Video Atlas Phẫu Thuật Tạo Hình Thẩm Mỹ (Aesthetic Plastic Surgery Video Atlas)

137
CHAPTER 11
Primary Rhinoplasty
Rod J Rohrich and Ronald E Hoxworth
of modern rhinoplasty, built upon this early foundation. When fi rst
described by Rethi in 1934, the open transcolumellar approach was
deemed radical. However, Sercer and his student Padovan provided
further modifi cations for a skin only incision, thus providing founda-
tion for the open approach as it is described today.
When reviewing the literature, it is readily apparent that the history
of rhinoplasty is rooted in the surgeon’s thorough understanding of
the three-dimensional nasal anatomy of the nasal region, profi ciency
in nasal and facial analysis, and fi rm grasp of the core concepts in
manipulating nasal soft tissues, cartilage, and bone.1 Having satisfi ed
these requirements, the surgeon relies on his or her aesthetic sense to
craft a result that will produce a balanced, harmonious nose in rela-
tionship to the rest of the face.2 The initial operation is critical to the
long-term result in primary rhinoplasty, because the tissues are vir-
ginal and undistorted by prior operative procedures.
INDICATIONS
Functional
●
Nasal airways obstruction:
●
Congenital
●
Traumatic
Reconstructive
●
Post traumatic
●
Congenital
Cosmetic
●
Desire to change shape of nose:
●
To change self-image
●
To create more nasal harmony
The indications for rhinoplasty fall along a spectrum from purely
functional to purely cosmetic. There can be great advantages to the
patient when rhinoplasty is performed for functional reasons. An
example is airway obstruction which can be signifi cantly improved if
not totally eradicated. Whether the etiology is congenital or traumatic,
patient satisfaction can be substantial after corrective surgery.
The patient who undergoes rhinoplasty for cosmesis stands to
benefi t with respect to self-image and self-esteem after a successful
rhinoplasty. However, patients who perceive a signifi cant deformity in
themselves when physically the deformity appears slight to the surgeon
should arouse suspicion. Such patients may not be satisfi ed with an
outcome, regardless of how well the rhinoplasty is executed. To avoid
this situation, additional preoperative visits may be necessary to com-
pletely understand not only what the patient desires, but also to
confi rm realistic patient expectations and emotional stability.
Summary
1. For a successful rhinoplasty, identify and understand the
indications for surgical intervention, whether cosmetic,
functional or both.
2. Evaluate the patient – what are their motivations and
expectations and are they appropriate candidates for
rhinoplasty.
3. Understand the normal anatomic relationships, obtain a
detailed history and perform a thorough physical exam.
Develop a systematic approach for evaluating each patient’s
particular features.
4. Know your own limitations and when not to operate.
5. Develop a formal plan with alternatives based on the clinical
evaluation. Inform the patient of the plan and be thorough in
your preparation.
6. Choose the operative approach (open versus closed) based on
the patient’s requirements and your ability. Understand the
utility of each approach and use accordingly.
7. Realize the dynamic interplay between the anatomic
structures and how alterations to a single element (e.g. bone,
cartilage, tip, septum, alar base) yield dynamic changes
between all elements involved.
8. Always be meticulous and effi cient, but do not proceed in
haste. Results are measured in millimeters, and even the
smallest alterations have dramatic consequences.
9. Have a standardized postoperative plan and make it clear to
the patient. Take the time to review this plan before and after
the procedure.
10. Be cognizant of potential complications and address them
when necessary.
INTRODUCTION
Historically, rhinoplasty remains one of the most complex and
challenging operations in plastic surgery.
Cosmetic rhinoplasty has its roots in nasal reconstruction with the
fi rst techniques recorded by Sushruta in India around 500 BC. Centu-
ries later these techniques gained more widespread access to the Euro-
pean medical community as they were reported and refi ned by
individuals such as von Graefe and Dieffenbach who published their
results in the 1800s. Later in that century, the fi rst intranasal approach
to rhinoplasty was described by an American otolaryngologist, John
Roe. Jacques Joseph studied nasal deformities, developed numerous
techniques and published his work in a classic two-volume set between
1928 and 1931. Safi an and Aufricht, considered among the forefathers

11
PRIMARY RHINOPLASTY
138
PATIENT SELECTION
Proper patient selection is vital to a successful outcome. Some patients
will likely be dissatisfi ed regardless of the surgery result. This emo-
tional dissatisfaction often supersedes technical failure as the most
common cause of poorly perceived results.
Gunter and Gorney3–5 have both commented on ‘danger signs’ that
may be exhibited (Box 11.1). Individuals who meet these criteria
should be approached with caution because surgical intervention may
not be in the best interests of either the patient or the surgeon.
Similarly, Gorney employs two systems to identify potential
problem patients:
● the fi rst uses the acronym SIMON (single immature males overly
expectant, narcissistic) to describe certain worrisome traits;
● the second plots the patient’s concern on one axis and the degree
of deformity on the other (Fig. 11.1) – patients who have an appro-
priate level of concern relative to their degree of deformity are
excellent candidates for treatment, but those who have minimal
deformity and a disproportionate level of concern should be avoided
because their expectations may exceed the amount of aesthetic
improvement possible.
If the level of skill and expertise required to perform the rhinoplasty
exceeds the surgeon’s ability, the patient should be referred to another
more profi cient surgeon.
The surgeon must rely on both subjective and objective fi ndings
when considering the relative indications and contraindications for
performing a rhinoplasty; the skills required to accomplish this develop
with time and experience.
PREOPERATIVE HISTORY AND
CONSIDERATIONS
PATIENT FACTORS
When initially assessing a patient for potential rhinoplasty, the surgeon
should concentrate on evaluating the patient’s desires and expectations
prior to performing the comprehensive facial analysis. Although there
are different methods for integrating the patient into the surgical
process, we fi nd that computer imaging provides an excellent way for
patients to gain a realistic understanding of the anticipated outcome.
Although the images are not a guarantee of surgical results, they do
provide a visual representation and a means for patient education.
These images, combined with standardized anterior, lateral, oblique,
and basal photographs, provide the basis for the preoperative surgical
plan.
To identify potential ‘problem patients’ preoperatively, we ask the
patient to fi rst describe what issues they have. We encourage them to
be as specifi c as possible, listing their concerns in order of importance
in their own words. A handheld mirror is useful in this situation. The
patient’s desires are then documented in the chart verbatim. Fre-
quently, the patient will state in general terms, ‘I just want a better
nose. What would you do?’ This has been a red fl ag in our practice
because it is usually a refl ection of general dissatisfaction, poorly
thought-out desires, or a poor self-image. We politely redirect these
patients in an attempt to ascertain their specifi c concerns about their
nose. Again, a disproportionate amount of concern in the presence of
a minimal deformity is a cause for concern.
Other red fl ags in rhinoplasty include:
● those patients who desire a result that cannot be predictably or
reliably delivered or that is outside the realm of the ‘aesthetic
norm’;
● individuals who seem litigious as a result of a previous rhinoplasty,
or who harbor hostility toward previous healthcare providers.
This second criterion is vague, but we place tremendous importance
on the development of our interpersonal relationship with our patients,
and if this cannot be forged, for whatever reason, we decline to perform
the operation. In other words, ‘do not operate on a patient you don’t
like’.
It should be noted that men tend to have a poorer understanding
of their deformity than women and have a more diffi cult time elucidat-
ing the changes they want.6–8
A second follow-up consultation is recommended to reiterate the
patient’s desires, develop a realistic operative plan, and reaffi rm the
patient’s understanding of the anticipated procedure.
NASAL HISTORY
A full and complete nasal history should be obtained. This includes a
prior history of:
Fig. 11.1 Graphic relationship between perceived and actual
deformity. This indicates that a disproportionate amount of concern
should yield caution (red zone) for the surgeon.
Box 11.1 13 danger signs that may signify
underlying psychologic issues5
1. Minimal disfi gurement
2. Delusional distortion of body image
3. Identity problem or sexual ambivalence
4. Confused or vague motives for wanting surgery
5. Unrealistic expectations of change in life situation as a result
of surgery
6. History of poorly established social and emotional relationships
7. Unresolved grief or currently in a crisis situation
8. Present misfortunes blamed on physical appearance
9. Older neurotic man who is overly concerned about aging
10. Sudden dislike for one’s anatomy, especially in an older man
11. A hostile, blaming attitude toward authority fi gures
12. History of seeing physicians and being dissatisfi ed with them
13. Indication of paranoid thoughts
Graphic relationship between perceived and actual deformity
Deformity
Patient concern

139
Preoperative History and Considerations
● trauma;
● previous nasal, septal or sinus operations;
● allergies;
● sinus problems;
● tobacco use;
● illicit drug use.
A list of current medications should also be obtained (both nasal
and non-nasal related). Nonsteroidal anti-infl ammatory agents and
certain herbal supplements may increase bleeding complications after
surgery and should be discontinued at least 7–10 days before a rhino-
plasty. Furthermore, patients are instructed to avoid consumption of
salicylic derivatives for 3 weeks prior and 1 week following surgery.
ANATOMIC FEATURES
Having determined that the patient is an appropriate candidate for
surgery, the next element to proper preoperative surgical planning is
critical facial analysis.9,10
Each individual nose has different proportions, morphology, and
relative relationships with the surrounding face. To preserve nasofacial
harmony, it is crucial to perform a systematic and meticulous analysis
of the nose and face. The evaluation is performed in a systematic
manner cultivated by the surgeon to assure consistency.11–13
Accurate diagnosis of the deformity(s) determines the optimal sur-
gical plan for correction. The surgeon should point out natural facial
asymmetries preoperatively so that the patient gains a better under-
standing of what is present before any operative intervention.
Skin type
The native skin quality infl uences the operative plan and subsequent
techniques performed.
First, skin type, thickness, and texture are assessed.
Thicker skin will tend to camoufl age changes to the underlying
osseocartilaginous framework, and may therefore allow a more ‘aggres-
sive’ surgery to demonstrate an appreciable change. Patients who have
thicker skin that has a more sebaceous character tend to have more
postoperative edema, especially in the tip or lobule area.
Thinner skin tends to reveal even minor changes to the underlying
framework. Therefore patients who have thinner skin can be more
challenging because there is less margin for error.
Systematic analysis of the nose and face
Next, a systematic analysis of the nose and face is undertaken.
Look for potential anomalies of the underlying facial
skeleton
Initially we evaluate potential anomalies of the underlying facial skel-
eton, including the maxillomandibular relationship.
We divide the face into thirds using horizontal lines adjacent to the:
● hairline;
● brow (at the level of the supraorbital notch);
● nasal base;
● menton.
The upper one-third is the least important because it is the most
variable.
The lower one-third of the face is then subdivided into thirds by
visualizing a horizontal line between the oral commissures (stomion):
● the upper third of this subdivision lies between the nasal base and
the oral commissures;
● the lower two-thirds lies between the commissures (stomion) and
the menton.
If there are disproportions, the patient may have underlying cranio-
facial anomalies (e.g. vertical maxillary excess) that necessitate
correction.
The nasal length (radix to tip [RT]) should be equivalent to the
stomion-to-menton distance (SM), as described by Byrd and Hobar.
A natural horizontal facial plane is determined by drawing a line
perpendicular to a plumb line superimposed over the head in repose
and the eyes in straightforward gaze. This will serve as a future point
of reference (Fig. 11.2).
The lip–chin relationship is assessed by dropping a vertical line
from a point one-half the ideal nasal length tangential to the vermillion
of the upper lip. The lower lip should lie no more than 2 mm behind
this line (Fig. 11.3). The ideal chin position is gender dependent. The
female chin should be slightly posterior to the lower lip, but equal to
the lower lip in men. Discrepancies in these relationships may warrant
orthodontics, orthognathic surgery, or a chin implant.
Nasal features
Frontal view Nasal deviation is evaluated by drawing a line from the
mid-glabellar area to the menton, bisecting the nasal ridge, upper lip,
and Cupid’s bow. This line will also pass between the central incisors
when occlusion is normal. Any deviation of the nose from this line
will likely require septal surgery.
The nasal dorsum is then assessed. The curvilinear dorsal aesthetic
lines are traced from the origin at the supraorbital ridges to the tip-
defi ning points, slightly diverging from each other along the dorsum
during their course. Ideally, the width of the dorsal aesthetic lines
should match the width of either the tip defi ning points or the inter-
philtral distance.
A relationship between the bony base width and the alar base is
then assessed. The bony base width should be 80% of the normal alar
base width, and a normal alar base width 2 mm wider than the inter-
canthal distance, or the width of one eye (Fig. 11.4A&B). If the bony base
is greater than 80% of the alar base width (assuming the alar base width
is normal), osteotomies will be required to narrow the dorsum. Males
tend to have a wider bony base than females and it is important not to
over-narrow the male dorsum creating a feminized result.
A natural horizontal facial plane
Natural horizontal
facial plane
Fig. 11.2 A natural horizontal facial plane. This is determined by
drawing a line perpendicular to a plumb line superimposed over the
head in repose and the eyes in straightforward gaze.

11
PRIMARY RHINOPLASTY
140
Next the alar base and alar rim are analyzed. If the alar base width
is over 2 mm and greater than the intercanthal distance, it must be
determined whether the cause is a narrow intercanthal distance, a true
increased interalar width, or alar fl aring:
● if the intercanthal distance is smaller than one eye width, it is
better to maintain a slightly wider alar base;
● if there is true increased interalar width, a nostril sill resection may
be indicated;
● if the increase in width is secondary to alar fl aring (>2–3 mm
outside the alar base), an alar base resection should be
considered.
The alar rims should also be assessed for symmetry, and should fl are
slightly outward in the inferolateral direction.
The tip is assessed to determine:
● the supratip break;
● the tip-defi ning points;
● the columellar–lobular angle (Fig. 11.5).
These points serve as landmarks to draw two equilateral triangles with
their bases opposed. If these triangles are asymmetric, the underlying
reason should be investigated, and the patient will likely require tip
modifi cation.
The fi nal assessment on frontal view is of the outline of the alar
rims and the columella, which should resemble a seagull in gentle
fl ight, with the columella lying just inferior to the alar rims. If the
curve is too steep, the patient likely has an increased infratip lobular
height, which will need correction. If, on the other hand, the curve is
fl attened, it is likely the patient has decreased columellar show which
may require columellar augmentation or alar rim modifi cation.
Basal view The basal view of the nose is addressed next, with the
outline of the nasal base describing an equilateral triangle with a
lobule-to-nostril ratio of 1 : 2 (Fig. 11.6). The nostril itself should have
The lip–chin relationship
Natural horizontal
facial plane
Fig. 11.3 The lip–chin relationship. This is assessed by dropping a
vertical line from a point one-half the ideal nasal length tangential to
the vermillion of the upper lip. The lower lip should lie no more than
2 mm behind this line.
The width of the bony base relative to the alar base is then assessed
A
B
Fig. 11.4 The width of the bony base relative
to the alar base is then assessed.
A, The bony base width should be 80% of the
normal alar base width. B, A normal alar base
width is equal to the intercanthal distance or
the width of one eye.

141
Preoperative History and Considerations
a teardrop-like geometry, with the long axis from the base to the apex
oriented in a slight medial direction.
Lateral view The lateral view is then analyzed, beginning with the
position and depth of the nasal root at the nasofrontal angle (radix).
This angle connects the brow and the dorsum through a soft concave
curve. The apex of this angle should lie between the upper lid eyelashes
and the supratarsal fold, with the eyes in natural horizontal gaze.
Although this angle can vary from 128 to 140º, it is ideally 134º in
females and 130º in males. Other important reference measurements
from this view include:
● the nasion–medial canthal distance, which should be approxi-
mately 15 mm;
● the nasion–corneal plane distance, which is approximately 11 mm.
While still concentrating on the lateral view, it is important to remem-
ber that the perceived nasal length and tip projection can be altered by
the position of the nasofrontal angle. For instance, if the nasofrontal
angle is positioned more anteriorly and superiorly than normal:
● the nose will appear elongated;
● the nasofacial angle will be decreased;
● the tip projection will appear diminished (Fig. 11.7).14,15
On the other hand, if the nasofrontal angle is too posteriorly and/or
inferiorly positioned, the nose will appear shorter, and the tip more
projecting. Ideally, the nasofacial angle (as defi ned by the junction
of the nasal dorsum with the vertical facial plane) should measure
32–37º.
TIP PROJECTION Tip projection is addressed on the lateral view. We
describe two methods to accomplish this.
● For the patient with normal upper lip projection, a line is drawn
from the alar–cheek junction to the tip of the nose. Tip projection
is considered normal if 50–60% of the tip lies anterior to a vertical
line adjacent to the most projecting part of the upper lip. The tip
is considered to be overprojecting if greater than 60% of the tip lies
anterior to this reference line, and may require reduction. If less
than 50% of the tip lies anterior to the line, the projection may
need to be augmented (Fig. 11.8).
● The second method we use to help assess tip projection is by com-
parison with the alar base width (which should be equal), as well
as by comparing the ratio of nasal length (RT) to the tip projec-
tion (alar base-to-tip); ideal tip projection is 0.67 × RT (Fig.
11.9A&B).
DORSUM The dorsum is then analyzed. The ideal nasal dorsum should
lie approximately 2 mm behind and parallel to a line from the radix
to the tip-defi ning points in women, but should be slightly higher in
men to avoid feminizing the nose (Fig. 11.10).
SUPRATIP BREAK The degree of supratip break is appraised when the
nasal tip projection and dorsum are evaluated. A slight supratip break
is preferred in women but not in men. This gives the nose more
defi nition and distinguishes the dorsum from the tip.
Frontal view of the nose
Fig. 11.5 Frontal view of the nose. The tip is assessed to determine
the supratip break, the tip-defi ning points, and the columellar–
lobular angle. These points serve as landmarks to draw two
equilateral triangles with their bases opposed.
Basal view of the nose
1/3
2/3
Fig. 11.6 Basal view of the nose. The outline of the nasal base
describes an equilateral triangle with a lobule-to-nostril ratio of 1 : 2.
The nostril itself should have a teardrop-like geometry, with the
long axis from the base to the apex oriented in a slight medial
direction.
The nasofrontal angle
Fig. 11.7 The nasofrontal angle. If the nasofrontal angle is
positioned more anteriorly and superiorly than normal, the nose will
appear elongated, the nasofacial angle will be decreased, and the
tip projection will appear diminished (yellow line). If the nasofrontal
angle is too posteriorly and/or inferiorly positioned, the nose will
appear shorter, and the tip more projecting (red line).

