Nasal deformities

Atlas Oral Maxillofacial Surg Clin N Am 12 (2004) 31–74

Nasal deformities John E. Griffin, Jr, DMD*, Ron Caloss, DDS, MD Facial Cosmetic and Reconstructive Surgery, Baptist Memorial Hospital, 300 Hospital Drive, Columbus, MS 39701, USA

Rhinoplasty is arguably the most challenging facial esthetic procedure. Success starts with properly assessing the surface features of the nose. One must have an appreciation for the underlying anatomic components that contribute to surface deformity and know the appropriate surgical maneuvers to alter the anatomy. One also must understand the dynamics of healing and its effect on long-term stability. Several objectives must be met to ensure success. The surgeon must strive to create a natural appearing nasal contour that is consistent with the patient’s desires. It is important to achieve balance among the upper, middle, and lower thirds of the nose and the surrounding facial features. The procedure also must preserve or improve the nose’s vital respiratory function.

Anatomy and analysis Knowledge of nasal anatomy and the specific effects of surgical manipulation on its form and function is essential. Equally important is an appreciation of fact that nasal anatomy can have significant variation among individuals. The external nose can be divided into the bony nasal pyramid, the cartilaginous nasal pyramid, and the nasal tip. Other anatomic components include the skin, septum, and turbinates. Bony pyramid Paired nasal bones and the frontal processes of the maxilla make up the upper third of the nose. Most of the bony sidewall is composed of the maxillary component. The nasal bones average 25 mm in length. The cephalic edges, which articulate with the frontal bone, are much thicker than the caudal edge, which overlaps the upper lateral cartilages. The nasal bones join in the midline to the underlying perpendicular plate of the ethmoid bone. Nasion is the point of junction between the nasal bones and frontal bone and should be approximately 6 mm above the intercanthal line. The radix is the deepest depression of the root of the nose and often is used synonymously with nasion (Fig. 1). The bony pyramid forms the main structural base for the nose with its cantilevered upper lateral cartilages. When osteotomies are considered, one must assess the size and shape of bony skeleton; a small bony arch is less likely to provide adequate support for proper form and function once weakened by osteotomies.

* Corresponding author. E-mail address: [email protected] (J.E. Griffin, Jr.). 1061-3315/04/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.cxom.2003.10.003

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Fig. 1. Nasal anatomy. (From Staffel JG. Basic principles of rhinoplasty. San Antonio: University of Texas Health Science Center at San Antonio; 1996; with permission.)

Cartilaginous pyramid The paired triangular-shaped upper lateral cartilages form the middle third of the nose. They extend as a cantilever from the caudal aspect of the bony pyramid. Rhinion is the midline point of junction between the nasal bones and upper lateral cartilages (see Fig. 1). The upper lateral cartilages fuse in the midline with the dorsal border of the septal cartilage and provide stability for a functionally important area of the nose (Fig. 2). Disrupting their attachment to the septum is sometimes necessary to straighten a crooked nose or reduce a dorsal hump deformity. When detachment is anticipated, one must assess the internal nasal valve area preoperatively. The internal nasal valve is formed by the caudal edge of the upper lateral cartilages, the septum, and the nasal floor. Osteotomy to close an open roof after hump removal can narrow the valve and cause substantial restriction on inspiration. If the angle between the upper lateral cartilage and the septum is less than 10, the nasal valve potentially will be

Fig. 2. Upper lateral cartilages fuse with dorsal septum. (From Staffel JG. Basic principles of rhinoplasty. San Antonio: University of Texas Health Science Center at San Antonio; 1996; with permission.)

Fig. 3. A smooth, unbroken esthetic line runs from the brow along the lateral edge of the dorsum and diverges slightly at the tip, where light reflexes are present over domes. (From Staffel JG. Basic principles of rhinoplasty. San Antonio: University of Texas Health Science Center at San Antonio; 1996; with permission.)

Fig. 4. Disrupted smooth esthetic line caused by disarticulated upper lateral cartilage. (From Staffel JG. Basic principles of rhinoplasty. San Antonio: University of Texas Health Science Center at San Antonio, 1996; with permission.)

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Fig. 5. Low radix disproportion caused by a relative underprojection of the upper third of the nose. (From Staffel JG. Basic principles of rhinoplasty. San Antonio: University of Texas Health Science Center at San Antonio, 1996; with permission.)

Fig. 6. Lower lateral (alar) cartilages are composed of the medial, middle, and lateral crura. (From Staffel JG. Basic principles of rhinoplasty. San Antonio: University of Texas Health Science Center at San Antonio, 1996; with permission.)

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Fig. 7. The domes are the most projecting part of the lower lateral cartilages. (From Staffel JG. Basic principles of rhinoplasty. San Antonio: University of Texas Health Science Center at San Antonio, 1996; with permission.)

nonfunctional because of lateral wall collapse against the septum on inspiration. The use of spreader grafts to maintain a functional nasal valve is discussed later. They should be considered for use with any nose predisposed to middle vault collapse, specifically those with short nasal bones, thin skin, or weak cartilages.

Fig. 8. The scroll is the fibrous attachment of the upper and lower lateral cartilages. (From Staffel JG. Basic principles of rhinoplasty. San Antonio: University of Texas Health Science Center at San Antonio, 1996; with permission.)

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Fig. 9. (A) Esthetic triangular tip. (B) Bulbous trapezoidal tip. (From Staffel JG. Basic principles of rhinoplasty. San Antonio: University of Texas Health Science Center at San Antonio, 1996; with permission.)

