &
17.2). With experience and by studying photos of secondary
patients before they had surgery, the surgeon can become
facile at recognizing patterns of nasal response and deformity,
so that secondary shapes not only indicate the predisposing
anatomy that produced them but also the procedures that will
correct them.
Deformities caused by prior open rhinoplasty
As the open approach has become more common, deformities
unique to that surgery are increasing and worsening (Fig.
17.23). In the author’s practice, the prevalence of second­
ary rhinoplasty patients who had their original surgeries
performed through the open approach has risen from 28%
to over 95% in the past 25 years. The deformities caused
by that approach are distinct from those that characterize
prior endonasal rhinoplasty – often much more severe, some
currently uncorrectable, and more commonly involving the
nasal base (e.g., wide or deformed and notched columellae,
excessively narrow tips, hard columellar struts, unacceptable
scars, alar rim notching, alar collapse, or over-resected nos­
trils). In contrast, those patients originally treated endonasally
most commonly seek secondary rhinoplasty for a dorsum
that is too high or a nose that is too long. In a review of
100 consecutive cases,190 secondary patients treated by the
open approach had more presenting complaints (5.6 vs. 2.6
for closed rhinoplasty patients) and had undergone more
procedures before seeking correction from another surgeon
(3.1 vs. 1.2 for the closed rhinoplasty patients). That review
was in 2002; the problem has only worsened since. The
Fig. 17.23  Common examples of noses deformed by previous unsuccessful open rhinoplasty. Deformities of the external valves, alar rims, and columella are more
common after open rhinoplasty; some are uncorrectable.
A
B
C
D

486
SECTION I
CHAPTER 17 • Closed technique rhinoplasty
1. Constantian MB. Rhinoplasty: Craft and Magic. St. Louis, MO:
Quality Medical Publishing; 2009. The author’s complete text. Covers
nasal phenomenology, so that preoperative and postoperative deformities
can be seen to form patterns; therefore the solutions are not limitless but
also form patterns. The rhinomanometric improvement in airflow is
given for each case where the information was available, and analysis and
exposition of intraoperative changes are emphasized. Chapters cover not
only rhinoplasty analysis and technique but anatomic variants, function,
right-brain training for rhinoplasty, body dysmorphic disorder, and the
author’s own complications.
2. Edwards B. A New Drawing on the Right Side of the Brain. New
York, NY: Penguin Putnam; 1999. A delightful and instructive
adventure into art. Most of us lose the ability to “see” what is really in
front of us as the left brain begins to dominate at about age 10, which is
why most adults draw at that level of sophistication. Yet plastic surgery,
not only rhinoplasty but breast reduction, TRAM flap shaping, forehead
flaps, and many other procedures benefit from the ability to call upon
right-brain skills at will. This book teaches how, in an entertaining way.
6. Sheen JH. Spreader graft: a method of reconstructing the roof of
the middle nasal vault following rhinoplasty. Plast Reconstr Surg.
1984;73:230–239. The most commonly referenced paper the rhinoplasty
literature since 1970.
9. Sheen JH, Sheen AP. Aesthetic Rhinoplasty. 2nd ed. St. Louis, MO:
Mosby; 1987:988–1011. This two-volume text is the second edition of
the book that started the revolution in rhinoplasty of the 1980s and
beyond. Our entire rhinoplasty lexicon derives from it. Virtually all of
the text is still current and any surgeon seriously interested in learning
rhinoplasty and its modern roots should own and study a copy.
52. Fomon S, Gilbert JG, Caron AL, et al. Collapsed ala: pathologic
physiology and management. Arch Otolaryngol. 1950;51:465–484. A
classic paper on what we now call external valvular collapse by a pioneer
who intuitively understood what the next generation of surgeons forgot:
that each airway has two sides.
138. Andrade C, Sandarsh S, Chethan KB, et al. Serotonin reuptake
inhibitor antidepressants and abnormal bleeding: a review for
clinicians and a reconsideration of mechanisms. J Clin Psychiatry.
2010;71:1565–1575.
187. Constantian MB, Lin CP. Why some patients are unhappy: part 1.
Relationship of preoperative deformity to surgical number and a
history of abuse or neglect. Plast Reconstr Surg. 2014;134:823–835.
188. Constantian MB, Lin CP. Why some patients are unhappy: part 2.
Relationship of nasal shape and trauma history to surgical success.
Plast Reconstr Surg. 2014;134:836–851. Parts 1 and 2 of the author’s
research establishing a link between childhood trauma, body shame, and
addictive plastic surgery.
189. Constantian MB. What motivates secondary rhinoplasty? A study
of 150 consecutive patients. Plast Reconstr Surg. 2012;130:667–678.
Why patients seek secondary surgery, a sobering commentary on how we
are doing.
191. Constantian MB, Martin JP. Editorial – Why can’t more good
surgeons learn rhinoplasty? Aesthet Surg J. 2015;35:486–489.
Access the complete reference list online at

Fig. 17.10 (A,B) Patient with thick nasal skin in whom skeletal reduction must
be more conservative and augmentations more substantial. (C) Patient with thin
nasal skin before rhinoplasty; (D) preoperative to secondary surgery; (E) 17
years after reconstruction, in whom skeletal and graft imperfections are more
likely.
Fig. 17.12 (A,B) The effect of bridge height on apparent nasal base size.
Although both nasal bases (lower nasal thirds) are the same size, the nasal base
on the right appears larger because the dorsum and nasal root are lower. This
illusion provides an important diagnostic and therapeutic tool. (C–F)
Unbalanced nose, low radix, in each case corrected by dorsal augmentation.
Notice the apparent difference in nasal base size and balance, created primarily
by the alteration in dorsal height. Tip grafts were also performed.
Fig. 17.13 (A–D) Patients who believe that preoperative nasal base size is
excessive, in whom the aesthetic goal may best be reached by a change in
balance instead of only size.
Bonus images for this chapter can be found online at