11
PRIMARY RHINOPLASTY
142
TIP ROTATION The nasolabial angle is used to determine the degree
of tip rotation. This angle is obtained by measuring the angle between
a line coursing through the most anterior and posterior edges of the
nostril and a plumb line dropped perpendicular to the natural horizon-
tal facial plane. This angle should be between 103–105 in women and
95–100 in men (Fig. 11.11).
Do not confuse the nasolabial angle with the columellar-labial
angle, which is formed at the junction of the columella with the infratip
lobule. This angle is normally 30–45º (Fig. 11.12). Increased fullness in
this area is usually caused by a prominent caudal septum giving the
illusion of increased rotation, even though the nasolabial angle is normal.
Alar-columellar relationship (lateral and frontal views) The
alar-columellar relationship is then assessed.
A line is drawn through the long axis of the nostril, and a perpen-
dicular line drawn from alar rim to columellar rim that bisects this
axis. The distance from the alar rim (point A) to the long axis line
(point B) should equal the distance between the long axis line to the
columellar rim (point C) if the alar–columellar relationship is normal
(Fig. 11.13).
If these measurements are not normal, nasal dismorphology can
be categorized into six classes:16,17
● classes I–III describe increased columellar show;
● classes IV–VI demonstrate decreased columellar show (Figs
11.14A–F).
Differences between male and female noses The proportions
given above generally apply to Caucasian women. Generally, the male
face tends to have a squarer, less rounded appearance, with stronger
more pronounced features. The key differences in males are summa-
rized in Box 11.2.7
Intranasal exam
An intranasal exam completes the preoperative analysis. This is per-
formed with a nasal speculum, headlight, and vasoconstriction. The
Tip projection
A=50%–60%
of AB
A
B
Fig. 11.8 Tip projection. Draw a line from the alar–cheek junction to
the tip of the nose. Tip projection is considered normal if 50–60% of
the tip lies anterior to a vertical line adjacent to the most projecting
part of the upper lip. The tip is considered to be overprojecting if
greater than 60% of the tip lies anterior to this reference line, and
may, therefore, require reduction. If less than 50% of the tip lies
anterior to the line, the projection may need to be augmented.
Other methods for assessing tip projection
A
1.0
0.67
B
A=B
A
B
Fig. 11.9 Other methods for assessing tip projection. A, A second method we use to help assess tip projection is by comparing it to the alar
base width – they should be equal. B, When comparing the ratio of nasal length (radix-to-tip [RT]) to the tip projection (alar base-to-tip), the
ideal tip projection is 0.67 × RT.

143
Preoperative History and Considerations
Analyzing the dorsum
Fig. 11.10 Analyzing the dorsum. The aesthetic nasal dorsum
should lie approximately 2 mm behind and parallel to a line from the
radix to the tip-defi ning points in women, but in men it should be
slightly higher to avoid feminizing the nose.
Tip rotation
95º–100º
Natural horizontal
facial plane
Fig. 11.11 Tip rotation. The nasolabial angle is used to determine
the degree of tip rotation. This angle is obtained by measuring the
angle between a line coursing through the most anterior and posterior
edges of the nostril and a plumb line dropped perpendicular to the
natural horizontal facial plane. This angle should be between 95 and
100° in women and between 90 and 95° in men.
Illusion of increased tip rotation
30º–45º
Fig. 11.12 Illusion of increased tip rotation. Do not confuse the
nasolabial angle with the columellar–labial angle, which is formed at
the junction of the columella with the upper lip/infratip lobule.
Increased fullness in this area is usually caused by a prominent
caudal septum and gives the illusion of increased rotation, even
though the nasolabial angle is normal. This angle is normally
between 30 and 45°.
Alar–columellar relationship
Normal
A
B
C
Normal ACR
Fig. 11.13 Alar–columellar relationship. A line is drawn through the
long axis of the nostril, and a perpendicular line drawn from alar rim
to columellar rim that bisects this axis. The distance from the alar
rim (point A) to the long axis line (point B) should equal the
distance between the long axis line to the columellar rim (point C) if
the alar–columellar relationship is normal (AB = BC≈−2 mm).

11
PRIMARY RHINOPLASTY
144
septum, turbinates, and internal nasal valve are evaluated for obvious
deformities or pathology. If turbinate hypertrophy is identifi ed, the
underlying etiology should be investigated. Turbinate enlargement
may be:
● congenital; or
● acquired (e.g. result of autonomic, environmental, medical, or
anatomic factors).
A detailed history is required to determine the cause.
PATIENT COUNSELING
After the initial history and physical examination, the procedure is fully
discussed with the patient. The risks and benefi ts of the procedure are
detailed, and all questions answered. The patient is provided with a
written, detailed estimate of surgical charges with complete explana-
tions. It is recommended that patients sign a form accepting fi nancial
responsibility. A second clinic visit is encouraged to review the previous
discussions. The deformities are reiterated, questions answered, and
the consent reviewed and signed. A preoperative instruction sheet and
a list of medications to be avoided are also provided (Box 11.3).
Prior to surgery we convert our operative plan into a graphic
re presentation (using Gunter Graphics5) to assist us in the operating
room. Modifi cations to the plan are documented intraoperatively,
transposed to the graphic depictions postoperatively, and placed in the
patient’s chart for future reference.
OPERATIVE APPROACH
RELEVANT ANATOMY
A complete knowledge of anatomy is paramount to obtaining the
superior result. The nose is divided into:
Abnormal alar–columellar relationships
Type I
Type II
Type III
Type IV
Type V
Type VI
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
A
B
C
Hanging columella
Retracted ala
Combination of I and II
Hanging ala
Retracted columella
Combination of IV and V
A
B
C
D
E
F
Fig. 11.14 Abnormal alar–columellar relationships. A–C, Classes I–III describe increased columellar show. D–F, Classes IV–VI demonstrate
decreased columellar show.

Operative Approach
145
● external skin and soft tissue;
● underlying framework (bony and cartilaginous);
● ligamentous support.
The rhinoplasty surgeon must be familiar with each structure’s native
morphology and its variants and have an appreciation for the dynamic
interplay between these components.
Skin
The thickness, mobility, and sebaceous character of the nasal skin vary
along its length, with the upper two-thirds being thinner, more mobile,
and less sebaceous than the inferior one-third.18
The nasal dorsum thickness averages approximately 1300 μm,
whereas the lobule skin thickness averages 2400 μm. A straight dorsum
actually has a slight underlying convexity of its osteocartilaginous
framework in the cephalic area; therefore a straight dorsal profi le is
actually produced by the combination of this convexity in the osteo-
cartilaginous framework with the variation in dorsal skin thickness.
Some ethnic subgroups, such as Africans, Hispanics, and those of
Mediterranean descent, can have thicker, more sebaceous skin. These
differences are important because the skin over the underlying nasal
framework can either reveal or mask changes depending on its char-
acteristics. For instance, it is advisable to err on the conservative side
when operating on a Caucasian woman with thin skin compared with
a man of African descent who has thick, sebaceous skin. More dra-
matic changes to the underlying framework are tolerated in the patient
who has thick skin to obtain an appreciable change in the external
appearance.
Muscles
Two muscles, in particular, are important in rhinoplasty:
● the levator labii alaeque nasi, which assists in maintaining the
patency of the external nasal valve;
● the depressor septi nasi, which can alter the upper lip length and
tip projection (Fig. 11.15).19,20
Evaluation of the depressor septi nasi is routine in our preoperative
assessment. Its effect on depressing the nasal tip and shortening the
upper lip can be appreciated in some patients on animation (especially
when smiling). In the subgroup of patients in whom this muscle
Box 11.3 Preoperative instruction sheet
Two weeks before surgery
1.
Some medications can interfere with anesthesia and cause
undesirable side effects that can affect your surgery. Please
read the enclosed medication information list and let us know
if you take any of them. Aspirin should not be taken for at
least 2 weeks before or after surgery. Acetaminophen is a
good medication to take for any aches or pains you may have
before surgery.
2.
Smoking will affect how you heal. It is very important to stop
smoking 4 weeks before your surgery.
3.
If you develop a cold, facial sore, or any other illness before
surgery, please notify us.
4.
If you are having surgery as an outpatient, please be sure
arrangements have been made for a responsible adult to drive
you to and pick you up after your surgery and to stay with you
for the fi rst 24 hours.
Evening before surgery
1.
Shampoo your hair and wash your face. Do not use conditioner
or hair spray after shampooing.
2.
Make some Jell-O and/or soup for after surgery.
3.
Get a good night’s rest.
4.
Do not eat or drink anything after midnight.
Morning of surgery
1.
Be at the surgery center/hospital by . . .
2.
Do not eat or drink anything if your surgery is scheduled
before noon. If your surgery is scheduled after noon, you may
have coffee or tea and dry toast no later than 6 hours before
your scheduled surgery time.
3.
Do not wear wigs, hairpins, hairpieces, or jewelry. Dress in old,
loose, comfortable clothes. Do not wear pullover tops or panty
hose. Wear slip-on shoes.
4.
Have someone drive you to your surgery and make certain a
responsible adult will be available to take you home and stay
with you for 24 hours. Put a pillow and blanket in the car for
the trip home.
Box 11.2 Key features of male noses (compared
with female noses)*
●
Dorsum tends to be straighter and wider with decreased
concavity at the superciliary ridges
●
Nasal dorsal profi le (a line drawn from the radix to the tip-
defi ning points) should approach 1 mm or less, instead of
falling 2 mm behind and parallel to this line in women
●
No supratip break
●
Tip rotation slightly less (95–100º vs 103–105º in females)
because less nostril show secondary to a longer nasal dorsum
●
Stronger chin abutting the plumb line drawn tangential to the
upper lip (vs 2–3 mm posterior to this line in women)
●
Broader, more bulbous, nasal tip, in general
●
Skin is usually thicker, masking the amount of change that can
be perceived.
*These proportions are general guidelines and vary between gender and racial
origin. They are only meant to be used as a systematic method of analysis with
general proportions and relationships. Each nose should be individualized to the
patient’s facial structure and tempered by their desires to create nasofacial
harmony and balance.
Levator labii alaeque nasi and the depressor septi nasi
Depressor septi
Levator labii
alaeque nasi
Fig. 11.15 Levator labii alaeque nasi and the depressor septi nasi.
These two muscles are important in rhinoplasty.

11
PRIMARY RHINOPLASTY
146
signifi cantly alters the nasal appearance, we dissect and transpose the
muscle. By doing so, several goals are achieved:
● enhancement of the tip–lip relationship;
● relative upper lip lengthening;
● relative fullness to the upper lip;
● maintenance of tip rotation/projection on animation.
Blood supply
The vascular supply to the nose is derived from branches of the
ophthalmic and facial arteries (Fig. 11.16).
It is important to note the vascularity to the nasal tip because an
open rhinoplasty approach using a transcolumellar incision will tran-
sect the columellar vessels (when present), leaving the lateral nasal
and dorsal nasal arteries as the remaining blood supply.
In our 1995 study,21 we found the lateral nasal arteries to be
present (either singularly or bilaterally) in 100% of cases, with the
columellar branches present 68.2% of the time.
The lateral nasal vessels are found approximately 2–3 mm above
the alar groove, so extended alar resections to this level are prohibited
because injury to these vessels after the transcolumellar approach
would severely compromise blood fl ow to the nasal tip. Furthermore,
be cautious when debulking the nasal tip after an open approach
because the subdermal vascular plexus connecting the dorsal nasal and
lateral nasal blood supplies may be damaged, leading to a similarly
disastrous result.
Extended alar resections to the level of the alar groove are
discouraged with the transcolumellar approach because injury to the
lateral nasal vessels, which are approximately 2–3 mm above the
alar groove, may severely compromise blood fl ow to the nasal tip.
Toriumi et al.22 studied the vascular and lymphatic anatomy of the
nose and determined that the transcolumellar incision itself did not
compromise major venous or lymphatic outfl ow. Furthermore, they
recommend dissection just above the perichondrium in the deep areolar
plane, leaving the musculoaponeurotic layer intact, which preserves the
major arterial vascular supply and avoids damage to the venous and
lymphatic vasculature that lies in a more superfi cial (subcutaneous)
plane. In this way, bleeding and postoperative edema are minimized.
Nasal vaults
The osteocartilaginous nasal framework can be subdivided into three
separate vaults: bony, upper cartilaginous and lower cartilaginous.
Bony vault
The bony vault (Fig. 11.17) constitutes the upper one-third to one-half
of the nose and is made up of the paired nasal bones and the ascend-
ing frontal process of the maxilla. It is important to note that the nasal
bones are narrowest and thickest above the canthal level. As a result,
osteotomies are rarely indicated above this level.
Upper cartilaginous vault
The upper cartilaginous framework begins where the nasal bones
overlap the upper lateral cartilages (ULCs) and septum for 4–6 mm,
creating what is known as the keystone area. This area should be the
widest part of the dorsum, and resembles a T shape in cross-section.
The remainder of this vault is comprised of the paired ULCs and dorsal
cartilaginous septum. Over-resection during dorsal hump reduction in
Vascular supply to the nose
Arcades
Columellar
branches
Superior
labial artery
Fascial artery
Angular artery
Lateral
nasal artery
Fig. 11.16 Vascular supply to the nose. This is derived from
branches of the ophthalmic and facial arteries.
Fig. 11.17 The bony vault. This constitutes the upper one-third to
one-half of the nose and is made up of the paired nasal bones and
the ascending frontal process of the maxilla.

Operative Approach
147
this area can lead to deformities such as the inverted-V deformity
and/or disruption of the dorsal aesthetic lines. A component dorsal
septal reduction is advised to avoid these complications.
Lower cartilaginous vault
The lower cartilaginous framework begins where the ULCs interdigi-
tate with the lower lateral cartilages (LLCs) in the scroll area. The
lower lateral cartilages comprise medial, middle, and lateral crura.
These cartilages are connected to each other, the ULCs, and the
septum by fi brous tissue and ligaments (Fig. 11.18). Disruption of
these ligaments can result in diminished tip projection during rhino-
plasty. Therefore if these structures are violated, maneuvers that
increase tip support (e.g. columellar struts, extended spreader grafts,
batten grafts, suture techniques) may be necessary.
The lower lateral cartilages comprise medial, middle, and lateral
crura, which are connected to each other, the ULCs, and the
septum by fi brous tissue and ligaments. Disruption of these
ligaments during rhinoplasty can result in diminished tip projection.
Nasal function – septum, turbinates, and nasal valves
The septum, turbinates, and nasal valves (internal and external) serve
as the anatomic functional foundation for the nose, contributing to
respiration, fi ltration, humidifi cation, temperature regulation, and
protection (Fig. 11.19).
Septum
The septum is made up of the septal cartilage, the perpendicular plate
of the ethmoid, the nasal crest of the maxilla, and the vomer.
Deformities in the septum can signifi cantly impaire airfl ow through
the nose and result in compensatory turbinate pathology. When
addressing septal deformities, it is important to assess all septal com-
ponents. When performing a septal resection, it is important to
remember that the perpendicular plate of the ethmoid is contiguous
with the cribriform plate posterosuperiorly. Therefore, a side fracture
of the perpendicular plate should be performed with care to prevent
iatrogenic fracture of the cribriform plate and its untoward conse-
quences (e.g. cerebrospinal fl uid rhinorrhea, potential ascending infec-
tion/meningitis). Restoration of a normal straight septum will help
re-establish laminar airfl ow.
Turbinates
The turbinates (Fig. 11.20) help to guide the transport of air during
respiration and condition/humidify inspired and expired air. They are
mucosa-lined extensions of the lateral nasal cavity and undergo a
normal autonomically mediated cycle of expansion and contraction.
Of all the turbinates, the inferior turbinate has the greatest impact
on airway resistance, providing up to two-thirds of total airway resis-
tance from its most anterior aspect.23
Over-resection of the anterior inferior turbinate can have a delete-
rious effect on its regulatory and physiologic functions, and can lead
to crust formation, bleeding, and nasal cilia dysfunction.
Over-resection of the anterior inferior turbinate can lead to crust
formation, bleeding, and nasal cilia dysfunction.
Internal nasal valve
The internal nasal valve (Fig. 11.21) can contribute up to 50% of the
total airway resistance and is the narrowest segment of the nasal
Cartilaginous framework
Pyriform
abutment
Upper
lateral
Lower
lateral
Elastic fibers
Suspensory
ligament
Fibrous
connections
Fig. 11.18 Cartilaginous framework. The cartilages are connected to
each other, the upper lateral cartilages and the septum by fi brous
tissue and ligaments.
The septum
Perpendicular plate
Septal cartilage
Nasal crest
of maxilla
Vomer
Fig. 11.19 The septum. This is made up of the septal cartilage, the
perpendicular plate of the ethmoid, the nasal crest of the maxilla,
and the vomer.

11
PRIMARY RHINOPLASTY
148
airway. It is composed of the angle formed by the intersection of
the nasal septum and the caudal margin of the ULC, and is usually
10–15º.24,25
In some cases, the anterior portion of the inferior turbinate may
be a signifi cant contributor to the decrease in the cross-sectional area
of this region.26
Patients with short nasal bones and long, poorly supported ULCs
have a propensity to have collapse at this area.
Traditionally, lateral traction on the cheek (positive Cottle’s sign)
diagnoses collapse of the internal nasal valve and signals the need for
spreader grafts to increase the valve angle and stent the airway open.
External nasal valve
The external nasal valve is the cartilaginous vestibule bounded by
nares and lateral alar sidewalls. It is caudal to the internal valve.
Obstruction at this area may be caused by foreign bodies, weak or
collapsed lower lateral cartilages, loss of vestibular skin, or scar tissue.
Several options are available to re-establish proper airfl ow through this
area, including alar batten grafts, lateral crural strut grafts, lysis of adhe-
sions, scar revision, mucosal grafts, skin grafts, or composite grafts.
Options for re-establishing airfl ow when the area of the external
nasal valve is obstructed include alar batten grafts and lateral
crural strut grafts.
INCISIONAL APPROACHES
The two basic incisional approaches to rhinoplasty are:
● the open technique;
● the closed (endonasal) technique.
Each has its advocates who use them successfully in the practice of
rhinoplasty.
Open approach
The open approach involves a transcolumellar incision, which can
assume varying geometries, depending on surgeon choice. Our prefer-
ence is a stairstep confi guration, which facilitates reapproximation
while breaking up the scar and preventing contracture deformities. The
open approach also involves skeletonizing the underlying osseocarti-
laginous framework, which gains enormous exposure for the manipu-
lation and correction of deformities.
Closed approach
The closed (or endonasal) technique can be performed using a carti-
lage-delivery approach or a nondelivery approach.
Delivery approach
The delivery approach involves an intercartilaginous incision, a mar-
ginal incision, and either a transfi xion or hemitransfi xion incision with
subsequent transposition of the lower lateral cartilages to a location
outside the skin envelope.
Nondelivery approach
A nondelivery approach uses either a transcartilaginous incision or an
eversion (retrograde) incision, with the lower lateral cartilages remain-
ing in their native positions. Manipulation and modifi cations of the
osseocartilaginous framework are then carried out, but the skin
envelope is not refl ected, as in the open approach.
Open versus closed approach
Most of our cases involve the open approach because it:
● provides excellent exposure and control;
● allows manipulation of the osseocartilaginous framework under
direct visualization;
● has minimal negative consequences, aside from the external scar
and occasional prolonged tip edema, which resolves in virtually all
patients and is not an issue provided the expectation level is set
preoperatively.
In our hands, the open approach allows for predictable and reproduc-
ible results. Furthermore, the increased accuracy and versatility of the
open approach results in a negligible external scar. Patients rarely
object to the transcolumellar scar because it is usually invisible at
conversation distances.
We reserve a closed approach for isolated deformities of the dorsum
or when minor tip modifi cations are necessary.
We perform all secondary rhinoplasties and post-traumatic rhino-
plasties exclusively using the open approach.
The turbinates
Middle
turbinate
Superior
turbinate
Inferior
turbinate
Fig. 11.20 The turbinates.
Internal nasal valve
Valve angle
10º–15º
Head inferior
turbinate
Nasal valve
Fig. 11.21 Internal nasal valve. This is composed of the angle
formed by the intersection of the nasal septum and the caudal
margin of the upper lateral cartilage, and is usually 10–15°.