In frontal view, the dorsum should be of sufficient height to create a distinct anatomic separation of the eyes and give a third dimension to midface. A smooth, unbroken esthetic line should run from the brow along the lateral edge of the dorsum and diverge slightly at the tip (Fig. 3). Disarticulation of the upper lateral cartilages or fracture of the nasal bones can disrupt this smooth transition between the upper, middle, and lower thirds of the nose (Fig. 4). In a deviated nose, the nasal bones and upper lateral cartilages point in the same direction. In a twisted nose, the nasal bones deviate in one direction and the upper lateral cartilages return toward the midline. In profile, the nasal bridge starts at the radix, which ideally is at the level of the supratarsal crease. The bridge should descend in a relatively straight line to the supratip break, which provides a transition to the nasal tip. When assessing dorsal profile, it is important to

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Fig. 10. The alar base width should equal intercanthal distance. (From Staffel JG. Basic principles of rhinoplasty. University of Texas Health Science Center at San Antonio, 1996; with permission.)

differentiate between a dorsal hump deformity and low radix disproportion. A dorsal hump is caused by bony and cartilaginous excess over the upper and middle third. The cartilaginous dorsum makes up most of the hump in most noses. A hump is a masculine trait, so a man can look good with a slight rhinion hump. Even a slight hump is an unattractive feature for women, however. A low radix disproportion is secondary to a relative underprojection of the upper third of the nose. The nose appears bottom-heavy. The radix is positioned below the ideal level of the supratarsal crease (Fig. 5). Correction requires augmentation of the radix area before addressing a dorsal hump so as not to overreduce the hump deformity. Nasal tip The nasal tip is the most complex anatomic area of the nose. Paired lower lateral (alar) cartilages that are composed of medial, middle, and lateral crura form the skeletal support (Fig. 6). The medial crura are contained within the columella and form a supportive pillar for the nasal base. The medial crura extend to the apex of the nostril and are important in establishing good nostril-lobular proportion, which should be approximately 1:1 to 2:1. The middle crura diverge from the columella and terminate at the domes, which are the most projecting part of the lower lateral cartilage (Fig. 7). The middle crura lateral angulation (angle of divergence) and cephalic angulation (angle of rotation) impact lobule shape. They are ideally 60 and 50, respectively. The angle of divergence determines the intercrural distance and light reflexes over the domes. The angle of rotation along with the length of the crura impact tip contour and nostril-lobular proportion. The soft-tissue triangle facets are the areas just caudal to the domes. Incisions should not extend into these areas because they may lead to scar contracture and deformity of the facets.

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Fig. 11. (A) Normal pear-shaped nostrils. (B) Asymmetric nostrils caused by dislocation of the caudal septum. (From Staffel JG. Basic principles of rhinoplasty. San Antonio: University of Texas Health Science Center at San Antonio, 1996; with permission.)

The lateral crura initially parallel the alar rim before they obliquely angle in a posterocephalad direction toward the piriform rims. The cephalic edge overlaps the upper lateral cartilage and forms a fibrous attachment, known as the scroll (Fig. 8). Large convex lateral crura can lead to a bulbous nasal tip. Cephalic trimming can produce a narrower, more

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Fig. 12. ‘‘Seagull in flight’’ alar-columellar margin. (From Staffel JG. Basic principles of rhinoplasty. San Antonio: University of Texas Health Science Center at San Antonio, 1996; with permission.)

refined tip. Methodic observation of the nasal tip’s surface anatomy and envisioning the specific and unique dimensions of the underlying cartilage are prerequisites to performing the appropriate surgical modification. It is also necessary to think in terms of proportion and balance instead of specific numbers or ratios, although the latter may guide analysis.

Fig. 13. Refined tip characteristics on lateral view. (From Staffel JG. Basic principles of rhinoplasty. San Antonio: University of Texas Health Science Center at San Antonio, 1996; with permission.)

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Fig. 14. Normal alar–columellar relationship with the rim 2 to 3 mm above the columella. (From Staffel JG. Basic principles of rhinoplasty. San Antonio: University of Texas Health Science Center at San Antonio, 1996; with permission.)

On basal view, the tip should be triangular in shape. A bulbous tip is trapezoidal (Fig. 9). The alar base width should be within 1 to 2 mm of the intercanthal distance (Fig. 10). Nostrils should be pear-shaped. Asymmetric nostrils are usually caused by dislocation of the caudal septum off the premaxillary spine (Fig. 11). On frontal view, one should assess the general morphology of the tip. A bulbous tip is caused by large lateral crura or domes that are too wide. The smooth outline that runs from the brow

Fig. 15. Septal anatomy. (From Staffel JG. Basic principles of rhinoplasty. San Antonio: University of Texas Health Science Center at San Antonio, 1996; with permission.)

Fig. 16. Open approach is performed via bilateral marginal incisions and a transcolumellar incision.

Fig. 17. Supraperichondrial dissection over the alar cartilage. (From Staffel JG. Basic principles of rhinoplasty. San Antonio: University of Texas Health Science Center at San Antonio, 1996; with permission.)

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Fig. 18. Transcolumellar incision (A) and dissection (B) between skin and medial crura. (From Staffel JG. Basic principles of rhinoplasty. San Antonio: University of Texas Health Science Center at San Antonio, 1996; with permission.)

along the lateral edge of the dorsum should diverge at the tip; the end points appear as light reflexes over the domes of the lower lateral cartilage. A third light reflex should be seen in the center of the arch of the line that joins the domes (see Fig. 3). The alar-columellar margin forms a gentle ‘‘seagull in flight’’ outline (Fig. 12). On lateral view, a refined tip has a characteristic double break (Fig. 13). The supratip break occurs where the dorsum ends and the tip begins, normally 1 to 3 mm above the most distal part of the tip or the tip-defining point. The tip should be the highest point in profile. An infratip break occurs at the junction of infratip lobule and columella, softly differentiating the two. The tip should have appropriate projection and rotation; specific measurements are of little use clinically. A well-projected tip is one that is in balance with the dorsum and face as a whole. A ptotic tip has poor projection or rotation. One must keep in mind that a poorly projected tip can give the illusion of a dorsal convexity or hump. On lateral view, the alar rim should be 2 to 3 mm above the columella (Fig. 14). The long axis of the nostril rim should be 10 to 30 above the Frankfort plane and in harmony with the columella. A hanging columella defect is secondary to excess caudal septum or convex medial crura. Excessive caudal septum also may contribute to a wide nasolabial angle.

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Fig. 19. Tension–counter tension aids in supraperichondrial dissection over the domes and columellar flap. (From Staffel JG. Basic principles of rhinoplasty. San Antonio: University of Texas Health Science Center at San Antonio, 1996; with permission.)