486.e1
References
References
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Quality Medical Publishing; 2009. The author’s complete text. Covers
nasal phenomenology, so that preoperative and postoperative deformities
can be seen to form patterns; therefore the solutions are not limitless but
also form patterns. The rhinomanometric improvement in airflow is
given for each case where the information was available, and analysis and
exposition of intraoperative changes are emphasized. Chapters cover not
only rhinoplasty analysis and technique but anatomic variants, function,
right-brain training for rhinoplasty, body dysmorphic disorder, and the
author’s own complications.
2. Edwards B. A New Drawing on the Right Side of the Brain. New
York, NY: Penguin Putnam; 1999. A delightful and instructive
adventure into art. Most of us lose the ability to “see” what is really
in front of us as the left brain begins to dominate at about age 10,
which is why most adults draw at that level of sophistication. Yet
plastic surgery, not only rhinoplasty but breast reduction, TRAM flap
shaping, forehead flaps, and many other procedures benefit from the
ability to call upon right-brain skills at will. This book teaches how, in
an entertaining way.
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87. Gruber RP. Open rhinoplasty. Clin Plast Surg. 1988;15:95–114.
88. Neu BR. Suture correction of nasal tip cartilage concavities. Plast
Reconstr Surg. 1996;98:971–979.
89. Constantian MB. Rhinoplasty: Craft and Magic. St. Louis, MO:
Quality Medical Publishing; 2009:498–516.
90. Sheen JH, Sheen AP. Aesthetic Rhinoplasty. 2nd ed. St. Louis, MO:
Mosby; 1987:259–270.
91. Sheen JH. Achieving more nasal tip projection by use of small
autogenous vomer or septal cartilage grafts. Plast Reconstr Surg.
1975;56:35–40.
92. Sheen JH. Tip graft: a 20-year retrospective. Plast Reconstr Surg.
1993;91:48–63.
93. Constantian MB. Grafting the projecting nasal tip. Ann Plast Surg.
1985;14:391–402.
94. Ortiz-Monasterio F, Olmeda A, Ortiz-Oscoy L. The use of cartilage
grafts in primary aesthetic rhinoplasty. Plast Reconstr Surg.
1987;80:161–174.
95. Nicolle FV. The comma-shaped tip cartilage graft. Aesthetic Plast
Surg. 1988;12:223–227.
96. Mavili ME, Safak T. Use of umbrella graft for nasal tip projection.
Aesthetic Plast Surg. 1993;17:163–166.
97. Adham MN. A new technique for nasal tip cartilage grafting in
primary rhinoplasty. Plast Reconstr Surg. 1996;97:649–655.
98. Johnson CM, Toriumi DM. Open structure rhinoplasty: featured
technical points and long term follow-up. Facial Plast Surg Clin
North Am. 1993;1:1–22.
99. Aiache G, Levignac J. La Rhinoplastie Esthétique. Paris: Masson;
1989:84–90.
100. Papel ID. A graduated method of tip graft fixation in rhinoplasty.
Arch Otolaryngol Head Neck Surg. 1995;121:623–626.
101. Duarte A, Atilano J, Cuenca R. Apex columellar cartilage graft.
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102. Kamer FM, Churukian MM. Shield graft for the nasal tip. Arch
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103. Garcia-Velasco J, Garcia-Velasco M. Tip graft from the cartilaginous
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104. Pollet J. Three autogenous grafts for nasal tip support. Plast
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105. Nicolle FV. Secondary rhinoplasty of the nasal tip and columella:
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106. Peck GC. The onlay tip graft for nasal tip projection. Plast Reconstr
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107. Sheen JH, Sheen AP. Aesthetic Rhinoplasty. 2nd ed. St. Louis, MO:
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108. Kline RM Jr, Wolfe SA. Complications associated with the
harvesting of cranial bone grafts. Plast Reconstr Surg. 1995;95:5–13.

486.e3
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139. Kuriloff DB. Nasal septal perforations and nasal obstruction.
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140. Ophir D. Resection of obstructing inferior turbinates following
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141. Slavin SA, Rees TD, Guy CL, et al. An investigation of bacteremia
during rhinoplasty. Plast Reconstr Surg. 1983;71:196–198.
142. Silk KL, Ali MB, Cohen BJ, et al. Absence of bacteremia
during nasal septoplasty. Arch Otolaryngol Head Neck Surg.
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143. Larrabee W. Prophylactic antibiotics in nasal surgery. Arch
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144. Toback J, Fayerman JW. Toxic shock syndrome following
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145. Jacobson JA, Kasworm EM. Toxic shock syndrome after nasal
surgery. Arch Otolaryngol Head Neck Surg. 1986;112:329–332.
146. Wagner R, Toback JM. Toxic shock syndrome following
septoplasty using plastic septal splints. Laryngoscope.
1986;96:609–610.
147. Casaubon J, Dion MA, Labrisseau A. Septic cavernous sinus
thrombosis after rhinoplasty. Plast Reconstr Surg. 1977;59:119–123.
148. Barat M, Shikowitz MJ. Nasofrontal abscess following rhinoplasty.
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149. Coursey DL. Staphylococcal endocarditis following
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151. Flowers RS, Anderson R. Injury to the lacrimal apparatus during
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152. Thomas JR, Griner N. The relationship of lateral osteotomies in
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154. Marshall DR, Slattery PG. Intracranial complications of
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155. Grocutt M, Chir B, Fatah MF. Recurrent multiple epidermoid
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156. Harley EH, Erdman JP. Dorsal nasal cyst formation. Arch
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159. Mabry RL. Visual loss after intranasal corticosteroid injection. Arch
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160. Ham KS, Chung SC, Lee SH. Complications of oriental
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164. Stoll W. Complications following implantation or transplantation
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165. Tobin HA. Extruded nasal implant. Otolaryngol Head Neck Surg.
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SECTION I
CHAPTER 17 • Closed technique rhinoplasty
166. Sheen JH, Sheen AP. Aesthetic Rhinoplasty. 2nd ed. St. Louis, MO:
Mosby; 1987:1136–1140, 1365–1407.
167. Colton JJ, Beekhuis GJ. Use of Mersilene mesh in nasal
augmentation. Facial Plast Surg. 1992;8:149–156.
168. Deva AA, Merten S, Chang L. Silicone in nasal augmentation
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169. Godin MS, Waldman SR, Johnson CM. The use of expanded
polytetrafluoroethylene (Gore-Tex) in rhinoplasty. Arch Otolaryngol
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170. Phillips KA. Body dysmorphic disorder: the distress of imagined
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171. Brunswick RM. A supplement to Freud’s “History of an Infantile
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172. Phillips KA, McElroy SL, Peck PE, et al. Body dysmorphic
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173. Hollander E, Cohen LJ, Simeon D. Body dysmorphic disorder.
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175. Denis PB, Denis M, Gomes A. Psychosocial consequences of nasal
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176. Jerome L. Body dysmorphic disorder: a controlled study of
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177. Phillips KA, McElroy SL, Peck PE, et al. A comparison of
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disorder: does it have a psychotic subtype? J Clin Psychiatry.
1993;54:389–395.
179. Sarwer DB, Wadden TA, Pertshuk MJ, et al. Body image
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dysmorphic disorder. New Research Program and Abstracts;
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183. Constantian MB. Rhinoplasty: Craft and Magic. St. Louis, MO:
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part 1. Relationship of preoperative deformity to surgical number
and a history of abuse or neglect. Plast Reconstr Surg.
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188. Constantian MB, Lin CP. Why some patients are unhappy: part 2.
Relationship of nasal shape and trauma history to surgical success.
Plast Reconstr Surg. 2014;134:836–851. Parts 1 and 2 of the author’s
research establishing a link between childhood trauma, body shame, and
addictive plastic surgery.
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of 150 consecutive patients. Plast Reconstr Surg. 2012;130:667–678.
Why patients seek secondary surgery, a sobering commentary on how we
are doing.
190. Constantian MB. Differing characteristics in 100 consecutive
secondary rhinoplasty patients following closed versus open
surgical approaches. Plast Reconstr Surg. 2002;109:2097–2111.
191. Constantian MB, Martin JP. Editorial – Why can’t more good
surgeons learn rhinoplasty? Aesthet Surg J. 2015;35:486–489.
192. Bliss M. William Osler: A life in Medicine. London: Oxford
University Press; 1999:15.