Operative Approach
149
There are advantages and disadvantages to both rhinoplasty tech-
niques (Table 11.1), but the correct approach is dictated by the patient’s
anatomic deformity and the surgeon’s experience. Clearly, what is
performed
to
alter
the
underlying
anatomy
is
far
more
important than the type of incision used.
The open approach provides full visualization of the nasal frame-
work to more accurately diagnose the cause of the nasal airway obstruc-
tion or the cosmetic deformity. The manipulation of the various
structures, including the dorsum, septum and the tip, can be done with
precision and can yield predictable results. We strongly recommend
the open approach when addressing a posttraumatic deformity, cleft
lip nose deformity, in secondary/revisional surgery, or when complex
tip modifi cations are necessary (Box 11.4).27
We fi nd the closed approach to be advantageous in patients who
have an isolated dorsal hump deformity or where there is minimal
change necessary to modify the tip structure. In these instances, we
prefer access through a marginal incision (situated approximately
1 mm cephalad to the caudal margin of the lateral crus). We combine
this with an intercartilaginous incision in cases of minor tip refi ne-
ment to allow for adequate cartilage delivery and exposure. If the
caudal septum also needs to be addressed, we perform a concomitant
hemitransfi xion or transfi xion incision (Box 11.5).
OPERATIVE TECHNIQUE
Preparation for surgery
● On the morning of surgery, any fi nal questions are answered.
● The patient is taken to the operating room and positioned supine
on the operating table.
● Noninvasive hemodynamic monitoring devices are placed, and all
pressure points are padded appropriately.
● Cefazolin 1 g is administered intravenously as a perioperative
antibiotic.
● We prefer general anesthesia for our patients, though local anes-
thesia with intravenous sedation is a viable alternative.
● After the administration of anesthetic, the nasal vibrissae are
clipped and the nares are prepared with povidone iodine solution.
● The anticipated incisional approach is marked and injected with
approximately 10 mL of 1% lidocaine with 1 : 100 000 epinephrine
into the nasal mucosa, along the septum and the soft tissue enve-
lope (Table 11.2).
● If performing an inferior turbinoplasty, these are likewise
injected.
● Next, the mucosa is treated with cottonoid pledgets soaked in
either oxymetolazone or 4% cocaine to facilitate shrinkage of the
tissue.
● A throat pack is placed in the oropharynx to prevent blood from
entering the gastrointestinal tract and causing postoperative nausea
or vomiting.
● Finally, the patient is prepared and draped for the procedure.
Incision
Closed approach
Accurate preoperative analysis is essential when deciding which inci-
sion to use. There are two basic techniques for access in closed (endo-
nasal) rhinoplasty: nondelivery or delivery.
Box 11.4 Endonasal approach
Advantages
●
No external scar
●
Limits dissection to areas needing modifi cation
●
Permits creation of precise pocket so graft material fi ts exactly
without the need for fi xation
●
Allows percutaneous fi xation when large pockets are made
●
Promotes healing by maintaining vascular bridges
●
Encourages accurate preoperative diagnosis and planning
●
Produces minimal postoperative edema
●
Reduces operating time
●
Results in fast patient recovery time
●
Creates intact tip graft pocket
●
Allows composite grafting to alar rims
Disadvantages
●
Requires experience and great reliance on accurate
preoperative diagnosis
●
Prohibits simultaneous visualization of surgical fi eld by
teaching surgeon and students
●
Does not allow direct visualization of nasal anatomy
●
Makes dissection of alar cartilage diffi cult, particularly in cases
of malposition
Box 11.5 Open rhinoplasty approach rationale
Distinct advantages
●
Binocular visualization
●
Evaluation of complete deformity without distortion
●
Precise diagnosis and correction of deformities
●
Allows use of both hands
●
More options with original tissues and cartilage grafts
●
Direct control of bleeding with electrocautery
●
Suture stabilization of grafts (invisible and visible)
Potential disadvantages
●
External nasal incision (transcolumellar scar)
●
Prolonged operative time
●
Protracted nasal tip edema
●
Columellar incision separation
●
Delayed wound healing
Table 11.1 Relative advantages of open vs closed (endonasal)
technique.

Open technique
Closed technique
Binocular visualization
+++
++
Evaluation of deformity
without distortion
+++
+
Precise diagnosis and
correction of deformities
+++
+
Direct control of bleeding
++
+
Nasal incision
+
+++
Operative time
+
++
Prolonged nasal tip edema
+
+++

11
PRIMARY RHINOPLASTY
150
Nondelivery approach The nondelivery approach uses either a
transcartilaginous (cartilage splitting) incision or a retrograde or ever-
sion incision.
TRANSCARTILAGINOUS INCISION
● The transcartilaginous incision (Fig. 11.22) is made several milli-
meters cephalad to the caudal margin of the lateral/middle crura,
so preserving a rim strip to support the ala. Double hook retraction
combined with digital alar eversion provides the necessary exposure
to facilitate this. The vestibular skin is carefully dissected off the
overlying cartilage to expose the cartilage for resection.
RETROGRADE APPROACH
● In the retrograde approach (Fig. 11.23), the vestibular incision is
made at the most cephalic margin of the lower lateral cartilage
rather than through it. A double hook retractor and digital manip-
ulation are used to facilitate exposure. The theoretic advantage
to this incision is that it maintains the caudal alar margins and
prevents potential scar contracture deformities in this area.
Delivery approach
● The delivery approach (Fig. 11.24) is used in cases where moderate
tip modifi cations are necessary, especially if the angle of divergence
(as a measure of tip bifi dity) is large.
● Using a double hook retractor in the ala and digital counterpressure
to expose the cartilaginous margins, a no. 15 blade scalpel is used
to create an intercartilaginous incision starting laterally just above
the cephalic margin of the lateral crus. It is extended medially
approximately 2 mm caudal and parallel to the limen vestibule.
● A marginal incision is then created along the caudal margin of the
lower lateral cartilage (from lateral crus to medial crus), ending at
the columellar–lobular junction.
● Sharp scissors are then used to dissect the soft tissue off the
cartilage just above the perichondrium, including over the dorsal
cartilaginous septum.
● The same incision is made on the contralateral side, and the two
incisions are connected in the midline over the anterior septal
angle, ending in a hemitransfi xion incision.
Nondelivery approach via the transcartilaginous incision
Cartilage splitting
incision
Transfixion
incision
Fig. 11.22 Nondelivery approach via the
transcartilaginous (cartilage splitting) incision
made several millimeters cephalad to the
caudal margin of the lateral/middle crura.
Nondelivery approach via the retrograde or eversion incision
Fig. 11.23 Nondelivery approach via the retrograde or eversion
incision. The vestibular incision is made at the most cephalic margin
of the lower lateral cartilage rather than through it.
Table 11.2 Location/volume distribution of 1% lidocaine with
1 : 100 000 epinephrine.
Location
Amount (mL)
Vestibules/aperture
2
Dorsum
1
Lateral walls
2
Tip/columella
2
Distal septum
2
Inferior turbinates
1
Total
10

Operative Approach
151
Delivery approach via the intercartilaginous, marginal and transfixion incisions
Intercartilaginous
Transfixion
Marginal
Fig. 11.24 Delivery approach via the
intercartilaginous, marginal and transfi xion
incisions. This approach is used when
moderate tip modifi cations are necessary.
Fig. 11.25 Open approach 1. A stairstep transcolumellar incision is
made across the narrowest portion of the columella.
● If necessary, this may be extended to a full (complete) transfi xion
incision.
● The lower lateral cartilage is then dissected free from the surround-
ing tissue and ‘delivered’ outside the incision.
● If there is diffi culty delivering the cartilages, the incisions may be
extended and the soft tissue undermined to a greater extent.
● Once the cartilages (and domes) are delivered, modifi cations may
be made.
Open approach
● In the open approach (Fig. 11.25), we use a stairstep transcolumel-
lar incision across the narrowest portion of the columella with a
no. 15 blade scalpel. The stairstep is important because it helps to
provide landmarks for accurate closure, prevents linear scar con-
tracture, and camoufl ages the scar.
● Bilateral infracartilaginous extensions are then performed (Fig.
11.26). These begin fi rst from lateral to medial along the caudal
border of the lower lateral cartilage, and then from medial to lateral,
from the level of the transcolumellar incision to the apex of the
middle crus where it joins the lateral incision. A double-pronged
skin hook placed along the alar rim is used to perform this maneu-
ver. External digital pressure is used to evert the ala and augment
visualization of the lateral crus.
When using the open approach and performing the stairstep
transcolumellar incision and bilateral infracartilaginous
extensions:
●
take your time – most mistakes are made trying to obtain
exposure;
●
keep the incisions superfi cial to prevent unnecessary injury to
the underlying cartilages;
●
identify the caudal border of the lower lateral cartilage before
cutting.

11
PRIMARY RHINOPLASTY
152
Skin envelope dissection
● Dissection of the skin envelope (Fig. 11.27) should be done metic-
ulously. It is important to perform the dissection in the supraperi-
condrial/submusculoaponeurotic plane because this avoids injuring
the arterial, venous, and lymphatic supply to the nose.
● There should be no residual soft tissue remaining on the lower
lateral cartilages if the dissection is performed properly.
● This dissection is then continued in a superior direction, exposing
the cartilaginous dorsum and ULCs.
● At the level of the bony pyramid, the scissors are traded for a Joseph
periosteal elevator, which continues the dissection in a subperi-
osteal plane to the radix.
● It is important to limit the extent of the subperiosteal dissection
to just the area of the bony dorsal hump that needs to be addressed;
otherwise, all periosteal attachments to the nasal bones may be
disrupted, leading to prolonged wound healing and potential nasal
bone malposition, especially after osteotomy.
When carrying out skin envelope dissection:
●
it is easier to go slowly through the correct dissection rather
than to spend more time fi xing mistakes from inadvertent
mishaps resulting from haste;
●
stay just above the perichondrium in the
submusculoaponeurotic plane;
●
limit lateral subperiosteal dissection over the bony pyramid;
●
make sure the ULCs are not detached from the nasal bones by
accidental dissection under the nasal bones (rather than on top).
Reducing the osteocartilaginous hump
We prefer to reduce the osteocartilaginous hump in component fashion.
This process involves the following four basic steps, after the skin
envelope dissection just described:
● separation of the ULCs from the septum;
● incremental reduction of the septum proper;
● incremental dorsal bony reduction (using a rasp);
● three-point palpation test.
Separation of the ULCs from the septum
● To minimize mucosal trauma resulting in potential internal nasal
valve stenosis or vestibular webbing, it is critical to create bilateral
superior subperichondrial tunnels before embarking on the reduc-
tion of the dorsal hump. This is done by elevating the mucoperi-
chondrium of the dorsal septum from caudal to cephalad with a
Cottle elevator until the nasal bones are reached.
● The transverse processes of the ULCs are then sharply separated
from the septum using a no. 15 blade scalpel without damaging
the mucosa.
● If necessary, spreader grafts or dorsal grafts can then be placed in
this enclosed space.28,29
Incremental component cartilaginous dorsal septal
reduction
● At this point, the cartilaginous dorsal septum is separated into
three components: the septum centrally and the transverse por-
tions of the ULC laterally.
● The cartilaginous septum is addressed by serially shaving the dorsal
hump deformity down with a sharp scalpel under direct vision.
This maneuver is done carefully, avoiding damage to the adjacent
ULCs. If the septum and ULCs were taken down en bloc and not
in component fashion, the patient would end up with a rounded
dorsum. The same result would apply if the ULCs were resected
to a greater extent relative to the septum.
● Although reduction of the ULCs is not routinely performed, certain
instances may warrant consideration. If so, it must be done after
the septal cartilaginous hump and bony dorsal hump are addressed.
Again, over-resection of the ULCs must be avoided to prevent
internal nasal valve collapse and long-term dorsal irregularity.
Maintaining the transverse portions of the ULC also preserves the
dorsal aesthetic lines.
Incremental dorsal bony reduction
● The method of reducing the bony dorsum depends on the amount
of deformity that requires resection.30
● Large humps (>5 mm) are reduced either by a power burr with a
dorsal skin protector or a guarded 8 mm osteotome.
Fig. 11.27 Meticulous skin envelope dissection should be done in
the suprapericondrial/submusculoaponeurotic plane.
Fig. 11.26 Open approach 2. Infracartilaginous extensions are then
performed with a double-pronged skin hook placed along the alar
rim and external digital pressure to facilitate visualization.

Operative Approach
153
● For humps smaller than 5 mm, a sharp rasp (we prefer a down-
biting diamond rasp) is used. When rasping, it is important to
maintain a slightly oblique bias to minimize potential mechanical
avulsion of the ULCs from the nasal bones. The rasping is done
in a controlled, methodical fashion, proceeding along the left and
right dorsal aesthetic lines, and then centrally. The nondominant
thumb and index fi nger are used simultaneously for maximal
control.
Three-point dorsal palpation test
● The three-point dorsal palpation test is performed repeatedly
throughout the component dorsal hump reduction process, after
redraping the skin envelope. This test is performed with a saline
moistened dominant index fi ngertip, which is used to gently palpate
the left and right dorsal aesthetic lines, as well as centrally, to
detect any dorsal irregularities or contour depressions.
Septal reconstruction/cartilage graft harvest
If the septum is deformed or if cartilage is needed for graft construc-
tion, the septum is harvested. The septum is an ideal source for car-
tilage graft harvest in rhinoplasty because of its close proximity to the
operating fi eld and its minimal donor site morbidity.
● In the closed approach, a Killian or hemitransfi xion incision is
generally used because a full transfi xion incision can lead to
decreased tip projection, especially if dissected down over the
anterior nasal spine.
● In the open approach, the cartilage harvest is begun by separating
the middle crura, incising the interdomal suspensory ligament, and
exposing the anterior septal angle. A no. 15 blade scalpel is used
to incise the septal perichondrium, exposing the distinct bluish-
gray underlying cartilage. A Cottle elevator is used to create a
submucoperichondrial plane posteriorly to the perpendicular plate
of the ethmoid down to the nasal fl oor and across the face of the
septum.
● The dissection should be more diffi cult at the junction of the car-
tilaginous and bony septum, and therefore proceed with caution in
this area because perforation of the overlying mucoperichondrium
is more likely.
● It may be advantageous to dissect two separate tunnels, one sub-
perichondrial and one subperiosteal, and then divide the junction
sharply to help avoid potential perforation in this area.
● The same dissection is then performed on the contralateral side.
● Next, a Vienna speculum is used to directly visualize both sides
of the septum to identify underlying deformity and help achieve
exposure for the septal harvest.
● When harvesting the graft, it is necessary to preserve an L-strut
with 10 mm of dorsal septum and 10 mm of caudal septum retained
to support the lower nasal vault. After the cartilage is resected, it
is preserved in saline. Any residual deviations in the ethmoid or
vomer are rongeured or resected, and any mucosal perforations are
repaired.
Inferior turbinoplasty
In patients with symptomatic nasal airway obstruction secondary to
inferior turbinate hypertrophy that is refractory to medical manage-
ment, an inferior turbinoplasty is performed. This can be done by:
● turbinate outfracture;
● conservative composite tissue removal followed by gentle
cauterization;
● submucous morselization of the turbinate bone; or
● submucous resection of the anterior one-third to one-half of the
inferior turbinate.23,26
The submucous resection is done by developing medial mucoperiosteal
fl aps, exposing the conchal bone using a Cottle elevator, and sharply
resecting the proper amount. The fl aps are replaced after this resection
without the need for suture repair.
It is important to note that the extent of the conchal bone resection
is limited to the anterior portion. This is done mainly to avoid com-
plications of bleeding if the posterior portion is resected.
Cephalic trim
When the tip is boxy or bulbous and requires better refi nement and
defi nition, if the tip-defi ning points need medialization, or when rota-
tion of the tip is desired, a cephalic trim (Fig. 11.28) is performed. This
is done by using a caliper to measure along the caudal margin of the
lower lateral cartilage to preserve a 6 mm rim strip. After this is demar-
cated, the cephalic portion of the middle and lateral crura is resected.
The cartilage is preserved for possible use later in the case.
Spreader grafts
Failure to preserve the middle vault can result in collapse of the inter-
nal nasal valve as well as cosmetic deformity, such as the inverted V
or saddlenose deformity. In this situation, spreader grafts (Fig. 11.29)
can be used to help stent open the internal valve, stabilize the septum,
and preserve the dorsal aesthetic lines.28,29,31 These grafts are usually
obtained from septal cartilage, and are designed to measure approxi-
mately 25–30 mm by 3 mm. Their cephalic ends can be trimmed
obliquely to fi t snugly underneath the bony dorsum and their caudal
ends can be placed either at:
● the septal angle (if lengthening of the nose is not desired); or
● extending past it (if lengthening is desired).
Furthermore, the grafts can be placed in a visible position (secured
in a higher position along the septum) or in an invisible position
(positioned lower) (Fig. 11.30). We secure the grafts with 5-0 PDS in
horizontal mattress fashion.
Tip modifi cation
Altering tip projection
It is important to recognize the factors that contribute to tip projection
in situ before embarking on a discussion on how to precisely alter tip
projection.27,32 There are six key anatomic elements to tip projection
Cephalic trim
Cephalic portion
of LLC’s is resected
6mm
6mm
Fig. 11.28 A cephalic trim of the lateral crura cartilage is performed
for nasal tip refi nement and defi nition.