Tip-supporting mechanisms are important to understand and appreciate. There are three major support mechanisms: (1) the size and shape of the lower lateral cartilages, (2) the medial crural feet attachment to the caudal septum, and (3) the attachment of the upper and lower lateral cartilages (the scroll). Other support mechanisms include the nasal spine, superior septal angle, interdomal ligament, and overlying soft-tissue envelope. Skin The soft-tissue envelope thickness is an important consideration in rhinoplasty. Thick skin obscures the surface anatomy and makes definition and angularity harder to achieve. It also does not contract well and holds edema for a prolonged period. Surface definition must be achieved by adding structural elements, such as tip grafts, to place the skin under stretch. Conversely, thin skin reveals every anatomic detail of the underlying skeleton. Great care must be taken to avoid sharp edges and soften contours with filler grafts. A soft-tissue envelope is ideally in the middle of the spectrum: thick enough to camouflage minor irregularities yet thin enough to lead to noticeable changes in contour and heal quickly with less edema. Another important consideration is the fact that skin is thinnest over rhinion. Dorsal reduction must be performed more judiciously in this area because the overlying thin soft-tissue envelope makes change more obvious. Any contour irregularity also is more evident. Septum and turbinates The septum is composed primarily of the perpendicular plate of the ethmoid, vomer, and quadrangular cartilage. They are transposed on either side by mucoperiosteal and

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Fig. 20. Subperiosteal dissection over nasal bones with an elevator. (From Staffel JG. Basic principles of rhinoplasty. San Antonio: University of Texas Health Science Center at San Antonio, 1996; with permission.)

mucoperichondreal flaps (Fig. 15). The septum is a key support mechanism of the lower two thirds of the nose and a frequent donor site in rhinoplasty. The distribution of each septal component can vary, and occasionally minimal cartilage may be present. Cartilage thickness also varies; it is thickest at the osteocartilaginous junction, whereas more anteriorly it can be thin. When the septum is considered as a donor site, evaluation of the distribution and substance of the septal components is important. Septal deviation is common and accounts for most nasal obstruction. Posttraumatic deformities can be difficult to correct because of scarring and calcification, which make dissection and resection more difficult. Obstruction can be caused by anterior cartilaginous or posterior bony deviation. Posterior deformities more frequently go uncorrected after septoplasty, which is the result of more limited access and greater difficulty in dissecting and extracting tissue without shredding the mucosal covering. There are three pairs of turbinates: superior, middle, and inferior. They provide a large surface area for temperature and humidity regulation of inspired air. The inferior turbinate responds to various environmental stimulants by hypertrophy. An obstructing turbinate cannot function properly, which leads to chronic hypertrophy and eventual hyperplasia. When indicated, partial resection of the inferior turbinate can prevent this pathophysiologic response.

Approaches There are two approaches to the nasal skeleton: external (open) and endonasal (closed). The technique used depends on the deformity and the knowledge and skill of the surgeon. The external approach provides maximal exposure for more difficult cases that involve extensive tip work, cleft lip and palate, severe posttraumatic deformities, rhinoplasty in non-white persons, or

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Fig. 21. Bilateral intercartilaginous (above) and marginal (below) incisions and a transfixion (above left) incision for delivery of the lower lateral cartilages.

select cases of secondary rhinoplasty. The main disadvantage is increased operating time and potential for a noticeable transcolumellar scar. The endonasal approach is less time consuming, minimizes scar contracture, and avoids a transcolumellar incision. There is more limited exposure compared with the open approach, however. External approach The open approach uses bilateral marginal incisions that extend along the caudal aspect of the lower lateral cartilages and a transcolumellar incision (Fig. 16). The alar rim is retracted with a double hook, and the caudal aspect of the lateral crus is identified with a blunt instrument. One must remember that laterally the cartilage obliquely angles in a posterocephalad direction toward the piriform rims. A #15 blade is used to incise the mucosa along the caudal aspect of the cartilage all the way to the domes. Dissection proceeds over the superficial side of the lateral crura in a supraperichondrial plane using converse scissors (Fig. 17). The marginal incision on each side is then extended from the dome along the middle and medial crura to the midcolumella. Care must be taken to avoid incising into the skin of softtissue triangle overlying the dome to prevent distortion caused by scar contracture. Care also must be taken to avoid transecting the caudal aspect of the medial crura, which lie beneath a thin mucosa. An inverted V transcolumellar incision is made through skin using a fine sawing motion with the tip of a #11 blade; care is taken not to bevel the incision or damage the medial crura. The inverted V helps realign the columellar flap when closing and camouflage the scar.

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Fig. 22. Intercartilaginous incision made over the caudal reflection of the upper lateral cartilage extending medially to the nasal valve. (From Staffel JG. Basic principles of rhinoplasty. San Antonio: University of Texas Health Science Center at San Antonio, 1996; with permission.)

This incision joins the marginal incisions on each side. Converse scissors are advanced across the columella between skin and the medial crura. Any remaining soft-tissue attachments across the transcolumellar incision are divided to release the columellar flap (Fig. 18). A small double hook is used to retract the columellar flap while scissors are inserted over the domes to connect with the previous dissection over the lateral crura. Tension–counter tension on the lower lateral cartilages and columellar flap aid dissection over the dorsum and upper lateral cartilages in a supraperichondrial plane (Fig. 19). This plane avoids major vasculature, which lies superficial to the musculoaponeurotic layer. Once at the caudal aspect of the nasal bones, a periosteal elevator is used to dissect in a subperiosteal plane over the nasal bones (see Fig. 20). The elevator is advanced to the radix with care to limit lateral dissection, especially if a dorsal graft will be placed. An Aufricht retractor can be inserted beneath the flap to expose the dorsum. The nasal septum can be exposed to harvest a septal graft or correct a functional septal deviation. The domes are divided, the septal angle is identified, and bilateral subperichondrial flaps are elevated off the septum. The upper lateral cartilages can be divided from the septum if additional exposure is needed. Endonasal approach There are two endonasal approaches for lower lateral cartilage modification: the delivery and transcartilaginous techniques. The delivery technique is indicated for moderate to severe tip deformities when improved exposure of the lower lateral cartilages is needed. It uses bilateral marginal and intercartilaginous incisions and a transfixion incision (Fig. 21). The nostril is retracted with a double hook.

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Fig. 23. (A,B) Transfixion incision made through the membranous septum inferior to the caudal margin of the cartilaginous septum. (From Staffel JG. Basic principles of rhinoplasty. San Antonio: University of Texas Health Science Center at San Antonio, 1996; with permission.)

