Phẫu Thuật Tạo Hình Thẩm Mỹ Khuôn Mặt Người Á Đông

II Rhinoplasty
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a
b
c
d
e
f
Fig. 6.13 Case 2. (a–c) Preoperative photographs show straight bony pyramid but deviated cartilaginous dorsum with mild hump. (d–f)
Postoperative photographs show well-aligned dorsum with reduced hump.

6 Correction of the Deviated, Twisted Nose
85
Fig. 6.13 (Continued) (g) Surgical diagram showing techniques used.
g

II Rhinoplasty
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16. Gryskiewicz JM. Visible scars from percutaneous osteoto-
m ies. Plast Reconstr Surg 2005;116(6):1771–1775
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456–466
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Plast Surg Clin North Am 2014;22(3):357–377
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the nasal septum in the deviated nose. Facial Plast Surg
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m inim izing secondary nasal deform ities. Plast Reconstr
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viated nose: optimizing results using a simpli ed clas-
si cation and algorithmic approach. Plast Reconstr Surg
2002;110(6):1509–1523, discussion 1524–1525
22. Jang YJ, Yeo NK, Wang JH. Cutting and suture technique
of the caudal septal cartilage for the managem ent of cau-
dal septal deviation. Arch Otolaryngol Head Neck Surg
2009;135(12):1256–1260
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tion. Arch Facial Plast Surg 2000;2(3):217–220
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roof of the m iddle nasal vault following rhinoplasty. Plast
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nal approach to rhinoplasty. Clin Plast Surg 1996;23(2):
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Plast Reconstr Surg 1998;102(6):2148–2157
27. Lee SB, Jang YJ. Treatment outcomes of extracorporeal sep-
toplasty compared with in situ septal correction in rhino-
plasty. JAMA Facial Plast Surg 2014;16(5):328–334
28. Gubisch W. Extracorporeal septoplasty for the m ark-
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of the crooked nose. Arch Facial Plast Surg 2004;6(4):
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nose and its treatm ent. Arch Otolaryngol Head Neck Surg
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87
7 Correction of the Saddle Nose
Keng Lu Tan and Chae-Seo Rhee

■Anatomic Considerations
Saddling of the nose is essentially caused by the loss of
nasal septal support for the dorsum of the nose. Support of
the nasal dorsum is provided by the cartilaginous and bony
structures involved in nasal projection. The nose is divided
into the upper, middle, and lower thirds, commonly known
also as the upper, middle, and lower vaults.
The upper third is supported by the pyramid of the
nasal bone. The interlocking of the quadrangular cartilage
with the nasal bone forms the keystone area, which is the
key area that should be preserved to prevent the collapse
of the saddling of the dorsum and creation of the inverted-
V dorsal deformity (Fig. 7.2). The quadrangular cartilage is
the single most important cartilage that supports the lower
two-third of the nose, including the nasal dorsum and the
paired upper and lower lateral cartilages. Most of the eti-
ologies mentioned above disrupt the integrity of this carti-
lage to cause saddle nose deformity. Therefore, correction
of the saddle nose deformity usually, if not always, centers
on reconstructing and reestablishing the strength of the
quadrangular cartilage.
The paired upper lateral cartilages constitute the lat-
eral side of the middle vault. The angle formed by the upper
lateral cartilage and the nasal septum is the internal nasal
valve. Since the strength of the upper lateral cartilages
relies heavily on the nasal septum, loss of support in the
nasal septum will result in collapse of the internal nasal

■Introduction
Nasal deformities a ecting mainly the lower two-thirds of
the nose due to the loss of septal height and tip support
are de ned as “saddle nose” deformities (Fig. 7.1). A sad-
dle nose was rst described by John Orlando Rose in 1887
as a “pug nose.” A pug is a kind of canine with an almost
complete absence of a snout or nasal dorsum. The depres-
sion noted on the middle vault of the nasal dorsal surface
resembles the saddle of a horse—hence the term saddling.
Complex deformities of the nasal septum can have both
an aesthetic and a functional impact on a patient’s nose.
If there is a severe compromise of the cartilaginous septal
integrity w ith subsequent loss of middle vault support by
the septum, dorsal depression develops, followed by loss
of tip de nition and other associated features (Fig. 7.2
and Fig. 7.3).1,2 This kind of nasal deformity is often very
distressing to the patient as the deformity is obvious and
unattractive. Functionally, patients can complain of nasal
obstruction due to the collapse of the internal nasal valve.
While saddle nose deformity is caused by the loss
of septal support and shows a true loss of dorsal height,
a pseudo saddle is a relative depression of the supratip
region caused by a hump nose. For correction, a saddled
nose requires the reconstruction of the sca old of the dor-
sum—for instance, the septum—but a pseudo saddle needs
to have the hump resected to allow the supratip region to
look normal again.
Pearls
• Evaluation of the degree of septal support is the
most important step in preoperative planning in a
patient with saddle nose deformity. This is because a
saddle nose is often due to a damaged cartilaginous
septum.
• Class 1 saddle nose has good cartilaginous septal
support with a minor supra-tip depression. This can
be easily corrected by cosmetic dorsal camou age.
• Class 2 saddle nose has moderate loss of septal
cartilaginous support with moderate dorsal
depression, which can be managed by reinforcement
and reconstitution of the septum and/or dorsum.
• Class 3 saddle nose has severe loss of septal
cartilaginous support with a moderate to severe
dorsal depression. Subtotal septal reconstruction
with costal cartilage should be administered to
correct this saddle deformity.
• Class 4 saddle nose has severe loss of septal
cartilaginous support with both bony and
cartilaginous dorsal depression, in which case the
dorsal framework from the radix to the tip needs to
be totally reconstructed with costal cartilage.
• Correction frequently requires straightening or
reconstituting the L-strut. A stable L-shaped strut
of septal cartilage to the nasal spine is crucial to
support the upper and lower lateral cartilages to
maximize the results in creating a straight and
functional nose.

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■Etiology of Saddle Nose
In recent years, most saddle nose deformities have come
from trauma, and from nasal surgeries, including septo-
plasty and rhinoplasty. In ammatory diseases were com -
mon causes in the past.2,3
valve. Rectifying a saddle nose without addressing this area
will leave functional problems such as nasal obstruction.
Lower lateral cartilages de ne the tip and are also sup-
ported by the septal cartilage. Loss of height and width of
the septal cartilage will cause misalignment of the lower
lateral cartilages, resulting in loss of tip de nition, tip ptosis,
cephalic rotation, and retrusion of the columella (Fig. 7.3).
Fig. 7.1 Saddle nose and pseudo saddle.
(a) Saddle nose shows loss of dorsal height
and support of the underlying nasal sep-
tal structures with upward rotated tip.
(b) As opposed to the presence of saddle,
the depression is due to an abnormal pro-
trusion over the dorsum rather than a true
depression itself.
Fig. 7.2 The keystone area and saddle. (a) Quadrangular cartilage, as seen in the illustration,
forms the single most important support structure for the nasal dorsum. The area of overlap-
ping with the nasal bone and upper lateral cartilage, the keystone area, deserves particular
attention. (b) When the keystone area is interrupted, it causes instability to the quadrangular
cartilage and thus saddling of the nasal dorsum, with a resulting inverted-V deformity.
a
b
a
b

7 Correction of the Saddle Nose
89
Systemic Diseases
Systemic diseases such as granulomatous diseases and
autoimmune diseases may compromise the integrity of
the nasal supporting structures and cause saddle nose
deformity. Granulomatous diseases such as Wegener’s
granulomatosis; infection such as leprosy and syphilis; and
autoimmune diseases such as relapsing polychondritis, sar-
coidosis, and Crohn’s disease may destroy the septal carti-
lage along the disease process due to chronic in ammation.
Malignancy
NK-T-cell lymphoma, squamous cell carcinoma, malignant
mucosal melanoma, adenocarcinoma, minor salivary gland
tumors, and metastatic lesions are just some of the malig-
nancies known to destroy structures that provide dorsal
support to the nose, inducing saddling.
Vascular Ischemia of the Nasal Septum
A classical cause of saddling is septal perforation due to
cocaine abuse, secondary to the repeated and sustained
action of sucking in cocaine through the nose. Ischemia to
Trauma
Trauma may physically destroy the cartilaginous or bony
structures of the dorsum and the nasal septum. Posttrau-
matic hematoma in the nasal septum may be a cause of
septal destruction or perforation due to hematoma orga-
nization and resorption or infection and abscess formation
secondary to the hematoma. Saddle deformity after trauma
is usually accompanied by a deviated nose, septal deviation,
and nasal valve collapse.
Iatrogenic Factors
Saddle nose could also be a secondary deform ity due
to resorption or a problem atic im plant used in nasal
septum or nasal dorsum reconstruction, especially if
the keystone area is inflicted during septoplast y or rhi-
noplast y. Over-resection of the quadrangular cartilage
causing weakening of the septal cartilage during surgery
could result in saddling. It is therefore im portant to pre-
serve at least 10 m m of the dorsal and caudal part of the
quadrangular cartilage w hen cutting the nasal septum .
Som etim es saddling caused by nasal surgery w ill not be
apparent im m ediately after the surgery but w ill slowly
m anifest over tim e.
Fig. 7.3 Loss of support of the nasal septum causes distortion of the lateral cartilages. (a,b) Considerable loss of septal support causes
the upper and lower lateral cartilage to distort. (c) Saddling of middle vault, tip ptosis with cephalic rotation, and columellar retrusion will
develop.
a
b
c

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After external and internal examination, discussion
about the preferred sources of grafts is mandatory. Patients
should be given the choice of autologous, homologous, or
synthetic grafts depending on the circumstances after the
pros and cons of each option have been discussed. Rib cage
views could be necessary if rib cartilage grafting is planned.
Most patients want to correct the both cosmetic and
functional problems. On some occasions, a patient may
request a higher projection and a better-de ned tip com -
pared with the premorbid nose. Therefore, a realistic con-
sultation should be carried out with the patient.
Classi cation of Saddle Nose
Deformity
Saddle nose can be classi ed into four groups that will
determine the repair of the nose.3 Understanding and hav-
ing a map of the deformity involved is the rst step to plan-
ning for a successful outcome.
Class 1: Good cartilaginous septal support with a
minor supra-tip depression. This can be easily
corrected by cosmetic dorsal camou age (Fig. 7.4a).
Class 2: Moderate loss of septal cartilaginous support
w ith moderate dorsal depression, which can be
managed by septal rearrangement, reconstitution,
reinforcement of the septum, and reconstruction of
the nasal dorsum (Fig. 7.4b).
Class 3: Severe loss of septal cartilaginous support
w ith moderate to severe dorsal depression. This
deformity calls for subtotal septal reconstruction
(Fig. 7.4c).
Class 4: Severe loss of septal cartilaginous support
w ith both bony and cartilaginous dorsal depression,
in which case a dorsal onlay graft and extended
columellar strut must be totally reconstructed
w ith costal cartilage. This can bypass the septal
reconstruction. The extended columellar strut
needs to be stabilized to the anterior nasal spine
(Fig. 7.4d).

■Surgical Techniques
Planning for the repair of a saddle nose begins with a metic-
ulous assessment. Treatment of the underlying causative
medical condition should be complete or at least the bony
and the cartilaginous structure of the nose should have sta-
bilized in its deformity before surgical repair is undertaken.
Surgical intervention largely depends on the degree of the
saddling according to the classi cation system mentioned
previously.
the nasal septal vasculature will eventually result in a large
septal perforation, especially in the cartilaginous portion,
and collapse of the dorsum. Similar assault to the nasal sep-
tum could be caused by prolonged use of oxymetazoline
nasal spray or other vasoconstrictive agents.

■Patient Evaluation
Assessment of the Patient
History of trauma, previous surgery, systemic diseases,
use of a topical vasoconstrictor, and cocaine abuse should
be elicited. Details of previous surgery and the surgical
manipulation could give insight into the available remnant
cartilage and structural de ciency that has resulted in the
saddling.
Proper consultation will start with thorough anatomic
evaluation for factors that could a ect the nasal deformi-
ties. Careful palpation and inspection can reveal the rela-
tion among the structural deformities including the nasal
septum, cartilaginous and bony dorsum, tip, nasal valve,
and turbinate. The resistance and resilience of cartilage
should be evaluated in accordance with the strength and
shape of the tip and caudal septum. Description of the nose
should be made from all angles. In the photos, the lateral
nasal length, the degree of depression, the presence of col-
umellar retraction, and the degree of tip rotation/derota-
tion should be carefully noted.
In general, saddle nose shows a broad dorsum, wide
base, and inverted-V deformity in case of keystone area
damage on frontal view. Lateral and oblique views reveal
lower pro le dorsum, saddling, retracted and short colu-
mella, low projection of the tip, and cephalic rotation in
severe cases. The basal view reveals a low tip, round and
ared nostrils, short columella, and wide base (Fig. 7.3).
The presence of a dorsal hump that gives rise to a saddled
appearance must not be confused with pseudo saddle.
Nasal cavity evaluation should be performed also.
Septal evaluation is critical for evaluation of traumatic
deformed nose. Sometimes overlapping fractured cartilage
and replacement of scar tissue in the a ected cartilage or
fracture lines can make septal mucosa elevation di cult.
Nasal valve obstruction should be assessed clinically fol-
lowed by acoustic rhinometry or rhinomanometry tests,
which could document and assess the level of obstruction
prior to the surgery. The availability of septal cartilage, sep-
tal perforation, and any deviation should be carefully noted
during endoscopic examination to facilitate planning of the
surgery. If endoscopic ndings suggest other medical prob-
lems causing the loss of septal cartilage, be sure that the
patient is screened for autoimmune or infectious diseases,
as previously discussed, before the repair is planned.

