Phẫu Thuật Tạo Hình Thẩm Mỹ Khuôn Mặt Người Á Đông

II Rhinoplasty
34
tion of the septum o of the maxillary spine. Once posi-
tioned at midline, the nasal base is secured with two 4–0
PDS sutures anchoring the septum to the periosteum. If
there is inadequate periosteum, one can use 16-gauge nee-
dles to bore into the nasal spine to hold the suture. Thin
slivers of costal cartilage can be used as splinting grafts to
further stabilize the newly midline structure. If the nasal
spine is deviated, a 5-mm osteotome placed at midline is
used to create a notch in the nasal spine before securing the
caudal septum with two 4–0 PDS sutures.
To support the nasal base, the senior author prefers
caudal septal extension grafts or caudal septal replace-
ment grafts to provide the strength to support a large dor-
sal graft w ithout collapsing. These caudal septal grafts are
secured to the nasal septum and w ith extended spreader
grafts, and stabilized w ith splinting slivers of costal car-
tilage or 0.25-m m PDS plates (Fig. 3.9). In the author’s
experience use of a caudal septal replacem ent graft, an
advanced technique, is used to replace a severely devi-
ated or damaged native caudal septum , as less cartilage
is required for a m ore predictable result. It is important
to know that these caudal septal grafts are the only grafts
that need to be straight. Septal cartilage has a low likeli-
hood of warping; however, it is typically weak in the East
Asian nose, m aking it a potentially poor choice of source
material. Instead, costal cartilage may be used after it
has gone through multiple cycles of soaking and drying
to determ ine its tendency to warp. Cross-hatching and
splinting w ith slivers of costal cartilage m ay be used to
counteract a minor deviation in the graft.
Management of the Nasal Base
At the caudal aspect of the nose, the nasal base is the last
component to create a stable foundation for all future tip
work and dorsal augmentation. Weakness at the nasal base
may manifest as collapse over time resulting in tip ptosis,
loss of projection, and polly-beak deformity. Unaddressed
deviation of the nasal base will result in persistent devia-
tion of the entire nose. Prior to addressing the nasal base,
it is important to reexamine the preoperative photographs
and assess relevant landmarks: caudal septum, nasal spine,
dentitia, and lip contour. The best vantage point is the head
of the bed, where the deviations or asymmetries will reveal
themselves.2
Patient considerations to take into account include
the smile. Changes in the nasal base may result in upper
lip sti ness, change in lip position, and upper lip crease
formation. In the East Asian nose it is common to blunt
or move the nasolabial angle. If the nose is moved down,
smiles that go up at the corners of the mouth will likely get
tethered medially and a horizontal crease w ill form. These
potential outcomes should be discussed with the patient
preoperatively.
Generally the nasal base will be either midline or devi-
ated. If it is midline, the nasal base may only need augmen-
tation, lengthening, or strengthening. If there is a caudal
septal de ection, a swinging door maneuver or caudal sep-
tum resection and a subtotal septal reconstruction may be
required. Minor caudal septal de ection can be addressed
with the swinging door maneuver, which requires dissec-
Fig. 3.9 Caudal septal extension graft splinted and secured with slivers. (a) Frontal view. Caudal septal extension graft external to nose.
(b) Frontal view. Caudal septal extension graft with supporting slivers. (c) Surgeon’s view. Caudal septal extension graft is secured to native
caudal septum with supporting slivers.
a
b
c

3 The Use of Costal Cartilage for Dorsal Augmentation and Tip Grafting
35
tion from the graft to the nasal dorsum (Fig. 3.11). On the
undersurface of the dorsal augmentation graft, the costal
perichondrium supplements rigid xation, preventing
graft mobility and migration.
From the beginning of the operation, the surgeon
should be thinking about rigid xation. Limited dissec-
tion of the dorsal skin envelope with the Joseph periosteal
elevator will yield a tight pocket, which is a key component
for rigid xation of the dorsal graft. Throughout the pro-
cess of serially carving the graft, it is necessary to place
the graft into the pocket to evaluate dorsal height. The sur-
geon should avoid excess manipulation of the pocket when
transferring the graft into and out of the pocket. In addition
to a tight pocket, the dorsal graft requires xation caudally.
Three-point xation with 5–0 PDS suture on each side of
the lower aspect of the graft holds the cartilage in place
until scar contracture takes over.14 To ensure a rigid xa-
tion, the bony dorsal surface is roughened by violating the
cortical bone with a no. 3 osteotome or narrow low-pro le
bone rasp. The perichondrium on the undersurface of the
dorsal graft can integrate into the cortical defects in the
native bone, with formation of an ossi ed bond between
the dorsal graft and the bony dorsum.
If there is no tight pocket, due to excessive elevation,
previous implant, or infection, the cephalic aspect of the
graft may be secured with a temporary 0.45-mm threaded
Kirschner w ire, removed on postoperative day 7.15 The
Kirschner w ire is advanced through a small stab incision
over the upper aspect of the dorsal graft and is engaged 3
to 4 mm into the bony dorsum (Fig. 3.12). If the graft is
not thick enough to engage multiple threads of the wire, a
transnasal suture technique utilizing 16-gauge needles to
create a tunnel through the nasal bone is employed. Sutures
looped through the tunnel and over the dorsal augmenta-
Dorsal Augmentation
After laying down a strong foundation at the nasal base,
middle vault, and nasal bones, the surgeon is ready to
increase dorsal height with a dorsal graft. The senior
author does not use alloplastic materials and acknowledges
the challenges involved with using autologous costal carti-
lage. The complexity of this graft lies in its inability to toler-
ate visible edges or warping. Serial carving, perichondrium
camou age, and rigid xation are key strategies to address
those challenges.5
In the senior author’s opinion, a single piece of cos-
tal cartilage works best. The central core of the harvested
costal cartilage is less prone to warping; however, as pre-
viously stated, the patient’s age strongly in uences the ten-
dency for warping and fracture. It is important to serially
carve the cartilage with soaking-drying cycles to allow the
piece to demonstrate its curvature. As the curvature cannot
be truly controlled, the surgeon should utilize the natural
curve by directing the concave side down and in contact
with the native dorsum. With rigid xation, this orienta-
tion will limit postoperative warping. The convex side of
the cartilage is carved into a canoe shape to allow smooth
transitions from graft to nasal dorsum (Fig. 3.10). In the
East Asian face, this canoe-shaped graft is ideally posi-
tioned to match the graft’s cephalic margin at the patient’s
midpupil.13
Perichondrium harvested with costal cartilage has
many functions in the dorsal augmentation graft. Alone it
can provide 1 mm of reliable augmentation. It should be
oriented with the previously cartilage-exposed surface
facing the osteo-cartilaginous structures and the muscle-
exposed surface facing the skin envelope. As soft tissue
coverage, costal perichondrium provides a smooth transi-
Fig. 3.10 Serial carving of dorsal augmentation graft.
(a) Dorsal augmentation graft is carved with a no. 10
blade. (b) Canoe-shaped dorsal augmentation graft in
frontal view. (c) Dorsal augmentation graft oriented
with concave surface facing down in lateral view.
a
b
c

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36
Perichondrium
Perichondrium
Rasped or perforated bone
Fig. 3.11 Perichondrium on undersurface of dorsal augmentation graft for xation. (a) Lateral view with concave surface facing down.
(b) Lateral view with superior undersurface of the graft covered in perichondrium. (c) Drawing showing the appropriate placement of
perichondrium on the undersurface of the dorsal augmentation graft in contact with the nasal bone for strong graft xation. (Used with
permission from Toriumi DM, Pero CD. Asian rhinoplasty. Clin Plast Surg 2010;37:335–352.)
Fig. 3.12 Kirschner wire placement. (a) Vertical incision with a no. 11
blade. (b) Placement of Kirschner wire. (c) Clipping Kirschner wire with
cutter. (d) Lateral view of Kirschner wire cut to length.
a
b
c
a
b
c
d

3 The Use of Costal Cartilage for Dorsal Augmentation and Tip Grafting
37
or replacement graft. Desirable tip projection and rotation
are con rmed before securing the medial and intermediate
crura with 5–0 PDS suture. Tip bulbosity due to convex lat-
eral crura is addressed with lateral crural strut grafts.16 The
strut grafts atten the crura. It is rare that repositioning is
needed in the Asian patient unless they have alar retraction.
Due to camou aging thick skin, the East Asian nose rarely
requires repositioning of the lateral crura, regardless of tip
cartilage orientation. The Asian situation is the opposite of
the hanging columella-tip lobule and retracted ala familiar
in the Caucasian nose. More often East Asian noses have
retracted columella and hanging alar lobules. Repositioning
of the lower lateral cartilages is a powerful maneuver that
could exacerbate the patient’s inherent problem. However, if
the ala is retracted or notched, lateral crural strut grafts with
repositioning can bring it down.
tion graft ensure rm contact for integration and bony xa-
tion (Fig. 3.13). Final xation occurs after tip manipulation
is completed to permanently set the dorsal height in pro-
portion to the nasal tip position.
Tip Contouring
Typically, the East Asian nose will require tip augmentation
and narrowing to address the native characteristics: small
and weak lateral crura, thick sebaceous skin, tip bulbosity,
retracted columella, and hanging alar lobules.2 Favorable
tip contour can be achieved with autologous costal carti-
lage in the East Asian nose.
Using 4–0 plain gut suture on a Keith needle, the medial
crura are reapproximated to the caudal septal extension
Fig. 3.13 Transnasal suture placement. (a) 16-gauge needle passed through nasal bones.
(b) Suture needle placed in lumen of 16-gauge needle. (c) Suture passed transnasally from
left to right. (d) Suture crosses back to the left side under the skin envelope and over the
dorsal augmentation graft.
a
b
c
d

II Rhinoplasty
38
thin-sliver alar batten grafts may be needed to support the
valve area previously held open by cephalically oriented
lower lateral cartilages.
Tip augmentation w ith autologous costal cartilage cre-
ates additional projection and re nement. Stretching the
skin creates tip de nition. This can be accomplished with
shield, lateral crural, and buttress grafts. The shield graft
provides the projection, but the lateral crural and buttress
grafts stabilize the tip graft, preventing rotation caused by
the cephalic pulling force of a thick skin envelope. Adjust-
ing the position of the shield graft varies the amount of
increased projection and infratip augmentation. In addi-
tion to stabilization, lateral crural and buttress grafts bev-
eled to meet the shield graft smooth the transitions from
the graft’s edges and prevent graft visibility. Most patients
that undergo placement of a shield graft with lateral cru-
ral grafts do not need any other work done on the lateral
crura, as they are deep to the in uence of the shield graft.
A less aggressive alternative is a rectangular, horizontally
oriented tip onlay graft secured with 6–0 Monocryl suture
(Fig. 3.15). Variation in the size and placement of the graft
can set the projection, tip width, supratip break, and over-
all re nement of the tip. With increasing amounts of tip
augmentation, the nostril-to-columellar ratio w ill move
from 2:1 to 1:1.
To prepare the site for lateral crural strut grafts, the
tightly adherent vestibular skin is dissected o of the under-
surface of the native lateral crura. Hydrodissection with 1%
lidocaine with 1:100,000 epinephrine makes this task easier.
The plane of dissection is continued laterally toward the pir-
iform aperture to create a pocket for the grafts. The carved
costal cartilage should be evaluated for ideal pieces 25–30
mm × 4–5 mm × 1–2 mm with a slight curve. Women will
have shorter grafts than men. After selecting ideal pieces
of costal cartilage with the concave side facing the vestib-
ular skin, the medial edge is cut at 45 degrees and placed
directly under the apex of the dome. It is secured with 5–0
PDS suture, keeping all knots away from the vestibular skin
to prevent extrusion (Fig. 3.14). Oblique dome sutures are
placed to atten the domes and orient the lateral crura with
the caudal edge higher than the cephalic edge.
Repositioning of the lower lateral cartilages involves
fully mobilizing the lateral aspects of the lateral crura. If
these cartilages are large, the lateral-most aspect may be
harvested for soft tissue camou age. The lateral crural strut
grafts are performed as described previously, except for the
lateral pockets designed to correct asymmetry of the ala: a
neutral or horizontal pocket for the lower alar lobule and
a downward-oriented pocket for the retracted alar lobule.
In repositioning, any planned cephalic trim is reduced, and
Fig. 3.14 Lateral crural strut graft technique. (a) Lateral crura dis-
sected free. (b) Lateral crural strut grafts suture in position under-
neath lateral crura.
Fig. 3.15 Shield graft versus horizontal onlay graft. (a) Shield
graft seen in surgeon’s view. (b) Horizontal onlay graft seen in sur-
geon’s view.
a
b
a
b

3 The Use of Costal Cartilage for Dorsal Augmentation and Tip Grafting
39
Base Reduction
After closure of the nose, the nasal base width is assessed.
As a result of structured rhinoplasty with autologous costal
cartilage augmentation, particularly with lateral crural strut
grafts, the East Asian nose may require nasal base reduction
to balance the nose with the width of the newly augmented
dorsum. This can be performed with techniques involving any
combination of internal or external excision and base-cinch-
ing sutures. Caution is warranted, as small errors in perform-
ing base reductions result in glaring deformities. Unsightly
scars at the nasal base are di cult to correct. To improve out-
comes, plan for an incision slightly adjacent to the alar-facial
or alar-vestibular junction. Avoid local anesthetics as they
can deform the tissue contours. Using a no. 11 blade, create
a slight bevel of the incisions to promote eversion of the skin
edge. Avoid all cautery. Meticulously close the base reduction
sites with a deep 5–0 PDS suture, 7–0 nylon vertical mattress
sutures, and 6–0 fast-absorbing gut simple sutures.
Glabellar Augmentation
To further balance the nose, it is important to evaluate the
East Asian face with lateral views. From this perspective, a
de cient glabella may be observed. This observation may be
made preoperatively and discussed with the patient through
digital image morphing software. The senior author performs
glabellar augmentation by an endoscopic technique. Attention
is directed at the forehead area, where two hairline incisions
are made, and the endoscope is dropped down to the glabellar
region in a subperiosteal plane. A soft piece of septal cartilage
covered with perichondrium is sutured on both sides with 5–0
PDS, keeping the suture tail long with needles attached. The
graft is deposited through the scalp incision site. Then using
16-gauge needles, ports are created on the lateral aspects of
the de cient glabella. The needles connected to the graft are
passed through 16-gauge needles and delivered externally.
Symmetry and positioning should be noted with the endo-
scope before tying the anchoring sutures at the skin. The scalp
incisions are closed with 5–0 PDS and 5–0 fast-absorbing gut.
The anchoring sutures are cut in 7 days. Another option is to
use autologous fat augmentation of the glabella.