11
PRIMARY RHINOPLASTY
154
(Box 11.6). Alteration of any of these anatomic structures can result
in incremental changes in tip projection.
A graduated approach to tip projection is dependent on precise,
incremental, nondestructive changes made to the tip complex, begin-
ning with suture modifi cation, proceeding to columellar struts, and
fi nishing with the use of tip grafts.
Spreader grafts
Spreader grafts
Fig. 11.29 Spreader grafts can be used to
help stent open the internal valve, stabilize
the septum, and preserve the dorsal aesthetic
lines.
Spreader grafts in a visible position
A
B
Fig. 11.30 Spreader grafts can be placed in a visible position
(secured in a higher position along the septum) or in an invisible
position (positioned lower).
Box 11.6 The six key anatomic elements to
tip projection
1.
Supporting ligament between the anterior septal angle and the
overlying dermis
2.
Length and strength of the lower lateral cartilages
3.
Suspensory ligament bridging the anterior septal angle
4.
Fibrous connections between the upper and lower lateral
cartilages (and septum)
5.
Abutment of the cartilages with the piriform aperture
6.
Anterior septal angle
Medial crural sutures to unify medial crura
Fig. 11.31 Medial crural sutures serve to unify the medial crura of
the lower lateral cartilages and are frequently used in conjunction
with a columellar strut (to help stabilize the strut).
The algorithm begins with suture techniques,33 which are able to
achieve an increase of 1–2 mm of tip projection. Suture techniques are
ideal for controlling cartilage in a precise, nondestructive fashion.
Although the choice of particular suture material is surgeon depen-
dent, the underlying premise is to choose a material that one can easily
work with that will hold the cartilage in its altered position long
enough to allow for the natural fi brotic reaction to solidify the result.
Although many suture techniques can be performed in both open and
closed rhinoplasty (with cartilage delivery), we fi nd them easier to place
using the open method, because it affords greater visualization and
ease of placement.
The four general types of suture technique used to alter projection
are:
● medial crural, medial crural septal, interdomal and transdomal.
Medial crural sutures Medial crural sutures (Fig. 11.31) unify the
medial crura of the lower lateral cartilages and are often used in

Operative Approach
155
conjunction with a columellar strut (to help stabilize the strut). They
can also be used to straighten out fl aring of the medial/middle crura
(either on the caudalmost aspect or near the domal area), thereby
effecting an increase in projection, albeit to a limited degree. We gen-
erally use 5-0 PDS suture in horizontal mattress fashion for this
technique, but the suture choice can vary by individual preference.
Medial crural septal sutures Medial crural septal sutures (Fig.
11.32) anchor the medial crura to the caudal septum, and can alter
projection as well as rotation. They are often used in conjunction with
columellar struts. We frequently use 5-0 clear nylon suture in spanning
fashion for this technique.
Interdomal sutures Interdomal sutures (Figs 11.33 and 11.34) are
placed through the medial walls of the domes in mattress fashion and
are tied so as to narrow the interdomal distance. This results an
increase in both tip refi nement and projection.
Transdomal sutures Transdomal sutures (Figs 11.35 and 11.36) are
placed across the dome of the middle crura in mattress fashion, such
that the vestibular skin is not perforated. Local anesthetic can be used
to hydrodissect a plane between the cartilaginous dome and the adher-
ent underlying mucoperichondrium to help prevent inadvertent incor-
poration into the suture bite. We generally use 5-0 PDS in horizontal
mattress fashion and leave the knots on the medial aspect of the
dome.
Transdomal sutures can be made:
● asymmetrical to correct anatomic asymmetries, if necessary;
● fashioned with one end left long on each side, and then subse-
quently tied together in spanning fashion (resembling an inter-
domal suture) to narrow the tip-defi ning points.
Medial crural septal sutures
A
Medial crural septal sutures
B
Fig. 11.32 Medial crural septal sutures. A, Medial crural septal sutures. B, Medial crural septal sutures anchor the medial crura to the caudal
septum and can alter projection as well as rotation.
Interdomal and transdomal sutures
Fig. 11.33 Interdomal and transdomal
sutures.

11
PRIMARY RHINOPLASTY
156
It is important to prevent overtightening of this suture, which can
result in an unnaturally sharp tip-defi ning point.
Placement of a columellar strut The next step in altering tip projec-
tion involves the placement of a columellar strut, which:
● is usually fashioned from septal cartilage;
● measures approximately 25 × 4 mm;
● can be placed in a ‘fi xed’ (secured to the anterior maxilla) or a
‘fl oating’ (not secured to the maxilla) fashion (Figs 11.37 and
11.38);
● not only controls the columellar profi le, but also bolsters tip
projection.
The strut is placed by dissecting a pocket between the medial crura.
A double-pronged hook is then used to gently retract the middle crura
anteriorly to set the desired projection and symmetry. The strut is
positioned in the pocket, and a 25-gauge needle is used to stabilize
this confi guration. Most are left fl oating on a soft tissue pad between
the base of the pocket and the nasal spine.
Medial crural sutures (see above) are placed in horizontal mattress
fashion to secure the complex. Further medial crural sutures can be
Interdomal sutures are placed through the medial walls of
the domes
Fig. 11.34 Interdomal sutures are placed through the medial walls
of the domes in mattress fashion. They are tied to narrow the
interdomal distance.
Transdomal sutures are placed across the dome of the
middle crura
Fig. 11.35 Transdomal sutures are placed across the dome of the
middle crura in mattress fashion with one end left long on each
side.
Narrowing the tip-defining points
Fig. 11.36 Transdomal sutures are tied together in spanning fashion
to narrow the tip-defi ning points.
Altering tip projection
Fig. 11.37 A columellar strut is placed in a nonsecured (fi xed)
fashion to alter tip projection.

Operative Approach
157
When changing tip rotation, the extrinsic forces holding the tip at
its current angle must be released. This is generally done by severing
the connection between the lower and upper lateral cartilages. This
frequently takes the form of a cephalic trim, as described above. Fur-
thermore, the fi brous attachments of the medial crura and the caudal
septum can be transected to release tension on the nasal tip and allow
for more cephalad rotation. This is generally achieved by resecting a
variable amount of the caudal septum (Fig. 11.42). This maneuver can
also affect tip projection.
Depending on the amount of tip rotation, it may be necessary to
perform a limited resection of the nasal mucosa and membranous
septum to maintain proper nasal balance and harmony.
After the tip is rotated, its position is maintained with suture
techniques (medial crural septal sutures) and/or a columellar strut or
septal extension graft.
Correcting the alar–columellar relationship
Class I deformity
When a class I deformity exists (see Fig. 11.14A), or when the long
axis–columellar rim distance (BC) is greater than 2 mm and the alar
rim–long axis distance (AB) is normal, that is an example of a true
hanging columella.
Correcting this involves resecting either the caudal septum, the
caudal portion of the medial crus, the caudal portion of the middle
crus, or a combination of these – whichever is responsible for the
deformity (Fig. 11.42).
Class II deformity
A class II deformity (see Fig. 11.14B) or a retracted ala (AB > 2 mm,
BC < 2 mm) can be treated in several ways:
Columellar strut secured to the anterior maxilla
Fig. 11.38 Columellar strut secured to the anterior maxilla in
(fl oating) fashion.
Onlay tip graft
Fig. 11.39 Onlay tip graft.
placed more caudally on the medial crura to control fl aring, if
necessary.
Tip grafts If more tip projection or defi nition is desired after the
preceding maneuvers, tip grafts may be used. We fi nd it easier to place
these grafts using the open approach because it allows excellent visu-
alization, precise placement, and facilitates subsequent manipulation,
if necessary. Grafts in general have a tendency to be visible, however,
so their use is reserved only for the patient in whom the prior, more
predictable methods do not result in satisfactory tip projection. There
are three general types of tip grafts (Box 11.7):
● onlay tip graft (Fig. 11.39);
● infratip lobular graft (Fig. 11.40);
● columellar tip graft (Fig. 11.41).
Decreasing nasal tip projection
When attempting to decrease nasal tip projection, again it is important
to recognize the anatomic factors that contribute to tip projection in
the fi rst place.
If the support derived from the fi broelastic and ligamentous attach-
ments is disrupted, tip projection becomes primarily dependent on the
length and strength of the lower lateral cartilages. Therefore, in the
open approach, if the skin envelope has been undermined and these
fi broelastic tissues have been severed, the primary means of decreasing
tip projection lies in altering these lower lateral cartilages. This may
include techniques such as transection, setback, and resuturing of the
medial or lateral crura.
If the tip projection is decreased signifi cantly, alar fl aring or colu-
mellar bowing may result and necessitate concomitant correction.
Altering tip rotation
Using the nasofacial analysis techniques described, rotation is evalu-
ated generally by the nasolabial angle. This angle, found by measuring
the angle between a line coursing through the most anterior and pos-
terior edges of the nostril and a plumb line dropped perpendicular to
the natural horizontal facial plane, should be between 95 and 100º in
women and between 90 and 95º in men (see Fig. 11.11).

11
PRIMARY RHINOPLASTY
158
Columellar tip graft
Fig. 11.41 Columellar tip graft. This is essentially a ‘combination’
graft.
Correction of class II deformity
A
B
Fig. 11.42 Resecting a variable amount of the caudal septum along
with release of the fi brous attachments can also affect tip projection.
Box 11.7 The three general types of tip graft
Onlay tip graft (see Fig. 11.39)
●
Can be fashioned from any type of cartilage, but cartilage
obtained from the cephalic trim harvest works exceptionally well.
●
Placed in a position overlying the dome of the middle/lateral
crura and fi xed in place using the techniques described in text.
●
We generally use 5-0 PDS suture, with the knots hidden
underneath the dome.
Infratip lobular graft (see Fig. 11.40)
●
Positioned with its superior margin overlying the dome/tip-
defi ning points and extending inferiorly a variable distance,
usually 10–12 mm.
●
Usually shield-shaped, and has rounded graft edges to avoid a
visible and palpable step-off.
●
Increases infratip lobular defi nition and projection.
●
Secured in the same fashion as described previously (see
Fig. 11.41).
Columellar-tip graft (see Fig. 11.41)
●
A more aggressive type of graft that we generally use in
diffi cult primary rhinoplasties, thick-skinned patients, and
secondary rhinoplasties with inadequate tip projection.
●
Its superiormost aspect is anchored to the ULCs.
●
Its inferiormost aspect is secured to the caudal margin of the
medial crura.
●
Essentially a ‘combination’ graft and can be visible, so it must
be placed carefully (see Fig. 11.41).
Infratip lobular graft
Fig. 11.40 Infratip lobular graft.

Operative Approach
159
● one method is to insert an elliptically shaped composite graft from
an access incision made in the vestibular skin (Fig. 11.43A&B) –
the graft is made slightly larger than needed to compensate for
secondary contraction;
● if the retraction is mild and there is no tissue defi ciency, an alter-
native technique is used with the lateral crura detached from the
accessory chain and repositioned inferiorly;
● a fi nal method is to place an alar contour graft (nonanatomic posi-
tion) in a pocket created along the vestibular rim to displace the
ala inferiorly.
Class III deformity
A class III deformity (see Fig. 11.14C) is a combination of a class I
and class II deformity, and is corrected with a combination of the
procedures outlined above to correct class I and class II deformities.
Class IV deformity
A class IV deformity (see Fig. 11.14D) is a hanging ala (AB < 1 mm,
BC < 2 mm).
This is usually treated with an elliptical excision of vestibular skin
(Fig. 11.44). Care is taken to avoid over-resection of skin because an
abnormal, rolled-in appearance of the alar rim can result.
Correction of class II deformity
A
B
Fig. 11.43 Correction of class II deformity.
A&B, An alar contour graft (nonanatomic
position) is placed in a pocket created along
the vestibular rim to displace the ala
inferiorly. This can be done through an
anterior (A) or posterior (B) incision.
Correction of a class IV deformity
Excision of
vestibular skin
Fig. 11.44 Correction of a class IV deformity. This is usually treated
with an elliptical excision of vestibular skin.

11
PRIMARY RHINOPLASTY
160
Class V deformity
A class V deformity (see Fig. 11.14E) is a retracted columella
(AB < 2 mm, BC < 1 mm).
The treatment of choice for this deformity is the placement of a
columellar strut (Fig. 11.45), which is positioned more caudally to
extend the caudal dimension of the columella.
Class VI deformity
A class VI deformity (see Fig. 11.14F) is a combination of class IV and
class V, and is treated with a combination of the techniques described
above.
OSTEOTOMY TECHNIQUES
Osteotomies are a powerful technique in rhinoplasty.34–36 The indica-
tions to perform osteotomies, regardless of technique are:
● to narrow the lateral walls of the nose;
● to close an open-roof deformity (after dorsal hump reduction);
● to create symmetry by straightening the nasal bony framework.
Contraindications to osteotomies can include:
● patients with short nasal bones;
● elderly patients with thin, fragile nasal bones;
● patients with heavy eyeglasses.
There are several osteotomy techniques, including medial, lateral,
transverse, or a combination of these. Furthermore, they can be per-
formed through either an external or internal approach37–39 (Figs 11.46
and 11.47).
A lateral osteotomy may be performed as ‘low to high’, ‘low to low’,
or as a double level (Fig. 11.46) and may be combined with medial,
transverse, or greenstick fractures of the upper bony segment.
No matter how the osteotomy is performed, however, it is neces-
sary to preserve Webster’s triangle (Fig. 11.47), which is a triangular
area of the caudal aspect of the maxillary frontal process near the
internal valve. Preserving this area maintains support to the valve and
prevents functional nasal airway obstruction from collapse.
Regardless of the technique used to perform the lateral osteotomy,
it is important to maintain a smooth fracture line by staying low along
the bony vault, thereby preventing the potential for a step-off defor-
mity. The cephalic margin of the osteotomy should not be higher than
the intercanthal line (the medial canthal ligament); the thick nasal
bones above this area increase the technical diffi culty, and it is pos-
sible to cause iatrogenic injury to the lacrimal system (with resultant
epiphora).
‘Low to high’ osteotomy
A ‘low to high’ osteotomy is generally used to:
● correct a small open-roof deformity; or
● mobilize a medium-wide nasal base.
It begins low at the piriform aperture and ends ‘high’ medially on the
dorsum. The nasal bones are then ‘greensticked’ to medialize them,
with predictable fracture patterns obtained based on nasal bone
thickness.
Occasionally, a separate superior oblique osteotomy is necessary to
mobilize thicker nasal bones enough to be greensticked.
‘Low to low’ osteotomy
A ‘low to low’ osteotomy is generally a more powerful technique in
that it results in more medial movement of the nasal bones, and is
therefore classically used for:
● a large open-roof deformity; or
● to correct a wide bony base.
Correction of a class V deformity
Cartilage graft
Fig. 11.45 Correction of a class V deformity. Treatment of choice is
placement of a columellar strut.
Lateral osteotomy
Low-to-high
High final positon
on medial aspect
Low positon
Pyriform
Aperture
Starts low at
pyriform aperture
ends low on
bony vault (BV)
Combination of both
techniques with extra ??
along nasomaxillary
suture line
Low-to-low
Double-level
(PA)
(PA)
(PA)
Low
Low
High
High
Fig. 11.46 Lateral osteotomy. This may be
performed as ‘low to high,’ ‘low to low,’ or as
a double level.

Operative Approach
161
It starts low along the piriform aperture and continues low along the
base of the bony vault to end in a lateral position along the dorsum
near the intercanthal line.
Because there is more bone between the cephalic aspect of this
osteotomy and the midline, this type of osteotomy is frequently accom-
panied by a medial osteotomy to better mobilize the nasal bones to
achieve the desired result.
Our technique of external perforated lateral
osteotomy
We have refi ned our preferred technique of external perforated lateral
osteotomy, which has proven to be well-controlled, predictable, and
reproducible.
The unique advantages of this technique are based on the preserva-
tion of the periosteal attachments,40 namely:
● decreased amount of dead space;
● reduced subluxation and subsequent airway compromise;
● greater overall stability after positioning.
Procedure
Our technique is as follows (Figs 11.48A–H).
● Inject intranasally and along the lateral nasal sidewalls with 2 mL
of 1% lidocaine with 1 : 100 000 epinephrine and allow 5–7 minutes
for the hemostatic process to take effect.
● Introduce a sharp 2 mm osteotome percutaneously on the midpor-
tion of the bony nasal pyramid at the level of the inferior orbital
rim and nasofacial junction. It must be held at a plane parallel to
the surface of the maxilla.
● To avoid injury to the angular artery, sweep the osteotome down
the lateral nasal sidewall in a subperiosteal plane.
● Position the osteotome at an angle such that one edge is in contact
with the bone and strike with the mallet. The endpoints are a
change in the feel and sound at that location.
● Extend the osteotomy in an inferior, superior, and superior-oblique
manner at the level of the piriform (Fig. 11.48A–D). Leave a 2 mm
gap between each individual osteotomy.
● Perform the same procedure on the contralateral nasal wall.
● After the osteotomies are completed, use gentle pressure between
the thumb and forefi nger to perform a greenstick fracture of the
nasal bones to position them in the desired location.
● Cover with fl esh-colored Steri-Strips and apply a dorsal compres-
sion splint (Denver splint) for 7 days to minimize postoperative
edema (Fig. 11.48E–H).
Medial osteotomies
Medial osteotomies are used to facilitate medial positioning of the
nasal bones. They are generally indicated in patients with thick nasal
bones or a wide bony base to achieve a more predictable result; green-
stick fractures in these subgroups can sometimes be diffi cult and can
lead to unpredictable fracture patterns.41
Medial osteotomy used in conjunction with lateral
osteotomy
Medial osteotomies can be used in conjunction with lateral osteotomies,
but it is not necessary to use both types in all cases. When using both
techniques, the medial osteotomy is usually performed fi rst because this
makes it technically easier to perform subsequent lateral osteotomies.
Although the cant of the medial osteotomy can be varied (i.e.
medial oblique, paramedian, transverse), for the reasons stated above,
the cephalic margin should not cross the intercanthal line.
Furthermore, it is paramount to avoid placing the medial osteot-
omy too far centrally as it connects with the lateral osteotomy causing
a rocker deformity, where the upper portion of the fractured nasal bone
‘kicks out’, resulting in a widened upper dorsum (Fig. 11.49). This can
be avoided by following an oblique angle.
After the medial and lateral osteotomies are created, the nasal
bones are greensticked to the desired position.
Double-level lateral osteotomy
Occasionally a double-level lateral osteotomy35 is needed to correct
lateral wall convexities that are too great to be corrected with a stan-
dard single-level lateral osteotomy or when there are signifi cant lateral
nasal wall asymmetries. This is done by:
● fi rst making the upper (more medial) lateral osteotomy along the
nasomaxillary suture line;
● then creating the lower (more lateral) osteotomy in standard low-
to-low fashion.
CLOSURE
After meticulous hemostasis is achieved and any excess debris removed,
the skin envelope is redraped. If the patient has thick skin, and espe-
cially if the patient is a woman, we may choose to place a single 5-0
Vicryl suture from the dermis (underside of the skin envelope) to the
underlying cartilaginous framework in an attempt to recreate a supra-
tip break.
The transcolumellar incision is then closed using 6-0 nylon suture
in simple interrupted fashion, making sure the coaptation of the
incision margins is precise (Fig. 11.50A&B). The stairstepping of the
original incision helps us close this accurately.
The infracartilaginous incisions are reapproximated using 5-0
chromic suture in simple interrupted fashion. We take special care to
prevent overbiting with the suture, which can create contour irregu-
larities and notching, especially in the soft triangle area.
If septal work has been performed, we place intranasal silastic
splints coated with antibiotic ointment. These are secured with a
transseptal 3-0 nylon suture.
The nasal dorsum is then carefully taped, and a malleable metal
splint is applied over the dorsum (Figs 11.51).
Webster’s triangle
Webster’s
triangle
Fig. 11.47 Webster’s triangle. This is a triangular area of the caudal
aspect of the maxillary frontal process near the internal valve.

11
PRIMARY RHINOPLASTY
162
A drip pad is fashioned from a gauze 2 × 2 and secured under the
nose with paper tape. The throat pack is removed, and the oropharynx
and stomach are carefully suctioned to help evacuate any blood that
may result in postoperative nausea and vomiting.
ALAR BASE SURGERY
If alar base surgery is necessary, it is generally performed after closure
of the transcolumellar and infracartilaginous incisions, but before
intranasal and external splints are placed. Alar base abnormalities
include wide or excessive nostril sills, a wide alar base, asymmetric or
malpositioned alar bases, or any combination of these.
Wide nostril sills
Wide nostril sills (or alar fl aring) is relatively common. It is corrected
by performing a small crescentic resection of the alar base, making
sure to avoid extending the incision into the actual vestibule (Fig.
11.52). The incision is placed approximately 1–2 mm above the base
A
B
C
Outline of the projected level and extent of the osteotomy
D
E
F
G
H
Fig. 11.48 Our technique of external perforated lateral osteotomy. A–C, The osteotomy is extended in an inferior, superior, and superior-
oblique manner at the level of the piriform. D, Outline of the projected level and extent of the osteotomy. E–H, Cover with fl esh-colored Steri-
strips and apply a dorsal compression splint (Denver splint) for 7 days to minimize postoperative edema.