7 Correction of the Saddle Nose
91
size should be created for insertion of the camou age
grafts to ensure the graft stays at where it should be. Dis-
placement of the camou age graft and distortion of the
nal shape will result if the size of the pocket created is
imprecise.
Class 2 Saddling
In class 2 saddling, there is often loss of cartilaginous sep-
tum stability. The stability should be reconstituted by add-
ing structural support. Thus, it requires open rhinoplasty
and reconstruction of the dorsal framework. Such structural
Class 1 Saddling
Only simple camou age on the supra-tip area using septal
or conchal cartilage, soft tissue or fascia is recommended
for saddles in this class. It can be achieved by endonasal
techniques. In thin-skinned individuals, camou age grafts
using cartilage should be slightly bruised or crushed to
prevent graft visibility through the skin contour. In thick-
skinnned individuals, better-de ned grafts may be nec-
essary in getting a desired outcome, or otherwise some
subcutaneous tissue can be trimmed from the overlying
soft tissue cover. Pockets of subcutaneous tissue of exact
Fig. 7.4 Four types of saddle nose defor-
mity. (a) Class 1: Good cartilaginous septal
support with a minor supra-tip depression.
(b) Class 2: Moderate loss of septal car-
tilaginous support with moderate dorsal
depression. (c) Class 3: Severe loss of sep-
tal cartilaginous support with moderate
to severe dorsal depression. (d) Class 4:
Severe loss of septal cartilaginous support
with both bony and cartilaginous dorsal
depression.
a
b
c
d

II Rhinoplasty
92
support includes the use of the spreader graft, septal batten
graft, or septal extension graft with or without reinforce-
ment of the caudal septum. Unilateral or bilateral spreader
grafts can be used as the extended version or not, depending
on the strength of the caudal part of the septum. Spreader
grafts are usually obtained from the septum if there is suf-
cient cartilage to graft. When harvesting septal cartilage
in Asians, care should be taken since the cartilage is not as
strong and thick as in Caucasians, and aggressive harvesting
of the septal cartilage will only further compromise septal
instability. Thus, it is important that a 1.0-cm strut be left
dorsally, anteriorly, and especially at the keystone region.
Sometimes the straight part of a perpendicular plate of
ethmoid bone can be used for reinforcement instead of the
septal cartilage. After the harvesting of cartilage, spreader
grafts (approximately two strips 3 mm in width and 15 to
25 mm in length each) are fashioned and placed over the
dorsal strut bilaterally. They are rst xed with a xation
needle and subsequently anchored with 4–0/5–0 PDS at two
or three positions (Fig. 7.5). An extended spreader graft can
be used when the caudal septum is oppy and needs extra
support. It can be used in conjunction with the septal exten-
sion graft and/or septal batten graft for further reinforce-
ment. The extension of the caudal end of the graft beyond
the lower border of the upper lateral cartilage increases the
reinforcement caudally, providing structural support along
the whole dorsum caudally down to the tip.4
In cases of class 2 saddling with rotated tip, more often
than not the caudal septum is de cient, short, and oppy.
In such cases, a septal extension graft is needed to make
the nasal tip strong and to get a projected tip (Fig. 7.6). The
septal extension graft is often fashioned from the septal
cartilage or the costal cartilage. The cartilage should be a
at, broad piece and should be overlapped with the exist-
ing septal cartilage. If the septal cartilage has a previous
fracture line or curvature, the overlapped region should
include this area. If needed, the other side of the septal
extension graft can be further strengthened with another
piece of cartilage. The septal extension can be sutured at
the sides to the spreader grafts superiorly and to the ante-
rior nasal spine inferiorly to make sure that the caudal
end of the nose is supported from below in the midline, is
straight, and will not collapse or bend during the healing
period.
Class 3 Saddling
Subtotal reconstruction of the nasal septum is recom -
mended. In this degree of saddling, one will nd the septal
cartilage not just weak, but with parts of it missing or with
volume, area, and integrity loss. Subtotal reconstruction of
the septum involves reconstituting the dorsal height of the
nose and the projection and rotation of the tip, by recon-
structing the L-strut. This maneuver often requires abun-
dant costal cartilage. The process begins with fabrication of
Fig. 7.5 Bilateral spreader grafts are temporarily xed with needle
and sutured with horizontal mattress sutures using 4–0/5–0 PDS.
Fig. 7.6 (a,b) The septal extension graft is the workhorse for sup-
porting the caudal end of the septum. It can function to strengthen
and straighten the caudal septum, lift the medial crura of the lower
lateral cartilage, increase tip projection, and derotate the tip down-
ward in the case of a rotated tip in a saddled nose.
a
b

7 Correction of the Saddle Nose
93
Class 4 Saddling
A total dorsal reconstruction from the radix to the tip is
necessary when there is major loss in the septal structure
and possible loss of the nasal pyram id bones. Total recon-
struction of the nasal bone may require a replacem ent
graft using costal cartilage. However, in cases of severe
saddling w ith loss of nasal bone, or if septal reconstruc-
tion is impossible or not needed, a one-piece dorsal onlay
graft and extended colum ellar strut could be used alterna-
tively. The extended colum ellar strut should be stabilized
rm ly to the anterior nasal spine. The one-piece block of
dorsal onlay graft could be designed using costal carti-
lage. It is form ed into a boat shape. The cantilever onlay
graft should ideally span the radix to the lower lateral car-
tilages. A groove is made in the caudal end of the onlay
graft, which is united w ith the extended colum ellar strut
over the anterior nasal spine (Fig. 7.8). This can support
the nose w ithout reconstruction of the septum . Upper and
lower lateral cartilages restore to the stable colum ellar
strut–dorsal graft. Last but not least, after the restoration
of the dorsal height and tip projection, the nasal tip needs
to be addressed m eticulously, which is described in a sepa-
rate chapter.5

■Key Technical Points
1. Techniques for a saddle nose correction vary
depending on the degree of saddling. Proper
assessment of the etiology and degree of saddling
forms the basis for the surgical technique used.
2. The camou age graft is the main technique used for
class 1 saddling. Careful design of the skin pocket is
the key to a successful surgery in camou age grafts.
3. Class 2 saddling requires partial reconstitution and
reconstruction of the septum and dorsum.
4. Subtotal septal reconstruction is required to address
a class 3 saddling. More often than not costal
cartilage is needed to reconstruct the dorsal support
and the L-strut. These two structures will form the
pillars of nasal dorsal reconstruction.
5. The reconstructed caudal L-strut needs to be
anchored rmly to the anterior nasal spine to
prevent long-term sequaelae and recurrence of
saddling.
6. In the class 4 saddling deformity, total
reconstruction is needed to restore nasal dorsal
height from the radix to the tip. Combined bony and
cartilaginous dorsal reconstruction needs hinging
w ith the columellar strut caudally, bypassing the
septal support.
the L-strut using one or two at and strong pieces of costal
cartilage or septal cartilage. This cartilage should sit rmly
on top of the anterior nasal spine, superiorly held rmly by
the bilateral spreader grafts (Fig. 7.7).
Other techniques that can produce the same stability
are to carve a thick, strong piece of dorsal strut to interlock
w ith a shorter but similar section of cartilage at the L-strut.
The L-strut can be anchored to the anterior nasal spine
w ith 4–0 PDS by drilling a hole through the nasal spine
w ith a 1-mm drill bit or a 16-gauge needle; or sutured to
the periosteum snugly using gure-of-8 suturing at two
points, one anterior and one posterior. The anterior nasal
spine should be rendered straight before the anchoring
is done. The L-strut should be placed rmly before the
extended spreader grafts are placed.
The new dorsum that the spreader graft forms should
be strong and straight, and an overlap into the nasal bone
is sometimes desirable to increase graft stability when the
nasal bone is stable enough to endure osteotomy. The two
sides of the upper lateral cartilage should be rmly sutured
to the spreader grafts using 5–0 PDS at two or three points.
Special attention is to be paid with regards to the symme-
try of the upper lateral cartilage when suturing so as not to
cause any iatrogenic deviation.
Once the grafts are rmly in place, the medial crura of
the lower lateral cartilages should be sutured to the new
L-strut. Re nement can be achieved by adjusting the angles
of suturing or by nal application of camou age grafts.
Fig. 7.7 Fabrication of the L-strut. The caudal septum is replaced
with a at costal cartilage piece and supported with an extended
spreader graft. The L-strut should sit rmly on the anterior nasal
spine and not oat on top of it. Support should be provided by it to
the lower lateral cartilages and not the other way around.

II Rhinoplasty
94
The external approach was used, followed by septal
mucosa elevation (Fig. 7.10). Costal cartilage and perichon-
drium were harvested. A boat-shaped dorsal onlay graft
was carved from the costal cartilage. The cantilever dorsal
onlay graft extended from the rhinion to the tip. A groove
was made at the caudal end of the dorsal onlay graft,
which was hinged to the extended columellar strut rmly
anchored to the anterior nasal spine. Upper and lower lat-
eral cartilages were restored to their positions and sutured
to the dorsal onlay graft. Perichondrium was used to drape
the dorsum from the radix to the onlay graft.
Six-month postoperative photos show greatly improved
nasal shape (Fig. 7.11).

■Case Studies
Case 1
A 31-year-old female patient visited the clinic complain-
ing of saddle nose deformity after previous septoplasty
(Fig. 7.9). She had a septoplasty 2 years previously and
slowly developed saddle nose deformity after the surgery.
On physical examination, her dorsum showed depression
from the rhinion to the tip. Palpation of the tip and dorsum
showed no underlying septal support. An intranasal exam
showed posterior septal deviation to the left side but no
cartilaginous support on palpation.
Fig. 7.8 Total dorsal reconstruction bypassing septal support. The costal cartilage graft is carved to recreate the dorsum from the radix
to the tip and for bypassing the nasal septum support. (a) An extended columellar strut should be stabilized rmly to the anterior nasal
spine. (b,c) Boat-shaped dorsal onlay graft carved from one piece of costal cartilage. An extended columellar strut is combined with the
onlay graft in tongue-in-groove fashion. The septum was partially replaced using carved costal cartilage. (d) The upper and lower lateral
cartilages are xed to the dorsal onlay graft.
a
b
c
d

7 Correction of the Saddle Nose
95
Fig. 7.9 (a–c) Case 1. The patient had developed saddle nose after septoplasty. A middorsal depression is observed and the septum is too
weak to support an onlay cartilage graft. A dorsal onlay graft was carved from costal cartilage. An extended columellar strut was anchored
rmly onto the anterior nasal spine inferiorly and superiorly and extends into the groove created at the caudal end of the dorsal graft.
Fig. 7.10 Case 1. Intraoperative photos. (a) Dorsal graft carved from the rib cartilage is hinged to the extended columellar strut.
(b) Lower lateral cartilages are reattached to the new dome created by the grafts.
a
b
c
a
b

II Rhinoplasty
96
rib cartilage, an extended columellar strut reinforced with
mini bilateral extended spreader graft was used for tip and
caudal support (Fig. 7.13). Lateral crural onlay grafts and
tip onlay grafts were added for tip contouring. A dorsal
onlay graft using carved rib cartilage was used for dorsal
augmentation.
Three years after surgery, a normal-looking nose can be
observed in all views (Fig. 7.14).
Case 2
A 22-year-old male visited the clinic due to a deformed
nose and nasal obstruction (Fig. 7.12). He had a nasal
trauma history in early childhood. On physical examina-
tion, he was found to have saddling of the lower two-thirds
of his nose; an under-projected, slightly upturned nasal
tip; and hypertrophy of both turbinates. Using autogenous
Fig. 7.11 (a–c) Case 1. Six-month postoperative photos show improvement of saddle from three di erent views.
Fig. 7.12 (a–c) Case 2. Preoperative photos show a typical severe saddle nose deformity with middle vault collapse and tip ptosis with
slight cephalic rotation.
a
b
c
a
b
c

7 Correction of the Saddle Nose
97
Fig. 7.13 Case 2. Surgical ndings. (a) Intraoperative photograph
shows dorsal onlay graft, bilateral lateral crural grafts, and tip onlay
grafts using rib cartilage with overlying perichondrium. (b) Surgical
diagram showing operative techniques.
a
b

II Rhinoplasty
98
References
1. Young K, Rowe-Jones J. Current approaches to septal saddle
nose reconstruction using autografts. Curr Opin Otolaryn-
gol Head Neck Surg 2011;19(4):276–282
2. Kevin Brenner JC. Saddle nose deform ity. In: Murphy M,
Azizzadeh B, Johnson CM Jr, Numa W, eds. Master Tech-
niques in Rhinoplasty. 1st ed. Saunders; 2011:293–298
3. Durbec M, Disant F. Saddle nose: classi cation and thera-
peutic managem ent. Eur Ann Otorhinolaryngol Head Neck
Dis 2014;131(2):99–106
4. Tardy ME Jr, Schwartz M, Parras G. Saddle nose deformi-
ty: autogenous graft repair. Facial Plast Surg 1989;6(2):
121–134
5. Daniel RK. Rhinoplasty: septal saddle nose deformity
and composite reconstruction. Plast Reconstr Surg 2007;
119(3):1029–1043

■Conclusion
Saddle nose deformity correction can range from a pro-
cedure as simple as applying a camou age graft to a total
nasal reconstruction. Saddle nose is a common problem
presented by Asian patients due to the inherent low-pro le
nose with a soft and under-developed nasal septum sus-
ceptible to insult. As a result, the volume and extent of sad-
dle nose repairs in the authors’ centers have provided the
opportunity to gain much experience and re ne techniques
in handling saddle nose. It should be assessed meticulously
and surgery planned w ith all eventualities anticipated to
ensure the best outcome. The best outcome is when the
procedure is done right the rst time. That being said, many
of the reconstructions for saddle nose may need revisions
in various stages.
Fig. 7.14 (a–c) Case 2. Three-year postoperative photos show well-augmented but smooth dorsum and more desirable tip projection
and rotation compared to preoperative status.
a
b
c

99
8 Alar Base Modi cation
Ian Loh Chi Yuan and Hong Ryul Jin
The potential indications for alar base surgery are (1)
increased alar base width, (2) excessive aring of the alar
side walls, (3) large nostrils, (4) thick alar side walls, (5)
hooded or hanging alar side walls, and (6) cleft nose or nos-
tril asymmetry.

■Patient Evaluation
A careful and detailed history should be taken during con-
sultation to identify the patient’s concerns. Examination
of the alar base should focus on the nostril shape, size,
and symmetry; the degree of alar aring; and the width
of the nasal base. Any pre-existing asymmetry of the nos-
trils should be noted and pointed out to the patient, and
corrected whenever possible during surgery; this is also
important to avoid any concerns that may have arisen iat-
rogenically after surgery.
Physical Examination
On frontal view, the alar rim should arc and end higher than
the columella, giving a gull’s-wing-in- ight appearance.
Exaggeration of the gull-in- ight curve implies retraction
of the ala or dependency of the infratip lobule. On lateral
view, the alar rim usually situates 2 to 3 mm above the
nasal columella, creating a columellar show. The lateral

■Introduction
The alar base describes the portion of the nose where the
alar side wall attaches to the midface. Modi cation to this
area changes the alar base width, the degree of alar aring,
and nostril shape and size. Ethnic variations in the alar base
have been well described. The majority of East Asian noses
(especially those of Southeast Asian origin) cannot conform
to the ideal anatomic relationship described in Caucasians.
The alar base of the East Asian nose is wider compared with
the European nose, with a marked tendency to are but not
to as severe a degree as those found in Africans or South-
east Asians, including those of Filipino, Malaysian, Indone-
sian, and Vietnamese ethnicity.1
The shape and extent of alar aring will depend on the
shape and elasticity of the underlying nasal cartilage, the
connection between the lateral crura and the face, and the
prominence of the nasal tip. In addition to the aring and
wide alar base, other abnormalities such as alar rim hang-
ing,2 retrusion of columella, wide columellar base, and exces-
sively thick alar rim should also be considered. Techniques
to change the alar shape are chosen after assessing all these
parameters individually and judging comprehensively, con-
sidering harmony of the ala with the rest of the face.
Given these ethnic variations, it should not be surpris-
ing that alar base surgery is one of the most commonly
requested procedures during consultation for East Asian
rhinoplasty.
Pearls
• Modi cations to the dorsum and nasal tip will
a ect the alar base width, as well as the deliberate
creation of illusions, as a result of objective changes.
• Alar base surgery should be performed as the nal
procedure in the rhinoplasty sequence.
• Appropriate design, symmetry, and meticulous
soft tissue handling are paramount in creating the
desired outcome in alar base surgery.
• The modi ed Weir excision is the most commonly
employed design for East Asians, who typically need
reduction of alar aring, nostril size, and alar base
width.
• The use of a cinching suture to maintain a tension-
free skin closure is an important part of alar base
surgery.
• It is paramount that a curved portion of the nostril
be preserved to avoid creating a teardrop nostril
during the excision design.
• Conservatism should be observed during resections,
as correction of over-excision is very di cult.
• Complications of alar base surgery include the
creation of a teardrop nostril, asymmetry of the
nostrils, and various scar-related complications,
including vestibular stenosis with accompanying
nasal obstruction.
• Most complications are iatrogenic and can be
avoided with good design and tissue handling.
• The bene ts of alar base surgery must be weighed
against the potential for complications; this is
especially true for East Asian peoples, whose skin is
more prone to scar-related complications.