SECTION I • Aesthetic Surgery of the Face
18 
Airway issues and the deviated nose
Ali Totonchi, Bryan Armijo, and Bahman Guyuron
SYNOPSIS
■ A thorough history and physical examination are crucial. History of
nasal trauma, prior surgery, airway complaints, and allergies are
carefully recorded.
■ Three-dimensional evaluation, as well as cephalometric analysis of
life-size photographs, is performed in order to evaluate the location
and severity of asymmetry.
■ A detailed evaluation of the upper nose (nasal bones and upper lateral
cartilages), septum, lower lateral cartilages, anterior nasal spine, and
medial crural footplates will provide an accurate assessment of
asymmetry.
■ It is important to use the intercanthal midline as the reference point
rather than the inter-eyebrows midline since most patients differentially
pluck their eyebrows to camouflage the nasal asymmetry.
■ The open rhinoplasty is the preferred approach for correction of the
deviated nose. It provides the widest exposure and the best
opportunity to anatomically realign the deviated structures.
■ A rare unilateral nasal bone asymmetry can be corrected with an onlay
graft, but it is not the optimal choice.
■ The mid-vault deviation is invariably associated with a septal deviation,
and a successful correction will require a problem-oriented
septoplasty.
■ When correcting the deviated mid-vault, it is always necessary to
separate the upper lateral cartilages from the septum.
■ The upper lateral cartilages should not be trimmed until the nasal
bones have been repositioned.
■ Deviation of the caudal third of the dorsum may require a septal
rotation suture.
■ Deviation of the base of the nose is invariably associated with
asymmetric lower lateral cartilages, the correction of which is
essential to a successful elimination of asymmetry from this part of
the nose.
■ Another integral component of the caudal nasal deviation is the
dislodgement of the cartilaginous septum to one side of the vomer
bone. Removal of the redundant and overlapping portion of the
cartilage is paramount to the straightening of the columella and the
base of the nose.
■ Longstanding deviation of the septum to one side is invariably
associated with enlargement of the opposing inferior and sometimes
the middle turbinate.
Introduction
Difficulty breathing through the nose can be due to mechani­
cal or dynamic reasons. The rhinoplasty surgeon’s under­
standing of the anatomy and physiology of the nasal airway
and the various causes of obstruction are vital to making the
correct diagnosis and providing the appropriate management.
The most common treatment modality in this situation often
involves submucous resection of the septum and/or inferior
turbinates. Despite being the correct choice in some situations,
the decision to perform such procedures should be based
upon a careful analysis of the findings. In addition, the etiol­
ogy of most nasal airway obstruction is not structural devia­
tion. In these scenarios, it is an inflammatory obstruction that
is amenable to medical management. Prudent assessment of
the pathology causing the nasal obstruction and sensible
choice of treatment will often lead to successful correction of
a challenging problem.
Anatomy
Specific anatomy, as it relates to the airway, can be organized
into soft tissue and osseocartilaginous categories. Although
less commonly involved in nasal airway disorders, the soft
tissue envelope with its underlying perinasal musculature
plays a vital role in maintaining the patency of the valvular
mechanism.
The perinasal musculature can be divided into an intrinsic
(having both origin and insertion within the perinasal area)
and an extrinsic group containing three paired muscles.1,2
The intrinsic group includes the procerus, which elevates
the dorsum and lowers the lateral cartilages. Its distal apo­
neurosis blends with the pars transversa of the nasalis muscle

488
SECTION I
CHAPTER 18 • Airway issues and the deviated nose
to form the superficial musculoaponeurotic system of the
nose. The pars transversa provides lateral wall stability and
can also be a dilator. The primary dilatory muscle of the ala
is the pars alaris and is responsible for alar flaring. In contrast,
the depressor alae or myrtiforme muscle, which originates
from the border of the pyriform crest and then rises vertically
like a fan up to the ala, acts as a depressor and constrictor of
the nostrils. Release of this muscle during alar base surgery
has a beneficial effect on the external valve.
The three paired muscles of the extrinsic group include the
levator labii superioris alaeque nasi, zygomaticus minor, and
the orbicularis oris. Of these, the levator labii superioris
alaeque nasi is the most important dilator with the zygomati­
cus minor providing lateral wall stability (Fig. 18.1).
Other soft tissue components involved in airway compe­
tence are the nasal alae. Although devoid of cartilage, they are
composed of a fibrofatty areolar tissue which is lined by
epithelium internally and externally. Collapse of these struc­
tures will lead to an airway obstruction.
When considering the structures of the osseocartilaginous
vault, the most important central support for the nose is the
septum (Fig. 18.2). The perpendicular plate of the ethmoid
articulates with the posterior edge of the quadrangular (septal)
cartilage, and both structures articulate with the vomer pos­
teriorly. The vomer then lays directly on the maxillary crest.
The anterior-caudal portion of the septal cartilage also rests
on the maxillary crest, however, in a tongue-and-groove
relationship. This point of articulation is unique in that the
perichondrium of the cartilage is only partially contiguous
with the periosteum of the crest allowing a decussation of
fibers which joins the contralateral perichondrium.2 This
crossed configuration can make a seamless submucoperichon­
drial dissection less than facile. It also lends this portion of the
septum susceptible to post-traumatic displacement out of the
groove of the crest.
The upper and lower lateral cartilages also play a signifi­
cant role in nasal support. The point at which the caudal
Fig. 18.1  The anatomy of the pertinent perinasal muscles.
Depressor septi
Levator labii
alaeque nasi
Fig. 18.2  The nasal septum is composed of the septal cartilage, the perpendicular
plate of the ethmoid superiorly, the vomer posteriorly, and the maxillary crest
inferiorly.
Perpendicular plate
Septal cartilage
Nasal crest
of maxilla
Vomer
margin of the upper lateral cartilages and the cephalic rim of
the lower lateral cartilages overlap is defined as the scroll
area. Cartilaginous overlap in this region has been shown
to enhance support at this level.3 Superiorly, another area
of overlap occurs at the junction between the cephalic
upper lateral cartilages and the nasal bones. This makes up
the keystone area and is characterized by a firm adherence
between these structures. Subsequently, trauma to the nasal
bones can shift this entire unit. In addition, the upper lateral
cartilages are fused to the septum in the mid-vault region and
separate as one moves caudally. This is clinically important
during placement of spreader grafts, as this region will require
sharp dissection to release the upper lateral cartilage from the
septum.2
Although not of structural significance, the inferior turbi­
nate occupies a large portion of the nasal airway and can
account for up to two-thirds of the total airway resistance.4 It
is composed of dense lamellar bone taking origin from the
medial wall of the maxilla bilaterally. The turbinates are
covered with an erectile mucosal tissue composed of pseu­
dostratified ciliated columnar epithelium. The submucosa
contains large quantities of seromucinous glands and vascular
channels containing cavernous sinusoids. These channels are
under the influence of the autonomic nervous system and
thus serve as the end target for decongestant medication. The
sympathetic system regulates the resistance vessels (and
therefore blood flow), and the parasympathetic system regu­
lates the capacitance vessels (and therefore blood volume) of
the nasal mucosa. The submucosa also contains large numbers
of mast cells, eosinophils, plasma cells, lymphocytes, and
macrophages. Thus, chronic inflammation, secondary to
stimulation of these abundant proinflammatory cellular con­
stituents, can lead to fibrous deposition and chronic hypertro­
phy of the turbinate.2
The internal nasal valve accounts for approximately 50% of
the total airway resistance and is the narrowest segment of
the nasal airway.5,6 It is formed by the angle between the
junction of the nasal septum and the caudal margin of the
upper lateral cartilage and is typically 10–15° (Fig. 18.3).