Operative Approach
163
Rocker deformity
Preferred superior
oblique osteotomy
Rocker deformity
Fig. 11.49 Rocker deformity. Placing the medial osteotomy too far
centrally as it connects with the lateral osteotomy can cause a
rocker deformity, where the upper portion of the fractured nasal
bone ‘kicks out’, resulting in a widened upper dorsum.
A
B
Fig. 11.50 Closure. A&B, The transcolumellar incision is closed using 6-0 nylon suture in simple interrupted fashion.
to prevent alar notching. The soft tissue at the base is mobilized with
judicious use of electrocautery and transposed medially to the desired
aesthetic endpoint, where it is sutured in place. We suture using the
‘halving principle’ in this region, because the interior incision is shorter
than the exterior incision.
Wide alar base
A wide alar base is corrected in a similar fashion, but the crescentic
excision assumes a more wedge-type geometry and may include a
small portion of the nostril sill (Fig. 11.53). If a transcolumellar inci-
sion was used at the start, it is crucial that the alar base excision stays
within 3 mm of the lateral alar groove because the blood supply to
the nasal tip can be jeopardized if the lateral nasal artery is inadver-
tently injured. Although some have advocated suture techniques for
narrowing the nasal base, we generally perform this with excisional
techniques.
DEPRESSOR SEPTI TRANSLOCATION
In patients who have a tension tip on animation (foreshortened upper
lip with decreased tip projection), a depressor septi translocation is
indicated. This is done as follows.
● An 8–10 mm transverse incision is made using electrocautery
centered on the frenulum.
● The distal depressor septi muscles are identifi ed and dissected
using electrocautery.
● The depressor septi muscles are released from either the orbicularis
or the periosteum (anatomic variation dependent).
● The muscles are transposed and their ends sutured together using
4-0 chromic gut suture.
● The transverse incision is closed vertically to lengthen the upper
lip (Fig. 11.54).
Optimizing outcomes
●
The key to a successful outcome begins with proper patient
selection.
●
A thorough understanding of normal and abnormal nasal
anatomy is paramount.
●
Full and complete disclosure of all risks and benefi ts including
fi nancial responsibilities, must be completed to both the
surgeon’s and patient’s satisfaction.
●
There is no substitute for an informed patient.
●
One should never enter the operating room without a well
thought-out plan.
●
The type of incision used is far less important than the
correction of the underlying problem. Choose appropriately
according to the deformity and your own experience.
●
If performing an open approach through a transcolumellar
incision, avoid excessively debulking the tip and avoid alar
base incisions greater than 3 mm outside the alar groove to
preserve blood supply to the tip.
●
Always perform the dorsal reduction before harvesting septal
cartilage so that the 10 mm L-strut is maintained.
●
Reduce the dorsum in component fashion to prevent an
inverted-V deformity.
●
Perform tip modifi cations using a graduated approach.
●
Preserve Webster’s triangle when performing osteotomies.
●
Close all incisions meticulously.
●
Take time to carefully place the postoperative splints/tapes so
as to prevent iatrogenic deformity.

11
PRIMARY RHINOPLASTY
164
COMPLICATIONS AND SIDE EFFECTS
In the author’s (RJR) practice, approximately 1 in 30 primary rhino-
plasty patients requires revision. The most frequent reasons for
reoperation include:
● further tip refi nement or correction of tip asymmetries (lower
third);
● parrot beak or pinched supratip deformity (middle third);
● excessive dorsal reduction or dorsal irregularities (upper third).
Functionally, continued nasal airway obstruction after primary rhino-
plasty has, in our experience, usually been from excessive narrowing
of the internal valve (without placement of spreader grafts). We used
to see this more frequently when we performed more aggressive resec-
tion of the transverse processes of the ULCs. Once we adopted the
component dorsum reduction technique with preservation of the
ULCs, the incidence of internal valve obstruction decreased.
Correction of wide nostril sills
Fig. 11.52 Correction of wide nostril sills. A small crescentic
resection of the alar base is performed, making sure to avoid
extending the incision into the actual vestibule.
Correction of a wide alar base
Fig. 11.53 Correction of a wide alar base. Correction is similar
fashion to that used for alar fl aring, but the crescentic excision
assumes a more wedge-type geometry and may include a small
portion of the nostril sill.
Fig. 11.51 The nasal dorsum is carefully taped, and a malleable
metal splint is applied over the dorsum.
Infection after rhinoplasty is exceedingly rare and usually involves
permanent sutures that are used for reshaping the tip structures.
Intra and postoperative bleeding are associated with consumption
of anti-infl ammatory medications or inherited coagulopathy such as
Von Willebrand disease (VWD). Patients with an inherited coagulopa-
thy occasionally bleed 1 week postoperatively.
Most rhinoplasty patients experience temporary numbness of the
nose tip. However, anesthesia and paresthesia can be permanent.
Rare complications include anosmia and lachrymal duct injury.
Complications of lateral nasal osteotomies are listed in
Box 11.8.
Depressor septi translocation
Fig. 11.54 Depressor septi translocation. The transverse incision is
closed vertically to lengthen the upper lip.

References
165
Box 11.8 Complications of lateral
nasal osteotomies
Infections
●
Local (abscess, cellulitis, granuloma)
●
Systemic
●
Intracranial
Operative trauma
●
Hemorrhage (hematoma, ecchymosis)
●
Edema
●
Nasal cyst
●
Anosmia
●
Arteriovenous fi stula
●
Epiphora
●
Canalicular bleeding
●
Neuromuscular injury
●
Intracranial injury
Cosmetic problems
●
Excessive narrowing or convexity
●
Insuffi cient mobilization of lateral bony walls
●
Unstable bony pyramid
●
Rocker formation
●
Redundant soft tissue
●
Stairstep deformity
●
Nasal bone asymmetry
POSTOPERATIVE CARE
All preoperative and postoperative instructions are given to the patients
in writing before and on the day of surgery. Postoperatively, we
routinely prescribe:
● cephalexin, 500 mg by mouth every 8 hours for 3 days;
● Medrol dose pack for 7 days (to minimize postoperative edema);
● hydrocodone/acetaminophen 5/500 for postoperative pain every
4–6 hours as needed;
● normal nasal saline solution for postoperative nasal congestion.
The patient is instructed to keep the head of the bed elevated at an
angle of 45º beginning immediately after surgery to help minimize
postoperative swelling.
Cool compresses are used periorbitally during the day for the fi rst
48 hours.
The patient is instructed to change the drip pad under the nose as
necessary until the drainage stops, at which time the drip pad and tape
can be discontinued.
Any manipulation of the nose, including rubbing, blotting, or
blowing, is discouraged for the fi rst 3 weeks postoperatively. Sneezing
should be done through the mouth during this time.
It is imperative to keep the nasal splint dry, and the patient’s hair
should be washed as in a beauty salon, with the patient leaning the
head backward over the sink.
We maintain our patients on a liquid diet on the day of surgery,
which is subsequently advanced the following day to a soft regular diet.
Any foods that require excessive lip movements, such as eating apples
or corn on the cob, should be avoided for 2 weeks after surgery.
During the fi rst 2 weeks, nasal congestion may be minimized by
the use of normal saline nasal spray and over-the-counter nasal sprays
such as oxymetazoline.
We ask the patient to return 5–7 days postoperatively, at which
time the sutures and nasal splints are removed.
The nose (especially the tip) may appear swollen and turned up,
and the tip may feel numb, but the patient is reassured that this is to
be expected and will resolve with time, with normal sensation return-
ing within 3–6 months.
The patient cannot let anything, including eyeglasses, rest on the
nose for at least 4 weeks. Glasses should be taped to the forehead.
Contacts can be worn as soon as the swelling has diminished enough
to allow easy insertion.
We ask our patients to avoid contact sports and restrict strenuous
activity that increases their heart rate (above 100 beats/min) or blood
pressure for 3 weeks after surgery. The patients are instructed not to
make any judgments about the nose until 1 year after surgery.
After the fi rst postoperative visit (within the fi rst week), the patients
are seen 1, 3, and 6 months postoperatively and yearly thereafter.
CONCLUSION
The history and evolution of rhinoplasty has spanned centuries.
Despite the technical and analytic advances, rhinoplasty remains one
of the most challenging procedures in all plastic surgery where the
difference between an acceptable and an unacceptable result is mea-
sured in millimeters or less. To achieve an acceptable result, it is
imperative that the rhinoplasty surgeon is familiar with nasal anatomy
and the techniques available to manipulate that anatomy. Further-
more, the rhinoplasty surgeon should be aware of his or her own
limitations and the potential for complications. Should a complication
occur the surgeon must be able to address these complications with a
secondary revision or at least know when to refer the patient to another
who can rectify the problem.
Much has been made about the incisional approach throughout
this evolution. What needs to be realized is that it is not the type of
approach that is most important, but rather the experience and confi -
dence of the surgeon and the particular needs of the patient. In the
end, the surgeon should choose the approach that he or she is most
comfortable with for a given situation.
The proportions and relative measurements detailed in this chapter
are given as a standardized approach to each patient. However, there
is no absolute approach to rhinoplasty and surgeons should develop
their own style based on these recommendations.
Finally, a successful result will be determined by proper selection
of the patient, the ability to accurately diagnose the deformity and
generate an operative plan, and the capacity to execute that plan in a
predictable, reliable, and reproducible fashion.
REFERENCES
1. Sheen JH, Sheen AP. Aesthetic rhinoplasty. 2nd edn. St Louis: Quality
Medical Publishing; 1998.
2. Loomis A. Drawing the head and hands. New York: Viking Press; 1956.
3. Gorney M. Criteria for patient selection: an ounce of prevention.
Presented at the Senior Resident’s Conference Risk Management
Course, Dallas, 1996.
4. Gorney M. Patient selection in rhinoplasty: patient selection. In: Daniel
RK, ed. Aesthetic plastic surgery: rhinoplasty. Boston: Little Brown; 1993.
5. Gunter JP. Rhinoplasty. In: Courtiss EH, ed. Male aesthetic surgery.
2nd edn. St Louis: Mosby; 1990.
6. Daniel RK. Rhinoplasty and the male patient. Clin Plast Surg 1991;
18:751–761.
7. Rohrich RJ, Janis JE, Kenkel JM. Male rhinoplasty. Plast Reconstr Surg
2003; 112:1071–1085; discussion 1086.
8. Wright MR. The male aesthetic patient. Arch Otolaryngol Head Neck
Surg 1987; 113:724–727.

11
PRIMARY RHINOPLASTY
166
9. Gunter JP, Hackney FL. Clinical assessment and facial analysis. In:
Gunter JP, Rohrich RJ, Adams WP Jr. Dallas rhinoplasty: nasal surgery
by the masters. St Louis: Quality Medical Publishing; 2002:53.
10. Rohrich RJ, Gunter JP, Shemshadi H. Facial analysis for the rhinoplasty
patient. Dallas Rhinoplasty Symp 1996; 13:67.
11. Byrd HS, Hobar PC. Rhinoplasty: a practical guide for surgical planning.
Plast Reconstr Surg 1993; 91:642–654; discussion 655–656.
12. Daniel RK, Lessard ML. Rhinoplasty: a graded aesthetic–anatomical
approach. Ann Plast Surg 1984; 13:436–451.
13. Rohrich RJ, Adams WP Jr, Gunter JP. Advanced rhinoplasty anatomy. In:
Gunter JP, Rohrich RJ, Adams WP Jr. Dallas rhinoplasty: nasal surgery
by the masters. St Louis: Quality Medical Publishing; 2002:8.
14. Guyuron B. Dynamics of rhinoplasty. Plast Reconstr Surg 1991;
88(6):970–978.
15. Guyuron B. Cosmetic follow-up: dynamics in rhinoplasty. Plast Reconstr
Surg 2000; 105(6):2257–2259.
16. Gunter JP, Rohrich RJ, Friedman RM. Classifi cation and correction of
alar–columellar discrepancies in rhinoplasty. Plast Reconstr Surg 1996;
97:643–648.
17. Gunter JP, Rohrich RJ, Friedman RM, et al. Importance of the alar–
columellar relationship. In: Gunter JP, Rohrich RJ, Adams WP Jr.
Dallas rhinoplasty: nasal surgery by the masters. St Louis: Quality
Medical Publishing; 2002.
18. Gonzalez-Ulloa M, Stevens E, Alavarez Fuertes G, et al. Skin thickness.
Report of our microscopic study of the total surface of the face and
body. Diagn Med 1961; 33:1880–1896.
19. Rohrich RJ, Adams WP Jr, Huynh B, et al. Importance of depressor septi
muscle: an anatomic study and clinical application. In: Gunter JP,
Rohrich RJ, Adams WP Jr. Dallas rhinoplasty: nasal surgery by the
masters. St Louis: Quality Medical Publishing; 2002:849.
20. Rohrich RJ, Huynh B, Muzaffar AR, et al. Importance of the depressor
septi nasi muscle in rhinoplasty: anatomic study and clinical
application. Plast Reconstr Surg 2000; 105:376–383; discussion 384–
388.
21. Rohrich RJ, Gunter JP, Friedman RM. Nasal tip blood supply: an
anatomic study validating the safety of the transcolumellar incision in
rhinoplasty. Plast Reconstr Surg 1995; 95:795–799; discussion 800–801.
22. Toriumi DM, Mueller RA, Grosch T, et al. The lateral nasal artery and
blood supply to the nasal tip. In: Gunter JP, Rohrich RJ, Adams WP Jr.
Dallas rhinoplasty: nasal surgery by the masters. St Louis: Quality
Medical Publishing; 2002:20.
23. Rohrich RJ, Krueger JK, Adams WP, et al. Rationale for submucous
resection of hypertrophied inferior turbinates in rhinoplasty: an
evolution. Plast Reconstr Surg 2001; 108:536–542; discussion 545–546.
24. Kasperbauer JL, Kern EB. Nasal valve physiology. Implications in nasal
surgery. Otolaryngol Clin North Am 1987; 20:699–719.
25. Haight JS, Cole P. The site and function of the nasal valve.
Laryngoscope 1983; 93:49–55.
26. Pollock RA, Rohrich RJ. Inferior turbinate surgery: an adjunct to
successful treatment of nasal obstruction in 408 patients. Plast Reconstr
Surg 1984; 74:227–236.
27. Adams WP Jr, Rohrich RJ, Hollier LH, et al. Anatomic basis and
clinical implications for nasal tip support in open versus closed
rhinoplasty. Plast Reconstr Surg 1999; 103:255–261; discussion
262–264.
28. Rohrich RJ, Hollier LH. Rhinoplasty – dorsal reduction and spreader
grafts. Dallas Rhinoplasty Symp 1999; 16:153.
29. Rohrich RJ, Hollier LH. Use of spreader grafts in the external approach
to rhinoplasty. Clin Plast Surg 1996; 23:255–262.
30. Rohrich RJ, Muzaffar AR, Janis JE. Component dorsal hump reduction:
the importance of maintaining dorsal aesthetic lines in rhinoplasty.
Plast Reconstr Surg 2004; 114:1298–1308; discussion 1309–1312.
31. Sheen JH. Spreader graft: a method of reconstructing the roof of the
middle nasal vault following rhinoplasty. Plast Reconstr Surg 1984;
73:230–239.
32. Rohrich RJ, Adams WP Jr, Deuber MA. Graduated approach to tip
refi nement and projection. In: Gunter JP, Rohrich RJ, Adams WP Jr.
Dallas rhinoplasty: nasal surgery by the masters. St Louis: Quality
Medical Publishing; 2002:333.
33. Gruber RP. Suture techniques. In: Gunter JP, Rohrich RJ, Adams WP Jr.
Dallas rhinoplasty: nasal surgery by the masters. St Louis: Quality
Medical Publishing; 2002:254.
34. Goldfarb M, Gallups JM, Gerwin JM. Perforating osteotomies in
rhinoplasty. Arch Otolaryngol Head Neck Surg 1993; 119:624–627.
35. Parkes ML, Kamer F, Morgan WR. Double lateral osteotomy in
rhinoplasty. Arch Otolaryngol 1977; 103:342–348.
36. Sullivan PK, Harshbarger RJ, Oneal RM. Nasal osteotomies. In: Gunter
JP, Rohrich RJ, Adams WP Jr. Dallas rhinoplasty: nasal surgery by the
masters. St Louis: Quality Medical Publishing; 2002:595.
37. Rohrich RJ, Janis JE, Adams WP, et al. An update on the lateral nasal
osteotomy in rhinoplasty: an anatomic endoscopic comparison of the
external versus the internal approach. Plast Reconstr Surg 2003;
111:2461–2462; discussion 2463.
38. Rohrich RJ, Krueger JK, Adams WP, et al. Achieving consistency in the
lateral nasal osteotomy during rhinoplasty: an external perforated
technique. Plast Reconstr Surg 2001; 108:2122–2130; discussion 2131–
2132.
39. Rohrich RJ, Krueger JK, Adams WP Jr. Importance of lateral nasal
osteotomy: an external perforated technique. In: Gunter JP, Rohrich RJ,
Adams WP Jr. Dallas rhinoplasty: nasal surgery by the masters. St
Louis: Quality Medical Publishing; 2002:615–631.
40. Ford CN, Battaglia DG, Gentry LR. Preservation of periosteal
attachment in lateral osteotomy. Ann Plast Surg 1984; 13:107–111.
41. Harshbarger RJ, Sullivan PK. Lateral nasal osteotomies: implications of
bony thickness on fracture patterns. Ann Plast Surg 1999; 42:365–370;
discussion 370–371.