II Rhinoplasty
100
of the alar base, and may make alar base surgery unneces-
sary. In case of doubt, alar base excisions should also be
performed as a staged procedure, after the patient has a
chance to evaluate the e ect that these other modi cations
may have on the alar base.
Quality of Skin
Alar base surgery is essentially a skin excision of the alar
base region. The quality of the patient’s skin is an impor-
tant determinant of the surgery’s outcome. The skin of the
alar base region is naturally thick and sebaceous. In addi-
tion, East Asian skin is thicker and more pigmented than
Caucasian skin. These factors predispose the East Asian
patient to hypertrophic scarring, keloid formation, and
post-in ammatory hyperpigmentation when undergoing
alar base surgery.3
A patient with thick sebaceous skin who gives a his-
tory of scar-related complications should be warned of the
possibility of these complications when planning alar base
surgery. And meticulous postoperative care should be prac-
ticed to minimize such complications.
Function
Any static and dynamic collapse of the external nasal valve
must be noted. Alar base surgery that reduces the size of
the vestibular aperture can cause external valve stenosis.
The patient should be asked to inspire through the nose
rapidly, and any collapse of the alar side wall should be
noted. Patients with small nostrils should have excision
designs that do not further reduce the nostril aperture;
view is also the best view for evaluating the alar-columel-
lar relationship. When the columella is not seen, this may
indicate a retracted columella or hanging ala. Normally, the
width of the alar base is equal to the distance between the
medial canthi. The thickness and aring of the ala and the
degree of recurvature of the alar base insertions should
also be noted. Ideally, the nose as seen from basal view
should be an isosceles triangle with a round apex, slightly
bulging alar side walls, and nostrils tilted 30 to 45 degrees
from the midline, with the appearance of a pear. The ratio
of the columella and infratip lobule is 2:1, and the begin-
ning of the are of the medial crural footplates divides the
alar base into halves (Fig. 8.1).
The E ect of Illusions on the
Nasal Base
Although alar base surgery is frequently requested as an
isolated procedure, the patient must be informed that the
appearance of the alar base is a ected by modi cation of
the nasal tip and dorsum, and that surgery to this area can-
not be considered in isolation. Increased nasal tip projec-
tion and dorsal augmentation will both create an illusion of
decreased alar base w idth. Conversely, narrowing the alar
base will create the illusion of a broader nasal tip. If surger-
ies in these areas are also required, the patient should be
advised accordingly.
In certain cases, modi cation of the dorsum and tip alone
may su ce to create the illusion of decreased alar base
width and aring, making alar base surgery unnecessary.
It is imperative that the patient be informed that modi-
cations to these other areas in uence the characteristics
Fig. 8.1 Ideal alar shape of East Asians. (a) Frontal view. (b) Lateral view. (c) Basal view.
a
b
c

8 Alar Base Modi cation
101
approach has been performed, the columella incision is
closed with a few mono lament sutures to restore tension
to the skin pocket. The need for alar base surgery is then
assessed from the basal view, frontal view, and pro le view
as outlined earlier in the chapter.
The alar base region consists of thick sebaceous skin
externally, hair-bearing vestibular skin internally, and
bro-fatty tissue in between. There are no cartilaginous
structures found here. The junction of the alar side wall and
lateral nasal sill form a natural curvature at the inferior lat-
eral aspect of the nostril, which must be preserved during
any alar base surgery to avoid creating a teardrop nostril.
The junction between the alar side wall and midface
forms the alar facial groove, and whenever possible, this
should be preserved. Leaving behind a 1-mm cu of soft
tissue above the alar facial groove when planning the infe-
rior incision greatly facilitates closure and faster wound
healing.
patients with dynamic collapse should consider functional
surgery to strengthen the lower lateral cartilages concomi-
tantly, such as the use of batten grafts, together with alar
base surgery if required.
Photographs
Proper photo documentation using a prime portrait lens
and di use lighting is a clinical and medico-legal require-
ment for rhinoplasty. A frontal view, pro le view, and basal
view are used in evaluating for alar base surgery. Computer
simulation can be particularly useful to illustrate the com -
plex relationships between dorsal length, tip projection, tip
bulbosity, and alar base width, with the patient’s decisions
carefully documented.
From the frontal view photograph, the width of the
nasal base can be evaluated; this should ideally lie just out-
side of the middle horizontal fth of the face in Orientals.
The base can appear wide from excessive aring or from a
large inter-alar distance. Excision targeting the right areas
must be designed to address these problems.
From the basal view the size of the nostrils and degree
of aring can be objectively assessed. Vertical lines pass-
ing through the alar facial groove can be drawn in the basal
view. Excess alar side wall lateral to this line gives an objec-
tive measurement of the degree of alar aring and aids in
planning the excision design (Fig. 8.2).
From the lateral view, a line drawn through the long
axis of the nostril allows the surgeon to evaluate the extent
of hanging alar deformity and the amount of “lift” required
to correct alar hooding.2

■Surgical Techniques
Surgical Anatomy
Alar base surgery is performed as the nal procedure in
the rhinoplasty sequence. This allows the surgeon to fully
evaluate the e ects from any modi cations to the dorsum
and tip on the alar base (Fig. 8.3). If an open rhinoplasty
Fig. 8.2 De nition of alar aring. The aring is determined
according to the degree of alar projection based on a vertical line
drawn at the alar-facial groove as seen from the basal view.
Fig. 8.3 Increased nasal tip projection
leads to decreased alar are. (a) Alar aring
is noticeable in the preoperative basal view.
(b) As the nasal tip is augmented, the are
of ala is decreased without any alar base
procedure being done.
a
b

II Rhinoplasty
102
Combined Alar Wedge Resection and
Sill Excision
The use of a modi ed Weir excision for reduction of alar
aring, nasal base width, and nostril size is demonstrated
in Fig. 8.5. This is the most commonly employed design in
East Asian patients. The excision design is drawn using a
ne-tipped felt marker or toothpick stained with methylene
blue prior to injection. The incision for the alar wedge exci-
sion is marked at 1 to 2 mm above the alar-facial junction.
This preserves the natural sulcus and makes eversion of the
suture easy, thus maximally camou aging the incision scar.
Excision inside the nostril must preserve the curved portion
of the nostrils and be checked meticulously for symmetry.
In alar wedge resection, the incision should not extend
to the medial side of ala, and in nostril sill excision, the nos-
tril base adjacent to the columella should be preserved to
preserve the natural alar sulcus and to prevent a tent pole
appearance.
In ltration is then administered. A small amount of
in ltrate containing adrenaline and lidocaine is preferred
by the authors. The volume of in ltrate should be kept
small to avoid distortion to the surrounding tissue. Ten
minutes is allowed to lapse before the incisions are made
for constriction of the blood vessels.
A fresh no. 15 blade is used to make the incisions start-
ing with the superior limb of the wedge excision followed
by the inferior limb. The incisions are beveled smoothly
toward each other to ensure symmetrical wedges of soft
tissue are removed from each side. Only skin and subcuta-
neous tissue are resected, and care should be taken to not
violate the muscle in the deep plane.
Bleeding is usually controlled by suturing and rarely
needs cauterization. If necessary, hemostasis is achieved
using bipolar cautery. A gure-of-8 suture is then passed
through the premaxillary soft tissue. A PDS 3–0 suture is
mounted on a large free needle and passed through the
medial incision on the right side, traversing deeply through
the premaxillary soft tissue to emerge through the medial
incision on the contralateral side. The needle then catches
the brofatty tissue in the free cut edge of the alar side
wall before being passed back in a similar manner to catch
the brofatty tissue of the right alar side wall. The suture
is then tied just tightly enough to relieve tension on the
excision sites, but not so tightly as to cause bunching of the
premaxillary soft tissue. The knots are then buried in the
soft tissue.
Meticulous closure using ne mono lament (6–0
nylon) sutures is then performed. The authors use absorb-
able sutures to close the incision on the inside of the nostril.
Suture removal is performed on the fth postoperative day.
Similar methods are used for isolated sill (Fig. 8.4b) and
alar side wall excisions (Fig. 8.4a). The apex of the wedge
excision should not extend into the vestibular skin if reduc-
tion of the nostril size is deemed undesirable.
Excision Design
The concept of narrow ing the alar base was introduced
by Robert Wier in 1892, and he described the use of
external alar wedge excisions to correct the unattractive
alar are. Di erent m odi cations of the Weir alar base
excision are possible, and the excision design is depen-
dent on the surgical objectives (Fig. 8.4). The alar ar-
ing is improved by perform ing a crescent-shaped wedge
resection of the ala along the alar-facial groove. The w ide
alar base can be reduced by a sliding alar ap or nostril
sill excision. On the other hand, a w ide alar base com -
bined w ith alar aring can be improved by com bining
alar wedge and nostril sill excision.
Fig. 8.4 Types of alar base surgery. (a) Wedge resection of the
ala to decrease the alar aring. (b) Resection of the nostril sill to
decrease the width of the alar base. (c) Sliding alar ap to reduce
the width of the alar base. (d) Combined sill and wedge resection
to correct the alar aring and wide alar base.
a
b
c
d

8 Alar Base Modi cation
103
Correction of Too-Wide Columellar
Base
When the medial crura are too divergent or prominent, the
columellar base is too wide and sometimes causes nasal
obstruction by obstructing the nostril. To correct this, a lat-
eral columellar incision is done bilaterally and the medial
crura are dissected and exposed (Fig. 8.7). Often suture
ligation of the two dissected medial crura is not enough to
narrow the columellar base. Removal of small amount of
soft tissue between the two crura or partial crural resec-
tion helps to reduce the base e ectively.

■Key Technical Points
1. The resection amount should be kept conservative.
Revision excisions are simple to perform but
restoration of excised tissue is extremely di cult.
2. Preservation of the curved portion inside of the
nostril during excision is necessary to prevent a
teardrop deformity.
3. The incision for the alar wedge excision is marked at
1 to 2 mm above the alar-facial junction.
V-Y Advancement for Large Alar
Wedge Resection
When a considerable amount of alar wedge resection is
done, a diameter di erence between the upper and lower
alar incisions will not create a natural alar-facial sulcus. A
V-Y shaped suturing can solve this problem; however, it can
create a new scar, which is best camou aged by placing it
along the nasolabial sulcus.
Correction of Hanging Alar
For correction of hanging ala, refer to Chapter 9 of this book.
Alar Base Surgery for the Cleft Nose
Complete correction of the cleft nose deformity requires
repositioning and reconstruction of the lower lateral car-
tilage, repositioning of the columella, and augmentation of
the premaxillary region in addition to alar base modi ca-
tion (Fig. 8.6). Detailed description of these complicated
techniques is not within the scope of this chapter.
Fig. 8.5 A combined sill excision and wedge resection of ala. (a) Preoperative picture of a patient with under-projected tip and dorsum,
bulbous tip, and wide alar base. (b) The tip has been projected with the use of a columellar strut and cap grafts, and the dorsum has also
been augmented. An illusion of inter-alar distance narrowing has already been created through tip projection. The design for alar base
excision has been marked out. Note how a portion of the curved area of the nostril has been preserved to avoid the creation of a teardrop
nostril. Also note how a small strip of vertical skin has been preserved on the right to facilitate closure later. (c) The right wedge excision
has been performed. (d) The gure-of-8 suture has been passed from right to left through the deep premaxillary tissue. Note how the
needle has engaged the brofatty tissue of the cut free edge of the alar side wall. (e) The direction of the needle is reversed and the needle
is passed back in a similar manner to catch the alar brofatty tissue on the other side. (f) The suture is tied and the knot buried. The inci-
sions are closed with ne mono lament sutures.
a
b
c
d
e
f

II Rhinoplasty
104
excision design should be placed as much as possible in
the alar-facial groove to achieve good camou age; a small
vertical cu of skin from the ala can be preserved to facili-
tate closure. With expected scar contracture, this incision
should eventually lie well camou aged in the groove itself.
In instances where the incision is made in the groove
directly, closure of the near vertical alar side wall skin to
the horizontal midface skin will be di cult. The tenuous
epithelialization of skin over this right-angled closure site
is often delayed and will break down frequently with minor
displacement, resulting in poor wound healing, granula-
tion, and scarring (Fig. 8.8).
The excision design should also be kept as inferior as
possible in the alar-facial groove. High excision designs are
conspicuous, especially in this sebaceous area of the face,
which scars poorly, and can be seen from the frontal, pro le,
and basal views, often resulting in patient dissatisfaction.
Occlusive antibiotic ointm ent should be applied to the
excision sites till epithelization occurs and stitch rem oval
is completed. Thereafter, silicone gel should be applied for
the following 3 m onths. The patient should also be advised
4. The superior extent of wedge sections should be kept
as inferior as possible in the alar facial groove. The skin
in this area is thick and sebaceous, and scar-related
complications here are conspicuous and unforgiving.
The lateral nasal artery also runs 4 mm superior to the
level of the nasal sill and should be preserved.4
5. Tension sutures ( gure-of-8) passed under the
premaxillary soft tissue aid in tension-free closure
and healing of the incisions.

