Aesthetic Surgery Techniques

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SECTION 3    CHAPTER 13  •  The Turkey Neck: Surgical Management
A
B
FIGURE 13.3  TR, a 56-year old woman. (A) Preoperative view, anteroposterior. (B) Preoperative view, left lateral.
FIGURE 13.4  TR, a 56-year old woman—preoperative design for platysma resection and elevation.
A
B
FIGURE 13.5  Composite parotid fascia auriculoplatysmal flap to cover triple-cable sutures.

103
Conclusion
A
B
FIGURE 13.6  TR, a 56-year old woman, 4-month postoperative surgical results. (A) Anteroposterior view. (B) Left lateral view.
A
B
FIGURE 13.7  GH, a 49-year-old woman, preoperative views. (A) Anteroposterior view. (B) Left lateral view.

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SECTION 3    CHAPTER 13  •  The Turkey Neck: Surgical Management
5.
Baker, D.C., 2008. Lateral SMASectomy plication and short scar facelifts:
indications and techniques. Clin. Plast. Surg. 35, 533–550.
6.
Fogli, A.L., 2008. Skin and platysma muscle anchoring. Aesthetic Plast.
Surg. J. 32, 531–541.
7.
Grover, R., Jones, B.M., Waterhouse, N., 2015. The prevention of
haematoma following rhytidectomy. A review of 1078 consecutive
facelifts. Br. J. Plast. Surg. 54, 481–488.
8.
Labbe, D., Giot, J.P., 2014. Open neck contouring. Clin. Plast. Surg.
41, 57–63.
9.
Fogli, A.L., Desouches, C., 2008. Less invasive face-lifting: platysma
anchoring techniques. Clin. Plast. Surg. 35, 519–529.
References
1.
Hodgkinson, D.J., 2012. Five-year experience with modified Fogli
(Loré’s fascia fixation) platysmaplasty. Aesthetic Plast. Surg. J. 36,
28–40.
2.
Hodgkinson, D.J., 2014. Total neck rejuvenation using a modified Fogli
approach and selective resection of anterior platysma bands. Clin.
Plast. Surg. 41, 73–80.
3.
Ellenbogen, R., Karlin, J.V., 1978. Visual criteria for success in youthful
neck in rhytidectomy by lipectomy and muscle sling. Plast. Reconstr.
Surg. 61, 376–383.
4.
Mendelson, B.C., Freeman, M.E., Wu, W., Huggins, R.J., 2008. Surgical
anatomy of the lower face: the premasseter space, the jowl and the
labiomandibular fold. Aesthetic Plast. Surg. 35, 519–529.
FIGURE 13.8  GH, a 49-year-old woman, preoperative design for platysma surgery and elevation combined with periorbital surgical rejuvenation.
A
B
FIGURE 13.9  GH, a 49-year-old woman, 6-month postsurgical results. (A) Anteroposterior view. (B) Left lateral view.

105
Synopsis
105
14 
Platysma Bands
Miles G. Berry MS, FRCS (Plast)
Jan J. Stanek MA, FRCS
The Clinical Problem (Fig. 14.1)
Platysma bands are vertical, cordlike structures in the ante­
rior neck that patients often describe as tendons and think
detract from an appealing neck. Along with transverse cervical
creases, submental skin, and/or fat excess and ptosis, they
are key features of an aging neck. Bands may occur medially
(paramedian or anterior) or laterally and start to make their
appearance in the latter half of the fourth decade in men and
women.1
Synopsis
Anatomy
Gray’s Anatomy describes the platysma as a broad sheet arising
from the fascia of the upper pectoralis major and deltoid. Having
crossed the clavicle, fibers ascend superomedially to insert
into the mandible, skin, and subcutaneous tissues of the lower
face, often blending with the lower oral and angular muscles.
The importance of platysmal manipulation in aesthetic neck
surgery was first noted in the 1920s.
Three common decussation patterns have been described2
(Figs. 14.1 and 14.2). The importance of understanding this
lies in the fact that mentohyoid decussation provides a continu­
ous sheet for submental support. The 10% of individuals in
whom there is no decussation—that is, separation—therefore
have minimal structural support. Bands may be medial and
lateral; Rohrich et al. have observed that it is only necks with
no decussation that can produce medial vertical bands.3 This
is not the entire story, however, because platysma bands may
form not only at the leading edge; many static bands result
from anterior folding against the relatively fixed midline.
Consider the linea alba in the abdomen—a corollary is the
jowl that forms only because the mandibular ligament prevents
further anterior translocation of the descending cheek substance.
Bands may be narrow (<2 cm) or wide (>2 cm) in their separa­
tion,3 and the latter are frequently associated with more fat
excess. The prime function of the platysma facial expression,
where it conveys fright, sadness, or horror.
The cause is controversial, with two differing views. First,
many believe them to be essentially hypertrophic muscle bands.
In fact, most adults have some degree of dynamic banding
(i.e., on forced contraction; see Fig. 14.1C). Bands apparent at
rest are referred to as static.
Others believe them to be age-related, due to a combination
of superficial musculoaponeurotic system (SMAS) attenuation,
ptosis, and redundancy, which stops conformation of the tissues
to the cervical concavity, and to the stretching of skin and fat
overlying the muscles—the two sides of the triangle becoming
the hypotenuse. Traditional management was based on tighten­
ing of the skin and SMAS, with a repositioning of the platysma
muscle to its more usual posterior location.4 However, a more
recent concept is skin redraping after structural reconstitution
of the cervicomental angle by midline apposition. Many years
of experience have demonstrated that lateral traction alone,
however simple in its attraction, is insufficient. Gonzalez has
proposed a different view, noting that the sagging senescent
skin and platysma become fibrosed, therefore fixing the bands
in a static state.5 However, 30 years of neck lifting have not
convinced me, and the bands are not seen when a person is
lying supine. Being a skin muscle—part of the panniculus
carnosus—the platysma has the same embryonic origin as
adjacent skin, so loss of tone is twofold; that is, seen in both
skin and muscle.
Iatrogenic (e.g., postliposuction)6 risk factors were found to
be submental obesity and, perhaps unsurprisingly, platysmal
nondecussation. Suction of the fat undoubtedly exposes pla­
tysmal pathology previously hidden from view.

106
SECTION 3    CHAPTER 14  •  Platysma Bands
SURGICAL OPTIONS
These include the following:
• Percutaneous (e.g., gigli)—probably work primarily
through denervation1
• Open (e.g., complete incision of the objectionable bands
and raising of full-width platysma flaps that are
subsequently sutured together in the midline to produce
a deep layer sling support9)
• Myotomy, with or without midline approximation10
Management Options
NONSURGICAL OPTIONS
Botulinum neurotoxin A has been used in 1500 patients from
three practices.7 A four-stage classification, based on various
criteria, including platysmal bands and skin laxity, has shown
good outcomes unrelated to anatomic variations but correlated
with the degree of muscle flaccidity and hypertrophy. The total
dose was relatively high, up to 250 botulinum units (BU), as
compared to a more conservative 40 BU in a single practice.8
A
B
C
FIGURE 14.1  Anterior neck of a 63-year-old woman smiling (A), static, at rest (B), and dynamic (C) on platysma activation showing the various states of platysma
banding.
Medial fiber decussation
1 – 2 cm below chin with
separate muscle bellies
in suprahyoid
75%
15%
10%
Type I
Type II
Best for support
Worst for support
Type III
Medial fiber decussation
all the way to thyroid
cartilage that cover
submentum like a sling
Separate medial
bellies that insert
directly into the chin
FIGURE 14.2  De Castro’s anatomic platysma variation patterns. (A) Type I. (B) Type II. (C) Type III. (Adapted from de Castro, C.C., 1984. The value of anatomical study of
the platysma muscle in cervical lifting. Aesth. Plast. Surg. 8, 7–11.)

107
Surgical Preparation and Technique
Leaving as much fat on the skin flap is the goal because
more padding helps with postoperative concealment of any
irregularities. Cutaneous dissection extends to the cricoid
inferiority and laterally for 4 to 5 cm on each side to aid with
platysma identification. The medial borders of the platysma
are identified, and careful submuscular dissection is performed.
We are advocates of direct submental lipectomy (Fig. 14.6)
when required, because this allows precise control and avoids
the unpredictable retraction and poor skin contour that bedevil
liposuction. At this point, subplatysmal dissection exposes the
lateral borders of the digastric muscles, which may be carefully
shaved if hypertrophic and are contributing to a nonaesthetic
contour of the submental neck. Prominent submandibular
glands are subject to a wealth of maneuvers, including
Interestingly, the absence of myotomy is difficult to
understand.
• Corset platysmaplasty11
This is ideal because the lateral platysma is not particularly
strong with respect to holding sutures, and central tightening
will assist with the minimization of bowstringing.
The Aesthetic Problem
As any Internet search will rapidly reveal, patients complain
bitterly about any degree of cervical banding, especially younger,
fourth- and fifth-decade patients. The recent proliferation of
external and later internal, tissue-tightening machinery bears
testament to the deep-rooted dissatisfaction with the smallest
of cervical imperfections.
The surgeon’s assessment follows a standard pattern, which
includes the following:
• Expectations—often completely unrealistic, but
absolutely critical to outcome success in aesthetic
surgery, where happiness is defined as when the
perception of reality meets expectations
• Skin quality and tone
• Subcutaneous fat presence and quantity
• Band presence—static or dynamic, number
and tone
• Additional factors, including mandibular length, chin
projection, submandibular gland prominence, and
hyoid bone location
Surgical Preparation and Technique
Management and Treatment Options
As noted, the patient’s expectations are fundamental, and the
balance between increasingly invasive surgery and results
versus possible complications cannot be overstated. Although
the face is usually relatively forgiving, the neck has a tendency
to punish any technical error visibly, no matter how tiny, and
edema, especially in the form of seroma, can lead to subsequent
skin retraction and deformity.
The need for myomectomies has been debated, but currently
they are probably required, if only for the element of denervation
they provide because the tendency of platysma is to undergo
bowstringing. When this occurs, division is mandatory.
Treatment and Operative Technique
Fig. 14.3 offers an algorithmic summary of the literature, rather
than a rigidly didactic protocol. Through a submental incision—
within (Fig. 14.4) for concealment11 or 5 mm behind the
crease—the platysma is identified. A retrosulcal incision gives
the optimal exposure with a concomitant face lift and is closer
to the submandibular glands if surgery is contemplated on
them. There is invariably a troublesome bleeder, branching
from the facial vessels, at the lateral incision, so good illumina­
tion and retraction (Fig. 14.5) are a great help.
• Aufricht 1960
• Labbé 1999
Closed
(“gigli”)
Open
Corset
repair
Without
myotomy
With
myotomy
(denervation)
• Matarasso 1999
• Kane 1999
• Rohrich 2006
• Gonzalez 2009
• Daher 2011
• Guerrosantos 1974
• Connell 1978
• Feldman 1990
• Marino 1963
• Adamson 1964
• McKinney 1984
Platysma bands
Surgical
Non-surgical
Lateral
traction
FIGURE 14.3  Algorithm for an approach to platysma banding based upon
techniques described in the literature.
FIGURE 14.4  Submental incision.