■Postoperative Care
All patients are seen on postoperative day 1. Vestibular
splints may be removed. The nose is cleaned and antibiotic
ointment is applied. Patients undergoing costal cartilage
grafting receive oral uoroquinolone and perform uoroqui-
nolone antibiotic nasal soaks in addition to a second-gen-
eration cephalosporin. The external cast, tape, lateral wall
splints, Kirschner wire, and columellar sutures are removed
in 7 days. If base reductions were performed, these sutures
are removed at 10 to 14 days postoperatively. A mild narcotic
pain medication is provided, but an early transition to acet-
aminophen is encouraged. Aspirin and nonsteroidal anti-
After attening the lateral crura, increasing projection,
and re ning the tip, the surgeon replaces the dorsal graft and
redrapes the skin to assess the relationship between projec-
tion and the dorsal height. Once it is considered satisfactory,
the dorsal graft can be secured into place for rigid xation.
Alar Batten and Alar Rim Grafts
In the East Asian nose, with its wide airway and thicker
lateral sidewalls, alar batten and alar rim grafts are infre-
quently indicated, because the lobules rarely pinch or col-
lapse. Costal cartilage is an excellent source material since
it maintains its strength even when carved very thin. If
costal cartilage is used for these grafts, a smooth taper is
necessary to prevent graft visibility.2
Alar batten grafts should be placed in precise pockets
oriented along the supra-alar crease and sutured into place.
These batten grafts are appropriate for internal valve col-
lapse and if the lateral crura have been repositioned with
lateral crural strut grafts. Alar batten grafts are indicated
for addressing lateral wall de ciency and pinching from
aggressive cephalic trim or other previous surgery. Alar
batten grafts are rarely needed in Asian patients, as their
airway tends to be relatively large.
Alar rim grafts are placed in precise pockets along the
marginal incision ending medially behind the tip complex.
These grafts address external nasal valve collapse, pinching
of the tip, and irregular transitions from the tip lobule to
the alar lobule.
Closure
At this point, the surgeon needs to perform a meticulous clo-
sure of the columellar incision to prevent the stigmata of the
open rhinoplasty approach, a visible scar. Closure begins with
an interrupted 6–0 Monocryl suture in the midline. This suture
aligns the soft tissue envelope and removes tension from the
skin edge. Using a 7–0 nylon suture, seven interrupted vertical
mattress sutures approximate and evert the inverted-V colu-
mellar incision. Between the nylon sutures, 6–0 fast-absorb-
ing gut suture is placed in a simple interrupted fashion. The
marginal incision is closed with simple interrupted 5–0 chro-
mic gut sutures, while observing the nostril margin. If there is
inadequate vestibular lining. this stitch can lead to notching of
the nasal rim, in which case a composite graft may be neces-
sary. The mucoperichondrial aps are reapproximated with a
4–0 plain gut suture on a Keith needle in a running mattress
fashion, closing the septum.
Radio-opaque 0.25-mm septal splints (Reuter bivalve
septal splints, Medtronic, Jacksonville, Florida) are sutured
in place if turbinate or septal work was performed to pre-
vent synechiae formation. Lateral wall splints are used if lat-
eral crural strut grafts were placed with repositioning of the
lateral crura. If there is any nostril asymmetry a vestibular
splint can be used intermittently. The senior author does not
use any nasal packing. The nose is taped and an external cast
is applied. Antibiotic ointment is applied to all incisions.

II Rhinoplasty
40
but stressed that she preferred a “natural look.”. In her pre-
operative computer imaging we agreed on a modest degree
of dorsal augmentation that would complement a moderate
increase in nasal tip projection (Fig. 3.16). We also discussed
chin augmentation to complement her nasal projection and
other facial features. We harvested a 3.5-cm segment of her
sixth rib through a 1.1-cm chest incision. Perichondrium was
harvested from the surface of the rib as well.
The rib cartilage was carved into three separate
segm ents that were exam ined for the proper bending
(Fig. 3.17). Over several hours a precisely carved costal
cartilage dorsal graft was fashioned and observed for a
tendency to bend. An external rhinoplasty approach was
used (Fig. 3.18) and special care was taken to dissect a
tight subperiosteal tunnel along the m idline of her nasal
dorsum . The base of the nose was stabilized using a caudal
septal extension graft sutured to two extended spreader
grafts that were placed into bilateral subm ucosal tun-
nels under the upper lateral cartilages. The dorsal graft
was fashioned so that it had a slight concave curvature
that was oriented against the nasal dorsum . A strip of
perichondrium was sutured to the undersurface of the
superior portion of the dorsal graft w ith 5–0 PDS suture.
A narrow ne rasp was used to roughen the nasal dorsum
to create a porous bone surface that could then integrate
w ith the perichondrium and x the dorsal graft to the
nasal bones. The dorsal graft t snuggly into the subperi-
osteal tunnel, xing the dorsal graft into position. Then
a shield graft was projected ~ 3 m m above the existing
dom es and sutured to the m edial crura. Bilateral lateral
crural grafts were sutured to the posterior surface of the
shield graft and then sutured to the lateral crura. To pre-
vent graft visibility perichondrium was sutured onto the
leading edge of the shield graft. The colum ellar incision
was closed using a 6–0 Monacryl subcutaneous suture
and 7–0 vertical m attress sutures.
in ammatory drugs are avoided postoperatively. Despite a
low level of discomfort, patients often refrain from taking
deep inspirations to protect the costal cartilage donor site.
Postoperatively, patients are encouraged to perform incen-
tive spirometry and ambulation to avoid atelectasis.

■Key Technical Points
1. The chest incision is made small to minimize the
visible scar; however, a surgeon should continue to
use a larger incision until familiar with the dissection.
2. By maintaining a protective cu of perichondrium,
the costal cartilage harvest technique should
ensure an intact harvest site, avoiding violation of
the pleura. All nal cuts of the costal cartilage are
performed with the blunt end of the Freer elevator.
A lifting motion is utilized to protect the underlying
perichondrium and pleura.
3. When opening the nose, the Joseph periosteal
elevator should be used in a limited fashion,
preserving a tight dorsal pocket, in anticipation of a
dorsal augmentation graft.
4. In the setting of spreader grafts or splinting, by
opposing concavities, the surgeon can utilize the
natural curvature of the costal cartilage grafts.
5. By keeping the upper lateral cartilages attached
to the dorsum, the surgeon can use submucosal
spreader grafts and does not need additional time to
reconstruct the dorsum.
6. The dorsal graft is secured only after all tip work is
complete.
7. The dorsal augmentation graft requires rigid xation
to prevent warping. The superior aspect of the graft
must be secured with a tight pocket, transnasal
suture, or Kirschner wire.
8. Tip projection may be achieved with a shield graft or
horizontal onlay graft. The horizontal onlay graft is
less aggressive and will not change the infratip lobule.
9. When increasing projection, one must control for
rotation with a stable foundation. Septal extension
grafts precisely control these variables.
10. Base reductions are technically di cult with the
potential for deformity. Avoid contour-altering local
anesthetics and cautery while performing base
reductions.

■Case Studies
Case 1
This Asian patient presented for augmentation rhinoplasty
and requested to have her rib cartilage used for the augmenta-
tion. She was interested in a modest degree of augmentation
Fig. 3.16 Preoperative computer imaging showing proposed
modest change in nasal dorsal height and tip projection. Chin aug-
mentation was recommended as well.

3 The Use of Costal Cartilage for Dorsal Augmentation and Tip Grafting
41
Fig. 3.17 (a) A 3.5-cm segment of the sixth rib was harvested through a 1.1-cm chest incision. (b) Harvested costal cartilage was carved
into three separate segments to allow selection of the best piece for the dorsal graft.
Fig. 3.18 (a) Bilateral spreader grafts were used to stabilize the caudal septal extension graft. The extension graft was placed to control
nasal tip projection and rotation. (b) Dorsal graft with slight bend with the concave side oriented inferiorly against the dorsum of the nose.
Perichondrium was sutured to the undersurface of the upper margin of the dorsal graft. (c) Dorsal graft with perichondrium sutured to
the undersurface of the superior end of the graft. (d) Shield graft sutured to the medial crura. The graft is projecting 3 mm above the
existing domes. (e) Bilateral lateral crural grafts sutured to the posterior surface of the shield graft to prevent over-rotation of the tip graft.
(f) Perichondrium sutured to the leading edge of the shield graft to minimize the likelihood of graft visibility.
a
b
a
b
a
c
d
e
f

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42
Fig. 3.19 (a–c,g) Preoperative photo-
graphs. Preoperative frontal view shows
a lack of de nition of the upper dorsum.
Lateral and oblique view show low nasal
dorsum and under-projected chin. Wide
nasal base is noted on basal view. (d–f,h)
Postoperative (2 years) photographs. Fron-
tal view shows a nice improvement in upper
dorsal de nition with symmetric aesthetic
dorsal lines. Lateral and oblique views show
a modest increase in dorsal height and
increased tip projection. The chin augmen-
tation helps to balance the increase in tip
projection.
a
b
c
d
e
f
g
h

3 The Use of Costal Cartilage for Dorsal Augmentation and Tip Grafting
43
The patient did well, with a nice improvement in the
appearance of her postoperative view (Fig. 3.19). The chin
implant balanced the changes to her nose and comple-
mented her other facial features.
Case 2
This patient presented for secondary rhinoplasty. The
patient was unhappy with her dorsal implant, which occa-
sionally became in amed. She underwent two previous
surgeries and wished to have her implant removed and
replaced with her own cartilage. She wanted a lower radix
and improved tip contour. We demonstrated her pro le
changes using computer imaging (Fig. 3.20).
At the time of surgery we noted a large Gore-Tex dor-
sal implant. The implant had two layers in the radix area
and was very di cult to remove (Fig. 3.21). A 4.5-cm seg-
ment of costal cartilage was harvested from her right chest
(Fig. 3.22). The patient underwent revision rhinoplasty
(Fig. 3.23). She had had a columellar strut placed in a previ-
ous surgery. We left the strut in place and sutured a costal
cartilage shield graft to the medial crura. The shield graft
was stabilized using a buttress graft sutured behind the tip
graft. Soft tissue and scar were sutured along the lateral
edges of the tip graft. A costal cartilage dorsal graft was
designed to set a lower radix. Perichondrium was sutured
to the undersurface of the dorsal graft to aid in xation of
the dorsal graft. Multiple perforations were made in the
bony dorsum to allow more rapid integration with the peri-
chondrium on the undersurface of the dorsal graft. A large
space was created with the dissection of the Gore-Tex dor-
sal implant. To xate the dorsal graft a threaded Kirschner
wire was placed through a small dorsal incision, through
the dorsal graft and into the bony dorsum. A composite
skin-cartilage graft was harvested from the right cymba
concha. The composite graft was sutured into the left mar-
ginal incision where there was a vestibular skin de ciency.
The Kirschner wire aided xation of the dorsal graft to the
bony dorsum. The Kirschner wire was removed on the sev-
enth postoperative day. The patient did well and she was
happy with her outcome (Fig. 3.24).
Fig. 3.20 Preoperative computer imaging showing lower radix.
Fig. 3.21 Gore-Tex dorsal graft removed. Note the double layer of
Gore-Tex over the radix region and its extension into the glabellar.
Fig. 3.22 Costal cartilage harvest from sixth rib.

II Rhinoplasty
44
Fig. 3.23 (a) Shield graft sutured to medial crura. (b) Buttress graft sutured behind leading edge of the shield graft. Soft tissue and scar
placed along edges of the shield graft for additional camou age. (c) Costal cartilage dorsal graft carved. (d) Perichondrium sutured to the
undersurface of the dorsal graft. (e) Kirschner wire advanced through a small incision over the nasal dorsum. (f) Composite skin-cartilage
graft harvested from right cymba concha. (g) Composite graft sutured into the left marginal incision. (h) Kirschner wire in position xing
the dorsal graft to the underlying bone.
a
b
c
d
e
f
g
h

3 The Use of Costal Cartilage for Dorsal Augmentation and Tip Grafting
45
Fig. 3.24 (a–c,g) Preoperative photo-
graphs. (d–f,h) Postoperative (2 years)
photographs.
a
b
c
d
e
f
g
h

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cial Plast Surg 2006;8(1):42–46
11. Ahmed A, Imani P, Vuyk HD. Reconstruction of signi cant
saddle nose deform ity using autogenous costal cartilage
graft with incorporated mirror im age spreader grafts. La-
ryngoscope 2010;120(3):491–494
12. Guyuron B, Uzzo CD, Scull H. A practical classi cation of
septonasal deviation and an e ective guide to septal sur-
gery. Plast Reconstr Surg 1999;104(7):2202–2209, discus-
sion 2210–2212
13. Toriumi DM, Swartout B. Asian rhinoplasty. Facial Plast
Surg Clin North Am 2007;15(3):293–307, v
14. Gunter JP, Clark CP, Friedman RM. Internal stabilization
of autogenous rib cartilage grafts in rhinoplasty: a bar-
rier to cartilage warping. Plast Reconstr Surg 1997;100(1):
161–169
15. Sarifakioglu N, Cigsar B, Aslan G. K-wire: a simple and safe
m ethod for internal stabilization of costal cartilage in L-
strut grafts. Ann Plast Surg 2002;49(4):444
16. Gunter JP, Friedm an RM. Lateral crural strut graft: tech-
nique and clinical applications in rhinoplasty. Plast Recon-
str Surg 1997;99(4):943–952, discussion 953–955

■Conclusion
In the East Asian nose, autologous costal cartilage is the
material of choice to address the rhinoplasty surgeon’s
goals: dorsal augmentation and tip re nement. This pre-
ferred but complex material is di cult to master, requiring
time for the surgeon to develop the judgment to properly
select, prepare, and utilize the grafts.
References
1. Toriumi DM. Structure approach in rhinoplasty. Facial Plast
Surg Clin North Am 2002;10(1):1–22
2. Toriumi DM, Pero CD. Asian rhinoplasty. Clin Plast Surg
2010;37(2):335–352
3. Toriumi DM, Dixon TK. Assessm ent of rhinoplasty tech-
niques by overlay of before-and-after 3D im ages. Facial
Plast Surg Clin North Am 2011;19(4):711–723, ix
4. Anantanarayanan P, Raja DK, Kumar JN, et al. Catheter-
based donor site analgesia after rib grafting: a pro-
spective,
random ized,
double-blinded
clinical
trial
comparing ropivacaine and bupivacaine. J Oral Maxillofac
Surg 2013;71(1):29–34
5. Toriumi
DM.
Discussion:
use
of
autologous
cos-
tal cartilage in Asian rhinoplasty. Plast Reconstr Surg
2012;130(6):1349–1350
6. Rejtarová O, Slízová D, Sm oranc P, Rejtar P, Bukac J. Cos-
tal cartilages—a clue for determination of sex. Biomed Pap
Med Fac Univ Palacky Olom ouc Czech Repub 2004;148(2):
241–243