Intercartilaginous incisions are made with a #15 blade. The incision is made just over the caudal reflection of the upper lateral cartilage and extends medially to the nasal valve (Fig. 22). A transfixion incision is made that extends through the mucosa on both sides of the membranous septum just below the caudal margin of the septum (Fig. 23). These two incisions are joined on each side by dividing the bridge of mucosa just beneath the domes with scissors. If access to the dorsum is necessary for reduction or augmentation, soft tissue is elevated off the upper lateral cartilages and cartilaginous dorsum in a supraperichondrial plane with scissors or a blade (Fig. 24). When the caudal aspect of the bony pyramid is reached, an elevator is inserted for subperiosteal dissection over the bony dorsum. A rocking motion and moderate pressure on the elevator tip along with external pressure from the thumb of the opposite hand are used to develop the subperiosteal plane. The elevator is advanced to the radix with care to limit lateral dissection. For tip delivery, bilateral marginal incisions are made and soft tissue is elevated off the lower lateral cartilages in a supraperichondrial plane (see Fig. 17). This plane is connected with the intercartilaginous incisions, which produces bilateral chondrocutaneous flaps that can be delivered and modified as necessary (Fig. 25).

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Fig. 24. Supraperichondrial dissection over the upper lateral cartilages and dorsum. (From Staffel JG. Basic principles of rhinoplasty. San Antonio: University of Texas Health Science Center at San Antonio, 1996; with permission.)

The transcartilaginous approach is used for cephalic reduction of otherwise symmetric lower lateral cartilages to manage mild tip bulbosity. It requires experience to perform effectively and avoid asymmetry. The lower lateral cartilages are incised full thickness at the desired level, and the cephalic strip of cartilage is dissected free and removed (Fig. 26). The cartilage splitting incision can be joined with a transfixion incision to gain access to the dorsum. Dorsum modification Hump The challenge in removing a dorsal hump lies in knowing how much to remove so that the desired result is achieved. A low radix disproportion or a severely ptotic tip must be managed properly. Placing a radix graft or increasing tip projection preserves dorsal height by decreasing or eliminating the need for actual dorsal reduction. This approach avoids having a nose that ultimately is too small for the patient’s face. Otherwise, the authors prefer to remove the hump before performing delicate tip work.

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Fig. 25. Delivery of the lower lateral cartilage for cephalic reduction. (From Staffel JG. Basic principles of rhinoplasty. San Antonio: University of Texas Health Science Center at San Antonio, 1996; with permission.)

Access to the dorsum is obtained through an external or endonasal approach. The authors prefer the open approach because of improved visualization. The safest way to reduce the dorsum is to excise the cartilage sequentially with a scalpel blade or serrated scissors. The blade tip should be kept at a 90 relationship to the septum to ensure symmetric excision (Fig. 27). The septal and upper lateral cartilages can be taken down together, as a unit, for a mild to moderate hump deformity without traumatizing the underlying mucosa. For a large hump, the upper lateral cartilages are divided sharply from the septum with a #15 blade, and mucosa is dissected off the upper lateral cartilages and septum with a Freer elevator. The septum and upper lateral cartilages are then reduced separately. Maintaining mucosal continuity in this way helps preserve the width of the vestibular apex and subsequently prevents impairment of the internal nasal valve. Once the cartilaginous hump is reduced, the bony hump is removed with an osteotome or rasp (Fig. 28). A rasp provides more gradual reduction and more control than an osteotome. Pulling the rasp at an oblique angle to the dorsum decreases the chance of inadvertent

Fig. 26. Transcartilaginous approach for cephalic reduction of lower lateral cartilages.

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Fig. 27. Cartilaginous hump reduction. (From Staffel JG. Basic principles of rhinoplasty. San Antonio: University of Texas Health Science Center at San Antonio, 1996; with permission.)

disarticulation of the upper lateral cartilages off the nasal bones. One must remember that the bony dorsum usually comprises a small part of the overall deformity. The soft-tissue envelope also is thinner over rhinion than the radix and supratip area. The bone and cartilage can be left slightly higher over rhinion to create a straight profile. In women, it can be taken down straight to create a slight curvature, which is an attractive feature in the female nose.

Fig. 28. Bony hump reduction. (From Staffel JG. Basic principles of rhinoplasty. San Antonio: University of Texas Health Science Center at San Antonio, 1996; with permission.)

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Fig. 29. Spreader grafts used to maintain a functional nasal valve. (From Staffel JG. Basic principles of rhinoplasty. San Antonio: University of Texas Health Science Center at San Antonio, 1996; with permission.)

The bony and cartilaginous hump can be removed simultaneously in one pass with an osteotome. The disadvantage of this technique is increased potential for overreduction. If this occurs, the resected dorsal tissue can be trimmed appropriately and reinserted as a graft. The mucosa and septum should be stripped from the undersurface of the excised hump to prevent mucosal cysts.

Fig. 30. Hemitransfixion incision and subperichondrial dissection to expose the cartilaginous septum. (From Staffel JG. Basic principles of rhinoplasty. San Antonio: University of Texas Health Science Center at San Antonio, 1996; with permission.)

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Fig. 31. Incising cartilage (A) and perpendicular plate of ethmoid (B). (From Staffel JG. Basic principles of rhinoplasty. San Antonio: University of Texas Health Science Center at San Antonio, 1996; with permission.)

When hump removal creates an open-roof deformity, lateral osteotomies can be performed to narrow the dorsum and close the defect. Specific details of performing osteotomies are discussed later. At times the bones settle after osteotomies, which necessitates additional lowering of the cartilaginous dorsum. As final adjustments to the dorsum are made, the surgeon should make repeated visual assessments of the profile and use palpation to ensure a smooth dorsum. Debris and clots should be suctioned from underneath the flap. To minimize the distortion caused by soft-tissue edema, the skin is redraped with a gauze sponge, and digital pressure is applied over the bony dorsum. If there is concern that osteotomies and narrowing of the middle vault will cause a nonfunctional internal nasal valve, spreader grafts should be used to reconstruct the dorsum (Fig. 29). Patients with short nasal bones (bony pyramid extends less than half the distance from

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Fig. 32. Fracturing the perpendicular plate and removing the graft. (From Staffel JG. Basic principles of rhinoplasty. San Antonio: University of Texas Health Science Center at San Antonio, 1996; with permission.)

the radix to the septal angle), long upper lateral cartilages, and a dorsal hump are a set up for this. The grafts act as a shim that pushes the upper lateral cartilages laterally. When an external approach is used to reduce the hump, an open sky view of the nasal septum is afforded through the open-roof deformity. Subperichondrial dissection with a Freer elevator exposes the septum for graft harvest and placement. Two equally sized strips are fashioned 2 to 3 mm thick and long enough to extend from the osteocartilaginous junction to the anterior septal angle. A strip is secured on either side of the septum with one or two mattress sutures of 5-0 polydioxanone (PDS); the dorsal edges should be flush with septum. The upper lateral cartilages are secured to the spreader graft with 5-0 PDS. Spreader grafts can be used in any situation in which there is high risk of middle vault collapse or when a nonfunctional valve already exists. Augmentation Dorsal augmentation is indicated when the bony and cartilaginous dorsal height is not adequate to be in balance with other parts of the nose and surrounding facial features. This is the case in low radix disproportion and saddle nose deformities. Although several autogenous and alloplastic graft materials have been used, autogenous septal cartilage is the tissue of choice. It is easily accessible and well tolerated, and it presents low risk of becoming infected and

Fig. 33. A quilting stitch is placed to hold the mucoperichondrial flaps together in the midline. (From Staffel JG. Basic principles of rhinoplasty. San Antonio: University of Texas Health Science Center at San Antonio, 1996; with permission.)