108
SECTION 3    CHAPTER 14  •  Platysma Bands
FIGURE 14.6  Direct submental lipectomy.
FIGURE 14.7  Midline apposition of medial platysma in a corset repair.
FIGURE 14.5  Example of an ideal neck retractor, useful for its light weight, narrow
blade, and bright light.
suspension and superficial gland excision, but are not the prime
focus of this chapter.
After meticulous hemostasis, the medial borders are brought
together in a corset11 (Fig. 14.7). In thin patients, care must be
taken not to leave a visible midline ridge after suturing; excess
medial platysma should be excised rather than inverted because
central ridges are usually visible.
Postoperative Considerations
Fig. 14.8 shows a preoperative patient, 48 years of age, who
recently stopped smoking and was feeling tired and old. Fig.
14.9 is the same patient postoperatively, 1 year following a
face and neck lift, trichloroacetic acid peel, rhinoplasty, endo­
scopic brow lift, and four-lid blepharoplasty. The residual
submental bulge is not lax platysma, as would appear on first
inspection, but hypertrophic submandibular glands that would
today be reduced surgically.
Complications
With a relatively wide range of botulinum toxin doses avail­
able,7,8 the novice should proceed with caution and start at the
lower end of the 5 to 20 botulinum units/band to avoid
dysphagia or dysphonia. Furthermore, caution should be
exercised in cases in which skin is particularly redundant, fat
is in excess, and submandibular gland hypertrophy is present3
to avoid exaggerating cord laxity postinjection.7 Personal
experience has shown that neurotoxin works best for very
early cervical bands in the submental area. The corollary is
well established with heavy bands, and there are those that
subscribe to the view that cervical bands in all but the very
young should not receive neurotoxin.
Surgical complications encompass the general gamut,
including infection, active scarring, and hematoma. Expand­
ing hematoma is one of the few true emergencies in facial
aesthetic surgery because airway compromise is dramatic.12
Recent evidence has suggested a role for fibrin tissue adhesives
in reducing complications, particularly hypertrophic scarring,
and walling off nascent seroma and hematoma before they
spread.13 Debate continues as to whether the incision should
be placed in a submental crease, where one exists, or a few
millimeters posteriorly. If in the crease, experience has shown
that 5 mm of anterior dissection allows better access, give, and
subsequent redrape. Careful apposition of the wound edges
and eversion tends to be well rewarded. However, skin excision
is currently out of favor, not least because an apparent excess
preoperatively quickly becomes the opposite when the obtuse
angle is corrected to the concave that requires greater length,
as explained by Pythagoras. Exceptions are a deep cleft or
mild chin ptosis.11 Seroma is a particular problem, no doubt
due to dependency, and retractions are troublesome when they
occur. A useful tip is relatively early (6 weeks postoperatively)
to give 50% diluted steroid injections with blunted needles for
a better field effect.

109
Complications
A
B
C
FIGURE 14.8  Preoperative patient, 48 years of age, recent smoking cessation, feeling “tired and old.”
A
B
C
FIGURE 14.9  Postoperative views 1 year following face and neck lift, trichloroacetic acid peel, rhinoplasty, endoscopic brow lift, and four-lid blepharoplasty.

110
SECTION 3    CHAPTER 14  •  Platysma Bands
7.
Matarasso, A., Matarasso, S.L., Brandt, F.S., et al., 1999. Botulinum
A exotoxin for the management of platysma bands. Plast. Reconstr.
Surg. 103, 645–652.
8.
Kane, M.A.C., 1999. Nonsurgical treatment of platysmal bands with
injection of botulinum toxin A. Plast. Reconstr. Surg. 103, 656–663.
9.
Connell, B.F., 1978. Contouring the neck in rhytidectomy by lipectomy
and a muscle sling. Plast. Reconstr. Surg. 61, 376–383.
10.
Guerrosantos, J., 2008. Managing platysma bands in the aging neck.
Aesthet. Surg. 28, 211–216.
11.
Feldman, J.J., 2014. Neck lift my way: an update. Plast. Reconstr.
Surg. 134, 1173–1183.
12.
Mendelson, B.C., Tutino, R., 2015. Submandibular gland reduction
in aesthetic surgery of the neck: review of 112 consecutive cases.
Plast. Reconstr. Surg. 136, 463–471.
13.
Berry, M.G., Stanek, J.J., 2015. Fibrin tissue adhesive for face- and
neck-lift. J. Plast. Reconstr. Aesthet. Surg. 68, 1325–1331.
References
1.
Daher, J.C., 2011. Closed platysmotomy: a new procedure for the
treatment of platysma bands without skin dissection. Aesthetic Plast.
Surg. 35, 866–877.
2.
de Castro, C.C., 1980. The anatomy of the platysma muscle. Plast.
Reconstr. Surg. 66, 680–683.
3.
Rohrich, R.J., Rios, J.L., Smith, P.D., et al., 2006. Neck rejuvenation
revisited. Plast. Reconstr. Surg. 118, 1251–1263.
4.
Webster, R.C., Smith, R.C., Smith, K.F., 1983. Face lift, part 2: aetiology
of platysma cording and its relationship to treatment. Head Neck
Surg. 6, 590–595.
5.
Gonzalez, R., 2009. Composite platysmaplasty and closed percutaneous
platysma myotomy: a simple way to treat deformities of the neck
caused by aging. Aesthet Surg J 29, 344–354.
6.
Kamer, F.M., Minoli, J.J., 1993. Postoperative platysmal band deformity.
A pitfall of submental liposuction. JAMA Otolaryngol. Head Neck
Surg. 119, 193–196.

111
Surgical Principles
111
15 
Prominent Nose
Igor Niechajev MD, PhD
The Clinical Problem
A prominent nose is regarded as abnormal if it is larger than
average, but even within different cultures this is very subjective.
Larger prevalence of the prominent nose in a total population
is seen in the Mediterranean basin and in the Middle East.1,2
Patients look at their noses through a prism of internal
reflection, which may also be the outlet for a psychological
load they carry inside. When patients are photographed in
profile and asked to draw the desired change in the nasal
profile, they will frequently draw the nose unreasonably small.
The surgeon must balance the patient’s dreams and desires
and the existent anatomic predispositions with his knowledge
of predictable surgical techniques and healing processes to
obtain favorable yet well-camouflaged results.
Although beauty can be interpreted variably, certain geo­
metric criteria and accuracy of proportions must be met. Goode
introduced a simple formula that delineates the approx­imate
relationship between tip projection and nasal length (Fig. 15.1).2,3
The Goode ratio is an expression of proportion in measurement
between a line drawn from the alar crease to the nasal tip and
from the nasal tip to the nasion. In the aesthetically-pleasing
Caucasian nose BC should equal 0.55 to 0.60 of AB. If it is more
than that, the nose is overprojected; if it is less, the nose is
underprojected. Adherence to this ratio prevents underprojection
or overprojection with rhinoplasty. If there is a preoperatively
unrecognized deviation from this ratio that persists after the
surgery, the final result will be substandard.
Surgical Principles
In the patient with the prominent nose, particular attention is
directed to the following features:
■ Age, gender, skin quality, and ethnicity
■ Overall nasal length
■ Height (Goode’s ratio)
■ Width (lateral facial proportions)
■ Nasofrontal angle (NF)—midface proportionate
development)
■ Nasolabial angle (NL)—female greater than male
■ Nose—upper lip distance (dental show)
■ Nose-chin proportions—mandible versus maxillary
development)
■ Shape and position of the chin—mandibular
hypoplasia
Basic rhinoplasty technique relies on three cardinal steps:
(1) reduction of the alar cartilages; (2) removal of the dorsal
hump; and (3) narrowing of the nasal pyramid by lateral
osteotomies and infracture.
A prominent nose requires a broader theoretical and practical
understanding of advanced rhinoplasty techniques and consider­
able skill. Aesthetic rhinoplasty has evolved considerably over
the decades, and we can now make a selection from a palette
of additional procedures on the radix–NF, modulation of the
NL, reduction of the nasal spine, lengthening or shortening of
the upper lip, chin reduction, chin augmentation, and advanced
tip procedures. To lower an overprojecting tip, the height of
the cartilaginous framework has to be reduced. Such tip setback
can be achieved by alar cartilage remodeling, as it was described
by Peck4 (Fig. 15.2). The lateral part of the alar cartilage is
excised and the intermediate crus area is scored to permit a
lateral slide of the alar cartilage. Gubisch and Eichhorn-Sens5
have refined the medial and/or lateral sliding technique, in
which the alar cartilages are cut and pushed down above the
lateral and/or inside the lower fragment and fixated in the
overlapping position by the permanent sutures (Fig. 15.3).
The NF can be deep, well-balanced, or shallow; this plays
an important role in our perception of the size and length of
the nose and facial harmony (Fig. 15.4). The NF also determines
the angle of inclination between the outlines of the nasal
pyramid and the vertical vector of the face, or how much the
nose sticks out.
SECTION 4 •Rhinoplasty
David J. Smith