47
4 Nasal Tip Modi cation in Asians:
Augmentation and Rotation Control
Hong Ryul Jin and Jong Sook Yi
an increase in tip projection w ith avoidance of exces-
sive increased tip rotation. The am ount of projection and
rotation necessary for a case di er according to personal
preference, age, sex, occupation, and overall facial fea-
tures. In general, m ost patients require and undergo dor-
sal augm entation, so the am ount of tip projection should
be balanced accordingly. Nasal tip w idth should always
be evaluated in the context of overall facial anatomy and
not as an isolated feature. If the face is relatively wide, a
narrow tip can appear conspicuous and demonstrate an
operated-on look.
To obtain a more aesthetically pleasing nasal tip in
Asians, several procedures are employed. Commonly
applied procedures are cartilage grafting techniques,
including various tip onlay grafts and septal extension
grafts. Theoretically, they may su ce when used individu-
ally, but in practice a combination of the various techniques
is necessary to achieve the desired goal. Since inherent tip
support is weak and the skin is relatively thick in Asians, tip
augmentation is rarely achieved by suture techniques alone
and is reserved for a select group of patients.2

■Introduction
The general goal in tip-plasty is to create a natural-look-
ing nasal tip that is in harmony with the nasal dorsum
and in balance overall with the facial features. This basic
philosophy applies not only to Asians but also to patients
from other ethnic backgrounds. Such harmony can only be
achieved with a su cient understanding of the pervading
cultural environment and with continuous exposure and
dedication to the speci c ethnic patient. It is mandatory,
therefore, that each operation be highly individualized
according to the ethnic background.
For tip surgery in Asians, projection, rotation, and vol-
um e are the three m ost important factors to consider. A
harm oniously matched projection of the nasal tip adjusted
to the augm ented dorsum , w ith a gentle round shape
instead of a well-de ned, angulated tip, along w ith subtle
accentuation are the ideals that contemporary Asian nasal
tip surgery aspires to achieve.1 One important point that
should be kept in m ind is that many Asian patients request
Pearls
• For tip surgery in East Asians, projection, rotation,
and volume are the three most important factors to
consider.
• Since inherent tip support is weak and the skin is
relatively thick in Asians, tip augmentation is mostly
achieved by cartilage grafting rather than suture
modi cation techniques alone.
• Patient preference, the character of the tip, and
surgeon experience and preference are some of the
factors to be considered in choosing the appropriate
approach for tip surgery.
• For the typical Asian patient, the open approach
gives better and more diverse options for modifying
the tip shape, while the closed approach is e ective
in limited cases.
• A cap graft with or without a columellar strut and
interdomal suture through the endonasal or open
approach provides an e ective increase in tip
projection and rotation.
• The septal extension graft is a workhorse used to
modify the tip shape, and it should be supported by
a strong caudal septum or reinforced with batten or
extended spreader grafts.
• When designing the septal extension graft,
projection and rotation are modi ed by carefully
designing the shape of the graft considering the
position of the new dome.
• Applying bone as a septal extension graft or overly
aggressive application of the septal extension graft
should be avoided to prevent pain, hardness, and
discomfort at the tip.
• Even for relatively thick skin at the nasal tip, tip
grafts need to be carefully beveled and carved to
keep from showing up in the long term.
• To complement modi cation of the tip shape,
cephalic resection, the shield graft, the premaxillary
graft, the lateral crural graft, and the alar rim graft
are also used.

II Rhinoplasty
48
In such cases, advantages and limitations of the endonasal
approach should be brought forward during the consulta-
tion and thoroughly discussed.
Regarding the character of the tip, two factors should
be considered in deciding the right approach. The rst is
tip support. When the size and strength of the lower lat-
eral cartilages are adequate, an endonasal approach can
be a good choice. When the cartilages are weak and sup-
port is minimal, however, endonasal tip-plasty techniques
become ine ective.3 The second factor is the status of tip
projection and rotation. Inserting a columellar strut, con-
verging the lower lateral cartilages, and placing a cap graft
will project the tip together with slight cephalic rotation.
This increase in rotation may create an excessively over-
rotated appearance in patients who already have a bor-
derline short nose. A septal extension graft via an external
approach is more appropriate for these patients. The best
indication, therefore, for the endonasal approach is when
the tip is slightly droopy w ith lower lateral cartilages that
are large and strong. It is also best used in patients who do
not have thick skin and severe deformities or asymmetry of
the tip cartilage.

■Surgical Techniques
Augmenting Tip Projection via the
Endonasal Approach
Cap Graft via the Endonasal Approach
The site where the graft will be placed is marked on the tip
skin. After the harvest of cartilage from the nasal septum or
the cymba concha, two to three pieces are overlapped and

■Patient Evaluation
Current tip shape and support need to be carefully observed
and analyzed when planning for tip surgery. A dependent,
caudally rotated, less projected tip with good cartilaginous
support is relatively easy to treat. The most di cult case is
a tip that is already slightly upturned, is poorly projected,
and has very weak lower lateral cartilages and a de cient
septum (Fig. 4.1). Care should be taken in this case because
trying to increase the projection of the tip without proper
maneuvers will increase the cephalic rotation and create a
short-looking nasal tip.
Tip support is evaluated by palpating the tip, the cau-
dal septum, and the skin because these structures are most
important in deciding the tip shape. A nasal tip supported
by large lower lateral cartilages and a strong septum is rela-
tively easy to control. However, many Asian patients have
the worst combination, rudimentary tip cartilages and a
retruded and de cient caudal septum with thick skin.
The patient’s wishes and expectations are discussed.
Contour of the tip shape is limited by many factors. Skin
and cartilage are most important. The patient’s wishes
should be thoroughly addressed because there can be mis-
understanding during discussions. A very sensitive patient
may complain of very subtle di erences in the nostril shape
as seen from below. Preoperative photos should always be
taken and analyzed before surgery. Increasing the tip pro-
jection may exaggerate pre-existing slight discrepancies of
the rim height or columellar slanting.
Patient preference, the character of the tip, and surgeon
experience and preference are some of the factors that are
to be considered in choosing the appropriate approach for
tip surgery. Many patients strongly demand an endonasal
approach to avoid a columellar scar from an open approach.
Fig. 4.1 Evaluation of tip shape and sup-
port. (a) In this hump nose patient, the tip
is slightly caudally rotated and projection
is less than optimal, but the cartilaginous
support is strong. This type of tip shape is
relatively easy to change favorably either
by the endonasal or open approach. (b) A
slightly cephalic rotated tip with poor tip
projection and weak support. This tip tends
to rotate more cephalically if projection is
increased without speci c measures to pre-
vent cephalic rotation.
a
b

4 Nasal Tip Modi cation in Asians: Augmentation and Rotation Control  49
Tip Projection and Rotation Control
Using the Septal Extension Graft
Concept
The septal extension graft is the workhorse for tip-plasty in
the Asian nose. By providing a rm foundation upon which
the lower lateral cartilages can be repositioned, tip projec-
tion and rotation are e ectively controlled. By changing its
shape and location, the graft can be e ciently used to aug-
ment, rotate or de-rotate, or lengthen the nose, or to cor-
rect the nasolabial angle.4
sutured, taking into consideration the degree of augmenta-
tion needed and the existing tip size. The size of the graft
is designed so that it does not exceed the usual interdomal
distance, which is 6 to 8 mm, and the margins are carefully
trimmed. One or two knots are made, and the threaded
needles are left uncut. The margins of the graft are trimmed
to make a smoother transition with the surrounding tissue
or are morselized using Brown-Adson forceps. Failure to do
this may lead to graft visualization. Using an infradomal
marginal incision, the insertion pocket is made slightly
larger than the graft (Fig. 4.2). The needles of a 5–0 PDS
suture are introduced through the incision site, coming out
through the previously marked dots on the tip. By pulling
on the suture, the graft can be placed at the center of the
pocket (Fig. 4.3). The incision site is closed while gentle
traction is maintained on the suture. The pulled-out suture
is xed w ith tape to the skin and removed after a week.
Utilizing Columellar Strut, Interdomal
Suture, and Onlay Graft via the
Endonasal Approach
Cartilage harvested from the nasal septum or the ear is
designed according to the planned procedure (e.g., cap graft,
shield graft, or columellar strut). The incision can be modi-
ed based on the size and the nature of the intended graft,
but bilateral infradomal marginal incisions extending to the
lateral columella are usually employed to expose and dissect
both lower lateral cartilage domes and the medial crura. An
intradomal suture is done at the lower lateral cartilage to
produce a slight increase in projection. This suture begins
from the upper part of the medial crus medially, passing
through the intermediate crus to exit at the lateral crus.
The suture is then done in reverse, from the lateral
to the medial crus and the knot thrown medial to the
medial crus. Care should be taken to maintain symmetry
of the domes and to avoid excessive medialization of the
lateral crura or lateral crural steal. If this happens, com -
plications such as deformity of the lower lateral cartilage
or an overly narrowed medial and lateral crural angle can
occur. To reinforce tip support, a pocket is made between
the medial crura, followed by insertion of the columellar
strut (Fig. 4.4). The columellar strut, harvested from the
nasal septum, should be straight with adequate length and
strength. An interdomal suture, incorporating the columel-
lar strut by passing the needle from side to side, is done
(Fig. 4.5). Alternatively, both domes are pulled out to one
side of the nostril and sutured as necessary. The excess por-
tion of the columellar strut that projects over the dome is
trimmed. An onlay cap graft is placed above the dome as
described previously, if necessary. The dome is relocated
to its natural position, the tip is positioned, and the dorsal
height is cross-checked from the lateral and basal views.
Fig. 4.2 Cap graft through the endonasal approach. Using an
infradomal marginal incision, the graft insertion pocket is made
slightly larger than the graft.
Fig. 4.3 A double layer of conchal cartilage is sutured with 5–0 PDS
and the needle is introduced through the incision, coming out through
the previously marked center of the graft on the skin. The needle is
pulled gently until the graft is placed at the center of the pocket.

II Rhinoplasty
50
xed to a portion of the caudal septum. This is used in cases
where only a moderate amount of projection is required
and where the septal cartilage is relatively thick and strong.
In any type, the graft can be reinforced using septal carti-
lage or bone to prevent possible bending or buckling by the
tension placed on the graft.
An end-to-end septal extension graft reinforced by
extended spreader grafts has distinct advantage compared
with the overlapping type: It avoids thickening or buck-
ling of the caudal septum and thus rarely causes nasal
obstruction.
The Septal Extension Graft Technique
1. For e ective execution, most septal extension
grafting is performed via the open approach. A large,
at piece of cartilage is typically harvested from
the posterior nasal septum. The septal extension
graft is designed considering the nal shape and
stability of the tip. For example, to correct columellar
retraction, the portion of the septal extension
graft corresponding to the columella is designed to
protrude past the septum, and the medial crura of
the lower lateral cartilage are sutured in a tongue-in-
groove fashion to the new caudal septum created by
the graft.
2. When the inherent septal support is strong, a septal
extension graft can be applied as an overlapping
type to the caudal septum (Fig. 4.6). Avoiding an
overly thick caudal septum by careful carving is
important for a well-breathing nose. A slightly
curved graft can be used in an e ort to place the end
of the graft in the midline.
A septal extension graft is designed with the degree of
tip projection and rotation taken into consideration. Lower
lateral cartilages are repositioned and sutured to the newly
formed caudal septum, resulting in immediate tip elevation
and rotation. This technique is useful in short nose cases or
to increase tip projection in patients who lack tip support,
since strong support of the tip can be achieved. However, it
would be prudent not to overuse the septal extension graft
when other methods of increasing tip projection are avail-
able (e.g., columellar strut or cartilage tip graft), because
the septal extension graft involves a more invasive proce-
dure requiring more tissue dissection compared with other
methods. One drawback is decreased tip elasticity result-
ing in a sti nasal tip, which, however, tends to improve
over time. Another drawback is that the extension graft can
bend when excessive tension is applied.5 This usually hap-
pens when the caudal septum is weak or the repositioned
lower lateral cartilage and the draping skin and soft tissue
exert too much tension on the new tip. The surgeon should
be conscientious in informing the patient of all these pos-
sibilities preoperatively.
Types of Septal Extension Grafts
Two di erent types of septal extension grafts exist: the
overlapping type and the end-to-end type. The overlapping
septal extension graft can be divided into various types
depending on the cartilage strength and integrity of the
caudal septum, amount of available cartilage, and desired
tip shape. A common type is a septal extension graft over-
lapping the entire caudal septum and extending to the
anterior nasal spine. Due to its increased stability it can
be used in major tip augmentation. It can be placed and
Fig. 4.4 Columellar strut and interdomal suture through endona-
sal approach for tip augmentation. After bilateral infradomal mar-
ginal incisions extending to the lateral side of the columella, both
domes and medial crura are exposed. A columella strut is inserted
after making a pocket between the medial crura. Both domes and
the strut are sutured together for stability.
Fig. 4.5 When performing this maneuver, start from the medial
crus going to the lateral crus, and then from the lateral crus mov-
ing to the medial crus. Care should be taken to maintain symme-
try of the domes and to avoid excessive medialization of the lateral
crus.

4 Nasal Tip Modi cation in Asians: Augmentation and Rotation Control  51
reinforcement can be obtained by trans xion
suturing of the membranous septum to the septal
extension graft using 4–0 plain gut. If indicated, a
cap graft or shield graft can be performed on the
newly created dome, to obtain further re nement in
tip shape (Fig. 4.10).
Other Useful Techniques to
Modify Tip Shape
Shield Graft
A shield graft placed at the antero-inferior part of the nasal
tip (above the medial crus) can increase tip projection
as well as enhance de nition of the supratip and infratip
breaks. Septal cartilage is commonly used, with rib carti-
lage used on occasion. The width of the upper part of the
shield graft is designed to be 6 to 8 mm in size, simulat-
ing the tip de ning points. The margins of the graft are
trimmed. At least four stitches to the medial crus are made
to maintain stability (Fig. 4.11). In this case a buttress graft
should be placed posterior to the shield graft to prevent
tilting of the graft and unintended cephalic rotation.8
3. After unilateral dissection, unless indicated
otherwise, contralateral dissection is minimized only
to the extent where the septal extension graft can be
securely sutured to the caudal septum (Fig. 4.7).
4. When the caudal septum is weak, reinforcement
is achieved in two ways: First, the posterior septal
angle of the caudal septum is suture- xed to the
anterior nasal spine. Second, the septal extension
graft is supported using a spreader graft or batten
graft. Using thin bone for battening purposes is
ne, but using it as a septal extension graft is not
advisable. If the harvested cartilage is big enough,
reinforcement and extension can be achieved
simultaneously by designing the graft as a batten
graft protruding from the caudal septum.
5. In the end-to-end style, the septal extension graft
is stabilized at two or three points: The posterior
septal angle is stabilized to the anterior nasal spine,
using gure-of-8 sutures x the septal extension
graft to the end of the caudal septum, and the septal
extension graft is stabilized with a unilateral or
bilateral extended spreader graft (Fig. 4.8).6,7
6. The lower lateral cartilage can be repositioned by
suturing it to the septal extension graft using 5–0
PDS or 6–0 clear nylon to create the new dome
(Fig. 4.9). Additional sutures between the lower
lateral cartilage and the septal extension graft
are performed to strengthen the xation. Further
Fig. 4.6 An overlapping type of septal extension graft depending
solely on the caudal septum for support.
Fig. 4.7 An overlapping graft is xed on the left side of the cau-
dal septum. 5–0 or 4–0 PDS is used to securely x the graft onto
the caudal septum. Note that the septal mucosal dissection is done
entirely on the left side, but partially on the right side, just enough
to secure the extension graft.