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Fig. 34. Correction of low radix disproportion with septal cartilage graft. (From Staffel JG. Basic principles of rhinoplasty. San Antonio: University of Texas Health Science Center at San Antonio, 1996; with permission.)

Fig. 35. An elliptical U-shaped septal cartilage graft fashioned for correction of a saddle nose deformity.

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Fig. 36. (A) Medial, intermediate, and lateral osteotomies. (B) Intermediate osteotomies flatten convex nasal bones. (From Staffel JG. Basic principles of rhinoplasty. San Antonio: University of Texas Health Science Center at San Antonio, 1996; with permission.)

reabsorbing. Quantity of septal cartilage is usually adequate for mild to moderate dorsal augmentation. To obtain septal cartilage, a hemitransfixion incision (through mucosa on one side of the membranous septum just below the caudal margin of the cartilaginous septum) is made to gain access. An amalgam plugger instrument or the backside of a #15 blade is scraped along the caudal septum on one side to develop a subperichondrial plane. A Freer or Cottle elevator is then used to dissect a mucoperichondrial flap. Flap elevation is continued past the osteochondral junction 1 to 2 cm (Fig. 30). The nasal speculum can be inserted underneath the flap and spread open to retract the flap and expose the cartilage. The cartilage to be resected is incised with a Freer or Cottle knife, with the surgeon taking care not to damage the contralateral mucoperichondrium. A caudal and dorsal strut of cartilage of at least 1 cm is preserved to maintain support of the external nose (Fig. 31A). Through this incision, the mucoperichondrium on the opposite side is elevated. The perpendicular plate of the ethmoid is then cut with mayo or heavy septal scissors superiorly, and the septal cartilage is freed from the maxillary crest inferiorly by blunt dissection (Fig. 31B). With a Freer elevator, the thin bone of the perpendicular plate of the ethmoid is fractured posteriorly. The four-sided graft is completely freed and removed with a septal forcep, being careful to preserve the thick cartilage at the osteochondral junction (Fig. 32). The hemitransfixion incision is closed and a quilting stitch is placed to approximate the mucoperichondrial flaps using 4-0 plain gut suture on a Keith needle (Fig. 33). A Cottle cartilage crusher can be used to crush the graft in preparation for augmentation. With low radix disproportion, there is a relative underprojection of the upper third of the nose. Augmenting the radix and maintaining dorsal height has several benefits. Esthetically, one avoids excessive dorsal hump reduction and creation of a small nose that is ill proportioned with the rest of the face. There is more shadowing along the lateral nasal wall and a narrower appearance to the bridge in frontal view. Functionally, the integrity of the middle vault can be maintained to avoid potential compromise of the internal nasal valve.

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Fig. 37. Vestibular stab incision overlying the piriform rim at or above the level of the inferior turbinate. (From Staffel JG. Basic principles of rhinoplasty. San Antonio: University of Texas Health Science Center at San Antonio, 1996; with permission.)

Through an external or endonasal approach, a tight subperiosteal pocket is created over the nasofrontal region. A small septal cartilage graft is placed to elevate the radix and create a straight dorsal profile (Fig. 34). At times, hump reduction also is necessary. If lateral dissection is minimized to ensure a tight pocket, the graft does not need suture stabilization to prevent migration. An external splint should be placed for 1 week, however. With a saddle nose deformity, the bony and cartilaginous dorsum lacks sufficient height, although tip projection is adequate. This can occur as a complication of primary rhinoplasty or trauma caused by loss of septal support for the upper and middle thirds of the nose. The entire dorsum or a limited area is augmented with onlayed septal cartilage shaped to an appropriate length and width. Surface irregularities in the graft can be shaved down, and the edges can be beveled with a blade to avoid palpable step-offs. A U-shaped graft may provide better contour and stability, especially if a stacked graft is needed for greater augmentation. To fashion it, an elliptical shaped graft is scored down the middle and paramidline of each side with a blade. A greenstick fracture is then made to create a U-shaped configuration (Fig. 35). Cartilage strips can be stacked underneath and ligated with suture to provide additional augmentation. Stabilization of the onlay graft may be sufficient if a tight pocket is developed with limited lateral dissection. Suture stabilization is sometimes necessary, however. The caudal end of the graft is sutured to the upper lateral cartilages or dorsal septum; a more cephalad suture near the cartilaginous bony junction provides even more fixation.

Osteotomies Osteotomies are indicated to close an open-roof deformity when the dorsum appears wide, to straighten a crooked nose, or to flatten a convex nasal bone. Three types include the medial, intermediate, and lateral osteotomies (Fig. 36A,B).

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Fig. 38. Lateral osteotomy advancing in a curved path toward the medial canthus. (From Staffel JG. Basic principles of rhinoplasty. San Antonio: University of Texas Health Science Center at San Antonio, 1996; with permission.)