112
SECTION 4    CHAPTER 15  •  Prominent Nose
A
N
Ala
.55–.60
B
C
FIGURE 15.1  Goode’s ratio. The nasal length is measured from the nasal radix to
the nasal tip (A,B). The radix begins at the level of upper eyelash margin, with the
patient’s eyes in primary gaze. The projection is measured from the nasolabial
junction to the tip (B,C). (Based on Tardy, E.M., 1997. Rhinoplasty: The Art and
Science. Saunders, Philadelphia, with permission.)
FIGURE 15.2  Peck’s technique for the setback of the prominent nose tip.
FIGURE 15.3  Tip setback by lateral and medial sliding and overlapping.
F
124º
N
G
FIGURE 15.4  Nasofrontal angle is measured between the line tangential to the
nasal dorsum (N) and the line tangential to the glabella (G). (F, Frankfort
horizontal.).
Inadequate Deepening of the Nasofrontal
Angle (Figs. 15.5 and 15.6)
Fig. 15.5 illustrates the importance of deepening of the NF
angle and its impact on optical impression of the length of the
nose. Fig. 15.6 shows the profile 2 years postrhinoplasty. The
radix was left untouched, and the optimal improvement was
not achieved. Despite the fact that the NL angle is 100° her
nose is perceived as long.
The shape of the NF angle is determined not only by the
interrelationship of the nasal and frontal bones but also by the
presence of the procerus and corrugator muscles and the amount
of subcutaneous fat. During the process of aging, the soft tissues
in the glabella region undergo gradual atrophy, and the high
minihump can arise and sharpen the features of the nasal profile.
To avoid this late sequel, I routinely remove part of the procerus
muscle and subcutaneous fat with Hartmann forceps (Fig. 15.7).
☛ Tip
By determining the NL, we can assess the position of the nasal
tip in relation to the nasal base. It is important to obtain the
correct value. If the upper lip is excessively pouty, the NL will
be smaller than that measured in a person with a similar nose
but a flatter lip. The opposite will occur if the pogonion is a
reference point in a person with a receding chin. The rational
method is to measure the angle between the line connecting
the subnasale and nasal tip and the line perpendicular to the
Frankfurt horizontal, which is the line drawn from the upper
border of the external auditory canal (Fig. 15.4).6 Therefore, it
is important to include the tragus on the lateral photographs.

113
Tip
A
B
C
FIGURE 15.5  Shown is a 23-year-old woman with a prominent tension nose before the rhinoplasty (A) and 2 years after the operation (C). (B) In the center is a computer
simulation of the result if the nasofrontal junction were not deepened during the operation.
FIGURE 15.6  Profile of a 22-year-old woman operated on 2 years ago by another
plastic surgeon. The radix area was left untouched, and her nose still appears very
long.
FIGURE 15.7  Decreasing the bulk of the soft tissues in the glabella region will
reveal the true shape of the bones constituting the nasofrontal junction.

114
SECTION 4    CHAPTER 15  •  Prominent Nose
nasal length is highly influenced by illusion. A deep NF or
obtuse NL creates the appearance of a short nose. The nose
may appear to be long when the NF is shallow and/or the NL
is acute.
Clinical Examples
Short Prominent Nose
Also known as a tension nose, it has an overprojecting dorsum,
which usually forms a hump. The NL is obtuse, and the nasal
spina is frequently overgrown (Fig. 15.10). The rate of functional
problems is high due to the overdevelopment and subsequent
deviation of the septal cartilage. This type of nose is frequently
seen in the people of Latin origin, both in Europe and South
America, and in the Middle East.
Long Prominent Nose
This usually has an arched dorsum, sharp NL, and drooping
tip (Fig. 15.11). Such noses are rather unusual in Northern and
Central Europe, but we see them in those from the Mediter­
ranean region and throughout the Middle East.
Long Nose
Depending on the height of the dorsum in the lateral projection,
this can be a low, long nose (Fig. 15.12) or, when the nose is
long and the tip is overprojecting, it is called a Pinocchio nose
(Fig. 15.13). The most famous person with such a nose was the
French novelist Cyrano de Bergerac (1619–1655), whose long
nose is a documented fact. He is best known as the inspiration
for Edmond Rostand’s famous drama Cyrano de Bergerac.
For routine daily work, I may use calipers (Fig. 15.8), but
for scientific purposes more precise measurements are required.
One of the tools available is the GIMP unix-like free operative
system. Using a measuring tool for distance and angle allows
the program to calculate angles by drawing lines connecting
two points superimposed on the patient’s photograph
(Fig. 15.9).6
Nasal length might be difficult to define if the nose appears
as a direct prolongation of the forehead. Our perception of the
B
A
C
FIGURE 15.9  A 22-year-old woman with a Levantine nose in repose (A), in a smiling sequence (B), and 5 years after septorhinoplasty (C). For scientific purposes, angle
measurement could be performed using the measuring tool in the GIMP program for distance and angle. (After Niechajev, I., 2013. Effect of the depressor septi nasi muscle
on nasal lengthening over time. Aesth. Plast. Surg. 37, 989–992.)
A
B
FIGURE 15.8  Incorrect (A) and correct (B) measurement of the nasolabial angle.

115
Clinical Examples
Rhinomegaly
This is the term describing a nose which is very large in all
dimensions—height, length, and width (Fig. 15.14). If nose is
overly large, it can overwhelm the remaining facial features
and draw unwanted attention from the surrounding persons.
Aging Nose
A loss of tip projection and rotation downward are commonly
seen in the aging population. The skin thickens, and the amount
and size of the sebaceous and sweat glands increase.2 The
cartilaginous third is mobile relative to the rigid bony part of
the nose and tends to drop with the passage of time (Fig. 15.15).
The treatment includes wide undermining of the cutaneous
sleeve and enforcement of the tip projection with the columellar
strut. Thickened and wide nostrils are reduced (Fig. 15.16).7
A prominent nose can, in some patients, be a cause for
offensive comments and nicknames, but in most of them it
just disturbs their own perception of their appearance. As a
group, patients with a large nose are usually grateful because
their desires are clear and their perceived deformity is real.
The key for the successful rhinoplasty is to see what others
do not see and have the ability to modulate and alter various
nasal components and other appropriate facial features
effectively.
A
B
C
D
FIGURE 15.10  Short prominent nose. The patient is a 22-year-old woman of Syrian and Turkish ancestry. (A,C) Before the rhinoplasty and (B,D) 2 years after surgery.
Preoperatively, the nasolabial angle was 95 degrees, with a prominent nasal spine and high, arched nasal dorsum. Postoperatively, undesired downward rotation of the tip at
smile is no longer present after realignment of the nasal structures.

116
SECTION 4    CHAPTER 15  •  Prominent Nose
A
B
C
D
E
F
FIGURE 15.11  Long prominent nose in a 25-year-old Kurd from Iran with rhinomegaly before (A,D), 6 years after (B,E), and 16 years after rhinoplasty (C,F). His nose
became longer, thicker and wider during the passage of time.

117
Clinical Examples
FIGURE 15.12  Long nose, low variant, in a 32-year-old Anatolian Turkish woman.
A
B
FIGURE 15.13  Long nose with an overprojecting tip, so-called Pinocchio nose, in
a 35-year-old Nordic woman before (A) and after (B) the deprojecting procedure
and refinement.
A
B
FIGURE 15.14  Rhinomegaly in 55-year-old man from Iraq of Assyrian ethnicity. His nose was large in all dimensions, and there was also severe septal deviation.

118
SECTION 4    CHAPTER 15  •  Prominent Nose
Secondary rhinoplasty, goal:
to increase tip projection
A
B
C
D
E
FIGURE 15.15  Aging nose in a 63-year-old Kurdish man from Iraq, with thick skin and loss of tip projection. His preoperative nasolabial angle was 70 degrees (A), his
nostrils were very wide, and the severe septal deviation obstructed breathing (B,D). (C,E) Surgery was performed with the open rhinoplasty approach, and the tip was
elevated and stabilized with a 35-mm-long columellar strut. The width of the nasal base and bulk of the alar lobuli were reduced.
Alar lobule
Nostril and alar lobule
FIGURE 15.16  The choice of technique for the alar resection depends on the
patient’s anatomy and aesthetic needs. A smaller width reduction of the alar base can
be done by the ellipsoid skin and subcutis excision in the nasal sill and vestibule.

119
Clinical Examples
References
1.
Niechajev, I., Haraldsson, P.O., 1997. Ethnic profile of patients undergo­
ing aesthetic rhinoplasty in Stockholm. Aesthetic Plast. Surg. 21,
139–145.
2.
Niechajev, I., 2016. Noses of the Middle East: variety of phenotypes
and surgical approaches. J. Craniofac. Surg. 27 (7), 1700–1706.
3.
Tardy, E.M., 1997. Anatomy of changes of ageing and sculpting of
nasal tip. In: Tardy EM. Rhinoplasty: The Art and Science, vol. 1.
Saunders, Philadelphia, pp. 243–250. vol. 2, pp, 526-540.
4.
Peck, G.C., 1990. Broad nasal tip. In: Peck, G.C. (Ed.), Techniques in
Aesthetic Rhinoplasty, second ed. Lippincott, Philadelphia, pp.
137–141.
5.
Gubisch, W., Eichhorn-Sens, J., 2008. The sliding technique: a method
to treat the overprojected nasal tip. Aesthetic Plast. Surg. 32, 772–778.
6.
Niechajev, I., 2012. Effect of the depressor septi nasi muscle on the
nasal lengthening over the time. Aesth Plast Surg 37, 987–992.
7.
Sheen, J.H., Sheen, A.P., 1987. Nostril aesthetics and types of alar
resection. In: Sheen, J.H., Sheen, A.P. (Eds.), Aesthetic Rhinoplasty,
vol. 1, second ed. Mosby, St. Louis, pp. 106–111, pp 254-266.