II Rhinoplasty
52
maneuver does not cause a dramatic decrease in tip vol-
ume, while in thin-skinned patients it can be an e ective
technique. This procedure can be done either endonasally
or with the open approach. The resection should leave at
least 7 to 8 mm of the lower lateral cartilages equally on
both sides.9,10 Care must be taken not to resect the interme-
diate crura that form the tip de ning points. Using a no. 15
blade, a partial-thickness incision is made to prevent injury
to the underlying mucosa of the lower lateral cartilage. The
cartilage is then dissected from the mucosa using iris scis-
Cephalic Resection of Lower Lateral
Cartilage Lateral Crus
When the tip looks too round or boxy due to a widened
interdomal distance of large lower lateral cartilages (boxy
nasal tip, bulbous tip), cephalic resection of the lateral crus
and convergence of the intermediate crus can reduce the
volume and narrow the tip. This maneuver also results in
slight cephalic rotation of the tip due to secondary scar
contraction. In patients who have relatively thick skin, this
Fig. 4.8 (a,b) An end-to-end type of septal extension graft is reinforced with a bilat-
eral extended spreader graft. In both types, the graft shape is decided considering the
amount of projection and rotation.
Fig. 4.9 Tip modi cation using a septal extension graft. Lower lat-
eral cartilages are moved and xed to a new dome created by the
septal extension graft.
Fig. 4.10 An additional onlay graft with conchal cartilage is used
for more projection or de nition.
a
b

4 Nasal Tip Modi cation in Asians: Augmentation and Rotation Control  53
Lateral crural strut grafts are commonly used to correct
the shape of or to reposition the lateral crus (Fig. 4.14).12
When the lateral crura are too concave or too convex, the tip
shape may appear unnatural. A straight piece of cartilage is
placed beneath the lateral crus to atten or straighten it out
and make for a more natural transition between the lateral
and intermediate crura.12 After dissecting the vestibular
skin beneath the lateral crus, a straight piece of cartilage
designed from the septal cartilage is inserted. The cartilage
graft and the vestibular skin are then through-and-through
sutured using 5–0 chromic gut. More sutures are added to
x the graft if necessary. Through this procedure the lateral
crura can be attened.
sors (Fig. 4.12). Immediately after the procedure, the tip
becomes narrower. With time, secondary scarring takes
place, making the tip even narrower.
Lateral Crural Graft
Lateral crural grafts prevent collapse of the lower lateral
cartilages and create a smoother alar–tip contour. There are
two types of lateral crural grafts: lateral crural onlay grafts
and lateral crural strut grafts.
Lateral crural onlay grafts are used to restore the lat-
eral crus w hen it has been dam aged or deform ed, and to
reinforce the alar cartilage w hen the tip is augm ented.11
When the lower lateral cartilage is severely dam aged
w ith loss of tip support, nasal tip support is rst restored
at the interm ediate and m edial crura through the use
of a septal extension graft or colum ellar strut. A graft
designed to m atch the lateral crural shape is then placed
on the lateral crus (Fig. 4.13). Using 5–0 chrom ic gut, the
cartilage graft and the vestibular skin are sutured using
through-and-through sutures. Sym m etrical grafts and
suturing are important to avoid postoperative asym m e-
try of the nasal ala. Cap or shield grafting can be per-
form ed sim ultaneously, as needed.
Fig. 4.11 Shield graft (arrow) via the open approach. The shield
graft is placed and secured to at least four sites using 5–0 PDS
or 6–0 clear nylon. The edges are beveled and a buttress graft is
added for more stability if necessary.
Fig. 4.12 Cephalic resection to reduce tip volume. At least 7 to
8 mm of lateral crura should be preserved, maintaining symmetry
on both sides.
Fig. 4.13 Lateral crural onlay graft. Septal or rib cartilage is
designed to match the shape of the lateral crus and is grafted onto
both lateral crura as a lateral crural onlay graft.

II Rhinoplasty
54
ics that can be shaped easily, such as Gore-Tex or Mersilene
mesh, more commonly employed. Rib cartilage can provide
su cient autologous grafting material. The premaxillary
area can be approached after dissecting between the medial
crura or through sublabial incision. A pocket slightly larger
than the graft is made, followed by insertion of the graft
material. Aggregates of small cartilages can be plumped in
the pocket, or a large piece of cartilage is inserted and xed
to the surrounding tissue or anterior nasal spine to pre-
vent slipping down or migration. It is important to design
the graft to t the curvature and shape of the premaxilla.
Diced cartilage wrapped with autologous fascia is another
good option. In case of an underdeveloped premaxilla with
poor tip projection, a premaxillary graft integrated into an
extended columellar strut can be used.
Alar Rim Graft
Alar rim grafting is a procedure in which a thin piece of
cartilage graft is placed along the alar rim starting from the
nasal facet (soft tissue triangle), to obtain a smooth tran-
sition from the tip lobule to the alar lobule. It reinforces
the alar margin and lowers the alar rim slightly when alar
retraction is present.14,15,16 In an open approach, soft tissue
dissection along the alar rim is started, beginning from the
nasal facet using sharp iris scissors. Dissection is performed
In cases where the lateral crura are positioned along
the longitudinal axis of the nose (“malpositioned”), the tip
can look like a ball, contributing to an unnatural look. The
appearance of the tip can be improved by changing the lat-
eral crura from a vertically oriented position to a more hori-
zontally oriented one. After the lateral crura are completely
dissected o from the vestibular skin, a long strut graft
can be applied, extending past the lateral crura. The lateral
crus is then rotated caudally and xed toward the piriform
aperture after dissection of the soft tissue in that area. This
lateral crural repositioning maneuver is well described and
used in Caucasians, but it is not so e ective in Asians, who
have relatively thick skin and subcutaneous tissue.
Premaxillary Graft
In Asians the premaxillary area is commonly underde-
veloped, resulting in retrusion of the subnasale, an acute
nasolabial angle, and columellar retraction. Autologous
(cartilage, bone) or arti cial (Gore-Tex, silicone, Mersilene)
grafts can be inserted near the anterior nasal spine or pre-
maxilla, to improve columella retraction and to achieve a
natural elevation and rotation of the nasal base.11,13
Autologous or synthetic grafts are inserted anterior to
the maxilla and just inferior to the anterior nasal spine. A
fair amount of material is usually needed, making synthet-
Fig. 4.14 Correction of alar-columellar disproportion. (a) Preoperative photo shows de cient nasal dorsum, hanging columella, and
slightly retracted alar rim. (b) Six months after surgery, the dorsum is well augmented and the ala and columella show a normal relation-
ship. (c) After degloving, the lower lateral cartilage is round in shape due to lack of angulation between the medial and lateral crura. (d) A
at piece designed from the septal cartilage is inserted in the dissected plane between the lateral crus and vestibular skin. The intermedi-
ate crura are xed to the septal extension graft. The resulting change in the shape and angle formed by the intermediate and medial crura
can be appreciated.
a
b
c
d

4 Nasal Tip Modi cation in Asians: Augmentation and Rotation Control  55
the septal extension graft considering the rotation and pro-
jection of the tip.
Tip Asymmetry or Deviation
Tip asymmetry or deviation is common when the natural
shape of the tip is modi ed. Exact positioning of the cau-
dal septum or septal extension graft in the midline is a key
element to prevent this complication. In addition, tip onlay
grafts need exact and symmetric positioning and suturing.
In many cases, a very mild asymmetry of thin, small lower
lateral cartilage is easily camou aged by thick nasal skin.
However, every e ort needs to be exerted in graft carving
and positioning to avoid asymmetry or tilting.
Graft Showing
Graft showing is not infrequently seen in thin-skinned
patients. Careful carving and avoiding overly aggressive
elevation w ill prevent this in most cases in medium- to
thick-skinned patients. However, in the very thin-skinned
patient, even this kind of measure will eventually end up
with the grafting showing. Perichondrium, fascia, or soft
tissue covering with extreme care on the beveling of the
grafts helps to prevent graft show-up.
Pain or Discomfort
Pain or discomfort of the tip usually disappears as time
goes by, but occasionally this remains continuously long
after surgery. Too much stretching of the tip by overzeal-
ous projection using a septal extension graft, using a hard
material such as septal bone or Medpor for a septal exten-
sion graft or columellar strut, or overly aggressive/inadver-
tent tissue work on the tip are the proposed etiologies. It
would be prudent not to push the limits in projecting or
rotating the tip using a septal extension graft and to use
additional onlay grafts on the new dome for maximal mod-
i cation of the tip. Often, pain or discomfort disappears
after graft removal.
Nasal Obstruction
Nasal obstruction can occur when an applied septal exten-
sion graft/columellar strut or the extended spreader graft
used to hold the septal extension graft is too thick, result-
ing in narrowing of the nostril. Buckling or dislocation of
the septal extension graft or caudal septum is another
source of nasal obstruction. Careful design of the graft to
avoid a thick columella or caudal septum and a strongly
secured, well-centered septum on the anterior nasal spine
are key elements to prevent buckling or dislocation of the
caudal septum.
close to the alar rim margin, taking care not to make the
pocket too big. A thin, at piece 2 to 3 mm in width and 12
to 15 mm in length is designed from the harvested septal
cartilage.16 The graft is inserted into the pocket and the inlet
is sutured after bruising the tip w ith Brown-Adson forceps.

■Key Technical Points
1. An onlay cap graft through the endonasal approach
is best achieved by adequate pocket dissection,
careful graft carving, and exact positioning through
guidance suture.
2. A combination of interdomal suture, columellar
strut, and onlay tip grafts through the endonasal
approach gives a minor to moderate tip
augmentation with gentle cephalic rotation.
3. A septal extension graft is designed with
consideration of the vector needed to augment or
rotate the tip.
4. The overlapping type of septal extension graft is
centered in the midline by careful carving and
positioning of the graft to avoid tip deviation.
5. The end-to-end type of septal extension graft is
put between the medial crura and aligned with
the caudal septum in end-to-end fashion with
gure-of-8 sutures. It is further reinforced with
extended spreader grafts or thin batten grafts.
6.
Various tip modifying techniques including shield grafts,
cephalic resection, lateral crural grafts, premaxillary
grafts, and alar rim grafts, are properly mixed with
septal extension grafts to further modify the tip.

■Complications and
Their Management
Loss of Projection
The increased projection achieved with a columellar strut
with onlay tip grafts may lessen as time goes by. Decreased
swelling with time and graft absorption may play a role
in projection loss. To prevent this, a septal extension graft
supported at the anterior nasal spine is used.
Over-rotation
Over-rotation is a common complication in which the pro-
jection is overly increased without considering the vector
of tip rotation. Without appropriate preventive measures,
increased projection using various tip grafts and struts
will eventually rotate the tip in the cephalic direction. This
complication can be prevented by appropriately designing

II Rhinoplasty
56
(Fig. 4.15). After consultation, she decided to use a silicone
implant for dorsum augmentation and conchal cartilage for
the tip (Fig. 4.16). A 3-mm -thick, I-shaped silicone implant
was carved and inserted via infracartilaginous incision
with infradomal extension. The tip was augmented using
a two-layer conchal cartilage onlay graft inserted through
the same incision. Photographs taken 6 months after sur-
gery show improved tip projection with a naturally aug-
mented dorsum (Fig. 4.17).

■Case Studies
Case 1: Tip Augmentation with an
Endonasal Onlay Graft
A 40-year-old female visited our clinic and wanted to
improve her nasal shape. Physical examination showed a
low and wide dorsum with a slightly under-projected tip
Fig. 4.15 (a–c) Case 1. A slightly low dorsum and less than ideal tip projection are observed from the preoperative photos.
Fig. 4.16 Case 1. Intraoperative photo shows a carved I-shaped
silicone implant with a two-layer conchal cartilage cap graft before
insertion.
a
b
c

4 Nasal Tip Modi cation in Asians: Augmentation and Rotation Control  57
augm ented w ith rib cartilage. The tip shape was m odi-
ed using an end-to-end septal extension graft rein-
forced w ith a bilateral extended spreader graft, cap graft,
lateral crural onlay graft, and alar rim graft (Fig. 4.19).
Photographs taken 1 year after surgery show improved
projection, rotation, and volum e of the tip w ith a harm o-
nious alar-colum ellar relationship. Her dorsum was ade-
quately augm ented, giving a m ore natural-looking nose
(Fig. 4.20).
Case 2: Tip Modi cation through an
Open Approach
A 39-year-old fem ale desiring to improve the appearance
of her nasal tip and dorsum visited our clinic. Her nasal
dorsum was low w hile the tip was w ide, am orphous,
and under-projected, and the alar-colum ellar relation-
ship was not in harm ony (Fig. 4.18). Her dorsum was
Fig. 4.17 (a–c) Case 1. Six months after surgery, the well-augmented dorsum and the tip are in balance.
Fig. 4.18 (a–c) Case 2. Preoperative photographs. Before surgery, a low dorsum with a poorly projected tip is evident.
a
b
c
a
b
c

II Rhinoplasty
58
Fig. 4.19 Case 2. Intraoperative photographs. (a) Rib cartilage harvest. (b) Septal extension graft using septal cartilage and reinforce-
ment with rib cartilage. (c) Repositioning of lower lateral cartilage. (d) Alar rim graft. After making an incision lateral to the nasal facet
and tunneling along the alar rim, a pre-designed piece of cartilage is inserted into the pocket. (e) Cap graft, lateral crural onlay graft, and
coverage with perichondrium. (f) Dorsal onlay graft with carved rib cartilage.
Fig. 4.20 (a–c) Case 2. Photos taken 1 year after surgery show a naturally augmented dorsum and the tip with good alar-columellar
relationship.
a
b
c
d
e
f
a
b
c

4 Nasal Tip Modi cation in Asians: Augmentation and Rotation Control  59
8. Whitaker EG, Johnson CM Jr. The evolution of open
structure rhinoplasty. Arch Facial Plast Surg 2003;5(4):
291–300
9. Zijlker TD, Vuyk H. Cartilage grafts for the nasal tip. Clin
Otolaryngol Allied Sci 1993;18(6):446–458
10. Daniel RK. The nasal tip: anatomy and aesthetics. Plast Re-
constr Surg 1992;89(2):216–224
11. Brenner MJ, Hilger PA. Grafting in rhinoplasty. Facial Plast
Surg Clin North Am 2009;17(1):91–113, vii
12. Gunter JP, Friedm an RM. Lateral crural strut graft: tech-
nique and clinical applications in rhinoplasty. Plast Recon-
str Surg 1997;99(4):943–952, discussion 953–955
13. Gunter JP, Landecker A, Cochran CS. Frequently used grafts
in rhinoplasty: nomenclature and analysis. Plast Reconstr
Surg 2006;118(1):14e–29e
14. Rohrich RJ, Raniere J Jr, Ha RY. The alar contour graft:
correction and prevention of alar rim deformities in rhi-
noplasty. Plast Reconstr Surg 2002;109(7):2495–2505, dis-
cussion 2506–2508
15. Boahene KD, Hilger PA. Alar rim grafting in rhinoplasty: in-
dications, technique, and outcomes. Arch Facial Plast Surg
2009;11(5):285–289
16. Toriumi DM. New concepts in nasal tip contouring. Arch
Facial Plast Surg 2006;8(3):156–185
References
1. Park SS, Jin HR. Non-Caucasian rhinoplasty. In: Flint PW,
ed. Cum mings Otorhinolaryngology—Head and Neck Sur-
gery. Vol. 1, 5th ed. Philadelphia, PA: Saunders Elsevier;
2010:568–579
2. Won TB, Jin HR. Nuances with the Asian tip. Facial Plast
Surg 2012;28(2):187–193
3. Sheen JH. Closed versus open rhinoplasty—and the debate
goes on. Plast Reconstr Surg 1997;99(3):859–862
4. Ha RY, Byrd HS. Septal extension grafts revisited: 6-year
experience in controlling nasal tip projection and shape.
Plast Reconstr Surg 2003;112(7):1929–1935
5. Kim MH, Choi JH, Kim MS, Kim SK, Lee KC. An intro-
duction to the septal extension graft. Arch Plast Surg
2014;41(1):29–34
6. Guyuron B, Varghai A. Lengthening the nose with a
tongue-and-groove
technique.
Plast
Reconstr
Surg
2003;111(4):1533–1539, discussion 1540–1541
7. Han K, Jin HS, Choi TH, Kim JH, Son D. A biomechani-
cal comparison of vertical gure-of-eight locking suture
for septal extension grafts. J Plast Reconstr Aesthet Surg
2010;63(2):265–269

60
5 Hump Resection
Tae-Bin Won and Hong Ryul Jin
Asian hump noses. In this chapter, characteristics of the
Asian hump nose will be addressed with emphasis on sur-
gical techniques commonly used to obtain reliable results.