■Complications and
Their Management
Scarring
Achieving an aesthetically acceptable scar is possible with
proper excision design, meticulous soft tissue handling and
closure during surgery, and good postoperative care. The
Fig. 8.6 Unilateral cleft nose deformity.
(a) Preoperative photo shows typical asym-
metric alar base of unilateral cleft nose
deformity. (b) Three-month postoperative
photo shows improved symmetry with ele-
vated left alar base.
Fig. 8.7 Narrowing of columellar base. (a) Too-wide columellar base by divergent medial crura causes nasal obstruction. (b) After lateral
columellar incision and dissection, the divergent medial crura are exposed, excised, and cinched together. (c) Immediately after surgery,
the columellar base looks narrower than before the surgery.
a
b
a
b
c

8 Alar Base Modi cation
105
looking nose after alar base surgery. Isolated and excessive
reduction of alar aring and inter-alar distance can create
the illusion of a bulbous tip or accentuate the appearance of
a long nose; the nose can also appear pinched or boxy from
the basal view if the columella projection is inadequate.
This occurs because the appearance of the tip width and
nasal length is referenced against the inter-alar distance
from the frontal view, while the adequacy of columella
projection is referenced against the inter-alar distance in
the basal view. Reduction of the inter-alar width therefore
creates an illusion of increased tip width, nasal dorsum
lengthening, and decreased tip projection. Consideration
of the interplay between these factors is important when
planning rhinoplasty.
Nasal Obstruction
Aggressive reduction of the alar base and reduction in
the nostril size can result in nasal obstruction. The nostril
forms the anterior boundary of the external nasal valve.
When this aperture is excessively reduced in absolute
terms, a static external nasal valve obstruction can result.
A dynamic collapse can also result if the patient has pre-
existing weak lower lateral cartilages.
Excision designs that spare the vestibular skin should be
used in patients who have small nostrils. Any pre-existing
weakness of the lower lateral cartilages should also be iden-
ti ed preoperatively and the patient informed of the poten-
tial risk for nasal obstruction after alar base surgery, with
the option of reinforcing the lower lateral cartilages with
batten grafts during the rhinoplasty o ered to the patient.5

■Case Studies
Case 1: Combined Nostril Sill and
Alar Wedge Resection
A 25-year-old woman visited the clinic desiring removal of
her nasal hump and re nement of her nasal tip (Fig. 8.9).
Physical examination revealed a mild reverse C-shaped
dorsum with a small hump. Her nasal tip was bulbous
with insu cient projection and her nasal base was wide.
There was no septal deviation, and her skin was fair and of
medium thickness.
An open septorhinoplasty approach was taken and her
septal cartilage harvested. Osteotomies were performed to
straighten her deviated dorsum while a caudal septal extension
graft was used to elevate her nasal tip. Soft tissue reduction of
the nasal tip was performed, with the excised material used as
a radix graft. Septal cartilage was used for dorsal augmentation.
Thereafter, as part of the nal rhinoplasty sequence, a
modi ed Weir resection was used to resect both the alar
side wall and the nasal sill to e ect reduction in alar aring,
nostril size, and nasal base width.
against excessive ultraviolet exposure to the operative site.
Intralesional steroids can be adm inistered if hypertrophic
scarring develops.
Teardrop Nostril
A teardrop nostril occurs when the curved portion of the nos-
tril is not preserved during alar base resection. This results
in the alar side wall and nasal sill meeting at an acute angle
after closure of the wedge excision. When seen from the
basal view, there is a loss of the normal kidney bean shape of
the nostril, with the nostril resembling a teardrop (Fig. 8.8).
The creation of a teardrop deformity is best avoided
with correct excision design, preserving the curved portion
of the nostril.
Asymmetry
Any pre-existing asymmetry of the nostrils must be identi-
ed and documented (Fig. 8.8). Correction of nostril asym -
metry is a technically di cult part of rhinoplastic surgery.
It is important to point this out to the patient before sur-
gery. Asymmetry in the alar base can be corrected with
non-symmetric excisions. However, asymmetries occur-
ring higher in the alar side wall, such as alar retraction
asymmetries secondary to contour, need to be corrected
through manipulation of the lower lateral cartilages, rim,
and/or composite grafts. These should be discussed with
the patient beforehand.
Poor Harmony of Alar Base with
Nasal Dorsum and Tip
The intimate relationships between these three areas have
been elaborated earlier, and a careful preoperative assess-
ment is necessary to avoid creating a disharmonious-
Fig. 8.8 Complications of alar base surgery. This patient demon-
strates several complications of alar base surgery including obvious
scarring in the alar-facial groove, asymmetric nostrils, and the cre-
ation of a right teardrop nostril.

II Rhinoplasty
106
nostril asym m etry was noted. Endoscopy revealed a right-
deviated nasal septum . The patient’s skin was thick and
sebaceous.
An open septorhinoplasty approach was undertaken
and the septal cartilage was harvested. Osteotomies were
used to straighten the bony dorsum. A columellar strut was
used to increase tip projection together with two stacked
cap grafts to the tip. Stacked septal cartilage was used to
augment the dorsum. Finally, a modi ed Weir excision was
used to excise the sill and alar side walls to reduce aring,
alar base width, and nostril size.
The 1-year postoperative photographs demonstrate
straightening and augmentation of the dorsum with increased
tip projection and tip re nement (Fig. 8.12). The alar base
width, nostril size, and alar aring have all been reduced.
Postoperative pictures taken 2 years later show signi -
cantly narrowed nasal tip, alar base width, and alar aring
(Fig. 8.10). Increased radix, dorsum, and tip projection is
evident. The dorsal hump has been camou aged.
Case 2: Combined Nostril Sill and
Alar Wedge Resection
An 18-year-old m an was seen in the clinic desiring re ne-
m ent of the nasal tip, correction of the deviated nose, and
augm entation of the nasal dorsum (Fig. 8.11). Physical
exam ination revealed an under-projected nasal dorsum
deviated to the left. The nasal tip was boxy and bulbous
w ith poor projection. The alar base appeared w ide and
Fig. 8.9 Case 1. Patient with combined
nostril sill and alar wedge resection. (a,b)
Preoperative photos show a mild reverse
C-shaped dorsum with a small hump. Her
nasal tip is bulbous with insu cient projec-
tion and her nasal base is wide.
Fig. 8.10 (a,b) Case 1. Two years after
surgery, the tip shows signi cant narrow-
ing with reduced alar base width and alar
aring.
a
b
a
b

8 Alar Base Modi cation
107
3. Rawlings AV. Ethnic skin types: are there di erences in
skin structure and function? Int J Cosm et Sci 2006;28(2):
79–93
4. Jung DH, Kim HJ, Koh KS, et al. Arterial supply of the nasal tip
in Asians. Laryngoscope 2000;110(2 Pt 1):308–311
5. Ballert JA, Park SS. Functional considerations in revision
rhinoplasty. Facial Plast Surg 2008;24(3):348–357
References
1. Farkas LG, Hreczko TA, Deutsch CK. Objective assessm ent
of standard nostril types—a morphom etric study. Ann Plast
Surg 1983;11(5):381–389
2. Yap E. Improving the hanging ala. Facial Plast Surg
2012;28(2):213–217
Fig. 8.11 Case 2. Patient with combined
nostril sill and alar wedge resection. (a,b)
Preoperative photos show an under-pro-
jected and deviated dorsum and boxy,
bulbous nasal tip with poor projection.
The alar base appears wide and the nostrils
asymmetric.
Fig. 8.12 (a,b) Case 2. After 1 year, his
nose is straight and the dorsum is well aug-
mented. The bulbous tip has been re ned
and the tip projection increased. The alar
base width, nostril size, and alar aring have
all been reduced.
a
b
a
b

108
9 Aesthetic Rhinoplasty for Southeast Asians
Eduardo C. Yap

■Introduction
Noses of Southeast Asian peoples are generally small and
short with a bulbous tip, thick skin and soft tissue envelope
(SSTE) and a low nasal dorsum. Nasal bones may be wide
at the attachment to the upper lateral cartilage. The tip is
usually upturned. There is a certain degree of hanging ala,
and columellar show is often de cient. The nasal frame-
work is usually small, with a small nasal septum. The lower
lateral cartilages are also small and weak, and the dome is
ill de ned with short medial crura. The anterior nasal spine
and premaxilla are often underdeveloped.
Because of the features just m entioned, the surgery
planned should include elongation and projection of
the tip, augm entation of the dorsum , alar lifting and re-
structuring of the colum ella for a better colum ellar show
and alar-colum ellar relationship, and augm entation of
the prem axilla to improve the nasolabial angle. The m ost
critical procedure is proper rotation and projection of the
tip to a new position. As the septum is the m ost stable
structure, the central part of the septum is harvested and
is used for an extended septal support graft for xation of
the lower lateral cartilage to form a whole new tip. This
m aneuver also extends the colum ella for a better colu-
m ellar show. The open approach is often used. The SSTE
dissection is w idely extended up to the piriform aperture
laterally, nasal spine inferiorly, and glabella superiorly.
The dissection plane should be below the super cial m us-
culo-aponeurotic layer system (SMAS) on the upper and
lower lateral cartilages, and below the periosteum on the
nasal bone.

■Patient Evaluation
“Thank you Dr. Yap for [the] nice work you did on my
nose; however, I don’t like to look at myself in the mirror
because I see a di erent person” (a female patient, 1 month
postoperative).
Pearls
• The bony-cartilaginous structure of Southeast Asian
noses is generally small in all dimensions, resulting
in a relative abundance of skin and soft tissue. To
achieve a long-lasting e ect, a strong framework is
needed to counteract the forces of wound healing
and the heavy skin and soft tissue complex.
• Hanging ala of various degrees is often noted and
can be easily corrected via “sail” excision. This
procedure also improves columellar show.
• The septal extension graft (SEG) is the workhorse in
providing sturdy support to the tip.
• The SEG may be inadequate as support in some
cases. Additional grafts can be used to support the
SEG (e.g., extended spreader and caudal margin
extension grafts). Because of the paucity of septum
that can be harvested, folded conchal cartilage
attached beneath the SEG is often used.
• Tip-plasty is done before dorsal augmentation. After
modifying the tip as desired, the dorsal graft is made
to blend the new tip and the radix.
• Among synthetic products for dorsal augmentation
material, expanded polytetra uoroethylene (ePTFE,
popularly known as Gore-Tex) is preferred because it
heals by tissue adhesion with no capsular formation.
It provides a more natural look albeit with some
undesirable potential complications such as
deviation, visibility, and infection.
• ePTFE in sheet form or preformed should be limited
to a single piece if possible. Stacking of sheets may
trap contaminants. The implant should be removed
from its package only when it is time for dorsal
augmentation to avoid prolonged air exposure.
• ePTFE in sheet form is preferred for a shallow
radix whereas the preformed type is preferred for
correcting a deep radix.
• The implant should be carved to follow the contour
of the nose. The caudal end of the implant should
be sutured to the dome to achieve a continuous
structure of the dorsum and the tip.
• A gap of space usually is left at the junction of
the upper cartilage and lower cartilage after
placement of the implant. This space should be lled
with cartilage to prevent postoperative supratip
depression.

9 Aesthetic Rhinoplasty for Southeast Asians
109
nique, the face and the auricles are draped as a whole.
Lidocaine 2% with 1:100,000 adrenaline is used as local
anesthetic. Caution is advised toward the safe dose of lido-
caine with adrenaline, which is 7.0 mg per kilogram of
body weight.
The conchal cartilage is harvested either anteriorly,
if only a small amount of cymba and cavum concha is
needed, or posteriorly, if a bigger amount is needed. The
anterior incision is done at the posterolateral portion of the
cavum concha. The skin of the cavum concha is dissected
above the perichondrium and elevated to the cymba con-
cha. An incision in the cartilage is then made near the skin
incision site, leaving 2 mm of cartilage beneath. Dissection
is then performed at the posterior side, making sure that
the perichondrium is preserved and remains attached to
the cartilage. The conchal cartilage harvested should con-
tain perichondrium on both sides to preserve the strength.
It should be soaked in normal saline solution at all times
before being fashioned as grafts.
For the posterior approach to conchal cartilage harvest,
an incision is made between the sulcus and the helix. Dis-
section is above the perichondrium. Bleeders can be cauter-
ized. To maximize the harvest of cymba and cavum concha,
two or three hypodermic needles are used to pierce anteri-
orly at the edge of the conchal cartilage through and through.
The cartilage is then incised and dissection is carried
above the perichondrium anteriorly, preserving 5 to 8 mm
of conchal cartilage near the external auricular canal.
Closure of incisions is a bit di erent. For incisions
done anteriorly at the cavum the donor defect should have
2 mm of conchal cartilage below the site of skin incision.
This will be helpful because it w ill serve as a platform for
skin wound healing. Closure with a simple interrupted
suture is done using nylon 5–0, including the cartilage to
avoid a crumpled look at the incision site. A bolster suture
is also applied to avoid hematoma formation. For a poste-
rior incision, closure is done using nylon 5–0 vertical mat-
tress sutures. Sometimes the harvest site of the cymba and
cavum concha contracts, especially at the big auricle; to
avoid collapse and contracture, a strip of cartilage between
the cymba and cavum is preserved.
Alar Lift Surgery via Sail Excision
Hanging ala is common in Southeast Asian noses. Before
the start of surgery the tip is manually pulled to its desired
position to simulate counter-rotation and projection.
Attention should also be given to the alar-columellar rela-
tionship. If there is a need for alar lifting it should be done
as the initial procedure since the whole lower part of the
nose is still mobile and will allow maximal exibility in
maneuvering the ala during marking, traction, excision,
and suturing.
The alar rim can be lifted by excision of a triangular
piece of tissue in the inner lateral vestibular skin (Fig. 9.1).
Rhinoplasty remains the most common facial aesthetic
procedure done in the Southeast Asian region. Patients
should determine the right surgeon for themselves through
thorough consultation with prospective surgeons. Prior to
discussing the surgical plan, the patient should always be
asked about the improvement sought for his or her nose.
Computer simulation can be a dangerous tool because it
may lead to future dissatisfaction resulting in arguments
with the surgeon. It should be explained to the patient
that improvements from the surgery largely depend on
the existing structures. The aim of aesthetic rhinoplas-
tic surgery is to improve the current appearance, not to
achieve perfection. The majority of outcomes are good and
fall within patients’ and surgeons’ expectations. However,
there may be some cases where the outcome falls drasti-
cally short of expectations. This is often seen in noses with
multiple aesthetic de ciencies (e.g., small nose, low bridge,
bulbous upturned tip, retracted columella, retruded pre-
maxilla, hanging ala, and wide alar base).
The patient should be aware that after the rhinoplasty
surgery, there are a few possible reactions to the new nose.
People who have frequent encounter with the patient (e.g.,
family members, o ce mates, and the patient herself) may
nd the change very obvious. Those who see the patient
occasionally (e.g., high school and college alumni friends)
may not be able to notice the di erence; these people will
generally comment that the patient looks more beautiful
than before. People who had never met the patient prior to
the surgery may not even notice that the patient has had
surgery done on the nose.
Patients should be informed of the surgery in detail
beforehand: extent of the surgery, duration of the surgery,
type of anesthesia given, donor site, possible morbid-
ity after harvest, and other pertinent points. Risks of the
operation should be discussed thoroughly as well. Setting a
realistic surgical goal is important. Patients are advised to
keep an old picture of themselves close at hand for two pur-
poses: for identi cation and to remind themselves of their
previous appearance. Their new noses should be compared
with their previous ones, not with other people’s noses.1

■Surgical Techniques
Conchal Cartilage Harvest
Most Southeast Asian rhinoplasties need conchal cartilage
for grafting since the harvested cartilage available from the
septum is limited. This procedure is done before the actual
rhinoplasty. Histologically, septal cartilage is a hyaline car-
tilage and is rmer; hence it is used as a support graft. Con-
chal cartilage, which is an elastic cartilage, is softer and is
used mainly for contour, ller, and camou age grafts.
The surgery can be done under general anesthesia or
intravenous sedation. Following the usual aseptic tech-