121
Surgical Preparation and Technique
121
16 
Aesthetic Nasal Tip Surgery
Kirill Pshenisnov MD, PhD
The Clinical Problem (Fig. 16.1)
There is great variance within the accepted norm for nasal tip
appearance. Fat bulbous noses or sharply projecting nose tips
are very complex anatomic structures and require considerable
surgical skill and experience when attempting tip rhinoplasty.
Shaping and final positioning of the nasal tip complex is the
most critical and sophisticated stage of rhinoplasty. Increased
control and predictability are best achieved by preserving the
anatomic structures of the nose and using suturing techniques
that are reversible and incremental. Limiting the use of tip grafts
reduces the incidence of visibility and incongruity that can follow
onlay cartilage grafts and is also consistent with the principles of
modern nondestructive rhinoplasty techniques. However, some
of these well-described maneuvers can still lead to complications.
Synopsis
The ideal nasal cartilage framework associated with acceptable
functional and aesthetic performance includes the following:
1. Stable and symmetric medial crura
2. Good angle of divergence (≈60 degrees)
3. Strong, horizontally oriented, almost flat lateral crura
4. Well-defined tip points (Fig. 16.2)
Surgical Preparation and Technique
Surgical Approaches: Open or Closed
Rhinoplasty
PRINCIPLES
Cartilage, ligaments, vessels, and nerves are to be preserved.
Reducing the nasal tip width usually begins with resection of
the cephalic portion of each lateral crus.
The first cartilage-reshaping suture is between the medial
crura; the second is between the domes (interdomal stitch [IDS]).
The IDS stabilizes the two medial alar cartilages in a well-
defined position, allowing for suture reshaping of the remaining
lateral wings.
A transdomal-defining suture (TDS) reduces flaring of the
lateral crura, creates tip-defining points, and slightly adjusts
tip projection. However, the use of TDS and a dome-spanning
suture can result in convexity of the lateral crura complex,
pinching the tip and narrowing the nasal vestibule. This can
cause breathing problems, especially in patients with thin skin.
Lateral crura struts that were suggested to correct this problem
are now rarely used because they require abutment with the
rim of the piriform aperture1 and can be palpable. Lateral struts
can create beautiful noses, but they are often large, immobile,
and stiff.2
In 2005, we introduced a second interdomal stitch (SIDS) to
refine the tip further into a well-designed, stable, and functional
shape based on modeling the lower lateral cartilages,3 and,
later, on similar techniques as described by Dosanjh et al.4 and
the figure-of-eight suture by Çakir et al.5
OPEN NASAL TIP APPROACH
The open approach is via an inverted V columella and
marginal incisions, with medial superficial musculoapo­
neurotic system (SMAS) preservation as a single unit
of superficial and deep layers. These include columella
vessels and the Pitanguy dermocartilaginous ligament
(Fig. 16.3A).
Long lateral crura, asymmetric domes, and medial crura
are mobilized from the medial SMAS bundle, which has the
points of soft tissue fixation on the upper lip and supratip
break of the nasal dorsum (see Fig. 16.3B). Separate dorsal
hump removal is carried out after elevation of the perichondral-
periosteum flap. A special Pshenisnov clamp is applied on the
septum as a guide for predictable reduction (see Fig. 16.3C).

122
SECTION 4    CHAPTER 16  •  Aesthetic Nasal Tip Surgery
CLOSED RHINOPLASTY TIP TECHNIQUE
This involves the following:
1. Marginal incision with rim flap
2. Intercartilaginous and transfixion incisions with caudal
septum flap
3. Subperichondrial dissection
4. Subtotal lower lateral cartilage mobilization, with
minimal cephalic resection
5. Medial SMAS with Pitanguy dermocartilagenous
ligament (DCL) mobilization
6. Grafts for tip support and modified intertransdomal
suture (MITDS; Figs. 16.5 and 16.6)
7. Caudal septum flap manipulations for tip projection
8. Pitanguy DCL plication in the area of the anterior septal
angle for supratip break formation
Case 16.1. Preoperative Evaluation
(Fig. 16.7)
Nasal Tip.  Wide, slightly bulbous, underrotated prominent
asymmetric tip, deviated to the left, with convex LLC on the
left and slightly concave lateral crus on the right; narrow
interdomal distance
Base of Nose.  Deviated posterior septum; asymmetric nostrils,
wider on the left, hanging alae, with depressed facets
Dorsal Profile.  Elevated, narrow, and deviated to the left; bony
cartilaginous hump, middle vault collapse
Skin Envelope.  Moderate thickness
Preoperative Considerations
Overall, the nose is long, overprojected, and asymmetric due
to septal deviation on the left. The nose should be straightened
and shortened, with conservative hump removal. The nasal
tip must be slightly reduced, medialized, and rotated upward,
with the nostrils opening on the frontal and side views.
Basic Surgical Concepts
The external appearance and function of the tip of the nose
mainly depend on the form of the supportive structures,
including the cartilage and ligaments. The tip to dorsum
relationship and tip to columella contours are important. The
healing process and rehabilitation depend on the extent of soft
tissue trauma.
Management and Preferred Techniques for Framework
1. LLC manipulations, together or separately, with medial
SMAS and caudal septum manipulation
2. Minimal LLC cephalic resections (see Fig. 16.5A)
3. Columellar strut
4. SIDS or its modification—modified IDS (Video 16.1)
5. LLC telescoping, sliding, overlapping, sandwiching
Outcome
The main issue is predicting the result of nasal tip modifications.
The end symmetry of the nasal tip is dependent on internal
healing forces and the resilience of the redesigned structure.
In cases of IDS, I use a continuous single suture between the
The medial SMAS with the Pitanguy ligament is intact (see
Fig. 16.3D).
A double-guard osteotome is used for en bloc osteocarti­
laginous hump removal (see Fig. 16.3E). The hump is removed
(see Fig. 16.3F). Lateral low-to-high percutaneous osteotomies
with a 2-mm chisel are performed. Then, the septoplasty is
completed. The caudal septum strip is excised, and the deviated
central-posterior part of the cartilaginous septum is resected.
The caudal septum is positioned medially and sutured to the
upper anterior nasal spine (Fig. 16.4).
The dorsal septum is straightened (see Fig. 16.3G and H),
and the bony dorsum is rasped. A slight nasal radix area
depression is camouflaged with diced cartilage.
The upper lateral cartilages are used as spreader flaps with
temporary needle approximation, followed by 5-0 PDS mattress
suture fixation (see Fig. 16.3I). The perichondrial-periosteum
flap is sutured back over the reconstructed dorsum (see Fig.
16.3J).
The cephalic margins of the lower lateral cartilage (LLC)
are not trimmed but folded with duplication to strengthen
the lateral crus (see Fig. 16.3K). The moistened cartilage graft
over the depression of the distal part of the upper lateral
cartilage (ULC) is shown on the right of the figure. The colu­
mellar strut between the medial crura and modified IDS is
tightened with an intact medial SMAS, shown with forceps in
Fig. 16.3L.
For tip creation and definition, nasal tip tripod modifications
are carried out with an everted and straightened lateral crus on
the side view (see Fig. 16.3M). The columella–lobular junction
contour is improved by shaving with a no. 15 blade.
Tip positioning uses projection and rotation control sutures
of the medial crus, with a columellar strut to the caudal
septum; However, it would be better to include the caudal
septum in the basal complex via a transfixion incision (see
Fig. 16.4).
FIGURE 16.1  The clinical problem.
Text continued on p. 128

123
Surgical Preparation and Technique
A
B
C
D
FIGURE 16.2  Current etalon appearance of the nasal tip cartilaginous framework after open approach suturing techniques on views from the anterior (A), side (B), bottom
(C), and above (D).

124
SECTION 4    CHAPTER 16  •  Aesthetic Nasal Tip Surgery
A
B
C
D
E
F
G
H
FIGURE 16.3  Intraoperative illustrations. See text for details.

125
Surgical Preparation and Technique
I
J
K
L
M
FIGURE 16.3 cont’d

126
SECTION 4    CHAPTER 16  •  Aesthetic Nasal Tip Surgery
FIGURE 16.4  Rhinoplasty worksheet.
B
A
FIGURE 16.5  Modified intertransdomal suture (MITDS) application
technique. (A) MITDS as two hemitransdomal sutures using one stitch.
(B) Cartilaginous framework modification after stitch tightening.

127
Surgical Preparation and Technique
A
B
C
D
E
F
FIGURE 16.6  Stages of application of the modified intertransdomal suture (MITDS) technique, front and superior views. (A) Lower lateral cartilage mobilization through the
left nostril, with the medial superficial musculoaponeurotic system (SMAS) dissected. (B) Columella strut between the medial crura. (C) MITDS applied, passing the thread
through both cephalic dome segments. (D,E) MITDS tightening. (F) Medial SMAS position.