■Patient Evaluation
The key in preoperative planning is determining the ideal
pro le, which is somewhat similar to performing dorsal
augmentation. There are two important points. The rst is
determining the level and height of the nasion. The level of
the nasion, in other words, is the starting point of the nose.
Di erences in the starting point among di erent races have
been emphasized consistently.5 Traditionally, the supratarsal
crease has been considered the ideal starting point for Cauca-
sians and the midpupillary line for Asians. However, there is a
trend in which contemporary Asian patients are asking for a
higher starting point. The authors consider the starting point
in Asians to be somewhere in between the supratarsal crease
and midpupillary line accounting for individual preferences
(Fig. 5.1). The height of the nasion is usually determined by
the nasofrontal angle. The ideal nasofrontal angle in Asians is
around 135 degrees for males and 140 for females.
The next step is determining the desired nasal tip pos-
ture, which is done by considering nasal projection and
rotation (nasolabial angle). The ideal pro le can be achieved
when a line is drawn from the nasion to the tip and the hump
can be resected and/or the dorsum augmented as needed.
Other practical issues to consider include skin thickness,
character of the hump, presence of deviation, and length of

■Introduction
Rhinoplasty is one of the most common facial plastic sur-
geries performed in Asia. Although the principles and
goals may be similar, the actual execution is quite di erent
from the Western version. Anatomic characteristics of the
Asian nose coupled with di erences in aesthetic standards
demand that it be approached in a unique way. Numerous
articles have been published highlighting these di erent
approaches and techniques.1,2,3,4 Rhinoplasty among Asians
involves peculiarities that distinguish the procedure from
its Caucasian counterpart.
Nasal hump surgery is commonly regarded as a “reduc-
tion” surgery in most Western rhinoplasty textbooks and
is also referred as “reduction rhinoplasty.” The common
goal of a hump nose surgery is to obtain a natural contour
of the nasal dorsum through adequate dorsal reduction
while dealing with the issues of an open roof. Although
there are Asian patients who have large humps, most Asian
hump noses di er from Western ones in that the size of the
nasal hump is not big, and the nose is frequently associated
with a relatively low nasal dorsum and under-projection
or under-rotation of the nasal tip. Naturally, correcting a
hump nose in Asians entails distinct di erences both in
concept and technique.
A small hump and the additional need for augmenta-
tion of the dorsum and the tip often minimize the amount
of hump removal and sometimes obviate the need for
resection itself. Prof loplasty instead of reduction rhino-
plasty might be a more suitable word when dealing with
Pearls
• Three common features of the Asian hump nose
are small size, low radix/low dorsum, and under-
projected tip.
• Management strategy should be focused on achieving
an ideal nasal pro le and not on hump removal.
• Obtaining a natural brow tip aesthetic line in the
frontal view is as important as obtaining an ideal
pro le in the lateral view.
• The amount of hump resection should be
tailored based on the predicted amount of dorsal
augmentation and tip projection.
• Radix and tip augmentation often minimizes or
obviates the need for hump removal.
• Among various techniques for addressing hump
nose, conservative humpectomy of the bony and/or
cartilaginous hump, followed by radix and/or dorsal
augmentation is the most commonly used method.
• In case of a large hump, component hump resection
with reconstruction of the rhinion using spreader
grafts is recommended.
• Complications of hump reduction include inverted-V
deformity, dorsal irregularity, and nasal obstruction.
These can be prevented by conservative hump
removal and use of spreader grafts or camou age
grafts.

5 Hump Resection
61
Anatomic Consideration and
Clinical Implication
The dorsal skin is thickest in the nasion and thinnest in the
rhinion (Fig. 5.3), resulting in a slight natural convexity in
the rhinion area. There are two clinical implications related
to this anatomic feature of the dorsum. First, when dissect-
ing near the area of the rhinion or hump, a curved perios-
teal elevator comes in handy; and second, when reducing a
hump, a at dorsum is indicative of over-resection.
Anatomy of the rhinion area of the osseocartilaginous
vault is another important point to understand when per-
forming a hump reduction. There is a broad overlap of the
nasal bones above and the septum and upper lateral carti-
lage (ULC) below (Fig. 5.4a). Many times it is su cient to
remove this bony hump until it reveals the underlying car-
tilage. There is a change in the shape of the dorsal septum
and in its relation with the ULC as it progresses caudally
from the bony junction—namely, from a broad “T” shape to
a “Y” shape to an “I” shape (Fig. 5.4b). Resection of the dor-
sal septum while performing hump reduction will destroy
this natural anatomy. Reconstruction with regard to the
the nasal bones. The characteristics of the nasal hump are
evaluated through careful visualization and palpation.
The hump may be generalized or localized. The general-
ized hump usually has a bony and cartilaginous component
while a localized hump can be the result of a prominence of
the nasal bone and/or upper lateral cartilage. A pseudo hump
refers to the visual phenomenon of an accentuated height of
the rhinion (resembling a hump nose), which can be caused
by a deep radix and/or a depressed lower vault near the supra-
tip (Fig. 5.2). Strategies in this situation should be focused on
restoring support and augmentation instead of resection.
We usually stress the pro le or oblique view when
evaluating the hump nose patient. However, there are also
salient features in the frontal view that we have to consider
and correct to achieve a good result in hump nose patients.
The frontal view is the most important view after all. Hump
stigmas in the frontal view include unnatural brow tip aes-
thetic lines (narrowing, widening, break, etc.), light re ex
in the area of the hump, and skin thinning with frequent
hyperemia or discoloration. Obtaining a natural brow tip
aesthetic line in the frontal view is as important as obtain-
ing an ideal pro le in the lateral view.

■Surgical Techniques
It is important to emphasize again that surgical techniques
of hump reduction are not that di erent from the Western
procedures. However, the decision of undergoing reduction
versus augmentation or redistribution is the key in manag-
ing hump noses in Asians.
Supratarsal crease level
Ideal nasion level
Midpupillary level
Fig. 5.1 Starting point of the nose in Asians. The ideal starting
point of the nose or the level of the nasion in Asians is considered
to be in between the supratarsal crease and the midpupillary line.
Fig. 5.2 Pseudo hump. A dorsal convexity can be seen in a patient
who has a depressed lower vault near the supratip, resembling a
hump nose.

II Rhinoplasty
62
When there is signi cant septal deviation or a need for
cartilage harvest, septoplasty is performed rst. Usually
the septal cartilage is harvested leaving 10 mm of carti-
lage dorsally and caudally, but when a considerable hump
resection is planned we leave more cartilage or harvest the
septal cartilage after humpectomy.
Sequence of Surgery and Tip-Plasty
Prior to dorsal work, we usually perform tip surgery.
Roughly 90% of the desired tip shape work (including pro-
jection, rotation, and de nition) is accomplished. The nal
touches are made after completion of the dorsal work. The
natural thickness of the dorsal septum w ill prevent aes-
thetic and functional complications such as the inverted-V
deformity and nasal obstruction.
The Approach: Open versus Closed
Hump reduction itself can be performed with equal suc-
cess via an endonasal or an open approach. Therefore, the
choice of approach is usually dictated by the need for con-
comitant procedures to the dorsum and tip. The authors use
the endonasal approach for a localized hump that does not
need additional dorsal work other than augmentation (i.e.,
spreader graft) and needs only minor tip manipulation. A
unilateral or bilateral intercartilaginous incision combined
with a partial trans xion or hemitrans xion incision is pre-
ferred for accessing the dorsum, and a separate marginal
incision is used for the tip.
An open approach is preferred in the majority of
patients who have a generalized hump needing removal of
the dorsal septal cartilage, have concomitant nasal defor-
mities such as asymmetry or deviation, and need major
tip changes. Although these maneuvers can be performed
endonasally, the authors prefer the open approach because
it provides better visualization and patient comfort in
applying and securing grafts, thus ensuring a more stable
and reliable result. The drawback of the open approach (i.e.,
a noticeable columellar scar) can be minimized by adhering
to basic wound closure techniques.
Dissection and Septal Cartilage
Harvest
Regardless of the approach, the soft tissue is elevated in
a supraperichondrial and subperiosteal plane. The ante-
rior septal angle is exposed and the entire nasal dorsum
visualized.
Fig. 5.3 Thickness of the dorsal nasal skin. The dorsal nasal skin
is thickest in the nasion and thinnest in the rhinion, resulting in a
slight natural convexity in the rhinion area.
Fig. 5.4 Relationship of the bony and cartilaginous dorsum.
(a) In the region of the rhinion area there is a broad overlap of
the nasal bones above and the septum and upper lateral cartilage
below. (b) The shape of the dorsal septum changes as it progresses
caudally from the bony junction from a broad “T” shape to a “Y”
shape to an “I” shape.
a
b

5 Hump Resection
63
authors use this sequence because it often minimizes or
obviates the need for dorsal reduction. It is not infrequent
to nd yourself in the odd situation where you need to aug-
ment the dorsum again after dorsal reduction to match the
desired height of the dorsum. Techniques of tip surgery are
beyond the scope of this chapter and will be dealt with in
another one. Brie y, for the typical Asian patient with weak
tip support, projection and rotation are usually performed
in two steps. The rst step is stabilization of the nasal tip.
This is the key step in Asian tip-plasty. The objective is to
establish a rm foundation on which further grafting can be
done. Stabilization of the nasal tip can be achieved by means
of either a columellar strut or a septal extension graft. Of
the two, the septal extension graft is by far the more power-
ful tool and can be used reliably in patients who have very
weak tip support or need a substantial increase in tip pro-
jection. It can alter projection and control rotation simulta-
neously. The second step is ne sculpting of the nasal tip.
This is done by combining sutures and a variety of grafts to
obtain the desired outcome (Fig. 5.5). The onlay graft such
as a cap graft or shield graft is the main workhorse.
Hump Reduction in Large-Hump
Asian Noses
Many techniques for nasal hump resection have been sug-
gested, including en bloc resection, component resection,
and Skoog dorsal resection.6,7,8,9 In the classic “composite
en bloc humpectomy” the components of the hump (bone,
dorsal septum, and both upper lateral cartilages) are all
removed together (en bloc), leaving an open roof. This
technique is usually applied to the generalized osseocarti-
laginous hump common in Western noses. Brie y, a no. 15
blade is held at the bony-cartilaginous junction of the dor-
sum in the horizontal plane and advanced caudally in the
plane of reduction to excise the cartilaginous portion of the
hump, transecting the upper laterals and the cartilaginous
septum, leaving it attached to the nasal bones. A 10-mm
Rubin osteotome is then inserted under the cartilaginous
segment and the bony dorsum reduced in the desired
plane, removing the entire osseocartilaginous hump en
bloc. Judicious rasping and cartilage trimming is followed
with careful palpation of the dorsum.
In “component humpectomy” the components of the
hump are reduced one by one, allowing precise manipula-
tion and preservation of the nasal mucosa. The upper lat-
eral cartilages are separated from the nasal septum prior to
hump reduction. The dorsal septum is reduced, followed by
bony hump removal (Fig. 5.6). Finally, the upper lateral car-
tilage can be trimmed, placed above the septum, or used as
autospreader grafts or spreader aps (Fig. 5.7). The authors
prefer to use this technique in large-hump Asian noses.
Lateral osteotomy is performed either endonasally or
percutaneously in patients who have an open roof defor-
mity, a wide dorsum, or an associated nasal deviation.
Fig. 5.5 Nasal tip surgery. Common steps in Asian tip-plasty with
poor tip support. Tip support is restored by (a) applying a septal
extension graft followed by (b) ne sculpting with additional onlay
tip grafts.
a
b

II Rhinoplasty
64
Fig. 5.6 Component hump reduction 1. (a) Visualization of the hump. (b) Upper lateral cartilages separated from the septum. (c) Reduc-
tion of the cartilaginous hump with a no. 15 blade. (d) Reduction of the bony hump with a Rubin osteotome.
Fig. 5.7 Component hump reduction 2. The upper lateral cartilages can be (a) trimmed with scissors or (b,c) used as autospreader aps.
a
b
c
d
a
b
c