II Rhinoplasty
110
mellar incision at the medial crura is made behind the skin
mound and anterior to the hair-bearing area. Another inci-
sion is made 2 to 3 mm caudal to the edge of the lower
lateral cartilage. The medial incision and the caudal mar-
ginal incisions are then connected maintaining 2 to 3 mm
of skin. Maintaining a 2- to 3-mm vestibular skin allowance
ensures good coaptation during closing with sutures.
Dissection of the lower lateral cartilage is approached
at three sites: rst at the medial crura, then at the lower
lateral cartilage, and nally at the dome. A soft tissue dis-
section is done at the medial crura. The dissection of the
lower lateral cartilage is done above the perichondrium. At
this time a transcolummellar incision can be made and the
domes are dissected away from the overlying skin and soft
tissue envelope. The dissection of the lower lateral cartilage
is carried superiorly and laterally up to the scroll junction
of the upper lateral cartilage and the lateral ends of the
lower lateral cartilage.
The dissection of the dorsum at the area of the upper
lateral cartilage should take place beneath the SMAS. This
is achieved by carefully applying blunt and sharp dissec-
tion at the dorsal septum near the anterior angle. Once the
plane is identi ed at the dorsal septum, a blunt dissection
is done lateral-ward until the piriform opening edge of the
maxillary bone is reached. At this time the lower lateral
cartilage should be fully mobile for tip repositioning.
The irregular triangular piece of skin tissue is shaped like
the sail of a sailboat. The two sides are marked at the inner
alar rim margin, and a skin groove in the lateral vestibule
area is marked by the transition of thin vibrissae to thick
vibrissae. The apex of the triangle is located at the highest
curve in the “gull wing” on the frontal view. The alar rim
skin is made to roll cephalically as a ap, thus lifting the
whole alar rim. The defect is closed using nylon 6–0 simple
interrupted sutures (Fig. 9.2).2
There are some instances where the alar base is lower
than the columellar base. The alar lift surgery should
be aggressive to lift the alar base as well. This procedure
involves a radical “sail” excision by extending the incision
inferiorly and posteriorly following the vestibular groove.
The design of the extended sail excision is actually a small
triangle inferior to the sail diagram; its apex is pointing
inferior-posterior (Fig. 9.3). Closure is done via absorbable
suture 6–0 simple interrupted at the sill area and nylon 6–0
simple interrupted at the rim (Fig. 9.4).
The Approach
Since the majority of Southeast Asian noses need struc-
tural modi cation, an open approach is preferred for better
visualization. A marginal incision is rst made. The colu-
Apex
Cephalic side
(vestibular
groove)
Caudal side
Base
Apex (peak of gull wing)
Fig. 9.1 Designing the “sail” for alar lift. The
two sides of the triangular sail are the caudal side,
which is the inner margin of the alar rim, and the
cephalic side, which is determined by a groove
in the lateral vestibule. The base is marked just
before the area of the sill. The apex is determined
by the highest point of the wing of the “gull in
ight” on frontal view.
Fig. 9.2 Closure of the sail excision. (a) Markings for the triangle shaped “sail” are made. If there is a need for alar base surgery, the mark-
ings are made higher. (b) The defect after excision of skin and subcutaneous tissue. (c) Closure using nylon 6–0 starts at both ends. The
caudal side acts as a ap that coapts with the cephalic side and the base.
a
b
c

9 Aesthetic Rhinoplasty for Southeast Asians
111
A safe approach to split the membranous septum is fol-
lowing the geometric rule of “two points in a plane deter-
mine a line.” Point A is the anterior angle of the septum
and point B is the footplate. The “plane” is the membranous
septum. After identifying the anterior angle of the septum,
the bers of the opposing medial crura are dissected via
blunt dissection up to the anterior nasal spine. This maneu-
ver exposes the footplates. A sharp dissection of the mem -
branous septum between the anterior angle of the caudal
septum (point A) and the footplate (point B) is now per-
formed until one reaches the caudal margin of the septum.3
Septum Dissection: It Is Not How
Much You Have but How Much
You Leave Behind
After the caudal edge of the septum is identi ed, the brous
attachments of the mucosa are sharply dissected to expose
the perichondrium. A bilateral subperichondrial dissection
is made until the bony parts of the septum are reached. The
central quadrangular septal cartilage is harvested, leaving
at least 10 mm of caudal and dorsal strut. Any deviation
in the remaining septum is straightened with various tech-
niques (Fig. 9.6). Any bony spurs and deviation are removed
using rongeur forceps.3,4,5
The attachments of the upper lateral cartilage with the
septum may be divided and corrected with spreader grafts
in cases where there is a gross deviation. Minor deviations
can be camou aged with a dorsal graft.
The upper dorsum comprises the nasal bones. The
plane of dissection is subperiosteal. Use a sharp periosteal
elevator, and take care to avoid injury to the dorsal nasal
nerve that exits 5 to 6 mm lateral to midline between the
nasal bones and upper lateral cartilage (Fig. 9.5).
Membranous Septum Dissection:
Two Points in a Plane Determine a Line
The membranous septum should be opened for access to
the caudal edge of the septum. The dissection also frees the
medial crura and footplate for tension-free tip reposition-
ing and columellar show.
Fig. 9.3 Extended sail excision for correction of hanging alar rim
and alar base. The extended correction is done by designing a small
triangle posterior to the sail diagram and following the vestibu-
lar groove as a guide infero-posterior to the nasal sill. Removing
the vestibular skin with its subcutaneous tissues and suturing the
defect will result in maximum lift at the alar base.
Fig. 9.4 Extended sail excision. (a) Preoperative and (b) imme-
diately postoperative correction of hanging alar rim and alar base.
This maneuver is done as an initial step, with no other procedures
having been done yet. Note the instant lift of the alar base and bet-
ter alar-columellar relationship.
Fig. 9.5 Dorsal nasal nerve (arrows) as it exits between the nasal
bone and upper lateral cartilage. Care should be taken to preserve
it. The subperiosteal dissection for the dorsal implant should be
medial to the nerves.
a
b

II Rhinoplasty
112
supratip area (Fig. 9.7). Intraoperative maneuvering of the
SSTE helps in the nal design of the SEG and dorsal grafts.
After the quadrangular cartilage is harvested, the edges
of the harvested cartilages, especially the inferior attach-
ments to the palatine crest, are checked for irregularities and
shaved for a smooth plane. The harvested cartilage from the
dorsal area is usually thicker and is best suited for use as SEG.
The inferior portions are used as additional support grafts
(e.g., spreader graft, caudal margin extension graft).5,6,7,8
Placement of the SEG needs three or four sutures for
xation: one central, one anterior, one inferior, and nally
a loop around (Fig. 9.8). The loop-around suture prevents
the swinging door deformity of the SEG, which may cause
internal valve obstruction and twisting of the tip. The SEG
may be weak or deviated, and it may be strengthened using
other support grafts (e.g., spreader graft or caudal margin
extension graft). The use of caudal extension grafts also
improves the columellar show and augments the premax-
illa. Folded conchal cartilage is also a good material for sup-
port of SEGs. It is placed between the inferior margin of the
SEG and the caudal strut. (Fig. 9.8 and Fig. 9.9).9,10
Tip Projection and Counter-Rotation:
A Must for the Southeast Asian Tip
Because the lower lateral cartilage is not always symmetric,
the domes are rst marked with gentian violet and then
xed to the anterior angle of the SEG using a 25-gauge
hypodermic needle, making sure there is no buckling of the
SEG or deviation of the tip. Avoid excessive tension of the
lower lateral cartilage. Two polydioxanone (PDS) 5–0 xa-
tion sutures are placed on the dome. The posterior edge of
the medial crura is sutured to the SEG via polyglactin (Vic-
ryl) 5–0 in the sequence vestibule skin–medial crura–SEG–
medial crura–vestibule skin.11
Designing the Septal Extension Graft:
Achieving Strength and Symmetry
Because the septum in Southeast Asian noses is usually
small, any septal cartilage harvested is utilized mainly for
support grafts (e.g., SEGs and spreader grafts). Therefore,
one should almost always harvest conchal cartilage for con-
tour and camou age grafts. The vector of the tip reposition-
ing should be kept in mind before commencing surgery to
achieve the ideal tip projection. Attention should also be
given to the varied thickness of the SSTE when redraping
the restructured nose since the framework will be elongated
antero-caudally and the SSTE will be stretched. The nor-
mally thicker radix skin will be redraped caudally, and the
thick bro-fatty tip skin will be relocated cephalically at the
Fig. 9.6 Dorsal and caudal struts. At least 10 mm of strut should
be preserved. In instances where there is a need for a bigger sep-
tum for support, more can be harvested from the caudal side, thus
leaving a smaller caudal strut of ~ 8 mm.
Fig. 9.7 Manual stretching of the SSTE for simulation. In struc-
tural rhinoplasty where the nose is elongated, the thicker radix skin
is pulled caudally when the SSTE is stretched to redrape the new
tip. The supra-tip bro-fatty skin will appear more cephalic and the
low radix will appear higher.
Fig. 9.8 The four-point suturing of the SEG and the folded conchal
cartilage for support of the SEG. The SEG should be xed with three
anterior sutures (dorsal, central, and caudal) and a loop-around
structure to prevent deviation and tip twisting. After the conchal
cartilage is scored on the concave side and folded, it is anchored
between the SEG and the caudal strut.

9 Aesthetic Rhinoplasty for Southeast Asians
113
Osteotomy: For Safety, Guide and Glide
Osteotomy is done on noses showing an inverted-V defor-
mity but only once the framework of the tip is accom -
plished. The inverted-V deformity usually disappears once
a dorsal implant is put in place, or sometimes just a lateral
osteotomy may be needed.
A medial osteotomy commences at 5 to 6 mm from the
midline and is directed superolaterally not to extend beyond
the imaginary line between the medial canthi. A wide plat-
form is needed to accommodate the dorsal implant. Oste-
otomy follows the “guide and glide” principle, where the
surgeon guides the osteotome to cut the bones and glides
along the desired path, which is usually thin. There will be a
feeling of resistance or a change in pitch from tapping of the
mallet when one reaches a solid bone. The lateral osteotomy
can be approached directly transcutaneously or intranasally.
The transcutaneous approach is done using a 3-mm osteo-
tome. The intranasal approach commences at the aperture
near the nasal process of the maxillary bone superior to the
inferior turbinate. A guarded curve osteotome is introduced
through a small stab incision in the nonhair-bearing area of
the vestibule just above the attachment of the inferior turbi-
nate. The guard should be palpated transcutaneously with the
nondominant hand along the tract of the lateral osteotomy.
The tract should run through the softer bones at the nasal
process of the maxilla. Some surgeons have approached the
lateral osteotomy intraorally at the gingivo-buccal sulcus.12
Designing the Dorsal Implant
The majority of Southeast Asian noses need dorsal aug-
mentation. In general, the thicker the implant the more vis-
ible it may become. Dorsal implants usually range from 2 to
4 mm in thickness. Depending on the design, the implant
should be one whole piece from the radix to the upper
lateral cartilage or extend slightly caudally over the lower
lateral cartilage.
There are several materials used for dorsal implants.
Autologous materials are still the best, and include carti-
lages, dermis, fascia, and fat. However, because of the need
for volume in dorsal augmentation, synthetic materials
are preferred. Synthetic materials include silicone, ePTFE
(Gore-Tex), and porous polyethylene (Medpor). There are
also homografts such as processed dermis, fascia, and rib.10
Of all the materials mentioned, the three most com -
monly used in dorsal implants are silicone, ePTFE, and car-
tilage. These materials have their respective bene ts and
risks. One bene t of silicone is that it is relatively cheap and
easy to remove when infected. However, when healed there
is a capsular formation that may give a surgical look years
later because the subcutaneous fat of the SSTE atrophies
with time. Silicone is also mobile despite the precise design
of the subperiosteal pocket. It has a tendency to migrate
superiorly to the radix or caudally to the tip, causing
A shield graft and a backstop graft are designed to fur-
ther counter-rotate and project the tip. Grafts are sutured
at the caudal portion of the dome using PDS 5–0 (Fig. 9.10).
Once the tip grafts are xed in place, the septal mucosa can
be sutured using a Vicryl 5–0 running quilt closure start-
ing at the inferior portion of caudal strut and running ran-
domly in a loop fashion. Make sure the areas of the internal
valve and the membranous septum are well coapted. At
this point the SSTE can be draped to check the tip projec-
tion and counter-rotation. Once the surgeon is satis ed
with the restructured tip, a dorsal graft can used to blend
the new tip w ith the radix.9
Fig. 9.9 Folded conchal cartilage as support for the SEG. This
graft prevents the collapse of the SEG and augments the anterior
nasal spine, improving the premaxilla.
Fig. 9.10 Contour tip grafts. Once the lower lateral cartilages are
attached to the SEG, multiple backstop, shield, and onlay grafts are
put in place for further counter-rotation and projection of the tip.

II Rhinoplasty
114
Designing a Preformed ePTFE Implant
Preformed ePTFE implants should be removed from the
sterile packaging only when it is time for insertion. Insert-
ing the implant is a trial-and-error procedure. First the SSTE
should be redraped and the radix down to the tip should
be palpated to determine the ventral shape of the implant.
The ventral side of the implant is then carved accordingly.
The implant is reinserted and the length of the implant is
checked against the dome. If the implant is long, then it is
cut (Fig. 9.11).
Attention is then directed at the new radix, supratip,
width, and rhinion. Because the rhinion’s convexity will be
at a di erent site from the stretched SSTE when redraped,
care should be taken to avoid a hump look of the implant.
The rhinion side of the implant can be determined in two
ways. One way is to apply external pressure to the dorsum
to produce a convexity of the implant; the other way is by
using a Brown-Adson forceps (one jaw beneath the implant
to palpate the bony-cartilaginous junction and one jaw
above the implant) and make a pinch mark once the bony-
cartilaginous junction is located (Fig. 9.12). The implant is
then removed and carvings are done accordingly.13
Since most tips in rhinoplasty go down on long-term
follow-up, it is recommended that the caudal end of the
implant be sutured to the dome to allow the whole unit of
the dorsum to blend well with the tip, even with long-term
resorption of the tip. The suturing also prevents caudal
deviation of the implant.
There may be a space between the upper cartilage and
the ventral side of the implant. The space should be oblit-
erated, preferably with cartilage rather than a thin sheet
of ePTFE because the latter may cause chronic pressure at
the mucosa between the upper lateral cartilage and lower
lateral cartilage, with subsequent infection (Fig. 9.13).
chronic pressure necrosis and subsequent extrusion. The
implant shapes are generally classi ed as “I” or “L” shapes.
The “I” shape implant extends from radix to the tip, while
the “L” shape implant has a strut that goes between the
medial crura to the anterior spine. The “L” shape maintains
the tip projection and prevents superior migration of the
implant; however, it is frequently associated with tip skin
pressure necrosis.
Expanded PTFE, on the other hand, heals w ith adhesion
and does not form a capsule. It closely adheres to the nasal
bone and cartilages, giving a more natural look. However,
in cases of long-standing reaction and infection it may be
di cult to remove. The incidence of ePTFE infection varies
worldwide, but if strict sterility and proper surgical tech-
nique are employed, the incidence is low.
Cartilage as an implant is best for correction of small
dorsal defects. Since the septal cartilage is mainly used for
support, conchal cartilage is used for the dorsal graft. If more
volume is needed, bilateral harvest of conchal cartilage is
done. The cartilage is cut into 5- to 8-mm strips. The strips
are scored on the concave side and stacked using nylon or
PDS sutures. Stacked conchal cartilage is e ective; however,
the strips resorb and may warp over time. There may also be
irregularities found when palpating the dorsum.13
Comparing the bene ts and risks of the three most
common materials used for dorsal augmentation, the use
of ePTFE is preferred because of its natural look and low
risk of reaction and extrusion. It comes preformed and in
sheets. Although ePTFE sheets can be stacked and sutured
together, it is recommended that a single piece of implant
be used as much as possible because of the risk of contami-
nants becoming trapped between sheets during handling.
Noses with a low radix need more augmentation, so a
preform implant is well suited while a nose with a shal-
low radix may just need a thin sheet. In suturing of sheets,
mono lament sutures should be used. Avoid using absorb-
able braided sutures to prevent impurities being intro-
duced and embedded in the ePTFE material.
Fig. 9.11 Preformed ePTFE implant. (a) The dorsal shape is ana-
lyzed to match the ventral side of the implant. (b) The ventral side
is carved using a no. 10 surgical blade.
a
b

9 Aesthetic Rhinoplasty for Southeast Asians
115
Fig. 9.12 Two ways to determine the rhinion. (a) External pressure on both ends will give a convexity of the ePTFE. (b) A better way is
inserting a Brown-Adson forceps up to the junction of the upper lateral cartilage and the nasal bone; the implant is pinched as a marker for
the rhinion. (c) The marks of the forceps teeth are noted and marked. (d) The marked area is carved out.
Fig. 9.13 Gap between ePTFE and upper lateral cartilage. (a) A space is often noted in the area of the upper lateral cartilage, especially
in a tip repositioned for projection. (b) The space can be lled up with cartilage. This is done to prevent collapse of the implant, causing
supratip depression.
a
b
c
d
a
b

II Rhinoplasty
116
Alar Base Surgery
The alar base may appear wide despite projection of the tip.
Alarplasty is done as the last procedure. An ellipse of skin
tissue in the nasal sill is excised following Weir’s technique.
Cinching of the alar base helps in coapting the alarplasty
defect for tension-free closure. Cinching should not be tight
because it can cause discomfort and a rotation look of the
tip. Closure is by nylon 5–0 simple interrupted sutures.