128
SECTION 4    CHAPTER 16  •  Aesthetic Nasal Tip Surgery
effectiveness of the suture improves if a strut is positioned
between the medial crura, the lateral crura are transected, and
the onlays are sutured together for upward rotation of the
nasal tip. In cases of alar convexity, MITDS serves as a lateral
crus-spanning suture, with a much more predictable outcome.
Adjustment of tip projection and upward rotation with tip
narrowing does not lead to narrowing of the minimal cross
section in the nasal vestibular area.
Postoperative Considerations
Intranasal gauzes are removed the following day. Columellar
sutures are removed on day 5. Intranasal splints and exter­
nal plaster remain until day 12 after surgery. No supratip
edema is observed in the early postoperative period. Figs.
16.9 and 16.10 illustrate 7-month and 2.5-year postoperative
outcomes.
Complications
See Table 16.1.
cephalic dome TDS3 to limit damage to the cartilage. I call this
the MITDS. The newly formed force vector between the upper
dome segments results in the following:
1. Stability of the tip and improved symmetry
2. Dome definition
3. Proper positioning of supratip and infratip break
points
4. Decreased tip width and creation of a tip diamond
5. Ability to manipulate the angle of divergence and domal
angulation
6. Tension force that straightens and strengthens the lateral
crura
7. Prevention of inversion of the lateral crura
8. Opening of external nasal valve
9. Upward tip rotation (Fig. 16.8)
MITDS models the cartilaginous framework, and the nasal
skin is then redraped, thus creating most of the ideal nasal tip
characteristics. MITDS creates a solid architectural matrix, with
well-positioned, tip-defining points (see Fig. 16.8A). After
10 years of experience with MITDS, I have found that the
A
B
C
D
FIGURE 16.7  Preoperative illustrations, standard views.

129
Complications
A
B
C
D
FIGURE 16.8  Cartilaginous framework of the nasal tip in an open approach, with medial superficial musculoaponeurotic system preservation after application of the
modified intertransdomal suture, lateral crus transection, and suturing with a tripod concept. The lateral crura are straightened, thus resulting in their firmness. They are also
everted, creating an opening of the external valve. Shown are front (A), basal (B), superior (C), and lateral (D) views.

130
SECTION 4    CHAPTER 16  •  Aesthetic Nasal Tip Surgery
A
B
C
D
E
FIGURE 16.9  Postoperative 7-month follow-up with no evidence of having had surgery, showing smooth contours of the nose without the stigmata of an open rhinoplasty.

131
Complications
A
B
C
D
E
FIGURE 16.10  Postoperative 2.5-year follow-up.
Table 16.1  Complications and solutions
The problem
Avoiding the problem
Correcting the problem
Extensive narrowing of the nasal tip
Prevent overtightening of the
MITDS
Have appropriate rigid fixation of the columellar
strut between cephalic portions of LLC, with
a good angle of divergence
Supratip Pitanguy DCL edema
Avoid false manipulations with
the Pitanguy DCL
With the DCL, use proper tension and fixation
for supratip break and nasal tip positioning
Deep supratip break
Avoid false manipulations with
the Pitanguy ligament
Use proper mobilization of DCL in a closed
approach
Dorsal irregularity, cephalic cartilage resection,
overtightening of the MITDS
Prevent overtightening of the
MITDS
Shave smooth with no. 15 blade
Asymmetry
View from above to gauge
asymmetry
Improve columellar strut stability and/or
relocate cartilage sutures
DCL, dermocartilagenous ligament; LLC, lower lateral cartilage; MITDS, modified intertransdomal suture.

132
SECTION 4    CHAPTER 16  •  Aesthetic Nasal Tip Surgery
References
1.
Gunter, J.P., Friedman, R.M., 1997. Lateral crural strut graft: technique
and clinical applications in rhinoplasty. Plast. Reconstr. Surg. 99,
943–952.
2.
Calvert, J.W., Patel, A.C., Daniel, R.K., 2014. Reconstructive rhinoplasty:
operative revision of patients with previous autologous costal cartilage
grafts. Plast. Reconstr. Surg. 133, 1087–1096.
3.
Pshenisnov, K.P., Patlazhan, G.I., 2008. Refinements in nasal tip surgery.
In: Eisenmann-Klein, M., Neuhann-Lorenz, C. (Eds.), Innovations in
Plastic and Aesthetic Surgery. Springer-Verlag, Berlin, pp. 292–296.
4.
Dosanjh, A.S., Hsu, C., Gruber, R.P., 2010. The hemitransdomal
suture for narrowing the nasal tip. Ann. Plast. Surg. 64, 708–712.
5.
Çakir, B., Doğan, T., Öreroğlu, A.R., et al., 2013. Rhinoplasty: surface
aesthetics and surgical techniques. Aesthet. Surg. J. 33, 363–375.

133
)
133
17 
Crooked Nose
Charles East MBBS, FRSC
The Clinical Problem (Fig. 17.1)
The deviated nose presents significant problems to the aesthetic
surgeon and is one area in which revisions for residual deviation
or asymmetry are common. Synonyms for the deviated nose
include crooked, S-shaped, and twisted. Deviated noses can
be defined when the nasal axis is displaced from the midline.
Sometimes defining the midline can be a problem, because
more than 90% of patients presenting for rhinoplasty surgery
have some degree of facial asymmetry. It takes a fraction of a
second to scan the face perceptively—starting across the eyes,
passing down the nose to the mouth, and then back up to the
eyes. It is therefore important in an asymmetric face to try and
choose the visual axis that aligns as closely as possible with
the philtrum and the upper dental midline smile.
Deviation of the nasal septum can be the result of develop­
mental deformity. The addition of trauma in the developing
nose or after nasal maturity contributes to displacement of
the septum or outer pyramid. It is important when evaluating
the causation of the deviation to inquire about trauma, even
relatively insignificant trauma in early childhood. Trauma can
occur at birth with septal dislocation, which will spontane­
ously correct in most cases. However, it is often associated
with a posterior septal vomerine spur, which may result in
a displacement from the maxillary crest and a contralateral
caudal septal dislocation from the spine with continued
growth.
The nose develops from a cartilaginous capsule that extends
to the skull base. Subsequent ossification from cranial to
caudal results in the cap of the nasal bones, lateral K area,
and central keystone area. The former equates to the junction
of the quadrilateral cartilage and the perpendicular plate of
the ethmoid, the latter refers to the connection between the
upper lateral cartilage and the nasal bone cap.
Clinical Assessment
EXTERNAL NOSE
■ Upper third—this is predominantly bony, and may be
central, to the left or right format for the lower third.
■ Middle third—the cartilaginous vault may be similarly
described but is more prone to asymmetry or collapse
from loss of height of the septum.
■ The lower third—symmetry determined by the
orientation of the tip cartilages over the septum and
lateral cartilages. It is here that the greatest variability
occurs.
INTERNAL NOSE
Intranasal visualization is essential to understand the problem.
A palpating thumb can push back the nasal tip to expose the
lower septum, and a speculum allows direct viewing of the deep
septum. Ideally, a nasoendoscope is available. This allows for
full determination of nasal septal deformities and nasal valve
function. Palpation of the external nasal pyramid produces
further information, such as the presence of one vertical nasal
bone or one oblique bone. The resilience and support of the tip
cartridges can easily be ascertained. Finally, it is important to
walk around the back of the patient with her or his head tilted
backward to make a final assessment of the axis of the nose.
NASAL SEPTUM
The nasal septum is the key structure in the deviated nose. It
is a supporting structure, particularly for the lower two-thirds
of the nose. Together with the conjoint upper lateral cartilages,
it forms a fixed tripod. Floating over this fixed tripod is the

134
SECTION 4    CHAPTER 17  •  Crooked Nose
so-called floating tripod of the lower lateral (alar) cartilages,
attached by various ligaments. These include the lateral scroll
ligament and interdomal sling, supported by muscular structures
such as the dilator nasi, pyriform ligament, and transversalis
muscles. Without a proper foundation, with a central septum
supported by upper lateral cartilages, there is little hope of
achieving a symmetric and stable nose.
The concepts of septal surgery have evolved considerably
since its first modern description by Cottle. An overriding
principle is that all cartilage anterior to a line drawn through
the nasal spine to the bone and cartilage junction of the central
K area must be preserved (Fig. 17.2). Septal resection, leaving
an L-shaped strut harvested from the nasal septum to support
the nose, can weaken the septum. This is far from ideal because
the least supported and most vulnerable part of the septum
is exposed to the deforming forces of postrhinoplasty wound
healing and any direct trauma. In a personal series of revision
rhinoplasty, a fracture of the L strut was found in nearly 40%
of patients. If a cartilage graft is required, the shape of the
septal resection behind the supporting line should be in an
arch rather than L shape to avoid fracture.1
The key area often overlooked by rhinoplasty surgeons
unfamiliar with the anatomy of the posterior septum is the
chondrovomerine spur, which must be released to allow the
FIGURE 17.1  Preoperative and postoperative views of a nasal septal bend.
Nasal
bone tip
Nasal
spine
Nasal
septum
FIGURE 17.2  Lateral view of the nasal septum, with an imaginary (dashed) line
drawn from the nasal spine to the central K area. All cartilage anterior to this line
must be preserved.
Nasal
septum
Vomer
FIGURE 17.3  Lateral view of the nasal septum. Shown is surgical separation of the
septal cartilage from the vomer and excision of the posterior septal cartilage to
enable mobilization and correction of a straight septum that is angulated from the
midline.
back of the septum to swing back to the midline. Failure to
release this area and the adjacent ethmoid plate results in an
invariable postoperative twist. Many surgeons have blamed
this postoperative complication on so-called cartilage memory,
when actually it is a failure to mobilize and stabilize the posterior
and inferior margins of the quadrilateral cartilage (Figs. 17.3
and 17.4).