167
CHAPTER 12
Secondary Rhinoplasty
Bahman Guyuron and David Stepnick
and execution of the surgery. Skill is also required to manage the
patient emotionally, analytically, and surgically, and to achieve aes-
thetic and functional objectives.1–5 Both comprehensive knowledge of
potential problems and fi nesse during surgery are necessary to achieve
the desired aesthetic goals. The surgeon must clearly understand the
patient’s concerns; defi ne the nasal imperfections, and establish real-
istic goals. In this chapter the manifold differences between primary
and secondary rhinoplasties are explored and discussed, including
patient evaluation, surgical planning, technical details, and postopera-
tive management.
PATIENT ASSESSMENT AND DEFINITION
OF NASAL FLAWS
When secondary rhinoplasty patients are questioned about the source
of their discontent, the answers are often much more explicit and
precise than those given by patients seeking primary rhinoplasty. The
secondary rhinoplasty patient has spent a good deal of time scrutiniz-
ing the nose and assessing its form and function. Some patients have
even garnered a vast knowledge of rhinoplasty by reading medical lit-
erature and searching the Internet and arrive at the surgeon’s offi ce
armed with drawings, photographs and/or quotations from some of the
experts in the fi eld. These patients may have consulted several rhino-
plasty surgeons, searching for one who will succinctly defi ne their
nasal fl aws or deformities, and who instills the most confi dence in
them.
Listening to these patients, understanding the nature of their dis-
satisfaction, determining if the dissatisfaction has a realistic basis, and,
particularly, noting the manner in which these concerns are expressed,
may provide tangible information germane to the patient’s level of
perfectionism, expectations, and whether it is likely that the patient
will be pleased with the outcome of any further surgery. A patient,
who states that his or her nose has been mutilated by the previous
surgeon, but in whom judicious physical examination discloses only
minor imperfections, is unlikely to be pleased with the outcome of
any surgical treatment. Such a fastidious patient will fi nd some reason
to express discontent with the results of the future surgery as well,
regardless of the outcome. Conversely, the patient whose nose
appears grossly imbalanced and marred with multiple fl aws yet makes
mitigating remarks about the previous surgery and the surgeon has the
highest probability of being satisfi ed with the outcome of another
procedure.
Many patients seeking information about their fi rst rhinoplasty are
unaware of any breathing diffi culties and often do not offer complaints
of breathing problems. Careful observation often reveals that many
of these patients are mouth breathers and internal examination may
show signifi cant airway compromise. The reason that these patients
deny having breathing diffi culty is that they have grown accustomed
to obstruction and have no way of knowing how much better their
breathing could be. Secondary rhinoplasty patients, on the other hand,
are distinctly aware of breathing problems and commonly associate it
Summary
1. The incidence of body dysmorphic disorder is higher on
secondary rhinoplasty patients and it should be considered
carefully in evaluating this group of patients.
2. Secondary rhinoplasty patients require more consultation time.
3. Patients seeking a secondary rhinoplasty often are persistent
in learning about the mishaps during the initial surgery that
necessitated a secondary rhinoplasty. Any unfounded
statement, hint, or gesture, indicating fault on the part of the
previous surgeon(s) is unfair and unethical.
4. Supra-tip deformity could be the result of under-resected
or over-resected caudal dorsum with resultant scar tissue,
postoperative loss of tip projection, or a combination of these
factors.
5. Careful internal nose examination is crucial to detect any nasal
valve dysfunction, residual septal deviation, enlarged turbinate
septal perforation or synechia.
6. The radix can be deepened by removal of the excessive bone
using a guarded burr with gentle side-to-side motion.
7. Both an inverted V deformity and internal nasal valve
dysfunction would be improved or eliminated by placement of
spreader grafts.
8. One may have to remove a wedge of bone between the
septum and lateral portion of the nasal bone on wide
secondary noses to be able to narrow the vault.
9. An inadequate tip projection can be corrected with an onlay
tip graft when the infratip lobule is defi cient, by a columella
strut if the columella is short, or a combination of these
techniques if both of these defi ciencies are co-existent.
10. During secondary rhinoplasty, a minor alar retraction is
corrected with an alar rim graft, a moderate retraction is
corrected using a rim graft and lateral crura strut, and the
severe deformity requires V–Y advancement of the nasal
vestibular lining and rim graft or composite graft.
INTRODUCTION
If one considers the number of factors that govern the outcome of
rhinoplasty, the frequency with which suboptimal results mandate a
secondary procedure is not surprising. Secondary rhinoplasty may be
performed to eliminate minor imperfections (revision rhinoplasty) or
may include many of the maneuvers routinely used during primary
rhinoplasty (secondary rhinoplasty).
Management of the secondary rhinoplasty patient is entirely dif-
ferent from the patient undergoing primary rhinoplasty, presenting a
technical challenge and requiring even greater precision in planning

12
SECONDARY RHINOPLASTY
168
with previous surgery. These patients have a baseline for airfl ow with
which the change in the airway that occurred after the previous rhi-
noplasty can be compared. They are keenly aware if functional capac-
ity is not what it used to be. The patient’s airway may have been
adversely affected as a consequence of an alteration in internal or
external valve function,6,7 formation of scar tissue, medialization of the
inferior turbinates and upper lateral cartilages, or any combination
thereof.8
Secondary rhinoplasty patients may demonstrate more apprehen-
sion before the second surgery than was present before their initial
procedure. These patients display a great deal of frustration and impa-
tience. They often have developed a negative attitude towards sur-
geons, and, considering the perceived failure that they have endured,
restoring their trust may prove diffi cult. To earn the patient’s trust,
one has to display compassion and confi dence, precisely describe the
nasal imperfections, and succinctly and thoroughly outline the surgical
plans.
One should allocate a longer time for consultation with a candidate
for a secondary rhinoplasty than one allows for a primary rhinoplasty
evaluation. Much of this time is spent in exploration, by the patient,
to fi nd out why the previous operation was unsuccessful. A skillful and
experienced surgeon can appropriately re-direct the patient’s focus.
Any unfounded statement made by the second surgeon may evoke
further anger on behalf of the patient or a desire for revenge. If appro-
priate, potential legal actions often can be averted by explaining how
diffi cult and complex rhinoplasties can be and how rare it is to attain
a perfect outcome under most circumstances. Although it is not neces-
sary to conceal or mitigate the previous surgeon’s misconduct, unjus-
tifi ed statements based solely on the patient’s emotional testimony or
perception should be avoided. A one-sided story may lead the inexpe-
rienced surgeon to unjustly incriminate the previous surgeon of wrong-
doing. Gestures, postures, or facial expressions, such as rolling the eyes
or shaking the head, either intentional or unintentional, may signify
to the patient that a wrongdoing or mishap during the previous surgery
is the reason for a suboptimal result. This is unfair and unethical. Any
such judgment should be deferred either until all of the facts pertain-
ing to the previous surgery have been scrutinized, or should be avoided
altogether.
Every attempt should be made to persuade the patient to return to
the previous surgeon. This is a professional courtesy and often offers
an economic advantage to the patient. However, the patient’s interest
remains the top priority, and whenever the former surgeon’s skill is
unknown or questionable, the more experienced and capable surgeon
should undertake patient care.
One must determine whether a septoplasty or turbininectomy was
actually performed and the operative records should be interpreted
cautiously. The maneuvers described in the operative note should be
substantiated by physical examination. The thoroughness of the
septoplasty should also be confi rmed, particularly if a suboptimal
septal form or position is noted.
Careful assessment of the face may disclose other facial disharmo-
nies relevant to the rhinoplasty that may be contributing to the
patient’s dissatisfaction. These abnormalities may include forehead
prominence or retrusion, variations of chin deformities,9,10 hypoplasia
of the malar bones, and a dysmorphic maxilla or mandible. If these
disharmonies go undetected, achieving an optimal outcome is diffi cult,
if not impossible. These features, only if deemed detrimental to the
outcome of rhinoplasty, should be brought to the patient’s attention
and documented. However, insistence in correcting these fl aws as a
condition to proceeding with the rhinoplasty should be avoided. It is
crucial to ensure that the patient has realistic goals and expectations,
and is not suffering from a psychological condition that may result in
patient dissatisfaction in spite of a successful technical outcome. Dis-
proportionate concern about the nose form should be analyzed care-
fully since the incidence of body dysmorphic disorder is higher on this
group of patients, as outlined in the primary rhinoplasty chapter.
Additionally, recommendations for selection of patients, also profi led
previously, should be carefully considered.
PHYSICAL EXAMINATION
The external nasal evaluation should begin with observation of the
skin. If the patient has thick, sebaceous skin, the previous surgery may
have failed as a result of these unfavorable conditions, and this will
remain a challenge during the secondary rhinoplasty. This factor must
be noted and discussed with the patient. These patients are less suit-
able candidates for external incisions, such as those used for alar base
narrowing or for open techniques. If indicated, referral to a derma-
tologist may be appropriate in an effort to reduce sebaceous over-activ-
ity prior to surgery. Tretinoin or isotretinoin are often prescribed, in
which case surgery should be postponed for at least 3–6 months after
the cessation of the treatment to minimize the likelihood of treatment-
induced hypertrophic scarring or bleeding. Effective techniques should
be incorporated into the surgical plan to achieve a better tip defi nition
for those patients with unfavorable nose integument characteristics.
During surgery, the surgeon must avoid any dead space, especially in
the supratrip area; otherwise blood may collect and be subsequently
replaced with fi brofatty tissue, thereby reducing tip defi nition.
Many patients have telangiectasis which may become more numer-
ous or pronounced after the secondary rhinoplasty. It is important to
inform the patient that additional measures may have to be imple-
mented at a later time to improve this condition.
Suboptimal scars from the initial surgery may forecast subsequent
healing problems. Some patients have thin skin, particularly over the
dorsum of the nose, as a consequence of dissection in the subcutane-
ous plane rather than the subperiosteal plane during the initial surgery,
leaving the periosteum attached to the underlying hump. In these
patients, as the dorsal hump is removed, some of the valuable soft
tissue is also eliminated. In patients with such thin skin, every dorsal
imperfection will be discernible. Therefore, it may be necessary to
augment the soft tissues using a layer of dermis or fascia graft. This
type of skin thinness may also result in a purplish discoloration of the
nose on patients who have undergone dorsal augmentation with allo-
plastic materials. This color change may become more noticeable in a
cold environment. This can be eliminated by the addition of soft tissue
in the subcutaneous plane of the dorsum.
A systematic examination of the external nose starting from the
radix and ending at the subnasale, may disclose a variety of imperfec-
tions. An under-resected radix, which is a fairly common fi nding,
results in an undesirable transition from the forehead to the nose and
is commonly associated with an appropriately lowered dorsum but a
fuller than ideal radix (Fig.12.1). The radix may also be too deep as a
result of a preexisting problem that was not corrected or perhaps of
under-correction during the initial surgery. Over-reduction of the radix
is extremely rare.
Asymmetry or irregularity of the nasal bones is another common
cause of concern for the secondary rhinoplasty patient (Fig. 12.2). In
Fig. 12.1 Profi le view of patient demonstrating under-resected
radix.

Physical Examination
169
Fig. 12.2 Frontal view of patient demonstrating asymmetric nasal
bones after primary rhinoplasty.
Fig. 12.3 Osteotomy during initial surgery may have been too
anterior, resulting in step deformity.
Fig. 12.4 Deviation of anterior septum resulting in appearance of
asymmetric upper lateral cartilages.
Fig. 12.5 Patient with inverted V deformity.
an optimal rhinoplasty outcome, there is a graceful transition of
shadows from the eyebrows to the tip of the nose. With suboptimal
results, these dorsal defi ning lines are distorted or a second line pos-
terior to the existing dorsal line can be seen, usually indicating a
step deformity due to the nasal bone osteotomy being too anterior
(Fig. 12.3). Upper lateral cartilages may also appear asymmetric as a
result of unilateral over-resection or, more commonly, caused by ante-
rior deviation of the septum (Fig. 12.4). Over-resection at mid-vault
may result in an inverted V deformity as a consequence of collapse
and medial shifting of the upper lateral cartilage (Fig. 12.5). Increased
awareness of this problem and, especially, the use of spreader grafts,
have reduced the prevalence of this deformity, although it is still seen
fairly commonly. This imperfection is often not noticeable intraopera-
tively, early postoperatively, or even after up to 1–2 years after surgery.
Depending on the thickness of the skin, it may only become discern-
ible several years after surgery.
Abnormalities in the tip area may range from minor imperfections,
such as asymmetry of the domes, to gross deformities and complete
distortion.11 An under-projected tip is a common feature of noses
requiring secondary surgery. Nasal-tip width abnormalities are also
prevalent. The alar rims may be retracted or hanging. Disproportionate
width of the alar base is a common undesirable fi nding in noses as
well. Supratip deformity may develop as a consequence of inadequate
resection of the caudal aspect of the dorsum, but it is more commonly
the result of excessive dorsal resection, loss of tip projection during
healing, or a combination of factors.12 As stated previously, over-
resection of the caudal dorsum may result in scar formation and
contraction, which ultimately create fullness in the supratip area
(Fig. 12.6).
An obtuse nasolabial angle (over-shortened nose) was the hall-
mark of rhinoplasties performed during the 1970s and early 1980s.
Sub optimal tip rotation is fairly common today due to repeated pleas
for conservatism by rhinoplasty educators. The columella may appear
too caudal in relation to the alar rim in many of the secondary rhi-
noplasty candidates as a result of alar retraction, protrusion of the
caudal septum (Fig. 12.7) or, more commonly, due to placement of a
Fig. 12.6 Profi le view of patient exhibiting supratip deformity.

12
SECONDARY RHINOPLASTY
170
columella strut. The ideal amount of columella visible on lateral view
is between 2 mm and 3 mm. Excessive columellar show is displeasing
and requires correction. Conversely, the columella may ostensibly
appear retracted as a result of excess caudal extension of the alar rim
or could be truly retracted as a consequence of a short anterior
septum.
In a basilar view, one can appreciate any asymmetry of the domes
or nostrils, infratip lobules/nostril discrepancy, and abnormalities of
the nostril shape. An overhead view may reveal a deviation of the nose
more clearly.
The nasal valves should be observed during inspiration. Collapse
of the nasal valves was a common sequelae of the rhinoplasties per-
formed before 1980, when many noses underwent aggressive resection
of the midvault. This problem, although still existent, is less common
today. Intranasal examination may also reveal inadequate correction
of the preexisting septal deviation, septal perforation, enlarged inferior
turbinates, synechiae, or neglected polyps.6,7
Because of the variety of nasal imperfections possible in patients
undergoing secondary rhinoplasty and the precision required to defi ne
and correct these deformities, patient assessment using digital life-
sized photographs becomes even more critical than in planning a
primary rhinoplasty.13 Life-sized photographs provide a blueprint for
surgery and ensure synchronicity between the surgeon’s and patient’s
goals.
INDICATIONS AND CONTRAINDICATIONS
In general, the secondary rhinoplasty should not be performed until at
least 1 year has elapsed since the primary rhinoplasty. On occasion,
the patient’s anxiety and the degree of deformity are such that the
surgeon cannot justify delaying the secondary rhinoplasty an entire
year. In this instance, the patient and physician should be aware that
unpredictable factors, such as swelling and scar tissue from the initial
surgery, may distort the predicted results despite good surgical judg-
ment, necessitating additional revision after healing is complete. More
than one offi ce visit may be required to ensure a clear mutual under-
standing between the surgeon and the patient before the surgery plans
are fi nalized. This will afford more time for healing before the surgery
is performed.
When discussing the procedure and risks, it is important for the
surgeon to inform the patient of routine general complications, such
as infection and bleeding, as well as those specifi c to rhinoplasty.
Unpredictability and possible failure to achieve the goals should be
revisited with the patients. The limitations that result from the pres-
ence of scar tissue, the fi nite supply of available and suitable cartilage
grafts, shrinkage of the skin, and telangiectasis must be explained to
the patient. The potential use of conchal or costal cartilage also should
be reviewed, depending on the surgical circumstances. Abnormal
healing, along with the potential for decrease in nasal airfl ow should
be reviewed.
Patients who seem to have a clear understanding of the surgery and
the anticipated realistic outcome are the best candidates for surgery.
Patients who seem unrealistic, make the surgeon uncomfortable,
demand perfectionism, have diffi culty in understanding the limitations
of surgery, or make incessant disparaging remarks about the previous
surgeon may not be proper candidates for secondary rhinoplasty.
SURGICAL TECHNIQUES
Correction of secondary nasal deformities may require either a minor
intermediate, or a major rhinoplasty. Minor revisions, such as inser-
tion of an isolated tip, dorsal, or spreader grafts can preferentially be
performed under local anesthesia with intravenous sedation. When-
ever possible, intermediate and major revisions or a full secondary
rhinoplasty should be optimally conducted with the patient under
general anesthesia because most of these patients have developed sig-
nifi cant scar tissues that render the diffusion of local anesthetic more
diffi cult, uneven, and less predictable. Furthermore, dissection of the
septum and soft tissue is more time consuming and onerous, demand-
ing signifi cant concentration. A patient sedated deeply enough to be
comfortable may aspirate blood present in the pharynx, whereas a
lightly sedated patient may experience discomfort, converse; and often
become garrulous during surgery, thereby distracting the surgeon.
Incision
Minor revisions can be performed using an endonasal approach.
However, an exonasal approach through a columellar step incision is
preferred for major revisions or a full secondary operation.14,15 This
approach affords the surgeon a better exposure and opportunity for
identifi cation of the anatomy and pathologic conditions. If the patient’s
initial surgery or previous revisions were performed using an open tech-
nique, a slight delay phenomenon will have occurred, providing more
safety for the second operation with respect to the soft tissue circula-
tion. If an endonasal approach has been used previously, the secondary
procedure can still be performed successfully using an open technique.
The key to a successful surgery is the ability to identify the imper-
fections and adequate exposure, regardless of the technique. Most of
the deformities can be detected readily during the external examina-
tion. However, it is not always possible to fully delineate the structural
fl aws, especially in the tip area, during physical examinations; thus
the surgeon may experience some unexpected fi ndings during surgery
and one has to be prepared to deal with these.
Following induction of anesthesia, the nose is packed with
gauze containing 4% cocaine or neosynephrine. Lidocaine containing
1:200 000 epinephrine is infi ltrated. If turbinectomy is a planned part
of the procedure, they are injected fi rst. After waiting a short period
for initial vasoconstriction the nose is injected profusely with xylocaine
containing 1:100 000 epinephrine to cause more intense vasoconstric-
tion and facilitate the surgical dissection. These two injections given
several minutes apart will maximize the vasoconstriction yet cause
minimal systemic effects. A step or inverted V incision is made in the
columella. The soft tissues are elevated with the dissection being con-
ducted at the interface between the nasal frame and overlying soft
tissue, until the entire dorsum is dissected free.
Alteration of the radix
An under-corrected radix can be rectifi ed by removal of bone from this
area using a guarded burr.16 This tool is safe and extremely effective if used
properly. After the skin and soft tissue in the nasion area have been
adequately elevated, the guarded burr is introduced into the site (Fig.
12.8). The surgeon can lower the nasion in an incremental fashion by
Fig. 12.7 Patient with hanging columella.