489
Introduction
Fig. 18.3  The internal nasal valve is defined by the angle between the junction of
the nasal septum and the caudal margin of the upper lateral cartilage and is
typically 10–15°.
Valve angle
10º–15º
Head inferior
turbinate
Nasal valve
Fig. 18.4  The external nasal valve is formed by the caudal
edge of the lateral crus of the lower lateral cartilage, the soft
tissue alae, the membranous septum, and the sill of the
nostril.
Internal valve
External valve
The external nasal valve is formed by the caudal edge of
the lateral crus of the lower lateral cartilage, the soft tissue
alae, the membranous septum, and the sill of the nostril and
serves as the entrance to the nose. This is an occasional site of
obstruction secondary to extrinsic factors, such as foreign
bodies, or intrinsic factors, such as weak or collapsed lower
lateral cartilages, a loss of vestibular skin, or cicatricial nar­
rowing (Fig. 18.4).7
Physiology
As described in Eugene Courtiss et al.’s overview on nasal
physiology, the nose has seven basic functions: respiration,
temperature regulation, humidification, particulate filtration,
olfaction, phonation, and as a secondary sex organ. The most
vital of these functions is respiration and can be described
using some basic laws of physics.8
When there is a pressure differential between the external
nasal vestibule and the nasopharynx, a gradient is formed and
air flows through the nose. Thus, an increase in nasal resis­
tance (decreases in nasal airflow) can result from such struc­
tural limitations as hypertrophied turbinates, septal deviations,
valve incompetence, or intranasal masses. The magnitude of
nasal airway resistance cannot be underestimated and, in fact,
is responsible for approximately half of the total respiratory
tree resistance.5,6
Bernoulli’s principle defines flow through a tubular struc­
ture such that the flow at the two ends is constant. In addition,
areas of constriction increase flow and areas of dilation
decrease flow. In these areas of increased flow, the pressure is
decreased and vice versa in areas of decreased flow.8 This
becomes clinically evident in the incompetent internal or
external nasal valve. Because these are areas of narrowing/
constriction, airflow is increased at the level of the valve,
leading to a decrease in pressure. This effectively generates a
collapsing force on the valves and is exacerbated upon heavy
inspiration or sniffing.2
Bernoulli’s principle can be mathematically substantiated
using Poiseuille’s law. This law provides that flow is directly
proportional to the difference in pressure multiplied by the
radius raised to the fourth power and inversely proportional
to the length of the tube.8
Flow
Constant K
dP r
Length
=
⋅
⋅
( )
4
This demonstrates that the longer the tube (nose), the less the
flow. Even more dramatic is that a minimal increase in the size
of the tube causes an exponential (r4) increase in flow. This has
clinical implications as the cross-sectional area varies through­
out the nose. It is narrowest at the internal nasal valve, larger
at the level of the mid-turbinates, and largest at the level of
the posterior choanae. As a result, minimal changes at the
level of the internal nasal valve can have profound changes
on nasal airflow and are subsequently cited as the most
common cause of nasal airway obstruction.9–11

490
SECTION I
CHAPTER 18 • Airway issues and the deviated nose
adhesive sheet with a pH slightly more acidic than serum. It
is produced by serous and mucous glands and by the goblet
cells of the mucosa at a rate of about 250 mL per day. This
blanket ultimately functions, in a rhythmic fashion, to sweep
particulate matter to the posterior nasopharynx.2,18
Olfaction
Olfaction clearly enhances our sense of taste and aids in
memory association. It may also play a protective role by
warning of potential environmental dangers when noxious
odors are perceived. Causes for an olfactory disturbance are
many and include infection, trauma, mechanical obstruction,
endocrine disorders, and medications, to mention a few. In
addition, nasal septal surgery can infrequently lead to
anosmia; fortunately, this is most often temporary.8,21
Phonation
It is well known that the voice is produced via vibrations of
the vocal cords with the passage of air. However, the quality
of the voice depends on the resonance of air through the
mouth, pharynx, and nose. As a resonance chamber, the nose
is a necessary component in the formation of certain vowels
and consonants alike. Patients may therefore ask if nasal
surgery will alter the sound of their voice. To that end, they
can be counseled that post-surgical changes in the sound of
one’s voice have not been substantiated. Septal perforations,
however, change airflow resistance and thus may change
voice quality and/or create a nasal whistle with inspiration.8
Secondary sex organ
It has been known for some time that mucosal engorgement
occurs during sexual arousal.16 A relatively recent discovery
in nasal physiology is the vomeronasal organ (Jacobson’s
organ, Ruysch tube). It is composed of bilateral blind ducts in
the mucosa of the anterior third of the human septum.22–25
Their role is not fully understood, but it is felt that they play
a part in reproductive behavior by acting as pheromone che­
mosensory receptors. The external opening of the ducts can
be found in the septal mucosa just posterior to the columellar
base and 1 mm above the maxillary groove.25
Access the Historical Perspective section online at

Basic science/disease process
With an understanding of the nasal airway anatomy and
physiology, one can more easily begin to identify potential
sites of obstruction and/or deviation. Although many causes
of nasal airway obstruction are “anatomic” in nature, and thus
amenable to surgical correction, medical reasons for obstruc­
tion cannot be overlooked. Surgical intervention in these
instances would be a disservice to the patient. Thus, there may
be more than one etiology and therefore more than one line
of treatment. This section will focus on the various etiologies
for nasal airway obstruction, with their respective treatment
recommendations to follow.
An understanding of laminar and turbulent flow is also
essential to a complete understanding of respiration and nasal
airflow physiology and dynamics. When laminar flow exists,
air moves through a straight tube in a predictable fashion. Air
near the walls of the tube is virtually still, whereas flow in the
center moves rapidly. This is in contrast to turbulent flow,
where the airflow follows a random path and forms eddy
currents and whorls. To overcome turbulence, a greater pres­
sure gradient must be generated. In other words, the less
laminar the airflow, the higher the resistance and the lower
the airflow. For example, during quiet respiration where pres­
sures are low and under 1.5 cm of water, nasal airflow is
considered to be laminar.12 During inspiration, the main
airflow is directed through the middle meatus with a smaller
amount coursing through the inferior meatus and an even
smaller amount up toward the cribriform plates.13,14
Finally, another less well understood factor in nasal airflow
is the nasal cycle (cycle of Minz). Approximately 80% of the
population experiences cyclical swelling and contraction of
the nasal mucosa. While one airway is enlarging, the other is
constricting.15,16 The process requires 30 min to 5 h to com­
plete, and total airflow and resistance remains constant
throughout this period.17
Temperature regulation and humidification
The physiologic nasal regulatory system is so efficient that
inspired air is heated almost to body temperature before it
even reaches the larynx. Even air at temperatures of −5°C is
brought to between 31°C and 37°C. This function typically
requires 70–100 calories per day.10,18
Regardless of the ambient temperature or humidity,
approximately 90% humidification is achieved during inspi­
ration before the air reaches the lungs. This requires 1 liter (L)
of water per day.19 A small amount of this water is recovered
during exhalation secondary to cooling of the exhaled air;
however, a net balance of −250 mL to −500 mL per day still
exists.20
Particulate filtration
Four mechanisms have been described by which the nasal
cavity achieves adequate filtration of inspired air. These
include impingement, electrostatic charge, vibrissae, and the
mucociliary blanket. Impingement is a phenomenon that
occurs when particles suspended in a gas become deposited
on the walls of a tube downstream from a bend or constric­
tion. Two such bends exist within the nasal cavity: the internal
nasal valve, where the airflow is changed from a column into
a sheet, and at the posterior nasopharynx, where the airflow
is sharply deflected inferiorly. These two anatomic impinge­
ment points are responsible for the deposition/filtration of
85–90% of particulate matter ≥5 µm.18 The electrostatic charge
of the walls of the nasal cavity is positive and produced by
the mucociliary blanket. Thus, the negatively charged inspired
foreign particles are attracted to the nasal walls and prevented
from traveling distally to more sensitive areas of the respira­
tory tract. Larger particles are trapped within the vibrissae,
which are found just within the nasal vestibule. The mucocili­
ary blanket is composed of two layers: the deeper layer is
thinner and less viscous and surrounds the cilia, while the
superficial layer is thicker and more viscous and houses the
cilia tips. As a whole, the mucociliary blanket is a thin, sticky,