135
Surgical Preparation and Technique
osteotomy allows the whole sidewall to be lifted to a more
vertical position. It is then obvious how much excess height
there is on the medial edge of the cut nasal bone.
The upper lateral cartilage is not reduced on the full side but
is turned inward to create an autospreader flap.2 This avoids
the need for septal graft harvest.
The next osteotomy is a faded paramedian on the vertical
side. An additional percutaneous transverse root osteotomy
will allow the central part of the nasal bones and perpen­
dicular plate to move freely across, in either direction, if
required. This now produces an open space on the vertical
side between the nasal bone, upper lateral cartilage, and
septum.
Finally the nasal bones are centralized using percutaneous
lateral and transverse nasal bone osteotomies. The lateral
osteotomy must be absolutely flush with the face of the
maxilla. As this third leaf is moved across, a deficiency in
the height of the nasal bone may be seen. This will require
a stepped or triangular-shaped graft for anterior height to
prevent the caudal septum being pulled back to its original
position.
Case Study
It is very important to fully assess nasal deformity if considering
surgical intervention. In Fig. 17.5A and B, a young woman
with a nasal septum deviation is clearly presenting with a
congenitally bent nose. In addition, there is a dorsal nasal
hump and male tip projection, in part highlighted by a class
2 malocclusion with a small chin projection on the lateral view
correction.
Fig. 17.5C and D show a bird’s eye view of the nose with
the patient on the operating table. The expected correction is
carried out by inserting a Howarth elevator into the right nares
and applying gentle lateral traction.
DORSAL MANAGEMENT AND OSTEOTOMIES
The basic premise to achieve a straight nose has to be a central
nasal septum, with symmetric nasal sidewalls. In correcting a
deviated nose, the greatest deficit always occurs on the more
vertically placed nasal sidewall, particularly distally, where
there is a deficiency in the anterior height of the upper lateral
cartilage.
Surgical Preparation and Technique
Open Rhinoplasty Approach
A standard, faded paramedian osteotomy is carried out on the
oblique side. A percutaneous, lateral, percutaneous low to low
Septal
cartilage
Ethmoid
plate baton
FIGURE 17.4  Angulated septum cartilage is released and held straight with an
ethmoid plate baton.

136
SECTION 4    CHAPTER 17  •  Crooked Nose
A
B
D
E
F
C
FIGURE 17.5  (A,B) Preoperative and postoperative
results from a nasal septum straightening and rhinoplasty.
(C,D) Preoperative and postoperative lateral views of the
same patient. (E) Bird’s eye view showing septal
deviation to the right. (F) Demonstration of passive
correction of the deviation by gently levering the left side
of the nose with an intranasal elevator.
Further Reading
1.
Tebbetts, J.B., 1998. Primary rhinoplasty: a new approach to the logic
and the techniques. Mosby, St. Louis.
References
1.
East, C., Kwame, I., Hannan, S.A., 2016. Revision rhinoplasty: what
can we learn from error patterns? An analysis of revision surgery.
Facial Plast. Surg. 32 (4), 409–415.
2.
Kovacevic, M., Wurm, J., 2015. Spreader flaps for middle vault contour
and stabilization. Facial Plast. Surg. 23, 1–9.

137
Surgical Preparation and Technique
137
18 
The Middle Eastern–Mediterranean Nose
Nazim Çerkeş MD
The Clinical Problem (Fig. 18.1)
The term Middle Eastern commonly refers to people of Turkish,
Persian, Arabic, and North African descent. Although a large
variety of nasal features can be seen, the population in Turkey
usually presents with a mixture of Middle Eastern and Mediter­
ranean nasal morphology.
Synopsis
Middle Eastern–Mediterranean patients possess a varied
combination of nasal characteristics1:
1. There is a significant dorsal hump.
2. A poorly defined nasal tip is present.
3. The nasal bones are usually thick and long.
4. Septal deviation is common and is often visible
externally.
5. The nasal length is often disproportionately long relative
to the tip projection.
6. A droopy nasal tip with an acute columellar-labial angle
is seen frequently.
7. The lower lateral crura and medial crura may be long
and strong. In these cases, the tip complex is usually
displaced caudally, away from the anterior septal angle,
which may need significant maneuvers to improve its
projection and position. Alar flaring and increased
interalar width are also common.
8. Thick nasal skin, with a highly sebaceous texture, is
frequently seen, particularly at the nasal tip, lobule, and
alar rims.
Thorough preoperative analysis and diagnosis of the deformi­
ties are essential for a successful rhinoplasty. After the diagnosis
is determined, the goals of surgery are established, and a
treatment plan is formulated according to the deformities that
are present.
Surgical Preparation and Technique
Reduction of Dorsal Hump
In the vast majority of Middle Eastern–Mediterranean patients,
reduction of a dorsal hump is required. The open rhinoplasty
approach provides better visualization of nasal dorsum anatomy,
including the nasal bones and upper lateral cartilages (ULCs),
and easier execution of maneuvers such as hump removal,
spreader flaps or spreader grafts, osteotomies, and onlay grafts.
I describe a different concept of nasal dorsum dissection the
perichondroperiosteal flap (PPF), and I have used this method
since 2005 in 1800 cases.2
Elevation of the dorsal nasal skin flap is in a supraperichon­
drial plane. A vertical midline incision is performed to the
perichondrium of the medial ULCs, starting from the caudal
border of the nasal bone and extending caudally up to the
anterior septal angle using a No. 15 blade (Fig. 18.2A).
Then, using a semisharp, 2-mm Freer elevator, the peri­
chondrium is elevated on both sides (see Fig. 18.2B). After
elevation of the perichondrium of the ULCs, the periosteal
attachments at the caudal border of the nasal bones are divided
using a sharp tip dissector or a No. 15 blade. The perichondrium
of the ULCs and periosteum of the nasal bone are united,
creating a continuous PPF on both sides (Fig. 18.3).
The ULCs are then separated from the septum. The carti­
laginous hump is reduced incrementally, preserving the ULCs.
A bony hump reduction is performed using a 6-mm straight
osteotome (Fig. 18.4). I avoid using a rasp to reduce a bony
hump due to the risk of damage to the dorsal soft tissues and
cartilages. Incremental resection of the dorsal hump is a very
useful and safe method. It helps avoid excessive reduction
from the dorsum and preserves the ULCs. Most Middle
Eastern–Mediterranean patients request a conservative dorsal
reduction. Excessive hump reduction may produce an ethnic
incongruity.

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SECTION 4    CHAPTER 18  •  The Middle Eastern–Mediterranean Nose
then sutured to the septum,4 using three or four horizontal
mattress sutures (Fig. 18.6). In most primary rhinoplasty cases,
spreader flaps are sufficient for restoring dorsal aesthetic lines
and preserving internal nasal valves. However, in patients with
dorsal deviation or a narrow cartilaginous dorsum, spreader
flaps can be combined with spreader grafts. In these cases,
I place suture spreader grafts about 1 mm below the dorsal
septum and approximate the ULCs on top of the spreader
grafts with sutures (Fig. 18.7). If there is a bony open roof
deformity or irregularities, a thin onlay graft can be added.
Any resected bony hump can be thinned with a blade to less
than 0.5 mm in thickness and replaced between two nasal
bones (Fig. 18.8). Alternatively, a cartilage graft from cephalic
resection of the lower lateral cartilage or a thin crushed
graft from the septum cartilage can be placed to eliminate
the open roof deformity and camouflage any irregularities.
Suturing the PPFs with 5-0 catgut over the graft provides stable
fixation.
I perform osteotomies using 2-mm straight osteotomes (Fig.
18.5). These delicate tools are less traumatic to the adjacent
tissues and produce less swelling compared to the larger
osteotomes. In most patients, I perform a medial oblique
osteotomy. A medial oblique osteotomy helps define the dorsal
aesthetic lines while preserving the nasal bone on the radix
area and helps prevent a rocker deformity.
After completion of a medial oblique osteotomy, low to low
lateral osteotomies are performed internally. Low to low
osteotomies help close any open roof, create a balanced dorsal
aesthetic line, and prevent a lateral bony step-off. In most of
my patients, I perform a transverse osteotomy as a greenstick
fracture, using my thumb. In patients with very thick nasal
bones, a wide bony pyramid, or a deviated bony pyramid, I
perform an external transverse osteotomy using a 2-mm
osteotome.
Spreader flaps are then used to restore the cartilaginous
dorsum.3 The ULCs are used as the flaps are folded in and
A
B
C
FIGURE 18.1  The clinical problem.

139
Surgical Preparation and Technique
caudal septum to the anterior nasal spine is essential for prevent­
ing postoperative dislocations.
Dorsal septal curvatures can be corrected by stenting with
spreader grafts or batten grafts. The spreader grafts can be
placed unilaterally or bilaterally or in an asymmetric fashion
In Middle Eastern–Mediterranean patients, septal deviations
are commonly seen and should be corrected. If the dorsal and/
or caudal portion of the septum cartilage is deviated, a septal
reconstruction should be performed.5 If the caudal septum is
not on the midline, it should be repositioned. Fixation of the
A
B
FIGURE 18.2  (A) A vertical incision is performed to the perichondrium of the upper lateral cartilages on the midline, starting from the caudal border of the nasal bone and
extending caudally up to the anterior septal angle using a No. 15 blade. (B) Using a semisharp, 2-mm Freer elevator, the perichondrium is elevated on both sides.
A
B
FIGURE 18.3  (A) Periosteal attachments at the caudal border of the nasal bones are divided using a sharp tip dissector or a No. 15 blade. The perichondrium of the upper
lateral cartilages and periosteum of the nasal bone are united, creating a continuous perichondroperiosteal flap. (B) Perichondroperiosteal flaps are elevated on both sides.