Surgical Techniques
171
A
Fig. 12.8 Guarded burr is used to lower radix.
B
gently moving the rotating burr from side to side. If the dorsal hump is
large, removing it fi rst may facilitate insertion of the guarded burr
between the skin and the bone of the radix. Occasional soft tissue inter-
ference with the movement of the burr should not discourage its use.
Repeated, judicious use of this tool will achieve the intended objectives.
However, caution should be exercised because this tool is very powerful
and may result in excessive bone removal if used too zealously.
Dorsal hump
A residual dorsal hump can be removed easily with a rasp. Use of an
osteotome, although advocated by some, may not be advisable because
of the inherent diffi culties in orientation and the irregular density of
the residual bony prominence, which behaves totally different than an
intact hump. It is crucial to elevate the soft tissues overlying the
dorsum as thoroughly as possible to prevent thinning of the dorsal
skin tissues. Removal of the hump may result in a wide-appearing
dorsum, requiring an osteotomy that may or may not have been
planned. If septoplasty is indicated, it is performed at this time through
an open technique and the needed cartilage is harvested. If there is no
hump to be removed, or dorsal surgery does not lead to an open roof,
the septum can be corrected through a closed incision.
Nasal bone osteotomy
Lateral osteotomies can be performed percutaneously or through a stab
wound in the vestibule. If the latter is selected, elevation of the peri-
osteum may not be achieved as easily during the secondary rhinoplasty
as it is during the primary surgery because the periosteum adheres
more intensely to the bone after the initial procedure. On the other
hand, the secondary osteotomy is often easier to perform if the previ-
ous osteotomy site can be utilized since usually there is not a great
deal of bone deposited in this site, even long after the previous oste-
otomy. Commonly, however, the initial osteotomy is performed too
anteriorly, resulting in a step deformity which necessitates a new sec-
ondary osteotomy more posteriorly. In patients who have experienced
repeated trauma, osteotomy can be diffi cult. Medial, vertical percuta-
neous and/or internal osteotomy may be necessary. A common reason
for the failure to optimally reposition the nasal bone medially is exces-
sive bone between the septum and nasal bones. This can readily be
corrected by removal of a wedge of bone from this site. To do so, a
medial osteotomy is fi rst begun along the medial aspect of the nasal
bones, aiming cephalically and medially. The second osteotomy is
started immediately lateral to the septum and midline bone, aiming
cephalically and laterally. The two osteotomies are joined at the nasion
and a wedge-shaped extra bone is removed. When the lateral osteot-
omy, including a percutaneous, anteroposterior, or a lateral low-to-low
osteotomy is completed, the nasal bone can be repositioned as a unit,
avoiding an unfavorable segmentation.
A small lateral depression over the nasal bone can be camoufl aged
by using a cartilage graft, or even a fat graft, as long as the airway has
not been narrowed signifi cantly by the medial displacement of the
nasal bone and the upper lateral cartilage and the internal valve
remains competent. If the patient experiences diffi culty breathing, it
may be necessary to correct the nasal valves by out-fracturing the nasal
bones, which will reposition the upper lateral cartilages and improve
the airway. This maneuver, however, is not predictable. Addition of a
cephallically extended spreader graft may prove helpful in maintaining
the nasal bones in the desired position.
Correcting the dorsal defi ciency
A depression resulting from over-resection or asymmetric resection of
the midvault is a common fi nding during secondary rhinoplasty. This
will often require a cartilage graft. Septal cartilage is the preferred graft
source to rectify an over-resected dorsum. If the patient has undergone
septoplasty previously, the available septal cartilage may be insuffi -
cient. However, the mere history of septoplasty should not cause the
surgeon to avoid exploring the septum. If available, the septal cartilage
graft is prepared and gently crushed, and the margins are beveled to
prevent a harsh dorsal line or step (Fig. 12.9). The graft is sutured to
the dorsum to avoid shifting. It is important to dissect the soft tissues
adequately to avoid forcing the graft out of desired position while
Fig. 12.9 Gently bruised septal cartilage in one to two layers is
optimal choice for dorsal augmentation.

12
SECONDARY RHINOPLASTY
172
healing. The caudal portion of the graft should be narrower than the
central portion (fusiform).
Conchal cartilage graft is the second choice for correcting minor
defi ciencies of the dorsum; for correction of major defi ciencies, a
costochondral graft is preferred.
Harvesting conchal cartilage graft
The ear is infi ltrated medially and laterally with xylocaine containing
1:100 000 epinephrine. Using a 25-gauge needle and brilliant green,
the site of the incision is planned, tattooing across the full thickness
of the ear within the conchal fossa while adequate cartilage is being
maintained for ear support. A postauricular incision is made and the
skin is carefully dissected away from the conchal cartilage leaving the
perichondrium on the cartilage graft. Guided by the tattoo marks, an
incision is made in the cartilage. The perichondrium is separated from
the lateral aspect of the conchal cartilage to be harvested. The cartilage
is removed, encompassing most of the conchal fossa, leaving suffi cient
frame for support of the ear. The wound is irrigated. A 5–0 plain catgut
suture is passed through the upper portion of the conchal fossa, taken
through the mastoid fascia, and brought out through the lower portion
of the fossa and clamped, leaving adequate suture loop. The post-
auricular incision is then repaired using running locked catgut 5–0
plain sutures. A cotton dressing is applied to the conchal fossa and the
previously placed suture of 5–0 catgut sutures is tied over it to elimi-
nate the dead space.
Harvesting costal cartilage graft
A submammary or an anterior chest wall incision is made for a female
or male patient, respectively. This incision is taken through the rectus
muscle using coagulation power of the cautery. The fi fth or the sixth
rib is exposed and the constochondral junction is identifi ed. The
perichondrium is elevated. The dissection is continued medially and
circumferentially with a great deal of care to avoid an injury to the
pleura using a periosteal elevator. A piece of cartilage graft is harvested
approximately 6 cm in length. A valsalva maneuver is conducted to
assure the integrity of the pleura. The wound is irrigated copiously. A
suction drain is placed in position. Meticulous repair is performed
using a combination of 3–0 and 5–0 monocryl, and 5–0 plain catgut.
Waterproof dressing is applied.
If the costal cartilage is used to avoid warping the cartilage, the
surgeon must follow Gibson’s principles17 or place a permanent Kirsch-
ner wire in the center of the cartilage to avoid warping.18 If an oste-
otomy is necessary to correct asymmetry or excess width of the nasal
bones, it is crucial that the surgeon perform the osteotomy fi rst, and
then apply the dorsal cartilage graft.
Correction of inverted V-deformity and
nasal collapse
It is commonly necessary to restore the competency of the internal
valves on secondary rhinoplasty patients by repositioning the upper
lateral cartilages. Collapse of the upper lateral cartilages disturbs the
function of the nose and engenders an undesirable nasal form known
as an inverted V deformity, as referred to earlier.4 Less severe deformi-
ties can be corrected by using a spreader graft;4 more signifi cant defor-
mities require the use of a splay graft.19
To insert the spreader graft, the upper lateral cartilages and muco-
perichondrium are separated from the septum. An appropriately sized
graft extending from the junction of the nasal bone and the upper
lateral cartilages (Keystone area) to the caudal end of the upper lateral
cartilage is prepared. This graft is designed approximately 3 mm wide
and 12–15 mm long; its thickness varies depending on the degree of
the internal valve collapse (Fig. 12.10). If the graft is too thin to achieve
the intended result, two layers are used. The graft is fi xed in position
using at least two through-and-through 5–0 monocryl mattress sutures.
This step is crucial; otherwise, the graft may become dislodged while
the splint is being applied, or during healing, which will result in a
loss of function and may induce a discernible dorsal irregularity. The
upper lateral cartilages are then sutured to spreader grafts and the
septum. Placement of the spreader grafts may have more of a positive
effect on the creation of optimal dorsal outline than the valve func-
tion.
The splay graft is employed when the lower lateral cartilages are
too attenuated or too short to allow a spreader graft to provide suffi -
cient improvement in the valve function and achieve the intended
aesthetic goals. The graft is tailored to extend from the posterior
extent of one upper lateral cartilage to the opposite side, spanning
the anterior septum.19 When the graft is inserted, the splay effect
provides signifi cant and enduring competency to the internal nasal
valves. The open technique, again, is the preferred approach for the
placement of this graft. The mucoperichondrium is separated from the
medial aspect of the upper lateral cartilages bilaterally to create a
pocket that extends to the posterior limits of the upper lateral cartilage.
Preferably, a conchal cartilage graft is harvested, tailored, placed in
position, and fi xed to the underlying anterior septal border, using 5–0
PDS suture. It may be necessary to minimally bruise the septal carti-
lage to avoid excessive widening of the lower portion of the nose. After
the cartilage is fi xed to the septum, the anterior border of the upper
lateral cartilages is sewn to the cartilage graft under mild tension to
create continuity, strength, and proper contour. If the dorsal projection
is considered to be optimal before application of the splay graft, it is
necessary to lower the existing dorsal contour commensurate with the
thickness of the cartilage graft to avoid excessive projection of the
dorsum.
Adjustment of the caudal dorsum
The caudal dorsum may appear over-projected as a result of inadequate
resection, causing a supratip deformity, which can be easily contoured.
After the dorsum is exposed, the upper lateral cartilages are dissected
Bilateral spreader graft
Fig. 12.10 Artistic illustration of bilateral spreader graft in position
and fi xed with three sutures.

Surgical Techniques
173
and separated from the antero-caudal septum. It is essential to main-
tain the mucoperichondrium over the caudal nasal vault intact to
prevent collapse of the upper lateral cartilages. These tissues at the
antero-caudal area are somewhat rigid after a primary rhinoplasty. On
rare occasions this rigidity of the soft tissues after removal of the
anterocaudal septum is enough to prevent skin from draping over the
newly shaped dorsum and may produce a space, setting the stage
for a recurrent supratip deformity. Use of a supra-tip suture will
reposition the soft tissue tenting over the caudal septum and will
eliminate this dead space (Fig. 12.11). Commonly, the supratip defor-
mity can be the consequence of an over-resected caudal dorsum or the
result of leaving a dead space that fi lls with clotted blood, subsequently
becoming scar tissue. When this occurs, the scar tissue is removed, a
cartilage graft is applied to the caudal dorsum and supra-tip suture is
used.
Tip refi nement
Secondary nasal tip deformity is exceedingly prevalent. The pathology
can include over-projection, under-projection, excessive or inadequate
width, or asymmetry. All of the principles discussed in the previous
chapter apply here as well. Excess width can be controlled with suture
technique. If the domal arches are too wide, a transdomal (dome defi n-
ing suture) would be used. If the domes have proper shape but are
positioned further apart, an interdomal suture would be a better choice.
Commonly, the continuity of the domes and upper lateral cartilages has
been interrupted, rendering the suture technique diffi cult, if not impos-
sible. Furthermore, the cartilages are more rigid. These factors set the
stage for an unpredictable response and asymmetry; thus, more intra-
operative trials are necessary for the placement of the sutures than for
the primary tip adjustments. Under these conditions, a subdomal graft
would control the interdomal distances and a tip graft would restore a
better form to the nose.20 Inadequate tip projection can be improved
with the suture technique, application of a columellar strut, placement
of a tip graft, or a combination of the methods. If the projection defi -
ciency is minimal and the domal arches are too wide, placement of a
transdermal suture will achieve both goals. It will narrow the domes
and increase projection. If the inadequate tip projection is because of
a short columella, a columellar strut is used. If the problem is the
defi ciency in the lobule, a tip graft will be utilized as an onlay or
a shuttle graft (Fig. 12.12). The excess projection can be lessened either
by resecting the footplates and the lateral crura using the tripod concept,
depending on the nose length and projection, or by removing the domes
if they are too wide or distorted to be avoided by using less invasive
maneuvers.
Lateral crura strut
A lower lateral strut can correct the collapse of lower lateral cartilage.18
The lower lateral strut is a piece of cartilage placed under the surface
of the existing lower lateral cartilage, extending from the maxilla to
the ipsilateral dome.
Correction of protruding columella
Excess caudal projection of the columella can be corrected by resecting
a rectangle-shaped piece of cartilage from the caudal septum and a
commensurate amount of lining from the membranes of the septum.
If an anteriorly based, triangle-shaped cartilage is resected, it will
induce cephalic rotation of the nasal tip. If the nose is under-projected
and the patient exhibits excessive caudal projection of the columella,
the footplates and the medial crura can be overlapped and fi xed over
the caudal septum.21 This is called the Fred technique.
Placement of a columellar strut
A columellar strut is a better choice when the lobule volume is pro-
portional and the columella is short. This will provide stability to the
central portion of the nasal base. A piece of cartilage, usually 2 cm long
and 3 mm wide, is prepared. The graft is placed in between the medial
crura over the nasal spine and fi xed in position symmetrically. This
maneuver alone will cause cephalic rotation of the tip, caudal projec-
tion of subnasale and increase in tip projection. Additional projection
can be achieved by resting the groft on the maxilla.
Tip graft
For patients with a defi cient lobule and inadequate tip protection, an
onlay or shield type tip graft is the preferred approach. Nasal elonga-
tion for correction of an over-shortened nose can be accomplished by
adding a cartilage graft to the caudal septum or by placing a strut that
extends from the medial crura to the septum, advancing the columella
caudally. This strut also may advance the alar rim, as long as the
medial crura and domes, and the lateral crura are still in continuity,
and the cephalic scar tissue has been released suffi ciently. If the alar
rims are in an optimal position, an onlay lobule cartilage graft may
advance the columella effectively without altering the alar rims.
However, this is only applicable when there is minimal defi ciency.22
The tongue and groove technique can be used to elongate the short
nose of varying degrees.
Footplates
The footplates may be widely displayed or coould be asymmetric. This
disharmony is corrected through the posterior portion of the hemi-
transfi xion incision. In the case of an under-projected tip and splayed
footplates it is advisable to approximate the footplates, which will
strengthen the tip support and narrow the base of the columella. For
Fig. 12.11 Suture technique to approximate supratip issue to
underlying cartilage after removal of scar tissue.

12
SECONDARY RHINOPLASTY
174
the short nose, the footplates are resected and the medial crura approx-
imated, resulting in caudal rotation of the tip.
Correction of retracted alar rim
If the retraction is minimal, it can be corrected with placement of an
alar rim graft.23 A piece of septal, conchal, or even costal graft is crafted
3 mm wide, 1 mm or less thick, and 8–10 mm long. A pocket is created
along the alar rim through an anterior incision. The graft is placed in
position and sutured using 6–0 absorbable catgut.
The V–Y fl ap is designed internally, based caudally at the alar rim.
The fl ap is elevated, dissected enough to unfold the alar rim, an alar
rim graft is placed. The V–Y advancement is then completed using
5–0 chromic catgut sutures. Two stents, one internal and one external,
are applied to encase the alar rim and suture in position using 5–0
nylon through-and-through suture which is tied lightly. A lower lateral
cartilage strut will also advance the alar rim caudally, if the patient
exhibits alar collapse, as well as rim retraction.
Alar base abnormalities
Most secondary rhinoplasty patients have a wider alar base than
optimal with some degree of asymmetry. Alar base reduction6 can be
performed by removing tissue from the nostril sill, the lateral alar base,
or a combination of both as dictated by the alar dysmorphology. What
is important, however, is that the graceful transition from the alar base
to the nostril sill should not be compromised because of a fear of scar-
ring. As the alar base advances medially, the alar rim will relocate
caudally to some degree. The alar base incisional scars usually heal
favorably unless the patient has thick sebaceous skin or has already
demonstrated poor healing potential in the previous surgery. Many
patients benefi t from a combination of several of the aforementioned
techniques (Figs 12.12, 12.13 & 12.14).
Short nostril
The nostril length can be increased by placement of an alar rim graft,
a columella strut, a narrowing of the footplate and excision of residual
lining from the soft triangle.
Splint and packing
If no osteotomy is necessary, a splint is avoided and adhesive strips
are suffi cient. Osteotomy mandates the use of a nasal splint; however,
Doyle stents will be used if septoplasty is required. Stents are necessary
for an extensive secondary or primary septoplasty with secondary
rhinoplasty.
The turbinates and septum are evaluated thoroughly before the
surgery and, if deemed benefi cial, a septoplasty and turbinectomy are
performed fi rst. Synechiae are released sharply or by using an electro-
cautery device with an extended tip. If electrocautery is used for this
purpose, the cauterization is mainly conducted on the turbinates to
avoid inadvertent septal perforation caused by thermal damage. A
Silastictm stent can decrease the likelihood of additional scar formation.
In most patients, minor revision rhinoplasty can be performed with
predictable or satisfactory outcome, and patient and surgeon satisfac-
tion. It is the major secondary rhinoplasty that can be somewhat
unpredictable and may require additional revision in a small percent-
age of patients. It is the combination of presence of scar tissue, lack
of appropriate sources for a graft (as a result of previous septoplasty or
A
B
C
D
E
Fig. 12.12 A, Photograph of the onlay tip punch and shield punch. B, The punch is being used to harvest the tip graft. C, A Skin hook is
used to facilitate retrieval of the graft from the punch. D & E, The tip graft is in position and fi xed using 6–0 Monocryl.

Surgical Techniques
175
Secondary rhinoplasty
I
J
A
B
C
D
E
F
G
H
K
Fig. 12.13 This secondary rhinoplasty patient underwent the following: through an open technique, a dorsal graft was applied, osteotomies
were made bilaterally, a columella strut was placed, a tip graft was applied, and the medial crura were approximated.

12
SECONDARY RHINOPLASTY
176
Fig. 12.14 This secondary rhinoplasty patient underwent the following: through an open technique, the small dorsal hump was removed
caudally, a septal cartilage graft was applied cephalically, the cephalic margin of the lower lateral cartilages was trimmed minimally, and a
shield graft was applied. The alar bases were narrowed.
Second case, secondary rhinoplasty
I
J
A
B
C
D
E
F
G
H
K

References
177
use of grafts), a change in the vascularity of the tissue, and a shortage
of lining that makes the results of secondary rhinoplasty less predict-
able than the primary rhinoplasty.
1.
When in doubt about the ability to satisfy the patient, the
choice is to avoid surgery.
2.
The majority of patients benefi t from the placement of
spreader grafts.
3.
Tip grafts and columella strut cannot be used interchangeably.
4.
Alar rim graft is useful in the majority of secondary rhinoplasties.
5.
Placement of a columella strut rotates the tip cephalically,
increases the tip projection and advances the columella
caudally. These changes should be considered in the aesthetic
planning.
Pitfalls
1.
Removal of caudal dorsal hump reduces the tip projection and
this has to be computed in the overall aesthetic plan.
2.
Patients who have telangiectasis at the alar base area are more
likely to experience deterioration with repeated surgeries.
3.
Repeated surgeries result in loss of dorsal soft tissue thickness,
revealing even the smallest dorsal fl aws.
4.
Use of uncrushed septal cartilage graft as a tip graft may result
in harsh and visible cartilage outline on patients with thin
skin, even after beveling.
5.
Placement of alar rim graft on a patient with hanging ala may
worsen this condition.
REFERENCES
1. Juri J, Juri C. Secondary rhinoplasty. Ann Plast Surg 1987; 18:366–376.
2. Millard DR. Secondary corrective rhinoplasty. Plast Reconstr Surg 1969;
44:545–557.
3. Peck GC. Secondary rhinoplasty. Clin Plast Surg 1988; 15:29–41.
4. Sheen JH. Secondary rhinoplasty. Plast Reconstr Surg 1975; 56:137–145.
5. Szalay L. Early secondary corrections after septorhinoplasty. Aesthetic
Plast Surg 1996; 20:429–432.
6. Constantian M. The incompetent external nasal valve: pathophysiology
and treatment in primary and secondary rhinoplasty. Plast Reconstr
Surg 1994; 93:919–931.
7. Constantian M, Clardy RB. The relative importance of septal and nasal
valvular surgery in correcting airway obstruction in primary and
secondary rhinoplasty. Plast Reconstr Surg 1996; 98:38–54.
8. Guyuron B. Nasal osteotomy and narrowing of the airway, Presented
at the annual meeting of the American Society of Plastic and
Reconstructive Surgeons, San Francisco, 1997. Plast Reconstr Surg
1998.
9. Guyuron B. Genioplasty. Boston: Little, Brown & Co, 1992.
10. Guyuron B, Michelow B, Willis L. Practical classifi cation of chin
deformities, Aesthetic Plast Surg 1995; 19:257–264.
11. Nicolle F. Secondary rhinoplasty of the nasal tip and columella. Scand J
Plast Reconstr Surg 1986; 20:489–499.
12. Guyuron B, DeLuca L, Lash R. Supratip deformity: a closer look. Plast
Reconstr Surg 2000; 105:1140–1151.
13. Guyuron B. Precision rhinoplasty. I. Role of life-size photographs and
soft tissue cephalometric analysis. Plast Reconstr Surg 1988; 81:489–
499.
14. Daniel R. Secondary rhinoplasty following open rhinoplasty. Plast
Reconstr Surg 1995; 96:1539–1546.
15. Gunter JP, Rohrich R. External approach for secondary rhinoplasty.
Plast Reconstr Surg 1987; 80:161–174.
16. Guyuron B. Guarded burr for nasofrontal deepening. Plast Reconstr Surg
1989; 84:513.
17. Gibson T, Davis WB. The distortion of autogenous cartilage grafts: its
causes and prevention, Br J Plast Surg 1958; 10:257.
18. Gunter JP, Friedman RM. Lateral crural strut graft: technique and clinical
applications in rhinoplasty. Plast Reconstr Surg 1997; 99:943–952.
19. Guyuron B, Englebardt CL. The alar splay graft. Presented at the
Annual Meeting of the American Society of Aesthetic Plastic Surgeons.
New York, May 5, 1997.
20. Guyuron B, Poggi JT, Michelow BJ. The subdomal graft. Plast Reconstr
Surg 2004; 113:1037–1040.
21. Fred GB. The nasal tip in rhinoplasty: use of the invaginating
technique to prevent secondary drooping. Ann Otolaryngol 1950;
59:215–223.
22. Hamra ST. Lengthening the foreshortened nose. Plast Reconstr Surg
2001; 108:547.
23. Guyuron B. Alar rim deformities. Plast Reconstr Surg 2001; 107:856–
863.