490.e1
Historical perspective
Historical perspective
Correction of the deviated nose remains one of the more chal­
lenging aspects for the rhinoplasty surgeon. Not only is the
deviated nose an aesthetic concern, but it is also of functional
consequence as well. Debate continues as to the optimal
approach. Anatomic reconstruction will provide a return to
normal anatomy at the risk of decreasing structural support
of the osseocartilaginous framework. Camouflage techniques
may provide a simpler solution to provide symmetry;
however, functional defects are denied correction.
Many of the pioneers of modern rhinoplasty techniques
recognized the importance of the septum, internal and
external nasal valves, and the turbinates in the etiology and
subsequent surgical approaches to the deviated nose. This
understanding has become the cornerstone to the reconstruc­
tion and functional restoration of the deviated nose. However,
the anatomic deviation and thus, functional obstruction, may
be at the bony pyramid, the upper lateral cartilages, the lower
lateral cartilages, the septum, nasal valves, turbinates, or any
combination of these entities. The ultimate goal is to provide
a consistent, stable long-term correction that is both aestheti­
cally pleasing and functionally sound, and this can only be
expected through correction of all these abnormalities.

491
Basic science/disease process
Miscellaneous causes of rhinitis may include such medica­
tions as oral contraceptives, antihypertensives (beta-blockers),
and antidepressants. Other causes include Wegener’s granu­
lomatosis, polymorphic reticulosis, cystic fibrosis, syphilis,
hypothyroidism, and poorly regulated diabetes.5,32
The septum
The septum and the nasal bones control the direction of the
nose, and thus deviation of the nose can result from malalign­
ment of one or the other or a combination of both. Often, the
nasal bones follow the direction of the deviated septum,
however these structures may move independently. Mid-vault
deviation consistently accompanies at least anterior and com­
monly mid and posterior septal deviation. Deviation of the
lower nose may involve the caudal septum, anterior nasal
spine, and lower lateral cartilages. In all types of septal devia­
tion, the middle and/or inferior turbinates may be enlarged.
The enlargement is usually juxtaposed to the concave side of
the septum. Previous studies have detailed and categorized
the types of septal deviation.33–36
There are six classes of septal deviation:
1. The most common type is a septal tilt in which the
septum itself has no significant underlying curvature,
but is tilted to one side. In most cases of septal tilt, the
internal deviation of the septum is to the left and the
external deviation of the nose is to the right. This is
usually accompanied by an enlargement of the inferior
turbinate ipsilateral to the external deviation (Fig. 18.5).
Rhinitis
Rhinitis can be the result of a number of different causes includ­
ing infectious, allergic, vasomotor, atrophic, rhinitis medica­
mentosa, postoperative, hypertrophic, and miscellaneous. It has
even been cited as the number one cause of nasal obstruction.9
Infectious rhinitis is the most common type and presents
in two forms: viral and bacterial. Viral rhinitis is more common
than bacterial etiologies and is usually the result of the rhino­
virus. Bacterial rhinitis is mostly caused by Gram-positive
isolates. Regardless of the etiology (viral or bacterial), there is
significant mucosal edema during infection, and this can last
for several weeks leading to a narrowed nasal airway with
subsequent obstruction.26,27
Allergic rhinitis is said to have a prevalence of between 14%
and 31% in the United States alone.28 True allergic rhinitis is
mediated by immunoglobulin E in response to an antigen–
antibody reaction. This most commonly presents in a seasonal
form from environmental factors such as an air-borne pollen
or spore. Associated symptoms include sneezing, urticaria,
and mucosal swelling.
Vasomotor rhinitis arises when the balance between the
sympathetic and parasympathetic nervous systems is dis­
rupted, such that the parasympathetic system is hyperactive.
This leads to copious amounts of watery rhinorrhea and
mucosal congestion. Although most commonly idiopathic in
nature, other potential causes include pregnancy and endo­
crine and emotional disorders.2
Atrophic rhinitis is a rare condition with its typical onset
in puberty and characterized by a slow, progressive atrophy
of the nasal mucosa. This results in crusting and often foul
smelling drainage.5 Several organisms have been isolated
from patients affected by this condition; however, their exact
mechanism in the pathogenesis remains unclear.29,30 A subcat­
egory of atrophic rhinitis is “empty nose syndrome”. This is
a poorly understood and highly debated iatrogenic disorder
which results from the destruction of normal nasal tissue,
specifically the turbinates. The most commonly reported
symptoms include a paradoxical nasal obstruction and feeling
of intranasal fullness.
Rhinitis medicamentosa (RM) occurs frequently in patients
who present with nasal airway obstruction. It is seen with
prolonged use of sympathetic agonists such as Afrin or Neo-
Synephrine and leads to a rebound phenomenon of mucosal
engorgement and profuse rhinorrhea. Patients often try
increasing both the dose and the frequency of nasal sprays
upon the onset of RM, worsening the condition. The swelling
of the nasal passages caused by rebound congestion may
eventually result in permanent turbinate hyperplasia.31
Postoperative rhinitis or symptoms of nasal obstruction
invariably affect virtually all patients after rhinoplasty. This is
usually a result of normal postoperative mucosal edema and/
or crusting within the nasal cavity. In addition, patients who
present with preoperative allergic rhinitis or vasomotor rhini­
tis may experience a postoperative “flare” and should be
counseled as such prior to surgery.
Hypertrophic rhinitis results from chronic mucosal inflam­
mation and can stem from any of the aforementioned types
of rhinitis. This chronic inflammation ultimately leads to
turbinate hypertrophy, most commonly the inferior turbinate.
As would be expected, this is a major cause of nasal airway
obstruction.
Fig. 18.5  (A) Septal tilt with (B) dislodgment of inferior cartilaginous septum from
maxillary crest.
A
B

492
SECTION I
CHAPTER 18 • Airway issues and the deviated nose
common form of this deviation is the reverse C with the
curve facing the patient’s right. The opposing inferior
and often the middle turbinates are enlarged (Fig. 18.6B).
4. S-shaped anteroposterior deviation is defined by two
curvatures next to each other, in opposing directions.
Externally, the anteroposterior deviation will present
with a shift of the nose to one side (Fig. 18.7A).
2. C-shaped anteroposterior deviation is usually associated
with deviation of the vomerine plate. External reflection
of the anteroposterior C deviation is often similar to the
septal tilt. The middle turbinate is often enlarged as well
(Fig. 18.6A).
3. C-shaped cephalocaudal deviation presents externally as
a C-shaped appearance of the nose. In reality, the most
Fig. 18.6  (A) C-shaped septal deviation, anteroposterior. (B) C-shaped septal
deviation, cephalocaudal.
A
B
Fig. 18.7  Localized S-shaped septal deviation and septal spur. (A) S-shaped curve
caphalocauda. (B) S-shaped curve anteroposterior
A
B