5 Hump Resection
65
will camou age for the wide nasal base. Minor resection of
the cartilaginous hump will decrease the need for spreader
grafts and rarely violates the nasal mucosa, which can
reduce the risk of infection when using alloplastic implants
for dorsal augmentation.
When the desired dorsal height exceeds the height of
the hump, there is a choice between leaving it alone and
performing augmentation on top of it. The authors prefer
to perform hump reduction to smooth the dorsum prior
to augmentation. The amount of resection in this situa-
tion depends on the material used for dorsal augmenta-
tion. When silicone is used, the undersurface of the rhinion
area can be carved away, camou aging for small residual
convexity. For other grafting materials, such as cartilage,
expanded polytetra uoroethylene (ePTFE), and homolo-
gous fascia, a complete humpectomy is performed because
it is better to perform a uniform augmentation that leaves
less chance of an irregular dorsum or residual convexity.
Final Touch: Dorsal Augmentation
and Tip Re nement
Dorsal augmentation is performed to obtain the desired
height of the dorsum and camou age any remaining irreg-
ularities. This can take the form of radix augmentation or
radix and dorsal augmentation (Fig. 5.10). The latter has the
Spreader Grafts
Spreader grafts are preferably positioned bilaterally in
patients in whom we have resected substantial amounts of
dorsal septum in the rhinion area (Fig. 5.8). The reasons
for incorporating spreader grafts after a humpectomy are
as follows:
1. To support and reinforce the rhinion (keystone),
preventing the inverted-V deformity. This is
especially important in patients who have short nasal
bones. A short nasal bone means a short connection
between the upper lateral cartilage and the nasal
bone, and often this connection is disrupted after
hump removal, causing middle vault collapse.10
2. To control midvault width and achieve a smooth
brow tip aesthetic line. The thickness of the septum
increases dorsally, and excision of the thick dorsal
septum will narrow the midvault.
3. To prevent nasal obstruction. This is the functional
counterpart of a narrow midvault, which can cause
nasal obstruction due to internal valve narrowing.
4. To correct deviation or asymmetry of the midvault,
if present.
5. There is no study on the amount of cartilaginous
resection and the use of spreader grafts; however,
the authors encourage their use when there is any
doubt.
Conservative Humpectomy in Asian
Small-Hump Noses
Because the hump is relatively small in most Asian hump
noses, composite resection may not be a suitable tech-
nique for hump removal. Often simple bony rasping with
minor trimming of the dorsal septal cartilage is su cient
to achieve the desired dorsal height or obtain the platform
for further dorsal augmentation. Using a small straight
osteotome instead of a big Rubin osteotome followed by
incremental rasping with small rasps or a drill under direct
visualization is helpful. Bony humpectomy will reveal the
overlapping cartilaginous vault underneath, and precise
reduction of the cartilaginous vault can follow (Fig. 5.9).
The authors use the term conservative humpectomy, and
it is the procedure used in the majority of small or isolated
hump nose Asian patients. Subsequent dorsal augmenta-
tion w ith onlay grafts above and/or below the hump in
combination with tip surgery contributes to the frequent
use of conservative hump removal.
Although the overlapping upper lateral cartilage can
be visible underneath the nasal bones in the rhinion, there
is rarely an open roof, obviating the need for lateral oste-
otomies. Another reason that lateral osteotomy is not fre-
quently performed is because further dorsal augmentation
Fig. 5.8 Spreader grafts placed bilaterally in the dorsal septum
after humpectomy.

II Rhinoplasty
66
Fig. 5.9 Conservative humpectomy in a small Asian hump nose. (a) Visualization of the hump. (b,c) Bony humpectomy using osteotome
and rasp. Bony humpectomy reveals overlapping cartilaginous vault in the rhinion. (d) Reduction of the cartilaginous hump (dorsal septum
and upper lateral cartilage).
Fig. 5.10 Radix and dorsal augmentation. (a) Radix augmentation with crushed cartilage, (b) Radix and dorsal augmentation with ePTFE.
(c) Radix augmentation with periosteum. (d) Radix and dorsal augmentation with perichondrium.
a
b
c
d
a
b
c
d

5 Hump Resection
67
Functional Problems
(Internal Valve Collapse)
Preservation of the internal nasal valve after dorsal hump
reduction is frequently emphasized in the Western litera-
ture. Dorsal reduction itself will narrow the nasal valve.
In addition, lateral osteotomy and infracture of the lateral
nasal walls to close the open-roof deformity can subse-
quently medialize the upper lateral cartilages, resulting
in internal valve collapse and leading to signi cant nasal
obstruction. Techniques to preserve or reconstruct the
middle vault and internal valve in the setting of hump
reduction include using the classic spreader grafts, the
“pushdown” technique,9 and spreader or auto-spreader
aps.11 However, obstruction due to internal valve collapse
is rare in Asians, even after medialization of the lateral
walls, due to their thick skin and soft tissue envelope with
wide internal valve angle.12 A previous study in Asian hump
nose patients showed no incidence of postoperative nasal
obstruction after lateral osteotomies regardless of the use
of spreader grafts.2
Residual Convexity
Causes of residual convexity include overly conservative
humpectomy, inadequate augmentation or resorption of
radix implant, and tip drooping. Failure in the estimation
of the appropriate amount of hump removal together with
failure to execute one or more steps of hump removal can
be the cause of a residual true hump. The thought that the
amount of hump resection should be minimized to adjust
the amount of dorsum that will be augmented may have
led to insu cient hump removal.
Irregularity of the Dorsum
The dorsum, especially the rhinion, where the skin is thin-
nest, is prone to show irregularities on long-term follow-
up. Visible dorsal irregularities are a common cause of
secondary rhinoplasty.13 The relatively thick dorsal skin
of the Asian nose and simultaneous dorsal augmenta-
tion with hump removal can reduce the chances of dorsal
irregularities. Veri cation of a smooth dorsum by careful
palpation after redraping of the skin is essential. Continu-
ous augmentation of the dorsum (from radix to the supra-
tip) can also reduce this problem. When performing radix
augmentation, try to avoid using solid cartilage grafts since
they are prone to show. The authors prefer soft tissue graft-
ing material such as fascia (autologous or homologous) or
ePTFE. When more augmentation is needed, crushed carti-
lage is inserted below the soft tissue graft.
advantage of a smooth and gapless transition in the thin-
skinned rhinion area. Careful palpation with wet gloves is
important for detecting irregularities after humpectomy.
Re nement of the tip is performed at the end to produce
a harmonious nose. To obtain a favorable facial balance
together with a harmonious nose, it is advisable to consider
genioplasty in the patient who has a retruded chin.

■Key Technical Points
1. A component humpectomy is used for large,
generalized hump noses. The components of the
hump are reduced one by one, allowing precise
manipulation and preservation of the nasal mucosa
and upper lateral cartilage.
2. A conservative humpectomy is used in the majority
of small or isolated Asian hump noses. This is usually
followed by dorsal augmentation above and/or below
the hump in combination with tip surgery.
3. When performing dorsal augmentation after
humpectomy, a combined radix and dorsal
augmentation has the advantage of a smooth and
gapless transition in the thin-skinned rhinion.
4. Use soft tissue or crushed cartilage when performing
radix augmentation since solid cartilage is prone to
show in this area.
5. Spreader grafts or aps are performed whenever
there is any doubt to minimize the chances of an
inverted-V deformity.

■Complications and
Their Management
Inverted-V Deformity
Causes of an inverted-V deformity are middle vault col-
lapse, failure to close the bony open roof, and detach-
ment of the upper lateral cartilage from the nasal bones.
Although this deformity is not common in small-hump
Asian noses, patients who have short nasal bones are rela-
tively predisposed. Short nasal bones mean a small overlap
between the cartilaginous vault and the nasal bones, and
this connection can be disrupted during hump removal. To
prevent middle vault collapse and subsequent inverted-V
deformity, spreader grafts, binding sutures, and camou-
age onlay grafts can be used.

II Rhinoplasty
68
1. The open approach
2. Septoplasty and septal cartilage harvest
3. Tip-plasty with columellar strut and cap graft
4. Conservative en bloc resection of the bony-
cartilaginous hump with bony rasping
5. Radix augmentation with bruised septal cartilage
The 1-year postoperative photos show improved brow
tip aesthetic lines in the frontal view. Lateral and oblique
views show a well-balanced pro le with smooth dorsum
and increased tip projection and rotation.

■Case Studies
Case 1
A 35-year-old female patient complained of a bump on
her nose (Fig. 5.11). Characteristics of her nose included
a moderate hump with a low radix, a slightly under-pro-
jected tip, and moderately thick skin. Operative techniques
were as follows:
a
b
c
d
e
f
Fig. 5.11 Case 1. (a–c) Preoperative facial photographs of a 35-year-old female patient show a moderate hump, low radix, and a slightly
under-projected nasal tip with moderate skin thickness. (d–f) Postoperative 1-year facial photographs show a balanced pro le with aug-
mentation of the radix and the tip.

5 Hump Resection
69
Fig. 5.11 (Continued) (g) Graphic drawing of operative procedures.
g

II Rhinoplasty
70
3. Component humpectomy: resection of the dorsal
cartilaginous hump with a no. 15 blade, incremental
reduction of the bony hump with a Rubin osteotome
and rasp, and trimming of the upper lateral cartilage
w ith scissors
4. Bilateral spreader graft to correct deviation and
control the width of the dorsum
5. Cephalic resection, columellar strut, and cap graft to
re ne the tip
6. Bilateral lateral osteotomy to close the open roof and
narrow the bony pyramid
The 1-year postoperative photos show a balanced pro le on lat-
eral view, with tip re nement. The nose is straight on the frontal
view, with smooth brow tip aesthetic lines of adequate width.
Case 2
A 23-year-old female patient presented with cosmetic
issues concerning her nose (Fig. 5.12). She wanted to get
rid of her hump. Analysis of her nose revealed a generalized
hump, low radix, slightly ptotic and bulbous tip, and mod-
erately thin skin. Operative techniques were as follows:
1. Septal cartilage harvest through a modi ed Killian
incision
2. The open approach and degloving of the nose with
detachment of the upper lateral cartilage from the
septum
a
b
c
d
e
f
Fig. 5.12 Case 2. (a–c) Preoperative facial photographs of a 23-year-old female patient show a generalized hump and slightly bulbous,
under-projected nasal tip with moderately thin skin. (d–f) Postoperative 1-year facial photographs show a balanced pro le with reduction
of the hump and the tip re ned. A straight nose with smooth brow tip aesthetic lines of adequate width is also noted in the frontal view.

5 Hump Resection
71
8. Skoog T. A m ethod of hump reduction in rhinoplasty. A
technique for preservation of the nasal roof. Arch Otolar-
yngol 1966;83(3):283–287
9. Hall JA, Peters MD, Hilger PA. Modi cation of the Skoog
dorsal reduction for preservation of the m iddle nasal vault.
Arch Facial Plast Surg 2004;6(2):105–110
10. Sheen JH. Spreader graft: a m ethod of reconstructing the
roof of the m iddle nasal vault following rhinoplasty. Plast
Reconstr Surg 1984;73(2):230–239
11. Gruber RP, Park E, Newm an J, Berkowitz L, Oneal R. The
spreader ap in prim ary rhinoplasty. Plast Reconstr Surg
2007;119(6):1903–1910
12. Suh MW, Jin HR, Kim JH. Computed tomography versus
nasal endoscopy for the m easurem ent of the internal na-
sal valve angle in Asians. Acta Otolaryngol 2008;128(6):
675–679
13. Won TB, Jin HR. Revision rhinoplasty in Asians. Ann Plast
Surg 2010;65(4):379
References
1. Toriumi DM, Swartout B. Asian rhinoplasty. Facial Plast
Surg Clins North Am 2007;15(3):293–307, v
2. Jin HR, Won TB. Nasal hump removal in Asians. Acta Oto-
laryngol Suppl 2007;558:95–101
3. Jin HR, Won TB. Nasal tip augm entation in Asians us-
ing autogenous cartilage. Otolaryngol Head Neck Surg
2009;140(4):526–530
4. Won TB, Jin HR. Nuances with the Asian tip. Facial Plast
Surg 2012;28(2): 187–193
5. Jin HR, Won TB. Recent advances in Asian rhinoplasty. Au-
ris Nasus Larynx 2011;38(2):157–164
6. Ishida J, Ishida LC, Ishida LH, Vieira JC, Ferreira MC. Treatm ent
of the nasal hump with preservation of the cartilaginous
fram ework. Plast Reconstr Surg 1999;103(6):1729–1733,
discussion 1734–1735
7. Rohrich RJ, Muza ar AR, Janis JE. Component dorsal hump
reduction: the importance of maintaining dorsal aesthet-
ic lines in rhinoplasty. Plast Reconstr Surg 2004;114(5):
1298–1308, discussion 1309–1312
Fig. 5.12 (Continued) (g) Graphic drawing of operative procedures.
g

72
6 Correction of the Deviated, Twisted Nose
Hun-Jong Dhong

■Patient Evaluation
A thorough social and medical history should be obtained
from the patient and entered into the medical record.
In particular, the obtained information should include
smoking status, occupation, degree of concern with
facial appearance, nasal trauma, previous nasal surgery,
and co-morbidities such as allergic rhinitis and chronic
rhinosinusitis.
Physical Examination
Examination of the External Nose
The initial step for successful correction of a deviated
nose is a system atic physical exam ination that analyzes
existing aesthetic problem s and underlying anatom ic
deform ities. When draw ing a straight line from the
m idglabellar area to the m enton, the nasal bridge and
tip should be bisected sym m etrically in an ideal nose.
Additionally, the nasal dorsum should be outlined by
two sym m etric brow tip aesthetic lines extending from
the m edial supraciliary ridges to the tip-de ning points

■Introduction
In rhinoplasty, correction of a crooked or twisted nose
remains one of the most challenging surgeries. Nasal
asymmetry is related to facial attractiveness, patient sat-
isfaction, and quality of life.1,2 Deformities include not
only aesthetic problems but also functional consequences,
and thus correction of these coexisting problems should
be accomplished simultaneously. The nasal anatomy of a
patient with a twisted nose may be related to a bony pyra-
mid deformity, septal deviation, asymmetry of the upper
and lower lateral cartilages, or various combinations of
these. The problem can be congenital, or acquired second-
ary to trauma or previous surgery. Furthermore, patients
often have baseline facial asymmetry, and this a ects the
outcomes of corrective rhinoplasty. Because an anatomic
reconstruction carries the risk of weakening the supporting
bony and cartilaginous skeleton, a thorough understanding
of nasal anatomy and physiology, precise preoperative and
intraoperative analysis, the surgical knowledge and skill
to perform a tailored surgical procedure, and meticulous
postoperative management are all essential for correction
of a twisted nose. In addition, the surgeon should be skill-
ful and competent to perform a revision surgery if needed.
Pearls
• Precise preoperative clinical analysis of external
and internal nasal structures is the cornerstone of a
successful corrective rhinoplasty.
• It is essential to have a su cient preoperative
discussion between the patient and the surgeon
about the surgical options and what can be corrected.
• Facial asymmetry should be thoroughly evaluated
preoperatively, and the patient should be informed
of the results of the evaluation.
• The surgeon should consider cosmetic improvement
of the deviated nose as well as its functional
restoration.
• Dorsal deformities frequently accompany a deviated
septum, and the most important step in corrective
rhinoplasty is to create a straight septum along the
midline.
• The stability of a reconstructed nose is determined
by the strength of the straightened septum, which
originates from the integrity of the keystone area,
reinforcement of the L-strut, and a xation to the
anterior nasal spine.
• All extrinsic and intrinsic deforming forces should
be evaluated and relieved intraoperatively with
meticulous manipulation of each osteocartilaginous
framework.
• Bony deviation is corrected with accurate
osteotomies based on detailed evaluation of each
bony pyramid.
• The preferred techniques for correction of the lower
two-thirds of a deviated nose are use of a spreader
graft and septal extension graft.
• Deformed osteocartilaginous frameworks should
be managed in a conservative manner to the extent
possible.
• Postoperative care and follow-up are as important as
the surgery.