The lateral osteotomy is all that is usually necessary to narrow the nose in primary rhinoplasty. It is started on the piriform rim at or above the level of the inferior turbinate. A nasal speculum is inserted to expose the piriform rim, and a vestibular incision is made with Iris scissors or a blade (Fig. 37). Some surgeons prefer to create a subperiosteal tunnel along the lateral nasal wall with a Freer elevator before performing the osteotomy. This is not necessary and actually can decrease the periosteal support of the nasal bones after they are fractured. A guarded osteotome is easier to localize along the nasal wall as the osteotomy proceeds; with experience, a 3-mm straight osteotome can be used safely with the benefit of decreased soft-tissue trauma. The osteotome is initially directed perpendicularly to the piriform aperture. The handle is redirected laterally as the osteotome is advanced along the ascending process of the maxilla in a curved path toward the medial canthus (Fig. 38). This technique has been referred to as a highlow-high osteotomy, which indicates the anteroposterior position of the osteotome as the osteotomy is being made. Going from a ‘‘high-to-low’’ or anterior to posterior position at the piriform base helps preserve a small triangle of bone at the base of the aperture. This keeps the inferior turbinate in a lateral position and minimizes the chance of airway compromise. As the osteotome is advanced along the lateral wall to the canthus, it goes from a ‘‘low to high’’ or posterior to anterior position. At the canthus, medial rotation of the osteotome creates a superior back fracture and medial osteotomy. Gentle digital pressure encourages reliable narrowing or straightening of the osseous nasal vault. Medial osteotomies are primarily used for management of asymmetries, such as a crooked nose. They also can be used to allow a controlled superior back fracture of lateral osteotomies. They should be performed before lateral osteotomies mobilize the bony pyramid. The osteotome may be introduced transmucosally if an external approach is not being used. A small, straight osteotome is used to create a short osteotomy that fades laterally. If the osteotomy is

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Fig. 39. Cephalic trim of lower lateral cartilages to decrease tip bulbosity and improve tip definition. (From Staffel JG. Basic principles of rhinoplasty. San Antonio: University of Texas Health Science Center at San Antonio, 1996; with permission.)

Fig. 40. Dome-binding sutures (A) and an interdomal suture (B) placed to narrow a bulbous tip width (C). (From Staffel JG. Basic principles of rhinoplasty. San Antonio: University of Texas Health Science Center at San Antonio, 1996; with permission.)

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Fig. 41. An interdomal suture placed to narrow a bulbous tip caused by an excessive interdomal distance but normal Vshaped domes. (From Staffel JG. Basic principles of rhinoplasty. San Antonio: University of Texas Health Science Center at San Antonio, 1996; with permission.)

too long and too close to the midline, through thick central bone, a rocker deformity may occur when trying to close an open roof. Intermediate osteotomies narrow the nasal vault when nasal bones are convex, wide, or asymmetric. A small, straight osteotome is used to create an intermediate level osteotomy that traverses the bony pyramid in an oblique fashion.

Nasal tip modification Nasal tip surgery is the most difficult part of rhinoplasty. Successful tip modification is founded on the ability to make an accurate diagnosis. The surgeon must formulate a mental image of the desired results based on esthetic ideals. He or she must then decide on the appropriate maneuvers to sculpt the new nasal tip. The surgeon must be adaptable as the surgery unfolds and modify the plan if necessary to achieve the desired results. Finally, the surgeon must recognize when the best result has been achieved for the case at hand. It is not always possible to achieve the desired result because of factors such as a thick soft-tissue envelope, weak cartilages, and pre-existing scarring. Recognizing limiting patient features is important in avoiding complications. The authors generally recommend an external approach to maximize exposure and visualization of the lower lateral cartilages. They also advocate techniques that preserve supportive tip structures and reorient rather than transect existing structures. This article presents various techniques that predictably alter tip shape, projection, or rotation. Cephalic trim Excising a cephalic strip of the lower lateral cartilage is a relatively easy maneuver for decreasing tip bulbosity and improving definition (Fig. 39). A #15 blade is used to make a beveled incision that blends the cut edge of the lateral crura with surrounding tissue. The underlying vestibular skin is left intact. Care should be taken to limit the excision medially in the region of the dome to preserve the scroll laterally. It is also important to maintain at least 6 mm of residual width to the lateral crura to support the alae. This prevents supra-alar pinching or

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Fig. 42. A shield graft can improve tip projection and definition. (From Staffel JG. Basic principles of rhinoplasty. San Antonio: University of Texas Health Science Center at San Antonio, 1996; with permission.)

lateral wall collapse with resultant obstruction. Cephalic trim of relatively flat or weak cartilages does not affect tip shape and is not indicated.

Dome binding sutures Mattress sutures applied to the domes of the lower lateral cartilages provide greater narrowing of the nasal tip and a more triangular lobule than is possible with the cephalic trim. Slight alteration in location of their placement also can affect tip projection and rotation. If the mattress suture is centered on the dome, it primarily increases tip projection. If the mattress suture is slightly offset lateral to the dome, however, it increases tip projection and rotation as more lateral crus is recruited medially. If the mattress suture is slightly offset medial to the dome, it decreases tip projection and rotation.

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Fig. 43. Shaping the shield graft to provide a smooth transition to surrounding structures. (From Staffel JG. Basic principles of rhinoplasty. San Antonio: University of Texas Health Science Center at San Antonio, 1996; with permission.)

Correct identification of the anatomic dome and careful placement of sutures are essential. 50 clear nylon suture is passed along the caudal margin and then back along the cephalic margin of the dome. It is important to initiate the suture medial to the domes so that the knot sets away from the overlying tip skin. As the suture is cinched down, the dome narrows and is more projecting as the lateral crus moves medially. After both dome sutures are placed, an interdomal suture can be applied to the middle crura to bring the domes closer together and further affect nasal tip width (Fig. 40A–C). Dome binding sutures may cause nasal obstruction as the lateral crus is moved medially by the action of the sutures. It is important to evaluate any change in position of the lateral nasal wall to the septum after the suture is placed. In some cases, a patient with a trapezoidal or bulbous tip has normal V-shaped domes but an abnormal interdomal distance. An interdomal suture of 5-0 PDS applied to the middle crura narrows the interdomal distance and creates a more triangular tip (Fig. 41).

Fig. 44. Securing the shield graft to the caudal margin of the medial crura. (From Staffel JG. Basic principles of rhinoplasty. San Antonio: University of Texas Health Science Center at San Antonio, 1996; with permission.)

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Fig. 45. A columellar strut graft is secured between the medial crura to increase tip projection or augment tip support. (From Staffel JG. Basic principles of rhinoplasty. San Antonio: University of Texas Health Science Center at San Antonio, 1996; with permission.)

Shield graft The shield graft can be used to increase tip projection and improve tip definition (Fig. 42). Septal or auricular cartilage can be used; however, the authors prefer septal cartilage because it is more rigid and easier to sculpt. It is sized in relation to the existing dome structures, its intended use, and the overlying skin thickness. For instance, it must be a longer graft if used to increase tip projection; it must be somewhat thinner if the overlying skin is thin to avoid surface irregularity. For the typical female patient, the graft is 8 to 12 mm wide, 10 to 15 mm long, and 2 to 3 mm thick at the leading edge. The leading edge is thicker and wider than the inferior edge. The graft should have a gentle curvature when viewed from the side to preserve the infratip break. All graft edges are beveled to provide a smooth transition to the surrounding tissues (Fig. 43).