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SECTION 4    CHAPTER 18  •  The Middle Eastern–Mediterranean Nose
INCREASING TIP PROJECTION AND ADJUSTMENT OF
TIP POSITION
A columellar strut graft is a versatile and powerful tool to
stabilize the columellar base, strengthen the weak medial and
intermediate crura, increase tip projection, and change rotation.
When a considerable increase in tip projection is desired, a
longer and stronger columellar strut should be used and medial
crura advanced onto the strut and held with sutures.
to balance dorsal asymmetries. Caudal septal curvatures can
be corrected using batten grafts from the septum cartilage
or ethmoid bone. If the caudal septum is severely deformed,
it is better to use a caudal septal replacement graft. If the
bony pyramid is deviated, a corrective osteotomy should be
performed.
Nasal Tip
Underdeveloped alar cartilages usually present with a loss of
tip projection and ill-defined nasal tip contours. An ill-defined
nasal tip with overlying thick skin mandates more aggressive
tip modification. In these patients, cartilage grafting is usually
required to increase tip projection and improve tip contours.6
In thick-skinned patients, proper positioning of the nasal tip
relative to dorsal height is essential for preventing postoperative
pollybeak deformity.
A
B
FIGURE 18.4  (A) The bony dorsum is exposed, with elevation of perichondroperiosteal flaps. (B) Bony hump reduction is performed using a 6-mm straight osteotome.
FIGURE 18.5  Medial oblique and lateral osteotomies are performed using a 2-mm
straight osteotome.
FIGURE 18.6  Upper lateral cartilages are folded in and sutured to the septal
cartilage using horizontal mattress sutures.

141
Surgical Preparation and Technique
FIGURE 18.7  Combination of spreader flaps and spreader grafts. The spreader
grafts are placed about 1 mm below the dorsal septum, and the upper lateral
cartilages are approximated on top of the spreader grafts.
A
B
FIGURE 18.8  (A) Following bony hump reduction and osteotomies, the resected bony cup is thinned and placed into the keystone area. (B) Suturing of
perichondroperiosteal flaps provides stabilization of the graft in situ. There is no need for a separate fixation of an onlay keystone graft.
FIGURE 18.9  A strong columellar strut is prepared with lamination of two struts
from the septal cartilage.
Strong columellar strut grafts can be prepared from the
thicker portions of the septal cartilage or lamination of two
struts harvested from septum cartilage side to side suture (Fig.
18.9). If a significant increase of the tip projection is needed,
advancing the lateral crura medially with a spanning suture
(lateral crural steal) and the simultaneous use of a long and
strong columellar strut give consistent results (Fig. 18.10). In
primary patients who do not have thick septal cartilage, and
in secondary rhinoplasty patients without sufficient septal
cartilage, a columellar strut can be fabricated from rib cartilage.
In patients with short medial crura and long lateral crura,
a lateral crural steal procedure is a useful technique that
elongates the medial crura, shortens the lateral crura, and
increases the tip projection. This technique also rotates the
nasal tip upward, augments the infratip lobule, and changes
the infratip lobule angle.7
After placement of the columellar strut, if an additional
increase in tip projection and further refinement is needed, a
tip graft can be used.8 Shield-type tip grafts are particularly

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SECTION 4    CHAPTER 18  •  The Middle Eastern–Mediterranean Nose
and rotation. To maximize stability and avoid asymmetry, it
should be stabilized to the existing dorsal septum with bilateral
spreader grafts.
Then the medial crura are stabilized to the caudal margin
of the graft with tongue in groove sutures to achieve the desired
tip projection and rotation. The tongue in groove technique is
an effective method to adjust tip projection and position. It is
particularly useful in patients with a long septum. In this
technique, the first sutures are passed through the medial crura
and caudal septum to judge the position of the tip. The medial
crura are fixated to the septum in tongue in groove fashion,
with through and through horizontal mattress sutures (Fig.
18.12). If the septum cartilage is not long enough, a caudal
septal extension graft can be placed and stabilized with bilateral
extended spreader grafts. The medial crura are fixated to the
caudal septal extension graft using tongue in groove fashion
sutures to adjust tip position and projection.
ELONGATION OF SHORT ALAR CARTILAGES
Short alar cartilages usually present with decreased tip projec­
tion and ill-defined nasal tip contours. They must be elongated
with cartilage grafts.10
In patients with a short alar cartilage, the lateral crural steal
technique and advancement of the medial crura onto a columel­
lar strut can be used to elongate the medial crura and increase
tip projection. However, this maneuver may further shorten
and weaken the lateral crura. In this case, the lateral crura can
be divided from the accessory cartilages and advanced medially;
a lateral crural graft is then placed between the lateral crura
and accessory cartilage to bridge the gap and reconstitute a
stable nasal tip tripod.6 With this method, both medial and
lateral crura are elongated, and the tip framework is strength­
ened (Fig. 18.13).
useful in patients with a short infratip lobule and in secondary
cases (Fig. 18.11).
A caudal septal extension graft is a rectangular cartilage
extended onto the caudal septum and sutured between the
medial crura.9 It is a useful method for increasing tip projection
A
B
FIGURE 18.10  (A) If a significant increase of the tip projection is needed, lateral crura can be advanced medially with a spanning sutures to elongate the medial crura.
This technique is termed lateral crural steal. (B) Simultaneous use of a long and strong columellar strut with lateral crural steal gives consistent results.
FIGURE 18.11  A shield-shaped tip graft is placed to increase tip projection and
elongate the short infratip lobule.

143
Surgical Preparation and Technique
improves the proportions among the parts of the nose. In many
patients, a combination of alar base and nostril sill excision,
in varying proportions, depending on the degree of excess, is
required. To minimize visibility of a scar, the excision should
be planned just above the crease (Fig. 18.14).
Alar Base
In Middle Eastern–Mediterranean patients, an increased interalar
width and alar flaring are common. In patients with an increased
interalar width, the alar rims are outside the medial canthal
line. In these patients, excision from the nostril sills will correct
alar flaring and shorten the interalar width. When the alar
bases are wide, a wedge resection from the alar base can be
performed. This maneuver reduces wide alar bases and
A
B
FIGURE 18.12  (A) The tongue in groove technique is an effective method in adjustment of tip projection and position. In this technique, a needle is first passed through
the medial crura and caudal septum to judge the position of the tip. (B) Then the medial crura are fixated to the septum in tongue in groove fashion with through and
through horizontal mattress sutures.
FIGURE 18.13  After lateral crural steal and advancement of the medial crura onto
a columellar strut, a lateral crural graft is placed between the lateral crura and
accessory cartilage to bridge the gap and reconstitute a stable nasal tip tripod.
FIGURE 18.14  In patients with a wide alar base, a wedge resection reduces the
wide alar base and improves the proportion between the parts of the nose.

144
SECTION 4    CHAPTER 18  •  The Middle Eastern–Mediterranean Nose
A
B
C
D
FIGURE 18.15  A 31-year-old patient presented with a dorsal hump and an underprojected and drooping nasal tip. She had a broad bony vault, deviated septum, and alar
flaring.
Case Study
A 31-year-old patient presented with a dorsal hump and
underprojected and drooping nasal tip. She had a broad bony
vault and deviated septum. The medial crura were short, the
lateral crura were weak, and the alar rims were retracted and
not well supported (Fig. 18.15).
Using the open technique described, the nasal dorsum and
nasal tip were exposed. After septoplasty and harvesting of
the septal cartilage, the bony and cartilaginous humps were
removed. Medial oblique and low to low lateral osteotomies
were performed. Spreader flaps were used to reestablish the
cartilaginous dorsum and dorsal width. Lateral crura were
advanced 3 mm medially with spanning sutures (lateral crural
steal). The medial crura were fixated to the caudal septum

145
Surgical Preparation and Technique
A
B
C
D
FIGURE 18.16  The patient from Fig. 18.15 is shown 1 year postoperatively. The dorsal hump was removed, tip projection was increased, and the tip was rotated. The short
medial crura are lengthened, the nasal tip is well supported, and alar rim retraction was corrected. Alar flaring was corrected, and the interalar distance was shortened.
The patient is shown 1 year postoperatively in Fig. 18.16.
The dorsal hump was removed, tip projection increased, and
the tip was rotated. The short medial crura were lengthened,
the nasal tip was well supported, and the alar rim retraction
was corrected. Alar flaring was corrected, and the interalar
distance was shortened.
with a tongue in groove suture to rotate the nasal tip and
increase tip projection. A thin columellar strut was placed
between the medial crura to stabilize the medial crura. Lateral
crural grafts were prepared from the harvested septum cartilage
and were placed underneath the lateral crura to reconstitute
a stable nasal tip tripod. Wedge resection from the alar bases
and nostril sills was performed to correct alar flaring and shorten
the interalar distance.

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SECTION 4    CHAPTER 18  •  The Middle Eastern–Mediterranean Nose
6.
Cerkes, N., 2014. Structural grafting of the nasal tip. In: Rohrich, R.J.,
Adams, W.P., Jr., Ahmad, J. (Eds.), Dallas Rhinoplasty: Nasal Surgery
by the Masters, third ed. Quality Medical Publishing/CRC Press, St.
Louis/Boca Raton, FL, pp. 395–433.
7.
Kridel, R.W.H., Konior, R.J., Shumrick, K.A., et al., 1989. Advances
in nasal tip surgery: the lateral crural steal. Arch. Otolaryngol. Head
Neck Surg. 115, 1206–1212.
8.
Sheen, J.H., 1975. Achieving more nasal tip projection by the use of
of a small autogenous vomer or septal cartilage graft. A preliminary
report. Plast. Reconstr. Surg. 56, 35–40.
9.
Byrd, S., Andodochick, S., Copit, S., Walton, K.G., 1997. Septal extension
grafts: a method of controlling tip projection, rotation and shape.
Plast. Reconstr. Surg. 100, 999–1010.
10.
Gunter, J.P., Freidman, R.M., 1997. Lateral crural strut graft: technique
and clinical applications in rhinoplasty. Plast. Reconstr. Surg. 99,
943–952.
References
1.
Rohrich, R.J., Ghavami, A., 2014. The Middle Eastern nose. In: Rohrich,
R.J., Adams, W.P., Jr., Ahmad, J. (Eds.), Dallas Rhinoplasty: Nasal
Surgery by the Masters, third ed. Quality Medical Publishing/CRC
Press, St. Louis/Boca Raton, FL, pp. 1195–1223.
2.
Cerkes, N., 2013. Concurrent elevation of upper lateral cartilage
perichondrium and nasal bone periosteum: the perichondro-periosteal
flap. Aesthetic Surg. J. 33, 899–914.
3.
Seyhan, A., 1997. Method for middle vault reconstruction in primary
rhinoplasty: upper lateral cartilage bending. Plast. Reconstr. Surg.
100, 1941–1943.
4.
Sheen, J.H., 1984. Spreader graft: a method of reconstructing the roof
of the middle nasal vault following rhinoplasty. Plast. Reconstr. Surg.
73, 230–239.
5.
Cerkes, N., 2011. The crooked nose: principles of treatment. Aesthetic
Surg. J. 31, 241–257.