493
Diagnosis/patient presentation
Diagnosis/patient presentation
History
A detailed patient history including history of nasal trauma,
previous nasal surgery, airway complaints, allergies, and age
is obtained. A negative history of airway obstruction is not a
reliable indication of a patent airway, since the patient has no
basis for comparison. Symptoms related to environmental
exposure such as grass pollens or pet dander should be elu­
cidated as this would indicate allergic rhinitis and merit
medical management. Complaints of nasal obstruction should
also be clarified. Do the symptoms occur during quiet or
heavy inspiration or both? A fixed obstruction such as an
enlarged turbinate, septal deviation, or mass will manifest in
both instances. However, obstruction that occurs only during
heavy inspiration may indicate an incompetent valve.
Physical examination
Attention to detail and careful observation are paramount to
glean critical information necessary to make the appropriate
diagnosis and direct an effective treatment plan. A patient
with dark pigmentation in the lower eyelid and injected
conjunctivae may have an atopic component contributing to
nasal obstruction.
The external facial/nasal appearance should be critically
examined with the patient encouraged to comment on his or
her concerns. The nasal aperture is examined during inspira­
tion for possible collapse of the external nasal valve.
Palpation is critical to appreciate the three-dimensional
construct and stability of the nose. This portion of the exam
should include palpation of the nasal bones, upper lateral and
lower lateral cartilages, as well as the membranous and caudal
cartilaginous septum. Palpation and percussion over the
frontal, ethmoid, and maxillary sinuses is performed to elicit
tenderness, which may be indicative of sinusitis. At this point,
the patient is asked to occlude one nostril and then the other
while taking a breath and state which side is easier to breathe
through. If nasal valve incompetence is suspected, the Cottle
test is employed. While the patient breathes quietly, the cheek
is retracted laterally to open the nasal valve. If breathing is
improved, it depicts a positive Cottle test and nasal valve
incompetence. Another maneuver allowing independent
evaluation of the external and internal nasal valves can be
undertaken by simply using a cotton-tip applicator to stent
the airway during quiet and heavy inspiration. Facial nerve
integrity is also assessed, as paralysis of the perinasal dilators
would contribute to a nasal airway obstruction.
Findings noted on the above external nasal exam are cor­
roborated with soft tissue cephalometric analysis of life-size
photographs. This is performed in order to assess symmetry
of the nose and its relationship to other facial structures.
Asymmetry may be present in other facial features, thus
affecting the global evaluation of the face. The AP view of the
face is also used to evaluate the dorsal nasal aesthetic lines,
as well as the width of the nasal dorsum.
Attention can now be turned to the internal nasal exam
which consists of anterior and posterior rhinoscopy. An ade­
quate light source and nasal speculum are required for anterior
rhinoscopy. The nasal speculum is held in the dominant hand
5. S-shaped cephalocaudal deviation is similar
to the previous type except that the curvatures
combine to form an S-shape in the cephalic
to caudal direction. Turbinate enlargement is
common with both types of S-shaped deviations
(Fig. 18.7B).
6. The last type of septal deviation is a localized
deviation or spur. This is a purely functional problem
and has no translation to external shape of the nose.33
Turbinate enlargement is not common with this type of
deviation.
Additionally, the deviation could be in the anterior septum or
in the tip, related to the structural asymmetry of the lower
lateral cartilages, either one being short or the other being too
long.
The internal nasal valve
The importance of functioning nasal valves in nasal airflow
cannot be understated, and they have been studied exten­
sively.9,37,38 The internal nasal valve is a crucial regulator of
nasal airflow dynamics and should be preserved and/or
reconstructed when performing rhinoplasty. Injury and desta­
bilization of this complex, either from surgery or trauma, may
result in collapse and subsequent nasal airway obstruction.
For example, in patients undergoing dorsal hump reduction,
great care must be taken when separating the upper lateral
cartilages and mucosa from the septum as loss of medial
support can cause an inverted-V deformity. This effectively
narrows the internal nasal valve. In addition, scar tissue may
obscure the normal 10–15° angle or cause obstruction by
cicatrix or mass effect.39
The external nasal valve
Normal function of this valve depends on the structural
integrity of the lower lateral cartilages, perinasal musculature,
and adequate soft tissue coverage. Functional compromise is
seen with encroachment of the nasal spine, and especially the
footplates, into the nostril opening. Architecturally weak
lateral crura further compound the effects of a widened colu­
mella.33 Other causes for external valve collapse include facial
nerve palsy, pinched ala deformity, and post-surgical vestibu­
lar stenosis secondary to synechiae and over-resection of the
lower lateral cartilages.
The turbinates
Mucosal swelling can significantly alter nasal airflow by
decreasing the cross-sectional area of the airway. When this
becomes chronic, mucous glands enlarge, the basement mem­
brane thickens with interstitial fibrosis, and there is eventual
hypertrophy of the conchal bone. In fact, previous studies
have shown that hypertrophy of the anterior ends of the
inferior turbinates is the primary cause of nasal airway
obstruction.39 As alluded to previously, turbinate hypertrophy
may also present in the patient with a deviated septum. In
these cases, the inferior turbinate on the side opposite the
deviation undergoes compensatory enlargement to create
equal airway resistance in both airways.

494
SECTION I
CHAPTER 18 • Airway issues and the deviated nose
preoperative evaluation and should not replace a comprehen­
sive history and physical examination.
Radiology
The radiographic standard of care for diagnosing paranasal
sinus disease and the structural integrity of the nasal vault
has become computed tomography and/or magnetic reso­
nance imaging. These scans can very accurately detect
air–fluid levels indicative of sinus disease or anatomic abnor­
malities such as septal deviations, spurs and bullosae, and
concha bullosa; all of which can cause nasal airway obstruc­
tion (Fig. 18.9).44
Patient selection
Paramount in the process of patient selection is a command­
ing knowledge of the nasal airway anatomy and physiology.
This, coupled with a skillfully directed history and physical
exam, will significantly augment the surgeon’s repertoire for
addressing the subtleties of the deviated nose and its untow­
ard effects on both form and function while allowing for more
predictable results. To that end, the surgeon must first be able
to identify between those patients who will best be served by
medical therapy alone and those who will require a surgical
intervention for the most favorable results. Once this crucial
and spread in a vertical fashion. With this, the examiner will
be provided with direct visualization of the anterior third of
the nasal cavity, including the external and internal nasal
valves, septum, and turbinates. The septum is evaluated for
deviation and perforation. Formerly obscure perforations can
become apparent after placing the nasal speculum in one
nostril and transilluminating from the contralateral nostril.
Any crusting, purulence, ulceration, or presence of polyps
should be noted. The color, size, and character of the turbi­
nates is also documented, as a pale-colored turbinate mucosa
may indicate allergy, whereas erythematous mucosa my
indicate infection, inflammatory process, or rhinitis medica­
mentosa (Fig. 18.8).
The above exam maneuvers should be performed before
and after vasoconstriction of the nasal mucosa using 0.25%
phenylephrine or 1% ephedrine sulfate. These agents can be
delivered via an aerosolized misting system or topically with
cottonoid pledgets. If available, topical cocaine can also
provide potent vasoconstriction as well as local anesthesia.
Posterior rhinoscopy is indicated when the initial survey is
negative for a source of nasal airway obstruction and patient
history suggests otherwise. Visualization of the posterior
nasal airway is best achieved using a 0 or 25° nasal endoscope;
however, should this apparatus not be available, it can also
be done using a warmed dental mirror placed in the posterior
oral cavity. This maneuver can reveal pathology such as
adenoid hypertrophy, posterior nasal masses and choanal
atresia.2
Rhinomanometry
Rhinomanometry is a test of nasal function that measures air
pressure and the rate of airflow in the nasal airway during
respiration. These findings are then used to calculate nasal
airway resistance. A more recent advancement has been the
introduction of acoustic rhinometry.40–42 This technique is
based on analysis of acoustic reflections from the nasal cavity
at a given distance from the nostril. Acoustic rhinometry gives
an anatomic/cross-sectional description of the nasal cavity,
whereas rhinomanometry gives a functional measure of the
pressure/flow relationships during the respiratory cycle.
Although technically considered objective tests, rhinomanom­
etry and acoustic rhinometry only provide “snap-shot” mea­
surements, which may not be representative of a more chronic
condition, since turbinate size and function are dynamic
processes that may change considerably over a few hours.43
As such, these tests are commonly not part of the standard
Fig. 18.8  Enlarged inferior turbinates.
Fig. 18.9  This is a CT scan indicating a large septal spur with deviation as well as
a concha bullosa.