Fig. 46. Dome division maximizes tip projection and a columellar strut provides postoperative tip support. (From Staffel JG. Basic principles of rhinoplasty. San Antonio: University of Texas Health Science Center at San Antonio, 1996; with permission.)

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Fig. 47. Alar resection narrows the alar base or reduces the nostril size. (From Staffel JG. Basic principles of rhinoplasty. San Antonio: University of Texas Health Science Center at San Antonio, 1996; with permission.)

Fig. 48. Scoring the concave side of the dorsal and caudal struts and securing a batten graft to the caudal septum eliminate residual septal deviation present after the deviated portion of the septum is excised.

Fig. 49. Reflection of mucoperichondrial flap off dislocated septum. A separate subperiosteal tunnel is created along the nasal floor and then joined with the dissection from above to minimize risk of tearing the flap.

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Fig. 50. (A) Elevating and repositioning a dislocated inferior septum can increase tip projection. (B) Excising and repositioning it can decrease tip projection.

The graft is secured in place with 6-0 PDS suture placed through the inferior aspect of the graft and caudal margin of the medial crura. The suture should not traverse the vestibular skin. A total of four to six sutures are placed (Fig. 44). The graft should project 1 to 2 mm above the existing domes to increase projection. The beveled edges should blend well with the surrounding dome structures. Columellar strut graft A rectangular strut of septal cartilage can be sutured between the medial crura to increase tip projection and augment tip support. It also can increase columellar show in the case of a retracted columella. A pocket is dissected between the medial crura with Converse scissors. A few millimeters of soft tissue are left overlying the anterior nasal spine to prevent the graft from directly interacting with it. The graft is sutured to the medial crura with 4-0 gut suture on a straight needle (Fig. 45). The suture may traverse vestibular skin because it is a temporary suture. The graft should be secured so as not to cause distortion or asymmetry in the nasal base, domes, and caudal margin of the medial crura.

Dome division with a columellar strut Vertical division of cartilage at the domes with a #15 blade and placement of a columellar strut graft can maximize tip projection and provide postoperative tip support (Fig. 46). This technique also produces greater narrowing of the bulbous tip compared with dome suturing. The method is better suited for thick-skinned patients who have decreased risk for potential sequelae, including visible cut edges of cartilage through the skin, a ‘‘pinched’’ nasal tip, and alar notching. Careful suture reapproximation of the medial and lateral crura should be considered to minimize risk of postoperative asymmetry, especially in thin-skinned patients.

Alar resection Alar resection is performed to reduce a large alar lobule or narrow the nostril (Fig. 47). Most people who require alar base narrowing also require nostril size reduction. One must assess correctly the amount that each nostril must be modified so that proper tissue excision is performed. There are two separate surfaces from which tissue can be excised. Excision from the cutaneous side narrows the alar base, whereas excision from the vestibular side decreases nostril size. Removing the proper proportion of tissue from each area is essential to avoid nostril and alar lobule disproportion. There are two technical points to mention. The inferior-most incision line should be made 1 mm on the nasal side of the alar-facial junction. This approach prevents blunting or obliteration of the natural crease present between the ala and lip. It is also important to preserve a medial

Fig. 51. (A) Excision of the entire caudal septum corrects excess along its entire length. (B) Excision of the nasal spine also corrects more posterior excess. Region of excision is shaded. (From Staffel JG. Basic principles of rhinoplasty. San Antonio: University of Texas Health Science Center at San Antonio, 1996; with permission.)

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Fig. 52. (A) Excision of the anterior caudal aspect of the medial crura corrects anterior columellar excess. (B) Excision of the entire caudal aspect of the medial crura corrects excess along the entire length of the columella. Region of excision shaded black.

Fig. 53. Local anesthesia with epinephrine and cocaine-soaked nasal pledgets are used primarily for vasoconstriction when a patient undergoes general anesthesia. 2% lidocaine with 1:100,000 epinephrine in a dental syringe and 27 gauge, 1-inch needle is used for infiltration. Typically, the total amount injected does not exceed 8 mL. Cocaine-soaked nasal pledgets are then placed, one along the nasal floor and another along the roof of the nasal cavity on each side. A total maximum dosage of cocaine should not exceed 1 mg/kg of body weight. Injection and placement of nasal packs are done before preparation and draping to allow 15 minutes for onset of vasoconstriction.

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Fig. 54. The infraorbital nerve is blocked with 0.5 mL of local anesthesia through a vestibular puncture.

Fig. 55. The sidewall, along the planned osteotomy, is infiltrated with 1 mL of local anesthesia through an intercartilaginous puncture.

Fig. 56. The dorsum is infiltrated with 1 mL of local anesthesia through a septal angle puncture.

Fig. 57. Judicious infiltration of local anesthesia over the entire lower lateral cartilages minimizes tip distortion.

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Fig. 58. The membranous septum and area of the domes are infiltrated with 1 mL of local anesthesia through an external tip puncture.

Fig. 59. A transfixion incision is made that extends through the mucosa on both sides of the membranous septum just below the caudal margin of the septum.

Fig. 60. The back side of a #15 blade is scraped along the caudal septum to develop a subperichondrial plane.

Fig. 61. A Freer elevator is used to dissect a mucoperichondrial flap. The cartilage to be resected is incised with a Freer knife.

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Fig. 62. The four-sided graft is completely freed and removed. The transfixion incision is closed, and a quilting stitch is placed to approximate the mucoperichondrial flaps.

Fig. 63. An inverted V transcolumellar incision is outlined for an external approach.

Fig. 64. A marginal incision is made along the lateral crus of the lower lateral cartilage.

Fig. 65. The marginal incision is carried along the medial crus of the lower lateral cartilage and connects with the transcolumellar incision.

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Fig. 66. Dissection over the cartilaginous framework is performed in a supraperichondrial plane.

Fig. 67. Dissection proceeds over the nasal bones in a subperiosteal plane to obtain full exposure of the nasal skeleton.

Fig. 68. The bony and cartilaginous hump has been removed simultaneously in one pass with an osteotome.