■Key Technical Points
1. In noses with hanging ala, perform an alar lift
surgery via a “sail” excision as the rst step because
the whole tip and ala are fully mobile, allow ing
accurate marking, excision, and closure of the defect.
2. The plane of dissection is above the perichondrium
in the lower lateral cartilage and upper lateral
cartilage, and is subperiosteal in nasal bones.
Dissection should be wide to allow redraping of the
SSTE with no tension.
3. Fixation of a SEG needs four sutures to achieve
stability. Additional grafts are used to support the
SEG if deemed necessary.
4. Fixation of the dome to the SEG should be free from
tension. Check for buckling of the SEG or deviation
of the tip.
5. Implants should be carved carefully in all
dimensions to achieve a good blending of the
implant with the underlying structures.
6. The caudal end of the implant should be sutured to
the dome to achieve a uni ed structure. If the tip
loses its projection over the long term, the whole
tip—including the implant—will go down as one
unit but still have good tip de nition. The xation
also prevents subluxation of the implant, causing
deviation.
7. A gap of space may occur between the implant and
upper lateral cartilage and it should be lled up with
cartilage.
8. The caudal margin of the implant should be cleared
from the line of incision.
9. Closure of incisions should be meticulous. No
fewer than seven sutures should be used in the
midcolumellar incision.
10. Alarplasty is done as the last procedure.
Designing a Sheet ePTFE Implant
Sheet ePTFE comes in several thicknesses. Usually sheets
of 2 or 3 mm thickness are used for minimal augmenta-
tion while preformed implants are used for bigger aug-
mentation. Depending on the dimensions of the sheet, it is
cut into individual strips of at least 50 mm length and 13
mm width. The strips are individually packed in a double
pouch and sterilized by gas or steam. Dividing a sheet for
multiple-patient use intraoperatively should not be done
because of the possibility of cross-contamination.
In designing a sheet implant, the length is rst esti-
mated by placing the sheet on top of the nose. The sides
are trimmed using a no. 10 blade and maintaining 5 to 6
mm at the medial portion. The cephalic and caudal ends
are trimmed beneath and at the corners. The sheet implant
is then inserted, noting speci cally any depression that is
found, which is usually in the middle third of the nose. A
small ePTFE sheet or cartilage is used to elevate the sheet
for better form. Cartilage is preferred over ePTFE sheet as
the material used to elevate the sheet implant because the
latter may dislodge the implant into the mucosa between
the upper lateral cartilage and lower lateral cartilage, caus-
ing chronic pressure and subsequent erosion and infection
(Fig. 9.13).
The SSTE is redraped for nal inspection. Palpation is
important at this time to identify a smooth dorsum from
the radix to the tip. After making certain that the new dor-
sum with ePTFE sheet implant is smooth with no depres-
sion, the caudal end of the sheet implant is then sutured at
the dome using nylon 6–0. If further projection or coun-
ter-rotation is needed, additional onlay or shield grafts
are used. Camou age grafts are also used at this point if
deemed necessary.13
Closure of the Incision
Closure of the trans-columellar incision should be done in
two layers. Vicryl 6–0 is rst used to suture the subcutane-
ous tissue, and the skin is closed using nylon 6–0 simple
interrupted sutures. To achieve symmetry in skin closure, it
is advisable to suture alternately left and right to follow the
cut pattern of the incision.

9 Aesthetic Rhinoplasty for Southeast Asians
117
beyond 2 months is usually related to immune response.
Early signs of infection can be reversed by intake of antibi-
otics. Persistent edema of the dorsum after augmentation
rhinoplasty may require removal of the implant and revi-
sion using an autologous graft.13
Tip cartilage visibility is seldom encountered in South-
east Asian noses because of the thicker tip skin; however,
in extensive tip projection and counter-rotation, cartilage
visibility may be an unexpected sequela. Therefore, it is
recommended that crushed cartilage or a soft tissue graft
be placed over the nal tip graft.8
The nal appearance of the reconstructed nose intraop-
eratively will represent the nal outcome of the new nose
postoperatively. Intraoperative palpation is an important
step to help visualize the nal shape of the reconstructed
nose postoperatively in the months to come.

■Case Studies
Case 1
A 25-year-old woman wanted a rhinoplasty to improve
the appearance of her face (Fig. 9.14). Physical examina-
tion showed a straight dorsum and septum. The dorsum,
however, was low; nasal bones appeared wide; the tip was
bulbous and slightly upturned; the columella was slightly
retracted with a retruded premaxilla; the alar base was
wide while the alar rim was hanging.
Alar lift surgery via a sail excision was done as the rst
step. Conchal cartilage was harvested anteriorly. The sur-
gery was an open approach septorhinoplasty with a septal
extension graft at the right side of the caudal strut. Folded
conchal cartilage was placed below the SEG for support and
for premaxillary augmentation (Fig. 9.15). After the dome
of the lower lateral cartilages was xed to the SEG, conchal
cartilage was used for tip grafts. A 3-mm ePTFE sheet was
used to augment the dorsum and was blended in with the
new tip and the radix. A small piece of conchal cartilage
was placed between the underside of the implant and the
upper lateral cartilage. A plumping graft using pieces of
conchal cartilage was inserted into the premaxilla. Alar
base surgery with a cinching technique was done as the last
procedure. Results are shown in Fig. 9.16.

■Complications and
Their Management
As most rhinoplasty in Southeast Asians involves alteration
of the nose’s structural framework, complications of the
surgery are also closely related to the restructured frame-
work. Most of the time, the amount of nasal septum har-
vested is only su cient for the SEG. There is almost always
a need to use conchal cartilage for contour grafts (e.g.,
shield grafts, cap grafts). Sound judgment is important as
to the amount of dorsal and caudal strut that is left behind,
which should be enough to hold the structural grafts and
contour grafts and to w ithstand the pressure force from the
SSTE during closure. Generally, a small nose with a small,
rm septum may need only 8 mm of strut while a nose
with a thin septum needs 10 to 12 mm of strut.10
The surgeon should be able to visualize the vector for
the new tip to properly place the SEG. The lower lateral car-
tilage should not be pulled too much because such forces
may cause buckling of the SEG. This, in turn, will cause
twisting of the tip and compression of the internal nasal
valve.4 The lower lateral cartilage should be symmetrically
xed to the SEG. Any de ciency in the desired tip projec-
tion and counter-rotation can be corrected by the use of
conchal cartilage for onlay or shield grafts, respectively. Do
not apply too much tension on the dome when xing it to
the SEG.
If twisting of the tip is noticed while still in surgery,
all grafts should be removed and all structures should be
realigned. In late-onset twisting of the tip, correction should
involve minimal access and minimal manipulation of the
whole structure. Correction is usually accomplished by place-
ment of a camou age graft (crushed cartilage, temporalis
fascia, or sacrodermal fat) to achieve symmetry; if there is an
accompanying obstruction in the internal valve, submucous
resection or scoring/suturing of the SEG can be done.
Palpation is very important to detect any gap between
the implant and its underlying structures in the radix and
supratip area. The tip should be well de ned visually and
con rmed by palpation before nal closure.13
Surgeons should adhere to the strict manner of han-
dling dorsal implants to avoid infection. Infection occur-
ring in the rst 2 months may be iatrogenic, while infection

II Rhinoplasty
118
Fig. 9.14 Case 1. A typical Southeast
Asian nose is shown. (a) Preoperative fron-
tal view shows a low but straight dorsum.
The tip is upturned, wide, and bulbous.
The nasal bones are wide. The alar base
is wide, the rim is hanging, and the colu-
mella is retracted. (b) Lateral view shows a
low dorsum and retracted premaxilla. The
columella is not visible and the alar rim is
hanging.
Fig. 9.15 Case 1. Schematic drawing of the soft tissue correction and structural grafting. The main support graft is a SEG, which is fur-
ther supported with an extended spreader and folded conchal cartilage. Tip de nition grafts include shield, backstop, and crushed onlay
grafts. Medial and lateral osteotomies were done. A 3-mm ePTFE sheet was used for dorsal augmentation. Soft tissue correction includes
sail excision for alar lift and alar base surgery.
a
b

9 Aesthetic Rhinoplasty for Southeast Asians
119
orly. The surgery was an open approach septorhinoplasty
with a septal extension graft at the right side of the caudal
strut and a caudal margin extension graft. After the domal
cartilages were xed to the SEG, conchal cartilage was used
for tip grafts (Fig. 9.18). A 4-mm preformed ePTFE piece was
used to augment the dorsum. A small piece of conchal car-
tilage was used to ll up the space between the underside
of the implant and the upper lateral cartilage. Pieces of con-
chal cartilage were used for a plumping graft. After closure
of the rhinoplasty incision, alar base surgery with cinching
was then carried out. Results are shown in Fig. 9.19.
Case 2
A 28-year-old man desired improvement of his nose, espe-
cially its tip (Fig. 9.17). Physical examination showed a
straight dorsum and septum. The dorsum, however, was
low with prominent glabellar frontal bossing; nasal bones
were wide; the tip was low and bulbous; the columella was
retracted with a retruded premaxilla; the alar base was
wide while the alar rim was hanging.
An alar lift via sail excision was done as the rst step.
Cavum and cymba conchal cartilage was harvested anteri-
Fig. 9.16 Case 1. (a) Postoperative frontal
view shows a better dorsal nasal aesthetic
line. The tip is narrower and counter-
rotated. The alar width is narrower. There is
a better alar-columellar relationship. (b) Lat-
eral view shows good tip counter-rotation
and projection. The dorsum is augmented
and the premaxilla is fuller. The columella is
visible and the alar rim is elevated.
a
b

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120
Fig. 9.17 Case 2. (a) Preoperative frontal
view shows a wide ala, a retracted colu-
mella, and a de cient middle vault. (b) Lat-
eral view shows a low dorsum, bulbous tip,
and retracted premaxilla. The middle vault
seems de cient.
Fig. 9.18 Case 2. Schematic drawing of the soft tissue correction and structural grafting. The main support graft is a SEG, which is further
supported with a caudal margin extension graft. Tip de nition grafts include shield, backstop, and crushed onlay grafts. Medial and lateral
osteotomies were done. A 4-mm preformed ePTFE implant was used. Soft tissue corrections included a 5-mm sail excision for alar lift and
a 2-mm alar base resection.
a
b

9 Aesthetic Rhinoplasty for Southeast Asians
121
7. Koch CA, Friedman O. Modi ed back-to-back autogenous
conchal cartilage graft for caudal septal reconstruction:
the m edial crural extension graft. Arch Facial Plast Surg
2011;13(1):20–25
8. Lin J, Chen X, Wang X, et al. A m odi ed septal exten-
sion graft for the Asian nasal tip. JAMA Facial Plast Surg
2013;15(5):362–368
9. Pernia NE, Galvez JA, Victoria FA. The dim ensions of the
nasal septal cartilage: a preliminary study in adult Filipi-
no Malay cadavers. Philipp J Otolaryngol Head Neck Surg.
2011;26:10–12
10. Toriumi DM, Bared A. Revision of the surgically overshort-
ened nose. Facial Plast Surg 2012;28(4):407–416
11. Yap E. Improving the hanging ala. Facial Plast Surg 2012;
28(2):213–217
12. Yap EC. Principles of structural rhinoplasty in South East
Asian noses. Philipp J Otolaryngol Head Neck Surg. 2014;
29:41–44
13. Yap EC, Abubakar SS, Olveda MB. Expanded polytetra uo-
roethylene as dorsal augm entation m aterial in rhinoplasty
on Southeast Asian noses: three-year experience. Arch Fa-
cial Plast Surg 2011;13(4):234–238
References
1. Akkus AM, Eryilm az E, Guneren E. Comparison of the ef-
fects of colum ellar strut and septal extension grafts for tip
support in rhinoplasty. Aesthetic Plast Surg 2013;37(4):
666–673
2. Baladiang DE, Olveda MB, Yap EC. The “sail” excision
technique: a m odi ed alar lift procedure for Southeast
Asian noses. Philipp J Otolaryngol Head Neck Surg. 2010;
25:31–37
3. Byrd HS, Andochick S, Copit S, Walton KG. Septal extension
grafts: a method of controlling tip projection shape. Plast
Reconstr Surg 1997;100(4):999–1010
4. Choi JY, Kang IG, Javidnia H, Sykes JM. Complications of
septal extension grafts in Asian patients. JAMA Facial Plast
Surg 2014;16(3):169–175
5. Jang YJ, ed. Rhinoplasty and Septoplasty. Seoul, Korea:
Koonja; 2014
6. Kim JH, Song JW, Park SW, Oh WS, Lee JH. E ective sep-
tal extension graft for Asian rhinoplasty. Arch Plast Surg
2014;41(1):3–11
Fig. 9.19 Case 2. (a) Postoperative frontal
view shows a good dorsal nasal aesthetic
line. The alar-columellar relationship is bet-
ter. The alar base is narrower. (b) Lateral
view shows a good augmented dorsum and
projected tip. The premaxilla is fuller and
there is columellar show. The alar rim is well
lifted.
a
b

122
10 Correction of the Short, Contracted Nose
Hong Ryul Jin
scar contraction from multiple rhinoplasties are thought to
be possible etiologies. This condition is rather common in
patients with weak lower lateral cartilages who had mul-
tiple rhinoplasties with silicone implantation.
Techniques to lengthen the nasal tip are oriented to
adding cartilage grafts to the caudal septum to caudally
rotate the tip, securing spreader grafts to a columellar strut,
tip grafts of various shapes, and placement of radix grafts
to elevate the nasion.1 Most postsurgical contracted noses
have both structural problems, such as weak alar cartilage
and decreased skin compliance caused by a damaged skin–
soft tissue envelope. Because of these features, short nose
correction has become one of the most di cult procedures
in rhinoplasty.