495
Treatment/surgical technique
Hypertrophic rhinitis
The treatment of hypertrophic rhinitis leading to turbinate
hypertrophy will be discussed in the section on “treatment of
turbinate disorders”.
Correction of deviated nasal bones
The deviated nasal bone can be unilateral depression of one
nasal bone or a bilateral deviation. The unilateral deviation
can be corrected with an onlay graft if the problem is not
functional. This is accomplished using a layer of septal carti­
lage or a layer of diced cartilage graft. Under general anesthe­
sia and with adequate local anesthetic infiltration to achieve
the desired nasal vasoconstriction, an inter-cartilaginous inci­
sion is made and the target nasal bone is exposed. The peri­
osteum is elevated using a Joseph’s periosteal elevator. A
septal or conchal cartilage graft, in the form of a single or
double layer or diced cartilage, depending on the degree of
the nasal bone shift, is applied, and the incision is repaired
loosely to allow for drainage. More commonly, however, a
visible shift of the nasal bone will induce some medial trans­
position of the upper lateral cartilage and thus compromise
the ipsilateral internal nasal valve function. Under this sce­
nario a unilateral outfracture of the nasal bone will produce
a better functional and aesthetic outcome. Through a small
vestibular incision at the pyriform aperture, the periosteum is
elevated using a Joseph’s periosteal elevator. A low to low
osteotomy is made, and the nasal bone is outfractured. To
avoid return of the nasal bone to the previous position, a
folded Adaptic saturated in bacitracin ointment is placed
between the nasal bone and the septum and kept in position
for at least 1 week. During this time, the patient is maintained
on systemic antibiotics.
Treatment of the deviated septum
Surgical correction of the deviated septum can be accom­
plished through an open technique if concomitant rhinoplasty
is planned or through an L-shape (Killian) type incision if the
correction of the deviated septum is the sole surgical goal.
When the open technique is used, the mucoperichondrium is
elevated off of the left side of the septum starting from the
caudal septal angle. A small incision may be needed anteriorly
in order to visualize the correct subperichondrial plane. Once
in the correct plane with the glistening, grayish cartilage in
view, the blunt end of a periosteal elevator is used to raise the
mucoperichondrial flap. Dissection is continued posteriorly
and cephalically. When the dissection reaches the junction of
the quadrangle cartilage and the vomer bone, it could prove
easier to start the dissection from the posterocaudal septum
and extend it anteriorly. The fibrous attachments are firm
anterocaudally, rendering the dissection arduous. The tech­
nique of septal correction is contingent upon the type of septal
deviation.
Septal tilt
The septal tilt is corrected by initially removing the postero­
caudal portion of the septum, leaving an L-strut septum
anteriorly and caudally. The sharp end of the septal elevator
is used to incise the septal cartilage, and the dull end is used
to elevate the mucoperichondrium. At least 15 mm of cartilage
step has been satisfied, the following steps and descriptions
in this chapter can be utilized for optimal patient care.
Treatment/surgical technique
Treatment of rhinitis based on sub-type
Infectious rhinitis
Viral rhinitis is most commonly self-limiting and treated
symptomatically. Oral and topical decongestants should be
used sparingly (limit to no more than 3 days at a time) to
avoid rhinitis medicamentosa.45 Rarely, a patient may become
secondarily infected with a bacterial isolate, in which case
antibiotics would be warranted.
Bacterial rhinitis/sinusitis should be treated with a 2–3
week course of directed antibiotic therapy. Decongestant use
should again be limited to a short duration only and as symp­
toms demand.45,27 The reasoning for the extended antibiotic
course is based on studies citing the bacterial (and viral)
damage to cilia requires a regeneration period of approxi­
mately 2–3 weeks.46,47 Empowered with this knowledge, it is
clear why a short course of antibiotics will likely fail secondary
to persistent mucostasis, which is followed by reinfection.
Allergic rhinitis
Allergic rhinitis, as previously mentioned, is quite common
and, as such, has entire specialties devoted to its diagnosis
and treatment. Although the rhinoplasty surgeon should be
able to recognize and diagnose allergic rhinitis in an effort to
avoid an unnecessary operative intervention, these patients
would best be served by a specialist, such as an allergist.
Vasomotor rhinitis
This troublesome autonomic imbalance is most commonly
treated with oral decongestant modalities. A less common but
more aggressive option in recalcitrant cases is division of the
vidian nerve. The vidian nerve carries parasympathetic and
sympathetic fibers from the greater superficial petrosal nerve
and deep petrosal nerve, respectively. Access is transnasal and
the nerve is transected at the level of the sphenopalatine
foramen. It should be noted that there is a steep procedural
learning curve and the results may be transient.48–51
Atrophic rhinitis
The treatment of this malady is symptomatic in nature, with
frequent nasal saline lavage. Should foul drainage ensue,
such things as alkaline nasal douches and/or 25% glucose
in glycerine can be applied to the nasal mucosa, as these
agents inhibit the growth of the foul smelling proteolytic
organisms.
Rhinitis medicamentosa
The treatment for rhinitis medicamentosa is simply stopping
the offending agent. Patients should be counseled that com­
plete resolution may not occur for several weeks after cessa­
tion. In the meantime, corticosteroids on a tapering dose (a
Medrol dose pack) can be instituted for symptom control.