Fig. 69. Lateral osteotomies are performed to close the open roof.

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Fig. 70. A columellar strut graft is placed in the pocket dissected between the medial crura to augment tip support.

Fig. 71. The graft is sutured to the medial crura.

Fig. 72. The convex medial crura are managed by excising the caudal aspect with Converse scissors.

Fig. 73. A suture wrapper is used to fashion a template for a shield graft.

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Fig. 74. The shield graft is secured in place to improve tip definition.

flap of tissue at the nasal sill when excising vestibular skin to avoid notching of the sill. Because the incision extends medially along the alar base, a back cut is made to preserve this small flap of tissue in the nasal sill area.

Septal surgery Deviated septum Septoplasty is indicated to correct a deviated septum that causes airway obstruction or external nasal deformity. In the case of a crooked nose deformity, obstruction and external nasal deviation are usually present. The foundation for a successful rhinoplasty depends on a structurally sound and straight septum. Septoplasty is typically performed before the rhinoplasty procedure. Access to the septum via a hemitransfixion incision and subperichondrial dissection is the same as previously described for harvesting a cartilage graft (see Figs. 30–33). Only the deviated or obstructing part of the cartilaginous and bony septum should be excised, however. It is prudent to maintain as much of the septum as possible in case cartilage is needed in the future for grafting. At least a 1-cm caudal and dorsal strut of cartilage should be retained for external nasal support. At least one mucoperichondrial flap must remain intact to prevent a septal perforation. This can be challenging when there is significant scarring and deviation from a previous fracture, especially if it occurs more posteriorly. If the dorsal and caudal struts of cartilage that remain are still significantly deviated, the concave sides can be scored with a #15 blade. A batten graft also can be cut out of a curved piece of resected cartilage and its convex surface sutured against the convex side of the caudal septum with 5-0 PDS (Fig. 48). This maneuver hopefully eliminates any residual external deviation. After the septoplasty is completed, the hemitransfixion incision is closed and

Fig. 75. Marginal and transcolumellar incision closure proceeds with 4-0 plain gut and 6-0 nylon, respectively. Telfa intranasal packs are placed to aid in hemostasis and are removed in 24 hours.

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Fig. 76. An external nasal splint is placed to close dead space under the flap and stabilize a dorsal graft and osteotomies. It is removed in 7 days.

a quilting stitch is placed to approximate the mucoperichondrial flaps using 4-0 plain gut suture on a Keith needle (see Fig. 30). Dislocated septum Dislocation of the caudal septum off the maxillary crest from previous trauma can cause asymmetric nostrils and a tip deformity (see Fig. 9). Access to septum is performed via a hemitransfixion incision on the side to which the caudal septum is deflected. Because subperichondrial dissection proceeds inferiorly over the deflected septum, it is easy to tear the flap. To avoid this, the hemitransfixion incision should be carried to the bony nasal floor so that a separate subperiosteal tunnel can be created from below along the nasal floor (Fig. 49). The two dissected spaces then can be joined with less risk of tearing the flap. Once exposure of the inferior septum and floor is complete, the lower dislocated edge of cartilage can be freed, elevated, and repositioned over the maxillary crest. Alternatively, the dislocated segment can be excised to create a new inferior edge that is repositioned over the crest. Nasal tip support could increase with the former maneuver and decrease with the latter. It is conceivable that tip position could be altered (Fig. 50). One should consider correcting the septum before performing dorsal profile alignment and delicate tip work that affect projection. Columellar excess Excessive columellar show can be secondary to a caudal septum that is too long, an overly prominent anterior nasal spine, or convex-shaped medial crura. Palpation of the columella reveals the culprit. The septum and anterior nasal spine present as solid resistance, whereas the medial crura are more pliant. Convex medial crura also create a convex columellar profile. A plunging caudal septum must be reduced. Access is gained through a hemitransfixion incision. Careful analysis directs the proper reduction of tissue excess: anteriorly, posteriorly, or along the entire caudal septum (Fig. 51). A #15 blade is used to excise the septum. Redundant membranous septum also should be removed so that the medial crura come into closer approximation with the caudal septum. If the anterior nasal spine also needs reduction, an anterior vestibular incision and subperiosteal dissection are performed. A rongeur can be used to reduce the spine. Instead of excising the overly long caudal septum, the medial crura can be interdigitated and sutured to it. An external approach is used to expose the medial crura, which can be dissected to expose the caudal septum. The crura are set back and secured to the caudal septum with 5-0 PDS. The suture is passed through the caudal edge of the medial crura and septum so that the two are flush. This maneuver provides excellent tip support and can be used to set tip projection and rotation and the alar-columellar relationship. Convex medial crura are managed by excising the caudal aspect with a #15 blade or finetissue scissors. Careful analysis directs the proper area of reduction: anteriorly, posteriorly, or

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along the entire length of the caudal medial crura (Fig. 52). A columellar strut graft should be placed to maintain appropriate tip support.

Case sequencing Properly sequencing a case with multiple objectives can be challenging. The authors present a case as an example of the appropriate order in which to proceed. The patient’s problem list includes a dorsal hump, a poorly defined nasal tip, and columellar excess caused by convex medial crura. The surgery was performed in the following order (Fig. 53–76): 1. 2. 3. 4. 5. 6. 7. 8. 9.

Injection of local anesthesia (see Figs. 53–58) Transfixion incision and septal graft harvesting (see Figs. 59–62) Access to the nasal skeleton via an external approach (see Figs. 63–67) Reduction of dorsal hump (see Fig. 68) Lateral osteotomies (see Fig. 69) Placement of columellar strut graft (see Figs. 70 and 71) Excision of the caudal margin of the medial crura (see Fig. 72) Placement of shield graft (see Figs. 73–75) Placement of external splint and nasal pack (see Fig. 76)

Further readings Johnson CM, Toriumi DM. Open structure rhinoplasty. Philadelphia: WB Saunders; 1990. Leeman DJ, Reino A, Lawson W. Cosmetic rhinoplasty. Oral Maxillofacial Surg Clin N Am 2000;12:739–53. Sheen JH, Sheen AP. Aesthetic rhinoplasty. 2nd edition. St. Louis: Mosby; 1987. Staffel JG. Basic principles of rhinoplasty. San Antonio: University of Texas Health Science Center at San Antonio; 1996. Werther JR, Tanner JP. Basic rhinoplasty. Oral and Maxillofacial Surgery Knowledge Update 1995;1:25–43.