■Patient Evaluation
The patient’s history of previous surgery needs to be ques-
tioned very thoroughly. Dates and number of surgeries,
surgeons’ names, materials used, techniques used, and any
speci c reasons for multiple surgeries, including complica-

■Introduction
The short nose, the so-called snub nose, is objectively
de ned as having a decreased nasal length w ith an
abnormally increased nostril show from the frontal view
(Fig. 10.1). The tip is rotated cephalically with a more
obtuse nasolabial angle on the lateral view. The astute
surgeon should also note that a deep nasofrontal angle
contributes to the subjective appearance of a short nose,
especially when combined with an obtuse nasolabial angle.
The short nose can be congenital in origin, but is usually
acquired secondary to trauma or from a previous rhinoplasty.
In postsurgical cases, over-resection of the lower lateral carti-
lage is a frequent predisposing factor in Caucasian rhinoplasty.
On the other hand, in East Asian patients, a postsurgical short
nose deformity arises from di erent mechanisms.
The exact pathogenesis of short nose developing after
rhinoplasty using an alloplastic implant is unknown yet
but capsular contraction around the implant used for dor-
sal augmentation, lower lateral cartilage necrosis by long-
term pressure from implants, chronic in ammation, and
Pearls
• Repeated rhinoplasties causing trauma to the skin,
soft tissue, and cartilages, implant use over the
lower lateral cartilage causing pressure necrosis,
and over-resection of cartilages will ensue scar
contracture with resultant short, contracted nose.
• With every e ort made to correct the deformity, often
the postsurgical contracted, short nose cannot be
elongated to a level equal to patient expectations. It is
crucial to have an adequate consultation before surgery.
• The strategies for correcting secondary short nose
deformity include skin envelope release through
wide undermining, elongation and derotation of
the tip component, augmentation of the dorsum,
and use of composite graft material to ll the gap
between the elongated skin envelope and the
underlying vestibular skin.
• In most cases of short nose correction, costal
cartilage is necessary for structural support and
onlay grafting.
• A septal extension graft strongly supported with
bilateral extended spreader grafts using rib cartilage
is the key structural foundation on which the lower
lateral cartilage can be repositioned.
• An end-to-end type septal extension graft has the
advantages of aligning the center into midline and
avoiding caudal septal deviation compared with the
overlapping type.
• Various onlay grafts over the repositioned lower
lateral cartilage can help to lengthen or augment the
tip.
• A chondrocutaneous composite graft taken from
the cymba concha is often needed to ll the gap
between the lengthened skin envelope and the
vestibular lining.
• A staged operation or even a forehead ap will
be necessary if the skin shortage is severe in an
extremely contracted or destroyed nose.
• Warping of the rib cartilage used as a dorsal onlay
graft can be minimized with proper techniques
but is not completely avoidable. It can be corrected
with revision surgery after full-blown warping has
occurred.

10 Correction of the Short, Contracted Nose
123
with cotton tips, and often a thin, membranous posterior
septum with missing cartilage can be felt. In extreme cases,
the caudal septum is missing, causing severe shrinkage and
contraction of the tip. In these cases, lengthening of the
nose is possible only after the caudal septum is restored.
Elongating a short, contracted nose is a very di cult
job, and even with extensive structural groundwork, the
nose can be lengthened only by 3 to 4 mm. Therefore, the
limitations of the surgery need to be explained thoroughly
to the patient and a reasonable surgical goal needs to be
set. Often the patients tend to have unrealistic expecta-
tions, such as that the nose will look normal and more
beautiful compared with its preoperative status. Realistic
patient expectations and a reasonable surgical goal consid-
ering the nasal status and the surgeon’s experience are the
most important factors in the success of the surgery.

■Surgical Techniques
Strategies for Correction
If the degree of cephalic rotation is mild and the tip sup-
port is strong, adding cartilage grafts on the tip and the
dorsum may give some degree of caudal rotation of the tip
and the illusion of nasal lengthening by dorsal augmenta-
tion. In a very short nose caused by severe cephalic rota-
tion of the tip-de ning point, merely raising the nasion
with an implant on the nasal dorsum, or pulling down the
tip-de ning point slightly by placing a graft on the nasal tip
has limited lengthening e ect. More radical reorganization
and repositioning of the lower nasal framework and skin
envelope are necessary. Proper surgical technique is chosen
considering the prior operative history, patient expecta-
tions, the degree of cephalic rotation of the nasal tip pres-
ent, skin mobility, and the amount of available cartilage for
use as grafts.
In most postsurgical contracted, short nose, caudal
rotation of the tip-de ning point and raising the nasion
superiorly are two key surgical goals. Caudal rotation of the
tip-de ning point is obtained by caudally readjusting the
lower lateral cartilage on the septal extension graft with or
without additional tip onlay grafts (Fig. 10.3). To caudally
rotate the tip w ithout losing projection, a rm structural
support reinforcing and lengthening all three legs of the
“tripod” of the nasal tip is needed.
When the central part of the nose (i.e., the columella
and the tip lobule) is lengthened with a septal extension
graft, the lateral crus moves vertically upward and so does
the alar margin. The alar margins also need to be lowered
to create a more balanced nostril after the placement of the
septal extension graft. Slight imbalance can be adjusted
with a lateral crural onlay or strut graft. Placing a long lat-
eral crural strut graft–lateral crural complex into a pocket
made in the piriform aperture may lower the alar margin
in the thin-skinned Caucasian patient, but this maneuver
tions, need to be evaluated. Thorough data are important in
planning surgery.
The external nose is palpated carefully to evaluate the
skin, underlying bone, and cartilage. When the skin is too
thick or has a scar that decreases its mobility, the amount
of lengthening of the nasal tip can be limited. A sense of the
adequacy of skin mobility can be gained by pressing down
on the skin and pulling on it (Fig. 10.2). Extremely thin and
adherent skin may cause di culty in undermining and will
raise the possibility of skin damage. Every e ort should be
exerted not to damage the skin in this case.
The nasal cavity, especially the septum, should be thor-
oughly evaluated. In revision cases, there is a high chance
that septal cartilage has already been used in the previous
surgery and not infrequently there are septal perforations.
The intact-looking septum needs to be carefully palpated
Fig. 10.1 Typical postoperative short nose deformity. (a) Abnor-
mally increased nostril show and short nose are evident from the
frontal view. (b) Lateral view shows excessively cephalically rotated
nasal tip, low dorsum, acute nasofrontal angle, and obtuse naso-
labial angle.
Fig. 10.2 Evaluation of skin mobility. Skin mobility is assessed by
pulling the dissected skin and soft tissue envelope over the carti-
lage infrastructure during the surgery.
a
b

II Rhinoplasty
124
Fig. 10.3 Illustrations showing key techniques used to correct short nose defor-
mity. Septal extension grafts reinforced with extended spreader grafts and tip onlay
grafts are used to lengthen the nasal tip. (a) End-to-end type. (b) Overlapping type.
(c) Bilateral conchal composite grafts are applied when the elongated skin envelope
and the vestibular lining cannot be primarily closed.
a
b
c

10 Correction of the Short, Contracted Nose
125
tochondral junction is con rmed by serial probing with a
26-gauge needle. Marking is usually 1.5 to 2.0 cm in length
in thin-skinned patients and 2.0 to 2.5 cm in thick-skinned
patients. A local anesthetic is in ltrated at the incision site.
Ten minutes after injection, the skin and subcutaneous tis-
sue is incised with a no. 10 blade. The subcutaneous fat is
alternately separated and retracted using Senn retractors
until the fascia and the external oblique muscle layer are
exposed. The fascia is then incised and the muscle bers
separated w ith Kelly or mosquito forceps. To adequately
expose the surgical eld, the muscle layer is retracted with
an Army-Navy retractor for better visualization, instead of
cutting with a Bovie, to minimize postoperative pain. The
perichondrium and the rib are su ciently exposed after
retracting the soft tissue and muscle.
Two parallel incisions are made on the perichondrium
of the rib along the superior and inferior borders, leaving
the central strip of perichondrium on the anterior surface
intact. Following this, several cuts are made perpendicu-
lar to the longitudinal incision to facilitate circumferential
re ection of the perichondrium, which is then dissected
from the rib with a Freer elevator. The straight portion of
the rib is often found to be of insu cient length for dorsal
implantation, necessitating extension of the cartilaginous
cut up to the synchondrosis portion to obtain a longer piece
of cartilage.
Harvesting is facilitated if an anterior cut is made at
the medial end of the cartilage before completing the dis-
section of the posterior surface of the costal cartilage. The
perichondrium of the posterior surface of the rib is dis-
sected o as much as possible with a curved elevator. The
costochondral junction is identi ed visually or with the
help of a 26-gauge needle and the cartilage cut is made.
There is a great risk of injuring the underlying pleura if a
complete cut is made using the no. 15 blade; thus, the nal
cut is completed with the Freer elevator to prevent such an
injury. After the lateral cut, a small two-prong retractor is
used to pull up the costal cartilage to expose the posterior
surface and the dissection is continued medially. After com -
plete dissection of the posterior perichondrium, the costal
cartilage is separated at the medial cut and delivered out.
A 3- to 4-cm length of costal cartilage is typically har-
vested. The central strip of perichondrium is dissected
and preserved for later use. The harvested costal cartilage
is soaked in warm saline to assess for and induce warping
prior to carving. Testing for air leakage from the pleura is
performed by lling the dissection pocket w ith saline and
then initiating positive-pressure hyperventilation. If no air
leakage in the form of bubbles is evident, the donor site is
packed with antibiotic-soaked gauze until the operation
is completed. Additional costal cartilage can be harvested
during the operation or the cartilage remaining after graft-
ing can be reinserted and preserved under the muscle layer
for use in future revision surgery. If air leakage is noted, a
Nélaton catheter is inserted at the leakage site and sutured
in a purse-string manner. After tight closure of the subcu-
is not as e ective for East Asians, who have thicker skin. In
most cases, the sti and inelastic skin envelope and de -
cient vestibular skin are the most commonly encountered
limiting factors during the lowering procedure of the alar
rim. The author prefers to use conchal composite grafts
from the cymba concha to ll the gap between the elon-
gated skin envelope and the de cient vestibular mucosa, at
the same lowering the alar margin (Fig. 10.3c).
Many Asian patients want tip augmentation even in a
situation that calls for the correction of short, contracted
nose; however, it is not easy to get both an improved pro-
jection and caudal rotation of the nasal tip. When su cient
projection is achieved, the nose is found to be adversely
rotated cephalically. Conversely, correcting the short nose
with only caudal rotation usually ends in insu cient tip
projection. Thus, an adequate compromise between aug-
mentation and caudal rotation of the tip needs to be found.
Graft Material Harvesting
In most cases, the septal cartilage or conchal cartilage is
insu cient and costal cartilage is used. Before deciding
to use costal cartilage, it is prudent to check the rib series
for possible calci cation of the cartilage. Not infrequently,
young female patients have severe calci cation of the cos-
tal cartilage.2 Calci cation makes harvesting and carving of
the cartilage di cult. If the cartilage is totally calci ed, it is
very di cult to use as graft material.
The costal cartilage graft is harvested mostly from the
sixth or the seventh rib for use in rhinoplasty. In female
patients, the incision is placed just above the inframa-
mmary crease for better cosmesis (Fig. 10.4). In male
patients, the incision is made directly over the chosen rib.
The proper cartilage is located after palpation, and the cos-
Fig. 10.4 Harvest of rib cartilage. Rib cartilage is being removed
from the small, inframammary incision. The incision can be mini-
mized by exactly locating the costochondral junction by probing
the cartilage using a 26-gauge needle.

II Rhinoplasty
126
augmentation, the periphery of the costal cartilage is sym-
metrically cut away, leaving a central core of the cartilage.
The central part of the cartilage is carved with a no. 10 scal-
pel and used as a dorsal implant. First, an appropriate shape
for the dorsum is designed. If a straight piece of rib carti-
lage with su cient length is harvested, this is the ideal sit-
uation. In most cases, a slightly curved cartilage is obtained
and a strategic approach and design are needed to obtain a
straight graft. After cutting away the peripheral cartilage
according to the design, the central part is sculpted into the
target shape (Fig. 10.5).
The cartilage is periodically soaked in physiologic
saline for 10 to 20 minutes at a time, and then brought out
to continue the carving while watching out carefully for
signs of warping. Once warping is evident, the remaining
peripheral concave portion of the cartilage needs to be cut
out. When the implant is carved in this manner, postopera-
tive warping can be minimized.6 It takes about an hour to
sculpt every piece of the harvested cartilage in this man-
ner to minimize the risk of warping. The completed, fully
carved cartilage graft has rounded marginal parts and
progressively narrowed upper and lower parts, yielding a
canoe-like shape from the frontal view. When seen from
the lateral view, it has a slightly concave side that comes
into contact with the nasal dorsum, and a dorsal side that
is slightly convex (Fig. 10.6). However, notwithstanding all
these e orts, very minor warping occur. Making several
cuts in the graft further minimizes the warping, although
these cuts may cause a potential warping deformity later.
A at, straight piece of cartilage is necessary for use as
a septal extension graft and extended spreader graft. For
these purposes, the cartilage is cut and carved as a at
piece and soaked in warm saline to check for any warping
before grafting. To minimize warping, the cartilage is cut
longitudinally or tangentially, leaving peripheral portions
symmetrically thick on the two sides of the central portion,
which counteracts and negates the expected distortion on
both sides (Fig. 10.7). This at, long piece of cartilage is
resistant to warping as long as the peripheral portions on
the sides remain symmetrical.
taneous and skin wound, the Nélaton catheter is removed
while simultaneously administering intense positive-pres-
sure hyperventilation.
The separated muscles are tightly approximated to
diminish postoperative pain and the wound is closed layer
by layer using 4–0 Vicryl sutures. No drain is inserted. The
skin margins are often bruised with discoloration due to
excessive retraction, and these are trimmed and sutured
with 6–0 nylon and a compressive dressing is applied. The
nylon sutures are removed on the seventh to tenth postop-
erative day. Ordering a chest X-ray to check for pneumo-
thorax immediately after the operation is not obligatory
if the surgeon is con dent that there was no air leakage
through the harvest wound. If the patient presents with
signs and symptoms of pneumothorax following surgery,
then a chest X-ray is warranted. Rarely, a pneumothorax
can occur even though there was no leakage during the
intraoperative checking. Mild pneumothorax can resolve
spontaneously with a serial follow-up of chest X-ray; how-
ever, a chest tube is inserted to expand the collapsed lung
in nonresolving or severe cases.
Carving of Costal Cartilage
Harvested autologous costal cartilage is designed and
carved into various forms depending on the purposes of the
graft: dorsum augmentation, reinforcement of the septum
in the form of batten or septal extension grafts, extended
spreader grafts to reinforce the septal extension graft, tip
onlay grafts, or as a premaxillary graft.
Costal cartilage consists of a core and peripheral
regions surrounding the core; a balance and stasis are
maintained by the internal stress created by the two com -
peting regions.3 Centrally cut pieces of cartilage warp
more quickly than the peripherally cut pieces; however,
the peripherally cut cartilage warps at a greater rate than
the centrally cut segment.4 Side-to-side warping is more
clinically evident due to less soft tissue resistance in this
dimension.5 To prepare a nonwarping implant for dorsal
Fig. 10.5 Design for dorsal onlay graft. (a) A straight portion of the harvested rib cartilage
is selected and marked. (b) After excising the peripheral portion, a central portion remains
for additional carving.
a
b