496
SECTION I
CHAPTER 18 • Airway issues and the deviated nose
is maintained anteriorly and caudally. The mucoperichon­
drium and periosteum caudal and posterior to the L strut are
elevated off the septum on the left side. The remainder of the
posterocaudal septum is disengaged from the perpendicular
plate, the vomerine groove, and anterior nasal spine. The
deviated portion of the cartilaginous septum, the vomer, and
perpendicular bone are removed as radically as needed. The
septum must then be repositioned after removal of a small
segment of the overlapping cartilage and fixated in the
midline. This is performed with a figure-of-eight suture using
5-0 PDS. Prior to repositioning of the septum, it is imperative
to ensure that the anterior nasal spine be in the midline,
otherwise correction of the septal deformity will not be ade­
quate. The nasal spine may be repositioned with an osteotomy,
if needed (Fig. 18.10).
C-shaped anteroposterior deviation
Correction of the anteroposterior deformity first requires
resection of the posterocaudal portion of the septum, as
described for septal tilt. An osteotomy of the anterior nasal
spine and residual vomerine plate is often necessary in order
to place this structure in the midline. Also, partial disjunction
of the perpendicular plate of the ethmoid and quadrangle
cartilage is done only if deemed beneficial to correct the devia­
tion in the cephalic third of the nose. Finally, the L-shaped
Fig. 18.10  Correction of septal tilt. The posterocaudal portion of the septum is
removed, leaving an L-strut septum anteriorly and caudally. The septum is
repositioned after removal of a small segment of the overlapping cartilage and
fixated in the midline with a figure-of-eight suture.
frame is scored in a cephalocaudal direction on the concave
surface if the other measures do not result in straightening the
septum. This seldom becomes necessary. However, the effects
of scoring are not predictable. Therefore, in order to control
the response to scoring, bilateral extramucosal stents are
placed and fixed in position with a through-and-through
suture. Stents are left for 2 weeks. The anterior deviation is
corrected by separation of the ULCs from the septum, oste­
otomy, reposition of the frame, and possible placement of
spreader grafts (Fig. 18.11A).
C-shaped cephalocaudal deviation
Correction of the cephalocaudal deformity also requires resec­
tion of the posterocaudal septum. Complete separation of the
junction between the cartilaginous septum and the maxillary
crest is performed, as well as a partial release of the cephalic
portion of the quadrangular cartilage from the perpendicular
cartilage if deemed necessary. An anterior nasal spine oste­
otomy may be needed to correct deviation at this level. The
dorsal L-strut cartilage is scored in an anteroposterior orienta­
tion on the concave side of the deformity, only if release of
tension caudally does not correct the deformity. Spreader
grafts are also utilized anteriorly to guide and control the
response from the scoring. If deviation only involves the
caudal septum, bilateral spreader grafts and a septal rotation
suture may suffice. Internal extramucosal stents are then
placed if the caudal portion of the septum has to be scored
(Fig. 18.11B).
S-shaped anteroposterior deviation
This type of septal deviation is corrected by removal of the
posterior portion of the cartilage and bone, bilateral cephalo­
caudal scoring of the cartilage on the concave surfaces if
necessary, and osteotomy, with repositioning of the nasal
spine and vomer bone. Cartilage memory is directed with the
extramucosal stents and spreader grafts anteriorly if it is
scored (Fig. 18.12A).
S-shaped cephalocaudal deviation
This type of septal deviation is corrected with removal of the
posterocaudal portion of the septal frame, bilateral anteropos­
terior scoring of the concave portion of the cartilage, release
of the septum from the maxillary crest, and partial release
from the perpendicular plate. The anterior portion of the
septum is then supported with bilateral spreader grafts, and
the cartilage memory is guided with bilateral extramucosal
stents posteriorly, when the cartilage is scored (Fig. 18.12B).
Localized deviation
Correction simply involves removal of the deviated portion
of the cartilage and bone while taking care to maintain a
sufficient amount of L strut for structural integrity. This is
followed by application of extramucosal Doyle stents for 4
days.
Treatment of the incompetent internal
nasal valve
Several techniques have been described to reconstruct the
incompetent internal nasal valve. These have included placing

497
Treatment/surgical technique
Fig. 18.11  Correction of C-shaped septal deviations. (A) Anteroposterior. Shown
in this illustration are the resection of the posterocaudal portion of the septum,
partial disjunction of the perpendicular plate of the ethmoid, and quadrangle
cartilage and the scoring of the L-shaped frame in a cephalocaudal direction on the
concave surface, only if necessary. (B) Cephalocaudal. Shown in this illustration
are the resection of the posterocaudal portion of the septum, partial disjunction of
the perpendicular plate of the ethmoid, and quadrangle cartilage and scoring of the
L-shaped frame in an anteroposterior direction on the concave surface. An anterior
nasal spine osteotomy may also be used to correct deviation at this level.
A
B
Fig. 18.12  Correction of S-shaped septal deviations. Corrections are similar to
those described in the correction of C-shaped septal deviations. Scoring of
cartilaginous deviations is performed on the concave surfaces. (A) Anteroposterior.
(B) Cephalocaudal.
A
B

498
SECTION I
CHAPTER 18 • Airway issues and the deviated nose
Fig. 18.13  The proper location of a spreader graft is illustrated.
conchal cartilage over the nasal dorsum and securing this to
the upper lateral cartilages or a suture technique, which tra­
verses over the nasal dorsum to secure either upper lateral
cartilage. Both techniques serve to flare or widen the upper
lateral cartilages and, thus, open the angle.52,53
Likely the most significant contribution in this area is the
spreader graft, which has been popularized by Sheen. A
precise submucoperichondrial plane is created between the
upper lateral cartilages and septum for placement of bilateral
rectangular pieces of cartilage. These pieces should extend
from the osseocartilaginous junction to a point just caudal to
the anterior septal angle and tapered at each end for contour­
ing. The main purpose of the spreader grafts is widening of
the nasal valve angle with an increase in both cross-sectional
area and overall airflow. Other benefits include added struc­
tural support, improvement of the dorsal aesthetic lines, and
nasal bone stabilization after osteotomy (Fig. 18.13).38,54,55
Spreader flaps could also be used and are created by folding
the free anterior margins of the upper lateral cartilages.56,57
The upper lateral splay graft, as described by Guyuron,
spans the dorsal septum but is deep to the upper lateral car­
tilages. The intrinsic spring in the splay graft elevates each
upper lateral cartilage with the septum as the fulcrum, thus
correcting any middle vault collapse and opening the internal
valve.58
The deviated anterior septum is corrected with a septal
rotation suture described by the senior author.33 After inser­
tion of the spreader grafts, a 5-0 PDS mattress suture is passed
cephalically on the side away from the deviation and caudally
on the side of the deviation and tied incrementally until the
deviated anterior septum becomes straight.
The caudal structural discrepancy is corrected by elonga­
tion or shortening of the lower lateral cartilages over a colu­
mella strut and lateral crura struts. If the tip projection is
optimal, the short side is elongated. If the tip projection is
excessive, the long side is shortened by overlapping the
medial and lateral crura.33
Treatment of the incompetent external
nasal valve
Treatment varies with the exact pathology; however, the basic
premise is based on reinforcing the lateral crura, alar rim, and
soft tissue envelope, thereby stenting the valve. This increases
the overall cross-sectional area and maximizes airflow. A
number of techniques have been written about and include
lateral crural strut grafts,59 lateral crural spanning grafts,60
cephalic trim grafts,61 suture techniques, and alar batten grafts
(Fig. 18.14). Any supportive cartilage graft placed in the
region of the alar lobule or rim will tend to support the exter­
nal nasal valve and prevent collapse, provided the soft tissue
envelope is supple. If there is a shortage of alar skin and/or
significant vestibular stenosis, more advanced options such as
a composite auricular graft, V–Y advancement,62 or alar base
flap may be required.63–65
Treatment of turbinate disorders
Although the primary goal of management of the turbinate
– maximize nasal airflow – sounds simple, it has been an area
of vigorous debate and controversy for over 100 years. There
are a myriad of medical (discussed previously) and surgical
treatments available for approaching the hypertrophic turbi­
nate. Unfortunately, upon review of the literature, there is a
paucity of comparative data analyzing the different tech­
niques. The range of surgical treatments can be divided into
the following categories: mechanical procedures, destructive
procedures, and turbinate resection procedures.66
Mechanical procedures
The mainstay in this category is turbinate outfracture. This
technique has the advantage of being quick and easy to
perform with relatively no morbidity. The downside is that
when this procedure is performed in isolation, recurrent