This page intentionally left blank

179
CHAPTER 13
Genioplasty
Bahman Guyuron and Adam Bryce Weinfeld
include burr reduction (ostectomy), osteotomy with caudal segment
repositioning, osteotomy with grafting or osteotomy with segmental
sectioning.11–15 Augmentation genioplasty can be accomplished with
autologous tissue grafts such as bone or cartilage or, more commonly,
with alloplastic implants.16,17 The benefi ts of alloplastic augmentation
include a shorter and less technically demanding procedure. However,
alloplastic genioplasty can pose limitations in achieving large augmen-
tation without causing lip retraction, has a lower success rate for cor-
rection of asymmetry and offers very limited potential to change the
vertical dimension of the chin.18
ANATOMY
From external to internal, the layers of the chin include skin, subcu-
taneous fat, muscles, periosteum and bone. The depressor angularis,
depressor labi inferioris and mentalis attach to the anterior plane of
the chin. The geniohyoid, genioglossus, mylohyoid and anterior belly
of the digastric attach to the lingual aspect. Following elevation of the
anterior periosteum and horizontal osteotomy, the blood supply of the
caudal chin segment is maintained via terminal lingual artery perios-
teal perforating branches that travel through the musculature attached
to the lingual side (Figs 13.4 & 13.5).
The mental nerve supplies sensation to the anterior mandibular
gingiva, mucosa and lower lip. It is a continuation of the inferior
alveolar nerve and exits the mandible via the mental foramen. The
mental foramen is located in the vertical plane between the fi rst and
second mandibular premolars. In the terminal portion of its course, as
it travels posterior to anterior, the nerve ascends to the foramen (Fig.
13.6). This upward trajectory must be understood when planning the
location and angle of a horizontal osteotomy.19–21 In order to avoid
direct nerve injury, the osteotomy should be placed at least 5 mm
caudal to the foramen and be executed at a caudal-oblique angle.
INDICATIONS AND CONTRAINDICATIONS
1. Genioplasty is performed to address chin disharmony. It does
not replace orthognathic surgery.
2. Augmentation genioplasty best serves the older patient with a
mild-to-moderate horizontal defect. This does not imply that the
use of osseous procedures for chin advancement in older
patients is ill advised.
3. Advancement or augmentation genioplasty should be done
conservatively on patients with long face deformities who do
not wish to have maxillary intrusion.
4. Genioplasty is contraindicated in patients who have severe
medical conditions that make surgical procedures unsafe.
5. Genioplasty should be avoided on patients whose
dysmorphology would not be suffi ciently corrected with an
isolated genioplasty to provide patient satisfaction.
Summary
1. The labiomental groove is 4 mm deep in a woman and 6 mm
deep in a man.
2. Riedel’s Plane is an easily employed anthropometric construct
used in the determination of the ideal projection of the chin. In
a balanced face, this line, which is drawn by connecting the
most projecting portions of the upper and lower lips, should
touch the most projected portion of the chin.1
3. The canine is the longest tooth in the mandible (average
length 25.5 mm). Horizontal osteotomies should be placed at
least 5 mm caudal to the canines to avoid injury (30.5 mm).
Osteotomy location should also be 5 mm caudal to the mental
foramen to reduce the risk of injury to the mental nerve.
4. The mental foramen is located in a plane between the fi rst and
second mandibular premolars.
5. Patients who have a deep labiomental groove often have an
Angle class II occlusion and may gain more benefi t from
orthognathic surgery than genioplasty.
6. Intraoral incisions should be placed 1 cm anterior (labial) to the
gingivolabial sulcus in order to maintain suffi cient soft tissue
for secure wound closure.1
7. Augmentation genioplasty with an implant is preferred in the
older patient with mild horizontal defi ciency, while an
osteotomy is a better choice for a younger patient.
8. Patients with Angle class III and Angle II malocclusion require
consideration of orthognathic surgery in addition to or instead
of genioplasty.
9. Augmentation genioplasty performed through a submental
incision may reduce the risk of cephalic migration, wound
dehiscence and infection.
10. Most complications of alloplastic genioplasty are successfully
treated with removal of the implant and osseous genioplasty.1–3
INTRODUCTION
The chin is the lower topographic limit of the face and thus plays an
important role in the perception of appropriate facial proportions.4,5 A
vertically defi cient or excessive chin places the lower third of the face
out of balance relative to the middle and superior thirds of the face.6
Horizontal defi ciency or excess diminishes facial pulchritude, most
notably in profi le (Figs 13.1 & 13.2). Additionally, the chin has a
pivotal role as a reference in the appreciation of other facial features,
most notably the nose. A large nose is often paired with a defi cient
chin and they have a reciprocally negative effect on the appearance of
each other and on overall facial attractiveness (Fig. 13.3).7–9
Improvements in the chin can be achieved by osteotomy or by the
use of implants or grafts for augmentation.10 Osseous procedures

13
GENIOPLASTY
180
Fig. 13.2 Horizontal macrogenia.
Fig. 13.1 Horizontal microgenia.
The presence of some medical conditions infl uences the type of geni-
oplasty that is prudent. Generally, patients with diabetes mellitus or
immune defi ciency are not ideal candidates for alloplastic augmenta-
tion.1,22 Patients over the age of 60 years old with a mild-to-moderate
horizontal microgenia are better candidates for alloplastic augmenta-
tion. On most other patients osteotomy is preferred, although the use
of implants is not considered inappropriate. Patients who smoke
cigarettes are not the ideal candidates for the use of grafts as a chin
augmentation material.
PREOPERATIVE HISTORY AND
CONSIDERATIONS
The cardinal determinants of chin harmony are its projection sym-
metry and vertical length. Assessment of the vertical dimension of the
chin is performed fi rst in frontal view analysis. The face is divided into
two anatomic portions using imaginary lines placed at the eyebrow
level and subnasale. The three segments that these lines create should
be equal in the harmonious face (Figs 13.7 & 13.8).
To assess the vertical dimension of the chin, the lower third is
further subdivided using a line passing through the stomion. The
distance from the stomion to the menton should be twice the length
of the distance between the subnasale to the stomion. Additionally,
the distance from the stomion to menton should be equal to the dis-
tance from the stomion to the line connecting the medial canthi.
Deviation from equality in either of these comparisons is measured in
millimeters and included in the plan for vertical modifi cation of the
chin.
The terminus of the female chin is a single light refl fection. In the
male chin, there are dual light refl ections indicating the underlying
increased width and rectangular shape of the chin. To determine the
chin symmetry, a vertical line is drawn passing through the mid-
glabella, the tip of the nose (as long as the nose is straight) and the
philtral dimple. The midpoint of a symmetrically located chin will fall
on this line (Fig. 13.9).8 If chin asymmetry is identifi ed, its cause should
be elucidated as it impacts procedure choice. To decide whether the chin
asymmetry is related to maxillary/mandibular disharmony or is intrin-
sic to the chin itself, the horizontal planes of the mouth and the eyes
are examined. The intercommissural line should be parallel to the inter-
canthal line. Otherwise, vertical asymmetries of one or both
of the jaws are likely to be present and genioplasty alone may not
correct this condition fully. If the intercommissural line parallels the
intercanthal line, a pure genial asymmetry is present and a genioplasty
with osteotomy can be planned to correct the deformity (Figs 13.10 &
13.11).
Horizontal excess or defi ciency is detected better in profi le. There
are multiple methods to determine ideal chin projection. The use of
Riedel’s plane is simple and practical. With the ideal chin projection
present, the most projecting portion of the upper lip, lower lip and

181
Preoperative History and Considerations
Fig. 13.3 The synergistic facial disharmony of a large nose paired
with microgenia.
Hyoglossus
Mylohyoid
Digastric
Geniohyoid
Genioglossus
Muscles that attach to the lingual aspect of the chin
Fig. 13.4 Muscles that attach to the lingual aspect of the chin.
Lingual aspect musculature left intact following osteotomy
Fig. 13.5 Demonstration of lingual aspect musculature left intact
following osteotomy to preserve blood supply to the caudal segment.
Inferior alveolar
nerve
Mental nerve
Mental foramen
Sensory nerves
Fig. 13.6 Sensory nerves. The inferior alveolar nerve transitions to
the mental nerve as it exits the mental foramen. Prior to this
transition the nerve makes a brief pass caudally then cephalically to
the foramen. Horizontal osteotomies are made at least 5 mm caudal
to the mental foramen to reduce the risk of direct neural injury.
chin are all tangent to the same line (Fig. 13.12). If the chin lies pos-
terior to the Riedel’s plane, horizontal microgenia exists. If the chin
lies anterior the plane, horizontal macrogenia exists.
The labiomental groove should be 4 mm deep in a woman and
6 mm in a man. A defi cient chin with a deep labiomental groove
should not be treated with augmentation alone in most incidences.
These patients are better candidates for orthognathic surgery rather
than genioplasty. Although independent of the associated pathology,
a deep labiomental groove can also be treated by adding autologous fat,
cartilage or bone grafts.
An intraoral examination is mandatory in the assessment of the
potential genioplasty patient. The maxillary/mandibular occlusal rela-
tionship is carefully examined. Signifi cant periodontal disease should

13
GENIOPLASTY
182
be identifi ed and adequately treated prior to genioplasty to decrease
the risk of infectious complications.
Life-size photography with soft tissue cephalometric analysis pro-
vides an opportunity for precise preoperative planning of augmentation
or osseous genioplasty to the millimeter in both the vertical and hori-
zontal planes.23 A circumspect facial analysis, coupled with life-size
photography, can lead to an accurate defi nition of chin dysmorphology.
CLASSIFICATION OF CHIN DEFORMITY
Chin pathology is classifi ed as types I–VII according to the prevailing
boney or soft tissue abnormalities.24 The type of deformity dictates
which procedure should be utilized in order to attain a pleasing
outcome (Table 13.1).
Group I deformities encompass macrogenic chins. Moderate-
to-severe pure horizontal macrogenia is managed by setting back the
caudal segment (Fig. 13.13). Correction of pure vertical chin excess
requires resection of a horizontal block or wedge segment (Fig. 13.14).
Face is divided into three equal sections
1/3
1/3
1/3
1/3
1/3
1/3
Subnasale
Glabella
Figs 13.7 and 13.8 The face is divided into three equal sections by
placing imaginary lines at the glabella and subnasale. Assessment
of these divisions aids in the analysis of facial vertical proportions.
Horizontal symmetry assessed by placement of
vertical dividing line
Fig. 13.9 Horizontal symmetry can be assessed by the placement of
vertical dividing line. This line connects the midglabella, tip of the
straight nose and philtral dimple. The topographic center of a
symmetric chin will also lie on this line.
Table 13.1 Classifi cation of chin deformities
Group I: Macrogenia
Horizontal
Vertical
Combination
Group II: Microgenia
Horizontal
Vertical
Combination
Group III: Combined microgenia and macrogenia
(bi-planer defects)
Vertical excess and horizontal defi ciency
Vertical defi ciency and horizontal excess
Group IV: Asymmetric chin
Normal anterior lower facial height
Short anterior lower facial height
Long anterior lower facial height
Group V: Pseudomacrogenia
Group VI: Pseudomicrogenia
Group VII: Witch’s chin deformity

183
Classifi cation of Chin Deformity
Removal of a horizontal segment with setback of the remaining caudal
segment is required for combined horizontal and vertical macrogenia
(Fig. 13.15).
Group II deformities are comprised of microgenic chins. Augmen-
tation genioplasty for mild or even moderate pure horizontal defi -
ciency is discussed in a later section. A horizontal osteotomy with
advancement of the caudal segment is a predictable method of treat-
ing horizontal chin defi ciency (Fig. 13.16). Pure vertical chin defi -
ciency is addressed with a horizontal osteotomy and caudal
repositioning (Fig. 13.17). Combined vertical and horizontal microge-
nia is managed with repositioning the osteotomized chin segment
caudally and anteriorly (Fig. 13.18). With any of these osteotomies,
whenever caudal repositioning is performed and a gap greater than
5 mm results, interposition bone grafting or placement of a hydroxy-
apatite block is indicated. Smaller defects are within the osteoblastic
fi lling (jumping) distance.
Patients with Group III chin deformities have osseous excess in
one direction and defi ciency in another. Combined horizontal excess
with vertical defi ciency is remedied with a horizontal osteotomy fol-
lowed by caudal and posterior repositioning of the caudal segment (Fig.
13.19). When vertical excess is paired with horizontal defi ciency, two
osteotomies are performed to remove an anteriorly based wedge of
bone. The caudal segment is then advanced cephalically and anteriorly
and the gap is closed (Fig. 13.20).
Asymmetric chins are classifi ed as Group IV. Patients with asym-
metric chins are not ideal candidates for genioplasty with alloplasts.
Asymmetric chins with normal lower facial height are treated by
removing a wedge from the excessive side followed by autografting of
that wedge on the side of defi ciency (Fig. 13.21). If lower facial height
is excessive, the caudal segment is repositioned cephalically and the
wedge is discarded. If the face is vertically short only one osteotomy
is performed and the caudal segment is differentially moved caudally
and the resultant gap is grafted with a segment of bone.25
In the correction of deformities classifi ed as I–IV, the magnitude
of caudal bone segment repositioning is determined using the knowl-
edge of the soft tissues responses to the skeletal alterations as outlined
(Table 13.2).8,26
Group V patients have pseudomacrogenia, an excess of chin soft
tissue that results in the appearance of chin excess. This diagnosis is
facilitated by review of radiographic studies demonstrating excess chin
soft tissue. This type of chin dysmorphology is corrected through a
submental incision. Pseudomicrogenia resulting from vertical maxil-
lary excess and clockwise rotation of the mandible constitutes the
group VI chin deformity. This type of deformity requires orthognathic
Lower facial third further subdivided
=
1/3
2/3
Menton
Stomion
Subnasale
Figs 13.10 and 13.11 The lower facial third is further subdivided into an upper one-third and lower two-thirds by placing a line at the
stomion. The stomion to menton length is twice as long as the subnasale to stomion length when appropriate vertical chin height exists.
Reidel’s line
Reidel’s line
Fig. 13.12 Reidel’s line. The most projecting portions of the upper
lip, lower lip and chin are all tangent to this line when lower facial
harmony is present.

13
GENIOPLASTY
184
A
B
C
Vertical macrogenia
Fig. 13.14 Vertical macrogenia. The broken line demonstrates an
almost horizontally oriented normal chin bone; the excess is almost
purely vertical. The middle diagram demonstrates two ostetomies to
shorten facial height. In the lower diagram the caudal segment is
repositioned cephalically and fi xed in place.
a chin that is excessive in the horizontal dimension, is long in the
central portion only, or appears asymmetric due to excess bone on one
side.
Reduction genioplasty by ostectomy is performed under local anes-
thesia and monitored sedation, or under general anesthesia. This
procedure is indicated for mild horizontal or mild vertical macro-
genia. The chin is infi ltrated with xylocaine containing 1 : 100 000
epinephrine. Access is obtained through a 4 cm submental or an intra-
oral incision placed on the labial mucosal surface anterior to the
sulcus. A 1 cm cuff of mucosa and mentalis muscle must be maintained
on the gingival side of the incision to facilitate the repair. The peri-
osteum is elevated off of the anterior surface of the mandibular sym-
physis. The mental foramina are visualized and the nerves are gently
protected with malleable retractors.
A
B
C
Horizontal Macrogenia
Fig. 13.13 Horizontal macrogenia. In the upper diagram the broken
line represents the normal bone outline. The middle diagram
demonstrates reduction ostectomy with burr. The lower diagram
demonstrates two oblique ostiotomies with resection of the
intervening segment and set back to the caudal segment. The
shaded area represents contouring of steps-offs following set back
with burr.
surgery. The group VII chin is the ‘witch’s chin’ characterized by soft
tissue ptosis, which is corrected by removal of excessive soft tissues
through an elliptical incision in the submental area.
OPERATIVE APPROACH
Osseous genioplasty
Osseous genioplasty refers to alteration of the chin with modifi cations
of the chin bone using two different methods that include ostectomy
and osteotomy with caudal segment repositioning. Ostectomy is used
exclusively for reduction genioplasty. This is indicated in patients with

Operative Approach
185
A
B
C
Combined horizontal and vertical macrogenia
Fig. 13.15 Combined horizontal and vertical macrogenia. In the
upper diagram the broken line demonstrates macrogenia in both the
horizontal and vertical plane. The middle diagram demonstrates two
obliquely oriented osteotomies to reduce the chin’s horizontal and
vertical dimensions. The lower diagram demonstrates the caudal
segment positioned posteriorly and cephalically and fi xed following
removal of the intervening segment.
An oval burr is used to incrementally remove bone from the ante-
rior surface of the mandible on one half at a time (Figs 13.13 & 13.22).
While the burr is being used, the fi rst-generation bone is copiously
irrigated with saline containing antibiotics (1 g of cephalosporins in
1 l saline) to avoid thermal damage. More bone is removed centrally
and the ostectomy is tapered laterally and superiorly to the level of
the mental foramen to prevent irregularities. A caliper is used to assess
the amount of bone removed on the fi rst half to have a precise account
of how much bone is removed. If the bone is removed on both sides in
continuum, it will be diffi cult to gauge the amount of removed bone
precisely. After a suffi cient amount of bone is removed on one side, the
procedure is repeated on the opposite side.
A
B
C
Horizontal microgenia
Table 13.2 Soft tissue responses to augmentation or
osseous adjustment
Osteotomy
Retraction: 0.9/1 to 1/1
Vertical reduction: 0.8/1 to 1/1
Advancement: 0.9/1 to 1/1
Burr osteotomy
Horizontal: 0.25/1 to 0.5/1
Vertical: 0.5/1 to 0.75/1
Augmentation: 0.8/1 to 1/1
Fig. 13.16 Horizontal microgenia. The broken line in the upper
diagram demonstrates the normal chin bone outline. In the middle
diagram illustrates an oblique osteotomy. In the lower diagram the
caudal segment is advanced and fi xed in place.