6 Correction of the Deviated, Twisted Nose
73
Examination of the Internal Nose
A patient with a deviated nose should be assessed for the
presence of nasal obstruction. Through endoscopic exami-
nation of the nasal cavity and nasopharynx, patency of the
external and internal valves, septal deviation, an inferior
turbinate condition, adenoid hypertrophy, and any abnor-
mal ndings must be evaluated preoperatively.4 These
(Fig. 6.1). Using this m ethod, the degree and type of
nasal deviation can be evaluated.
If the deviation is ambiguous, a bird’s-eye view or lat-
eral illumination is helpful to identify any subtle defor-
mity more clearly (Fig. 6.2 and Fig. 6.3). Then meticulous
palpation of each anatomic element, including the bony
pyramid, upper and lower lateral cartilages, cartilaginous
dorsum, and columella, should be performed to evaluate
size, shape, symmetry, and resilience. Facial asymmetry is
not rare in patients with a deviated nose, and most patients
become extremely conscious of their facial appearance
after surgery.3 Therefore, any minor asymmetries should be
described preoperatively to prevent patients from attribut-
ing them to surgery. The common causes of facial asym -
metry are listed below.
Fig. 6.1 Facial midline and brow tip aesthetic line. The brow tip
aesthetic line begins at the medial brow, curving inferiorly along
the dorsal border, and gently blending with the tip-de ning point.
It should be parallel, uninterrupted, and symmetric.
Fig. 6.2 (a,b) A bird’s-eye view: Dorsal
irregularities are more obvious because
the distance between the nasal tip and lips
and the distance between the lips and chin
become less.
Common causes of facial
asymmetry include:
• Di erence in facial width
• Asymmetric eyebrows
• Orbital level di erence
• O -center anterior nasal spine
• Lateral placement of the piriform aperture
• Nonhorizontal alar base
• Maxillary or mandibular hyper-/hypoplasia
• Malar prominence or recession
a
b

II Rhinoplasty
74
Surgical Planning
The next step is planning the surgical procedure based on
clinical analysis. The surgical plan may consist of correction
of the deformity and reinforcement of the framework. The
appropriate approach and surgical techniques should be
determined according to the deformities of each anatomic
element. If use of a graft technique is anticipated, the sur-
geon should know the materials preferred by the patient
before the surgery.7 Patients must be informed about the
pros and cons of each graft material, including autologous
(septal, conchal, or costal cartilage), allograft (fascia lata,
alloderm), and arti cial materials (Gore-Tex, silicone).8
Patient Interview and Selection
Once the surgeon has developed a plan, there should be a
discussion with the patient about the details of the pro-
cedure and expected surgical outcome. Because there can
be discrepancy in the de nition of an optimal outcome
between the perspectives of the surgeon and the patient,
the surgeon should explain the results of the analysis and
the expected outcome of surgery based on the photographs.
Additionally, the surgeon should explain the potential dif-
ferences between surgical goals and ultimate outcomes.
The nal step of the preoperative evaluation is patient
selection, and this is as important as the clinical assess-
ment. Patients who have a realistic expectation for the
surgery and an understanding of the surgical limitations
are good surgical candidates. Surgeons should pay particu-
lar attention to detect poor surgical candidates who show
alterations should be somewhat predictable preoperatively
by several tests, such as acoustic rhinometry and paranasal
computed tomography. If there is anything that could cause
nasal obstruction, it should be managed during corrective
rhinoplasty.
Examination of the Nasal Skin and
Soft Tissue Envelope
The clinical analysis of external nasal deformities should
include an evaluation of the skin–soft tissue envelope
(SSTE). If the patient has a thick SSTE, it w ill take longer
for the edema to subside and will disrupt the postopera-
tive aesthetic outcome.5 In contrast, a thin SSTE is likely to
reveal small remnant deformities underneath the skin.
Medical Photography
Standardized photographs are essential in the preoperative
facial evaluation to con rm the clinical analysis of the nose
and the face. Frontal, lateral, oblique, basal, and bird’s-eye
views are the basic photographs that should be obtained.
Medical photographs enable the identi cation of impor-
tant facial ndings that may have been missed during
initial inspection and allow for comparison of the postop-
erative outcome and preoperative status.6
Fundamental facial analysis includes measurements
and evaluation of proportions of the eyebrows, medial can-
thus, nasion, rhinion, alar sidewall, alar facial junction, col-
umella, columellar-labial junction, philtrum, mouth angle,
and gnathion (Fig. 6.4).
Fig. 6.3 (a,b) E ect of oblique lighting.
A light and darkness contrast can exagger-
ate the deformity of the brow tip aesthetic
lines.
a
b

6 Correction of the Deviated, Twisted Nose
75
line for surgery. The deviated nose needs to be analyzed
according to each anatomic domain (upper, middle, and
lower third) and reciprocal relationships from a perspec-
tive of aligning to the midline.
Upper-Third Deviations
Deviation of the upper one-third of the nose is caused
by asymmetry and hump of the bony pyramids. Through
meticulous palpation and computed tomography, the size,
shape, and symmetry of each bony pyramid should be
evaluated. In cases of minor deformities, the bony dorsum
can be corrected by a camou age or rasping technique. A
patient who has only a deviated bony dorsum is likely to
have a history of nasal trauma or a humped bony pyra-
mid.12 Generally, most bony pyramidal deviations entail a
de ected middle third of the nasal dorsum.
Camou age
This technique can be applied to a patient who has a
localized depression or asymmetry of the bony pyramid.
Crushed septal cartilage is the preferred graft material. The
material is placed under a periosteal ap to reduce mobility
and visibility. The skin over the bony dorsum is relatively
thin; therefore, the surgeon must be certain to conceal the
contour of the graft on the skin.13
Rasping
In some cases with bony pyramidal deformities, rasping
can be a convenient surgical modality. If the bony pyra-
mid has a symmetric arch but the dorsal pro le is devi-
ated or deformed, the rasp can be solely applied to correct
excessive concern about minor deformities or have unreal-
istic expectations.

■Surgical Techniques
Choice of Approach
The choice between endonasal and external approaches
depends on the surgical plan and the surgeon’s preference.6
Although preoperative clinical analysis may enable selec-
tion of a particular approach, patients who undergo the
endonasal approach must be informed of the possibility of
conversion to an external approach for more complete cor-
rection. In general, the endonasal approach can be applied
for cases with subtle deformities of the upper or middle
vault, and for patients with keloid, who require avoidance
of unpredictable contractures associated with an open
approach.9 Meanwhile, an external approach is preferred
for the management of deviation of the lower two-thirds
and severe asymmetries of the nasal bone, and some cases
require maximal exposure, mobilization, and reshaping.
Through bilateral marginal incisions connected to a trans-
columellar inverted-V incision, complete exposure of the
nasal tip and midvault in the supraperichondrial plane can
be achieved. To approach a bony pyramidal deformity, an
extended dissection in the subperiosteal plane is essential.
Correction of Deviation
Although there have been various classi cations for the
deviated nose,3,4,10,11 they all originated from the need for
statistical analysis of outcomes rather than a clinical guide-
Facial analysis
• Eyebrows
• Medial canthus
• Nasion/rhinion
• Alar side wall
• Alar facial junction
• Columella
• Columellar–labial junction
• Philtrum
• Mouth angle
• Gnathion
Fig. 6.4 Facial analysis. The nasion, nasal tip, and philtrum
should all be along the midline. The distance from each
landmark on both sides to midline should also be the same.
Evaluation of facial asymmetry is very important in consulta-
tion of deviated nose.

II Rhinoplasty
76
tent, and double lateral (Fig. 6.5). Though osteotomies are
usually performed underneath the soft tissue envelope, a
percutaneous external approach can be used for lateral and
transverse osteotomies. Puncture site visibility after percu-
taneous osteotomy is negligible.16 To produce an accurate
fracture line despite anatomic di culties, the tip of the
osteotome should always be sharp.
Lateral Osteotomy
The purpose of the lateral osteotomy is to cut the nasal dor-
sum from the side wall. It enables the surgeon to obtain
complete mobility of the nasal bones and then reposi-
tion them on the midline. As shown in Fig. 6.6, the lateral
osteotomy makes a continuous curved fracture line on the
lateral aspect of the bony pyramid with an osteotome and
hammer. Endonasal osteotomy is frequently performed
using the vestibular approach. First, a small linear incision
is made with a no. 15 blade on the lateral endonasal wall at
the anterior margin of the inferior turbinate. Then iris scis-
sors are inserted to dissect the soft tissues in the subperi-
osteal plane along the lateral rim of the piriform aperture.
The dissection only needs to be wide enough to insert a
guarded osteotome (curved or straight). When determin-
ing the start point of a lateral osteotomy, Webster’s triangle,
which is a small triangular portion of the frontal process of
the maxilla, should be preserved because the inferior tur-
binate inserts into this structure. Otherwise, the internal
valve may be compromised (Fig. 6.6). The triangle can be
preserved by starting the osteotomy at the slightly antero-
superior point of the piriform aperture edge.17 Through
cautious palpation of the guard tip, the lateral osteotomy
the deformities. In many cases, rasping is used to trim the
dorsal contour before bony pyramidal reconstruction of
asymmetrical nasal bones through osteotomies. It should
be noted that rasping must be performed carefully with
consideration of how the bony pyramid will be positioned
after the reconstruction.
Osteotomy
The osteotomy is one of the most essential but di cult
techniques of corrective rhinoplasty. It involves cutting the
nasal pyramid bones to correct a deviation. Without oste-
otomies, the deviated bony dorsum cannot be completely
corrected. The osteotomy is a blind procedure, with no
direct visualization of cutting lines; therefore, it is chal-
lenging to learn. Thus, surgeons should make an e ort to
gain reliable and reproducible surgical skills.
To avoid unnecessary complications, it is essential to
have sound knowledge of the basic anatomy of the bony
dorsum before performing an osteotomy. The bony dor-
sum is composed of the frontal bone, nasal bone, and fron-
tal process of the maxilla; and these structures are joined
together. The characteristics of the bone, especially changes
in thickness, should be understood. Generally, the nasal
bone is thicker in men than in women. It is thickest at the
nasofrontal suture line (5 to 6 mm) and then becomes pro-
gressively thinner toward the lower margin (2 to 3 mm).14,15
The lateral wall of the bony dorsum consists of the nasal
bone and the frontal process of the maxilla, and the thick-
ness of the lateral process is less than 2.5 mm.
There are various types of osteotomy, including medial
(medial oblique, paramedian), lateral, transverse, intermit-
1
2
3
4
5
Lateral osteotomy
Medial osteotomy (medial oblique)
Transverse osteotomy
Medial osteotomy (paramedian)
Intermediate osteotomy
1
2
3
4
5
Fig. 6.5 Various types of osteotomy. Compared with
a medial oblique osteotomy, a paramedian osteotomy
is more useful in the patient with short, narrow nasal
bones.

6 Correction of the Deviated, Twisted Nose
77
margin, medial movement of the nasal bone can induce a
greenstick fracture of the medial and upper portion of the
nasal bone that is needed for shifting of the nasal bone.
However, these greenstick fractures do not always take
place appropriately, and can result in an undesirable out-
come. To avoid incomplete connection between medial and
lateral osteotomies, a percutaneous transverse osteotomy
can be performed. Asians in particular have a relatively
at and thick bony dorsum.18 Because of these anatomic
features, a percutaneous transverse osteotomy for back
fracture is more frequently required than in Caucasians. A
medial osteotomy may also be needed for some patients
who have a bony dorsum that is too narrow and requires
widening with a spreader graft. The upper limit of the
medial osteotomy should be under the level of the inter-
canthal line, particularly in a paramedian osteotomy. An
osteotomy should be su ciently complete to mobilize the
bony pyramid while decreasing tissue trauma as much as
possible to achieve optimal consistency.
The author’s tips for performing a safe osteotomy are
as follows:
1. Do not make periosteal elevation over the nasal
bone too far laterally. Periosteal attachment over the
bones provides stability of bony fragments.
2. Use the smallest possible osteotome. This minimizes
trauma to the soft tissue adherent to the internal
surface.
3. Feel the sensation of the break through the bone
during tapping.
4. Avoid damage to the junction between the upper
lateral cartilage (ULC) and nasal bones.
5. Use a “low-to-high” or “high-low-high” lateral
osteotomy to avoid complications.
Midvault and Tip Deviations
Deviation of the lower two-thirds of the nose is the most
complex condition. Many combined pathologies of the
cartilage frameworks may coexist and a ect each other.
The surgeon should evaluate aberrant anatomy during the
operation. The main surgical procedures include the cam -
ou age graft, straightening of the septum along the mid-
line, reconstruction of the anterior nasal spine, xation of
the deviated lower lateral cartilage to the newly positioned
septum, forming a symmetric dome, and rebuilding a rm
and straight columella.
Nasal Septum
The most important and fundamental procedure in cor-
rection of the twisted or crooked nose is straightening of
the nasal cartilaginous septum with or without reinforce-
ment.19 Deforming forces causing septal deviation may be
can be continued along the designated osteotomy line. The
osteotomy should stop at the level of the intercanthal line
and approximate the upper margin of medial osteotomy.
In some patients who have a severe asymmetric contour
or excessive convexity of the lateral bony wall, a single lat-
eral osteotomy is not enough to construct a symmetric nose.
In these cases, an additional osteotomy on the deformed lat-
eral bony wall is useful to produce a symmetric and natural
concavity of the lateral nasal wall (double osteotomy). The
fracture line should be parallel to the lateral osteotomy and
approximate the nasomaxillary suture line.
Medial Osteotomy
The medial osteotomy is a surgical technique that involves
separating the medial aspect of the nasal bone from the
bony septum. Generally, medial oblique and paramedian
osteotomies are preferred among the various medial oste-
otomies. Using a 2- or 4-mm osteotome, a medial osteot-
omy should begin at the inferior margin of the junction of
the nasal bone with the dorsal bony septum, toward the
upper margin of the lateral osteotomy. When performing a
medial osteotomy, it should be noted that the thickness of
the bony dorsum varies considerably by region; therefore,
it is important and challenging to make a controlled aes-
thetic fracture line. Because the nasal bone gradually thick-
ens toward the frontal bone, an upper margin of a medial
osteotomy that is too high can result in the restriction of
medial shifting of the nasal bone or a rocker deformity.
Finally, back fracture of the mobilized nasal bone is
performed at the level of the medial canthal line and can
be done with a greenstick fracture. After lateral osteotomy
with superior oblique extension of the upper osteotomy
Fig. 6.6 Lateral osteotomy. To avoid over-narrowing of the nasal
cavity, it is recommended that a small triangular area (yellow col-
ored area) of the piriform aperture at the level of the nasal oor be
preserved. Lateral osteotomy usually begins at or just above the
junction of the inferior turbinate and the lateral nasal wall.