147
Surgical Preparation and Technique
147
19 
The Asian Rhinoplasty
Naoyuki Ohtake MD, PhD
Kazunari Karahashi MD
Nobuyuki Shioya MD, FACS
The Clinical Problem
In recent years, young Asian women have often described
their ideal nose as having a thin, gentle lateral curve and a
slightly upward nasal tip. They also desire a narrower tip and
ala than their present nose. Generally, the nasal tip is round
and the skin is thick in Asians, especially in northeastern Asians.
In addition to this, the most significant point is the lower part
of the nose.
Surgical Preparation and Technique
Augmentation of Dorsum Nasi
Many Asians have an inferiority complex about their physical
characteristics in comparison to Westerners, typically because
of their flat noses. In a clinical setting, patients hesitate to
choose foreign materials such as silicone due to media bias.
Foreign material implantation is commonly used in Asian noses
to augment the profile.
SILICONE IMPLANT
The design and customized carving of a silicone block is one
of the most important processes for making the desired profile
shape of the nose. It is not so complicated to incise from the
nostril to make a pocket on the dorsum of nose for implantation.
An implant that has an I-shaped implant solely on the dorsum
of the nose is relatively stable when it is implanted. However,
the implant that has an L-shaped strut implant that underlies
the subcutaneous tissue of the nasal tip tends to increases the
risk of complications (Fig. 19.1).
AUTOGRAFTING THE DORSUM OF THE NOSE
Autografts are harvested from various donor sites and include
cartilage, dermofat, and fascia. These grafts have their advan­
tages and disadvantages.
Cartilage grafting
Costal cartilage grafting.  We frequently use costal cartilage for
posttraumatic reconstruction surgery. This can be collected in
large amounts and processed easily.
Ear cartilage grafting.  Ear cartilage is collected from the back of
the ear to avoid auricular deformity. Although it is difficult to
collect long, linear strips of cartilage for augmentation of the
entire dorsal back of the nose, multiple strips of cartilage are
combined to offset the wavy configuration. These cartilage
grafts should be placed linearly anteriorly and laterally, adapt­
able to any uneven contours of the dorsum nasi. We combine
two pieces of these grafts. Absorption of the graft remains a
problem, however, and fine surgical manipulations are required
(Fig. 19.2).
Dermofat grafting
Dermofat grafting is highly significant for the restoration of
subcutaneous soft tissues at the back of the nose because of
its high bioavailability. However, the supportability is poor
when an excess amount is used. This is probably beneficial
for patients with subcutaneous soft tissue damage (e.g., a history
of long-term implantation of foreign materials) and patients
with skin thinning due to aging.
Fascia grafting
The fascia is not thick and is predominantly used in combination
with other graft materials according to the requirements of
augmentation and restoration. When grafting cartilages alone,
late complications include palpable grafted cartilages and visibly

148
SECTION 4    CHAPTER 19  •  The Asian Rhinoplasty
apparent edges associated with thinning of the skin and
subcutaneous tissues. The combination of multiple fascial grafts
is effective for prevention. The concomitant use of multiple
fascial grafts is also effective for the prevention of the so-called
warping deformity.
Temporal fascia is frequently used as a donor site. When it
is used with cartilage, this works as a wrapping and prevents
spontaneous absorption of the cartilage.
FIGURE 19.1  L-shaped silicone implant.
C
B
A
FIGURE 19.2  Ear cartilage grafting. (A) Ear cartilage is collected from the back of the ear. (B) Processing of the collected ear cartilage. (C) Combining the two pieces of
the processed cartilage.
Nasal Tip Surgery
NARROWING OF THE NASAL TIP TO THE BACK
OF THE NOSE
This is a method that was developed in the 19th century by
Joseph. This procedure, which resects the medial aspect of the
lateral crus, has been used until recently. A noncartilage region
between the lower lateral cartilage (LLC) and upper lateral
cartilages (ULCs) and the central crus is shifted posterosupe­
riorly. This is effective when performed concurrently with the
technique described above (Fig. 19.3).
EXTENSION AND AUGMENTATION OF THE NASAL TIP
Although it is effective just to narrow the round nasal tip,
it is necessary to add certain tissues to extend the nasal tip
and entire length of the nose. Two to three pieces of ear
cartilage grafts are layered and placed in the nasal tip. The
risk of graft displacement should be considered. Therefore,
we believe it to be necessary to use cartilage grafts for basic
structural support and then cover the nasal tip with flexible
soft tissues as a subcutaneous pad. In extreme cases that
require further extension, it may be effective to add car­
tilage graft to the anterior rim of the nasal septal cartilage
(Fig. 19.4).

149
Surgical Preparation and Technique
above the anterior nasal spine for augmentation to expand
the angle.
ALAR BASE PLASTY
Joseph developed the original method that was applied to
African Americans, and the technique reported by Furukawa
became popular in Japan after several modifications. Furukawa
introduced the nasal index, or the width-to-height ratio; the
ideal for Japanese people is between 0.6 and 0.7.
Although surgical scars are more likely to be visible in Asians,
the scar should be along the junction of the alar base and the
nostril floor (Fig. 19.5).
ENHANCEMENT OF THE COLUMELLA
Cartilage is grafted between the right and left medial crus of
the LLC in the columella. Its main purpose is to enhance the
columella. This technique is significant as a supplement for
the technique used in the narrowing procedure but is extremely
ineffective in terms of augmentation.
For the expansion and reduction of the nasolabial angle
in patients with well-developed nasal septal cartilage, and
for dulling the nasolabial angle, it is effective to resect the
anterior rim of the nasal septal cartilage and the bone of the
anterior nasal spine. In patients with perpendicular or sharper
angles, cartilage and soft tissue grafts are filled into the area
B
A
D
C
FIGURE 19.3  Narrowing of the nasal tip to the back of the nose. (A,B) Partial resection of the lower lateral cartilage. (C) Preoperative view. (D) Postoperative view.

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SECTION 4    CHAPTER 19  •  The Asian Rhinoplasty
inflammation can be improved with antibiotics, there is little
chance of a permanent cure. The ideal treatment includes
removing the implant, washing the inner cavity sufficiently
to draw out the infection, and delaying another rhinoplasty
(Fig. 19.6).
DISPLACEMENT
There are patients in whom the implant is displaced from the
center line after surgery, appearing as a deviated nasal deformity.
Although this may be caused by the augmentation, there are
many cases when it is caused by the original deviated nose.
Complications
Complications Associated with Silicone
Implants
INFECTION
Diagnosis of infection is not difficult because the entire external
nose will redden and swell, and the patient will experience
pain. Fearing that the implant will be removed, most patients
visit the hospital after the condition becomes severe. Although
A
C
D
B
FIGURE 19.4  Extension and augmentation of the nasal tip. Frontal views—preoperative (A) and postoperative (B). Profile views—preoperative (C) and postoperative (D).

151
Secondary Rhinoplasty
Complications Associated with
Cartilage Grafting
WARPING
Warping is considered to originate from the layer structure of
the cartilage. To avoid this, the layers of the cartilage must be
symmetrically shaped. When a large block is available, it is
best divided into two or three longitudinal layers and recon­
nected together to get rid of the deformity and maintain the
desired shape.
WAVING
This complication often occurs when elastic cartilage, such as
auricular cartilage and septal nasal cartilage, is used. It can be
avoided by making an incision while processing the cartilage,
crushing it to correct the deformity, trimming it, and checking
that the linearity with the plain surface is smooth before it is
inserted into the nose.
REABSORPTION
Although the quantity of cartilage is maintained, even in a
relatively ischemic environment, some reabsorption is inevitable.
Additionally, because absorption does not occur evenly, the
resultant deformity appears as an asymmetric curve or irregular
surface. Resorption cannot be avoided completely in a transplant
of cartilage alone. Using the cartilage as a pillar to maintain
volume, it is necessary to combine fascia or dermal fat to
minimize the appearance of absorption deformation.
Secondary Rhinoplasty
There is no standard surgery method chosen for a secondary
rhinoplasty. It must be decided on a case-by-case basis, depend­
ing on the degree of complications and the patient’s social
background, age, and psychological state.
The framework that becomes the pillar of the nose and
supplementary subcutaneous soft tissue must be considered
for any correction of nose tip deformation. In some cases, skin
reconstruction may also have to be considered. For these reasons,
multiple revision surgeries may become necessary.
MOBILITY
This is a condition in which the implant is not inserted correctly
into the subperiosteal pocket, making the cephalad implant
position between the brows unstable, especially when the tip
of the nose is shaken from side to side. The only way to fix
this condition is another surgery to relocate the implant under
the periosteum.
EROSION, IMPLANT EXPOSURE, AND EXTRUSION
These complications may occur due to oversized implants or
untreated infections. It is most likely to happen at the tip of
the nose, but also rarely appears at the nasal dorsum, between
the brows, and inside the nasal cavity. Although erosion closes
naturally when the extruding implant is removed, there will
be a contracture along the implant space. Once this occurs, a
large deformation cannot be avoided (Fig. 19.7A–C).
A
B
FIGURE 19.5  Alar base plasty. (A) Preoperative view. (B) Postoperative view.
FIGURE 19.6  Implant infection.