10 Correction of the Short, Contracted Nose
127
The septal extension graft is reinforced with a septal
batten graft or extended spreader graft to prevent twist-
ing. The septal cartilage and the upper lateral cartilage are
separated in the same plane, using the sharp side of a Freer
elevator or with iris scissors. It is important to ensure that
the septal mucoperichondrium is dissected upward contin-
uously until the upper lateral cartilage is reached, to make
sure that accurate separation of the junction of the nasal
septum and the upper lateral cartilage is achieved. The cau-
dal end of the extended spreader graft needs to be tapered
thin to prevent thickening of the upper part of the caudal
septum, which can lead to nasal obstruction.7 The graft is
placed between the upper lateral cartilage and the nasal
septum along the upper side of the septum and then xed
temporarily with a needle (Fig. 10.8b). Suturing with 5–0
or 4–0 PDS is used to x the spreader graft to the nasal sep-
tum and the separated upper lateral cartilage to the septal
cartilage–spreader graft complex using horizontal mattress
sutures (Fig. 10.8c). Care should be taken during the sutur-
ing to ensure that the upper lateral cartilage on one side is
equal in length to the other side.
Tip Repositioning and Tip Grafts
The lower lateral cartilage is released from the upper lat-
eral cartilage and piriform aperture and repositioned on
the new elongated nasal septum (Fig. 10.9a). A lengthening
e ect can be obtained by lowering the nasal tip and rotat-
ing it caudally.
Additional lengthening can be gained through the use
of various grafts on the newly extended lower lateral car-
tilage. Shield grafts and cap grafts are commonly used. For
Skin Undermining
Wide dissection of the skin–soft tissue envelope is impor-
tant to allow the skin to be maximally stretched when it
is is redraped to the elongated framework. The thick scars,
especially those on the lower lateral cartilage and junction
of lower and upper lateral cartilages, need to be excised
and/or released to make the skin more exible and easily
maneuvered. In a severely scarred case, inadvertent dam -
age to the overlying skin may take place, in which case a
ne suturing of the skin with an underlay of soft tissue
such as fascia helps to heal the scar.
Elongating the Framework
The supporting structure to reposition and x lower lateral
cartilages is then constructed. After dividing the lower lat-
eral cartilage and elevating the septal ap, a septal exten-
sion graft is added. With the overlapping type, the septal
extension graft is designed to reach the anterior nasal spine
inferiorly and to project the nasal tip superiorly while
rotating it caudally (Fig. 10.8a). The remaining nasal septal
cartilage and the graft placed need to be rmly xed at the
anterior nasal spine. Especially in cases where septal car-
tilage was separated from the anterior nasal spine, suture
xation needs to be meticulously performed. Because the
redraping skin tension is high, the nasal septum and the
tip easily twist.
Fig. 10.6 Final shape of dorsal onlay graft. The completed, carved
cartilage graft has a canoe-like shape from the frontal view. When
seen from the lateral view, it has a slightly concave side that comes
into contact with the nasal dorsum, and a dorsal side that is slightly
convex. A perichondrium attached to the cephalic side prevents
movement of the graft.
Fig. 10.7 Carving of rib cartilage for a at, straight piece. The car-
tilage is cut and carved as a at piece by cutting in the longitudinal
or tangential direction. Symmetric peripheral portions on the two
sides of the central portion counteract and negate the expected
distortion on both sides.

II Rhinoplasty
128
tion along the alar rim is made beginning at the nasal facet
using sharp iris scissors. Dissection is performed close to
the alar rim margin, with care taken 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; the medial end of the graft is
slightly bruised using Brown-Adson forceps and inserted
into the pocket.
a weak lateral crus, lateral crural onlay grafts are placed
to reinforce it (Fig. 10.9b). If rotation and projection of
the nasal tip are excessively adjusted, the alar margin can
appear unnatural, slightly retracted, or collapsed.
Alar rim grafts can be used to provide a smoother natu-
ral continuation from the nasal tip to the alar margin and to
lower the alar rim slightly (Fig. 10.9c). A soft tissue dissec-
Fig. 10.8 Elongation of the framework. (a) An overlapping type of septal extension graft is xed to the caudal septum. The septal exten-
sion graft is designed to reach the anterior nasal spine inferiorly and to extend the nasal tip anteriorly while rotating it caudally. It can be
xed to the anterior nasal spine for further stability. (b,c) Bilateral extended spreader grafts are reinforcing the septal extension graft. 4–0
PDS sutures are used to x the grafts and reattach the upper lateral cartilage to the graft complex.
Fig. 10.9 Repositioning of lower lateral cartilages and additional tip grafts.
(a) Lower lateral cartilages are released from the upper lateral cartilage and
piriform aperture and repositioned on the new elongated nasal septum. (b)
Additional lengthening can be achieved with cap grafts and lateral crural
onlay grafts. (c) An alar rim graft is being introduced into the pocket made
along the alar rim.
a
b
c
a
b
c

10 Correction of the Short, Contracted Nose
129
cartilage, on the other hand, carving is di cult and the ossi-
ed portion may resorb with time, leaving irregularities on
the dorsum.2 In such situations, the cartilage can be diced
into very small pieces, wrapped in temporalis fascia, and
then grafted to the nasal dorsum. This is called the “Turkish
delight” method and has the advantage of having no risk of
cartilage distortion and the shape of the dorsum appears
natural.8,9 However, the temporalis fascia needs to be inde-
pendently harvested, and making the graft completely t
the shape of the dorsum is not easy. Resorption is known
to be minimal, but the exact degree is somewhat di cult
to predict. After one year, a 10 to 20% resorption compared
with the immediate postoperative volume is expected. This
may increase if the original cartilage is very soft.
Composite Graft and Skin Closure
When the lengthened skin and vestibular skin cannot be
primarily sutured together, a chondrocutaneous composite
graft taken from the cymba concha is prudently used to ll
the gap, especially in the area of the soft tissue triangle. The
natural curvature of cartilage harvested from the cymba
concha ts well with the defect at the intended graft site,
especially at the soft tissue triangle, and the resulting donor
site scar is usually not prominent postoperatively. The
shape of the intended graft is marked on the skin, which
is then incised along those marks together with the carti-
lage, but sparing the contralateral perichondrium and skin.
In ltration of anesthetic solution directly over the harvest-
ing portion is avoided to increase the viability of the graft.
Dissecting this perichondrium from the posterior conchal
bowl to free the graft completes harvesting of the conchal
composite graft. A small donor site defect is closed primar-
ily; a full-thickness skin graft, usually sourced from the
postauricular area, may be necessary when the the defect
is too big to close primarily.10 When harvesting postauricu-
lar skin to graft any residual defect at the cymba concha, a
slightly bigger area than the actual defect size is harvested
because the skin usually contracts once it is detached from
the donor site. Removing the subcutaneous fat and soft tis-
sue from the skin graft increases the graft’s viability after
implantation. A compression dressing is placed on the
cymba concha for 3 to 4 days and an antibiotic ointment
applied to keep the wound moist.
Before primary closure of the columella, the caudal
part of conchal composite graft is sutured at the marginal
incision followed by the cephalic part, which is sutured to
the vestibular skin to ll the defect (Fig. 10.11). After sutur-
ing the composite graft on the recipient sites, the graft is
xed to the recipient bed with gentle pressure either by
packing or through-and-through sutures with silastic sheet
application.
Dorsal Augmentation
Carved boat-shaped grafts, unlike silicone grafts, tend to
move over the nasion and the rhinion because the shape
does not completely t over the nasal bone and upper lat-
eral cartilage (Fig. 10.10). To reduce graft mobility, a strip of
costal perichondrium is sutured to the undersurface of the
nasion end of the carved cartilage after rasping of the radix.
The harvested perichondrium is also used on the radix and
dorsum to prevent step formation and to create a smooth
transition between the dorsal graft and glabella. The cos-
tal cartilage is xed to the caudal parts of the upper lateral
cartilage and nasal septum with 5–0 PDS or 6–0 clear nylon
sutures. The graft is xed at the nasion part inside the tight
subperiosteal pocket. The dorsal onlay graft extended to
include the nasion makes the nose appear longer.
The quality of cartilage varies individually. Slightly
hard cartilage without any calci cation in the middle-aged
patient is the best material. It is di cult to control the warp-
ing completely in young patients, as their costal cartilage is
often short, thin, and excessively weak or soft. In calci ed
Fig. 10.10 Dorsal augmentation. A carved rib cartilage graft is
being introduced to the dorsum.

II Rhinoplasty
130

■Complications and
Their Management
Skin Damage
When the skin envelope is strongly adherent to the under-
lying scar tissue, inadvertent skin damage can occur during
the dissection. Dorsal skin tightly adhering to underlying
scar tissue is sometimes extremely di cult to dissect. The
torn skin needs to be carefully sutured and the soft tissue
or fascia underlined for further support.
Pneumothorax
Pneumothorax following rib cartilage harvest can be pre-
vented by careful harvesting, leaving underlying peri-
chondrium behind. In most cases, if no air leakage was
identi ed with the Valsalva maneuver after harvesting,
there is no need to check the chest X-ray after surgery
unless the patient complains of chest tightness with low
oxygen saturation. If air leakage is noted, a Nélaton cath-
eter is inserted at the leakage site and sutured in a purse-
string manner. After tight closure of the subcutaneous
and skin wound, the Nélaton catheter is removed with
simultaneous administration of intense positive-pressure
hyperventilation.
Warping of Implanted Rib Cartilage
Warping may occur after replacing the dorsal alloplastic
implant with rib cartilage (Fig. 10.12). Even though the
author takes all preventive measures to prevent warping,
such as balanced carving using the core of the rib cartilage,
repeated immersion and checking of curvature, creation
of a tight pocket for insertion, and suture xation on the
dorsum, it is still almost impossible to completely pre-
vent warping of costal cartilage. In such cases, the author
takes out the curved rib graft and carves it straight before
reinserting it into place, which solves the problem in most
instances. If that is not possible, the author dices the curved
rib and wraps it in temporalis fascia. In the author’s experi-
ence, autogenous rib cartilage is able to maintain its origi-
nal volume even years after the surgery. Adding some soft
tissue such as the mastoid periosteum will help to re ne
the radix in this case.
Movability of the Costal Cartilage
Onlay Graft
Movement of a costal cartilage onlay graft after revision is
rare. Possible reasons for migration of the implant include a
large and wide pocket created during dissection to remove

■Key Technical Points
1. A su cient amount of cartilage is needed to build
a stable platform to lengthen the nose. Usually, rib
cartilage harvesting serves this purpose.
2. Rib cartilage carving is strategically tailored
according to the sites where grafts are used. For
a dorsal onlay graft, the center of the cartilage is
used; tangentially cut cartilage is used for extended
spreader grafts or septal extension grafts.
3. Wide undermining of the skin envelope is necessary
to redrape over the lengthened platform.
4. An end-to-end type or overlapping type of septal
extension graft to lengthen the caudal septum is a
platform to reposition the lower lateral cartilage.
5. The septal extension graft is designed considering
the rotation and projection of the tip and needs to
be strongly supported with a bilateral extended
spreader graft.
6. The lower lateral cartilage needs to be released
from the upper lateral cartilage and scar tissue for
repositioning to the new dome.
7. The nasion is moved upward by adding a dorsal
onlay graft in the low dorsum. Additional tip
onlay grafts are used to add to caudal rotation and
projection of the tip.
8. The lateral crural onlay graft and alar rim graft help
to lower and support the alar rim.
9. A chondrocutaneous composite graft from the
cymba concha lls the gap between the skin
envelope and de cient vestibular lining.
Fig. 10.11 Adding a chondrocutaneous composite graft. When
the skin of nasal vestibule and lengthened nasal skin cannot be
sutured primarily, a chondrocutaneous composite graft is used to
ll the gaps between them.

10 Correction of the Short, Contracted Nose
131
ity or pain in the nasal tip. In most cases, this discomfort
decreases with time; however, in some cases the graft
needs to be removed. Asymmetry of the nostrils may occur
when the septal extension graft is not exactly in the mid-
line or if tip onlay grafts are not symmetric.

■Case Studies
Case 1: Correction of Short Nose
Due to Contracture after Multiple
Rhinoplasties
A 28-year-old female presented with short nose and left
nasal obstruction (Fig. 10.13). She had undergone four rhi-
noplasties using Gore-Tex twice, silicone once, and autolo-
gous costal cartilage once over the past 9 years, with the
most recent surgery 2 years previously. She had a typical
postsurgical short, contracted nose with exaggerated nos-
tril show in the frontal view and severely cephalic rotated
nasal tip with low-set nasion in the lateral view.
Her surgical diagram shows that a septal extension
graft, dorsal onlay graft, bilateral extended spreader grafts,
lateral crural onlay grafts, shield graft, and cap graft were
placed using irradiated homologous costal cartilage. Bilat-
eral conchal chondrocutaneous composite grafts were
used to ll the gap between lengthened skin and vestibular
lining.
a large or stubbornly planted alloplastic implant around the
radix area; residual capsule after silicone implant removal;
and inappropriate xation of the costal cartilage, especially
at the radix area. To prevent this, complete removal of the
underlying capsule, roughening of the radix with rasp, and
perichondrium applied on the undersurface of the radix
skin above the graft are necessary. In rare cases, a K-wire
xation of the graft at the radix part is needed.
Nasal Obstruction
Applying a too-thick septal extension graft, especially the
overlapping type, can make the nostril inlet small, caus-
ing nasal obstruction. An end-to-end type septal exten-
sion graft with a thin, at piece of cartilage can prevent
this complication. Also, beveling and thinning the extended
portion of the extended spreader graft binding to the septal
extension graft is important to prevent thickening of the
caudal septum. If the septal extension graft is weak, the
caudal septum may buckle, causing deviation and nasal
obstruction.
Tip Problems
Too much tension exerted on the skin, especially when the
septal extension graft is made of septal bone or alloplas-
tic material such as Medpor, may cause pressure sensitiv-
Fig. 10.12 Warping of dorsal onlay rib graft. (a) Warping developed after placement of dorsal onlay graft with autogenous rib cartilage.
(b) Six months after revision, the nose is straight. (c) In revision surgery, the dorsal onlay cartilage was removed in pieces. (d) The warped
portion was recarved and put together by wrapping with mastoid periosteum before reinsertion.
a
b
c
d

II Rhinoplasty
132
Her appearance 2 years after the operation showed
improvement in the contracted and short nose. Caudal
rotation of the nasal tip, a decreased nasolabial angle, and
increased height of the nasal dorsum make the nose appear
signi cantly longer than prior to revision (Fig. 10.14).
Fig. 10.13 Case 1. (a,b) A short, con-
tracted nose, developed after multiple rhi-
noplasties, is evident from the frontal and
lateral views.
Fig. 10.14 Case 1. (a,b) Two years after
revision surgery using rib cartilage, the
nose looks much better than before. Her
dorsum is well elevated and the tip is cau-
dally rotated.
a
b
a
b