II Rhinoplasty
78
Through meticulous dissection of the midvault in the
supraperichondrial plane, the nasal dorsum is exposed
enough to be evaluated. After intraoperative evaluation of
any dorsal deformities and causative factors for each ana-
tomic component, the bilateral subperichondrial dissection
of the septum is extended to the dorsal septum and across
the upper lateral cartilage while preserving mucoperichon-
drial integrity. The dissection should be w ide enough to
align the septum to the midline. Next, the dorsal septum is
released from the upper lateral cartilage, and this enables
evaluation and assessment of any intrinsic deformity of the
dorsal septum. In the presence of dorsal septal deviation, a
unilateral or bilateral spreader graft may be the treatment
of choice (Fig. 6.9).
The spreader graft acts to x the dorsal septum into a
straight orientation and prevent late return of the defor-
mity. In addition, the grafts can maintain or restore the
integrity of the internal nasal valves. The ideal graft mate-
either intrinsic or extrinsic. Release of extrinsic forces is
essential to correct the cartilaginous septal deformity, and
these prevent surgical failure or recurrence.20 Extrinsic
forces may originate from the upper lateral cartilage, bony
septum, nasal spine, septal mucosa, lower lateral carti-
lage, and columellar soft tissue. Through elimination of the
e ects of extrinsic forces one by one, a deviated septum can
be straightened. If the freely mobilized septum shows any
deformity, intrinsic deforming forces must be addressed
and corrected. Intrinsic forces can be released by weaken-
ing the cartilage or through reinforcement with sutures
and grafts.
The septum should be straightened while maximiz-
ing residual dorsal nasal support. With these two goals
in mind, the deviated portion of the septum should be
resected while preserving at least an 8- to 10-mm dorsal
and caudal L-strut (Fig. 6.7).21 The resection can include
the maxillary crest, the perpendicular plate of the ethmoid,
and the vomer. In the keystone area, the L-strut should
remain attached to the perpendicular plate. In addition, the
attachment between the nasal spine and the caudal portion
of the L-strut should be preserved if possible. If the caudal
septum is subluxated from the midline of the nasal spine,
the septum needs anatomic correction with separation
from the nasal spine and lower lateral cartilage, followed
by xation using a gure-of-8 suture technique (Fig. 6.8).
Various surgical techniques can be applied for straight-
ening the septum, including the swinging door technique,
wedge resection, batten graft, spreader graft, cutting and
suture technique, and scoring and suture technique.22,23,24,25,26
In complex cases, extracorporeal septoplasty may be an
e ective, safe, and reliable technique, especially for mark-
edly twisted noses undergoing surgery.27,28
Middle Third
After the straightened nasal septum has been aligned in
the midline, the midvault must be reconstructed to achieve
an aesthetic and functional outcome. Using various septal
supporting grafts and precise suture technique, the mid-
dorsum should be rmly straightened.
Fig. 6.7 L-strut of septal cartilage. It is important to preserve the
L-strut with at least an 8- to 10-mm width to prevent saddle nose
deformity. The size of the L-strut depends on the strength and sti -
ness of the remaining septal cartilage.
Fig. 6.8 Repositioning of the dislocated caudal septum. When the caudal septum is subluxated, it is frequently necessary to separate
the cartilaginous septum from the underlying bone. Then disarticulated cartilage should be xed to the anterior nasal spine using sutures.

6 Correction of the Deviated, Twisted Nose
79
Lower Third
As in the midvault, correction of lower-third deformities is
based on how to make a straight and strong caudal sep-
tum. Deforming forces from the cartilaginous framework
of the midvault frequently a ect the tip; therefore, a care-
ful dissection is sometimes needed to detach the lower
lateral cartilages from the upper lateral cartilage. If the
caudal septum is not in the midline, it should be carefully
released from the maxillary crest and anterior nasal spine
and a xed to the midline. Furthermore, if there is congeni-
tal deformity or posttraumatic change of the anterior nasal
spine or maxillary crest itself, these deformities should be
preferentially corrected. Caudal deviation of the septum
can be e ectively corrected with an extended spreader
graft or septal batten graft using harvested cartilaginous
and bony septum.31
The next step is to create a rm vertical strut in the
m idline. A septal extension graft is useful when the tip
is weak or deviated. It is e ective for obtaining a straight
caudal end and prom inent projection. However, one m ust
be careful to avoid functional nasal obstruction caused
by the thickened caudal septum , and the patient should
be inform ed of the loss of exibility of the mem branous
septum . The end of the septal extension graft should be
beveled and is a xed to the caudal septum with multi-
ple anchoring sutures. The septal extension graft acts as
a reliable strut not only for supporting the lower lateral
cartilages, but also to control tip position and de nition
(Fig. 6.11). The degree of tip projection and rotation, and
the colum ellar pro le and strength can be determined by
the size and shape of the designed graft and the position. A
m ore stable columella reconstruction is obtained through
tight xation of each of the m iddle and m edial crura to the
septal extension graft.
rial is septal cartilage, especially the posteroinferior por-
tion, which has the most consistent width. The grafts are
secured with several 5–0 PDS mattress sutures parallel to
the dorsal septum. To decrease the likelihood of recurrence,
the deviated septal cartilage can be cross-hatched before
suturing. In the case of outward bowing of the midvault on
the convex side of the dorsum, a batten graft can be placed
below the junction of the septum and upper lateral carti-
lage. As shown in Fig. 6.10, slight dorsal deviation can be
straightened through the di erential suture between the
upper lateral cartilage and septal dorsum.29 Similarly, this
suture technique can be used to correct remnant deviation
after a spreader graft.30
Fig. 6.9 Spreader graft. After separation of the upper lateral carti-
lage from the septal cartilage, a spreader graft is inserted and xed
using 4–0 PDS. This procedure is helpful in widening the air passage
as well as in cosmetic improvement of middle-third deviation.
Fig. 6.10 Oblique suture to correct cartilaginous deviation. Compared with the horizontal suture, the di erentially oblique suture pro-
vides force to draw deviated septal cartilage to the midline. This technique can be used to correct the cartilaginous deviation (a) without
or (b) with a spreader graft.
a
b

II Rhinoplasty
80
and skin adhesive, the nasal dorsum is taped with ¼-inch
paper tape. Strips of di erent lengths are carefully applied
transversely from the bony dorsum to the supratip while
avoiding excessive pressure over the reconstructed frame-
work. Symmetric long strips are applied from the bony dor-
sum along the caudal aspect of the nasal lobule to support
the tip. An external splint is applied for patients who have
undergone osteotomies to support the repositioned struc-
tures and to control bone bleeding. The splint is placed over
the upper two-thirds of the dorsum while compressing
medially. The lower margin of the splint should not extend
over the supratip area to avoid dead space between the
supratip skin and the underlying framework. After 5 to 7
days, columellar sutures, skin tape, and the external splint
are gently removed.

■Postoperative Management
Prophylactic antibiotics are used while the nasal splint
is applied. Short-term, high-dose steroids can be used
intraoperatively and postoperatively to minimize wound
edema. Generally, patients who have used anticoagulants
are instructed to stop the medication for 1 week preop-
eratively and can begin the medication 5 to 7 days postop-
eratively. Analgesics for postoperative pain are prescribed
as needed. Patients should avoid straining related to con-
stipation or nausea, and prophylactic medication for the
causes of straining should be prescribed as needed. Anti-
biotic ointment should be applied to the incision site daily.
Saline nasal spray is used three to four times daily to keep
mucosal surfaces moist and clean. Patients should avoid
sun exposure to facial bruises to prevent skin pigmentation.
At a minimum, patients should be seen in follow-up at 1
week, 1 month, 3 months, and 6 months, and postopera-
tive medical photography should be obtained. Thereafter,
patients should be evaluated every 1 to 2 years to assess
long-term results.

■Key Technical Points
1. The deviated nose consists of a bony upper third
and cartilaginous lower two-thirds, and each
compartment should be assessed considering
di erent surgical concepts and techniques.
2. The choice of approach depends on a surgical plan
that is based on an accurate preoperative clinical
analysis.
3. The midvault and tip are dissected in the
supraperichondrial plane, and the bony dorsum
requires subperiosteal dissection.
4. Precise osteotomy is a key procedure for correcting
bony pyramidal deformities.
The symmetry of the lateral crus and domes should
be evaluated and properly corrected. The interdomal liga-
ment is sutured to the domal segment of the septum or the
extension graft. The a xation should be adjusted for ideal
symmetry of each dome. The cephalic border of the lateral
crus can be trimmed to be in line with the pro le contour
of the extension graft.
Wound Closure and Dressing
If an external approach is applied, the columella incision
should be repaired rst. Subcutaneous approximation with
5–0 vicryl should be followed by meticulous skin closure
with 6–0 nylon. Several quilting sutures are needed on
the dissected mucoperichondrial ap, and a small muco-
sal incision can be made on one side of the septum to pre-
vent septal hematoma, if needed. Internal splints, such as a
silastic sheet, can be applied to avoid hematoma between
the mucoperichondrial aps and to stabilize the recon-
structed structures, which promotes the healing process
and prevents mucosal problems like synechiae. A single
through-and-through suture is su cient to x the splint
to the septum. Prophylactic antibiotics are needed while
the splint is in place. Splints are generally removed 1 to 2
weeks after surgery in the outpatient department. In cases
of extensive septal reconstruction, the splints remain in
place for longer periods (up to 3 weeks). Soft nasal packing
(e.g., NasoPore, Gelfoam) is enough to control bleeding and
to support a ap or graft. Packing is removed within 1 to 2
days. External dressings are composed of soft tissue taping
and an external splint. After skin preparation with alcohol
Fig. 6.11 Septal extension graft to correct the caudal deviation.
The septal extension graft is a very useful technique to correct cau-
dal deviation when the tip is weak and resilient.

6 Correction of the Deviated, Twisted Nose
81
year after surgery; therefore, the patient should be given
reassurance. In some cases with excessive scarring, local
steroid (triamcinolone acetate) injection may be helpful.
Super cial injection should be avoided to prevent whitish
pigmentation. Of note, steroid injection can result in sub-
dermal atrophy with subsequent undesirable problems,
including dorsal contour deformities and translucency of
the epidermis.
Dorsal Irregularity/Deviation
In some patients, dorsal deviation or irregularity can pres-
ent during the postoperative period. The cause and degree
of deformities should be evaluated to determine whether
revision surgery is needed. Common causes of late bony
deviation are listed below. Immediate postoperative devia-
tion should be reassessed as soon as possible, and minor
deformities in the early postoperative period can be cor-
rected with manual pressure. If revision is required, it can
be done 6 to 12 months after the primary surgery.
5. In correction of the twisted nose, straightening and
reinforcement of the nasal cartilaginous septum
are the most important procedures. For this, the
septum should be released from extrinsic deforming
forces, with subsequent assessment of the intrinsic
deformities, while preserving the L-strut.
6. The integrity of the keystone area must be
maintained and the caudal end of the L-strut should
be rmly a xed to the anterior nasal spine using
a gure-of-8 suture. If the anterior nasal spine is
displaced, it should be repositioned.
7. A spreader graft is a useful tool for simultaneous
straightening and reinforcement of the cartilaginous
dorsum.
8. Tip correction is based on a straight and strong
caudal septum as a reliable vertical strut in the
midline.
9. The a xation of lower lateral cartilages should be
adjusted for ideal symmetry of each dome at the
midline.
10. The columellar incision should be repaired with
meticulous suturing without tension.

■Complications and
Their Management
Bleeding/Hematoma
Slight postoperative oozing is common in the rst 48 hours
after rhinoplasty. Toilet gauze dressing is helpful to reduce
patient discomfort, and head elevation can reduce bleed-
ing by decreasing venous pressure. If bleeding persists, the
surgeon should immediately evaluate the wound. When
further nasal packing is not enough to control bleeding, the
surgeon should consider total removal of packing mate-
rials and reevaluation of the nasal cavity. A patient who
complains of uncontrolled nasal pain should be assessed
for septal hematoma. Regardless of location, postoperative
hematomas require immediate drainage. An untreated sep-
tal hematoma can result in devastating complications, such
as septal abscess and perforation. Insertion of a silastic
drain into the drainage site of the hematoma helps prevent
recurrence.
Persistent Edema
Postoperative edema usually occurs within the rst 4
weeks. Various modalities are available to minimize edema,
including cold compresses, head elevation, taping, and
perioperative steroids. Late edema can be observed several
months postoperatively, and it originates from ongoing scar
remodeling. Most late edema is self-limited around the rst
Causes of late deviation of the bony
pyramid include:
• Incomplete osteotomies: incomplete connection
between the medial and lateral osteotomies.
Memory of the overlying soft tissue can pull the
nasal bone to the original position.
• Incomplete correction of the posterior–superior
de ection of the bony septum.
• Insu cient correction of deformities of the
cartilaginous lower two-thirds.

■Case Studies
Case 1
A 22-year-old man presented with a crooked nose that
had a C-shaped deformity of the septum to the right with
subjective nasal obstruction on the right side. The brow tip
aesthetic lines were asymmetric, and the bony and carti-
laginous dorsum was o the midline (Fig. 6.12).
This case required corrections of both the bony dorsum
and the midvault; therefore, open corrective rhinoplasty
was performed. The author prefers to use the external
approach to correct the lower two-thirds deviation, which
usually needs a spreader graft or septal extension graft.
Through the external approach the author can con dently
apply graft materials as well as evaluate the anatomic

II Rhinoplasty
82
In this case, surgical techniques included lateral and
medial osteotomies, release of the cartilaginous septum
from the upper lateral cartilage, a left-sided spreader graft,
septoplasty, repositioning and reinforcement of the cau-
dal septal L-strut with a gure-of-8 suture and columellar
strut, cephalic trim of the lower lateral cartilage, and inter-
domal suture on the tip. The patient was satis ed with the
functional and aesthetic outcomes after surgery.
At 1 year after the surgery, the dorsum had a symmet-
ric contour without any postoperative distortion.
abnormalities. In terms of order of procedures, septoplasty
is carried out rst after elevation of the skin soft tissue
envelope. If there is a hump deformity, rasping or humpec-
tomy is done. The next step is to correct the lower two-
thirds deformities using grafting and suture techniques.
This is followed by tip surgery, which is mainly for cosmetic
purposes. Medial and lateral osteotomies are usually done
at the end of the operation to avoid soft tissue swelling dur-
ing surgery. In cases w ith a wide alar base, its correction
w ill be the nal procedure.
a
b
c
d
Fig. 6.12 Case 1. (a,b) Preoperative frontal and bird’s-eye views show a C-shaped deviated bony and cartilaginous dorsum. (c,d) Postop-
erative photographs show a straightened nose.