BASIG PRilN@[PLES** M'sTAFnpouF

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@F RHIN@PLASTnF
by
J. Gregory Stalfel, M.D.

FACIAL
PLASTIC
SL]RGERY

Contents

Chapter1
Chapter2

Anatomy

Photography

Chapter3
Chapter4

Analysis
Anesthesia

8
16

Chapter5

BasicTechnique

20

Endonasal

20

External

32

Chapter6

TheHump

39

Chapter7

The CrookedNose

42

Chapter8

The SaddleNose

45

Chapter9

TheTip

46

Prcjection

z+o

Rotation

51

Shape

54

Detinition

57

Alar Base

Chapter10

NasalFractures

59

Chapter1

nasalanatomyvariesso muchthat"standard"
Individual
Forthe purposesof this manual
diftersubstantially.
drawings
points
are
emphasized.
certain

Nasalbone

Upperlateralcatilage
Alar (lowerlateral)catilage

pertaining
Anatomic
considerations
to the septumare
as lollows:

Anatomy

Lateralcrus
Medial crus

Lower lateralcartilages
willbe referred
to as alar
cartilagesfor easeof
teaching.Classictextbooks
referonlyto the lateraland
medialcrura of the alarcartilage;however,
the transitionbetweenthe mediaiand
lateralcrurahasalsobeen
calledthe middle(or intermediate)crus. Thispartof
givesrise
the alarcartilage
to the breakpoint at the
junction
columellar
lobular
andthe tip definingpoint
just belowthe supratip
regron.

suprar,pbreak---r,---./
tipdetiningpoint-'(k

frfruf,OOr"rt-),

Thedome is thejunctionbetweenthe medialand lateral

crura(orthe middleand lateral
crura).lt is the mostangulated
partof the alarcartilage.

Anatomy

Surgical imolications

Thefollowing
anatomicrelationships
are important
in rhinoplasty.
At
the rhinion(junction
of the bonyandcartilaginous
dorsum)the
upperlateralcartilagesjointheseptumto formone singlepieceof
cartilage.The attachment
betweenthemis fibrousneartheseplal
angle(anglebelweenthe caudalanddorsalseptum).In a patienl
witha crookednose,dividingthisattachment
duringrhinoplasty
allowsstraightening
of the nose.

'n"

Theanglebetweenthe septumandthe lowerborderof the upperlateralcartllage

is calledthe nasalvalve. Evenminimalconstriction
in
thisareacausessubstantial
restriction
of air flow. Humpremoval
withosteotomies
in peoplewith
can narrowthe valve,especially
shortnasalbones.

Iil

Anatomy

Therefore,
instead,they
manysurgeonsavoidusingosteotomies;
placea smallpieceof cartilagebetweenthe septumandthe upper
lateralcartilage.This"spreadergraft" movesthe upperlateralcartilageawayfromthe septum.

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to the
The upperlateralcartilages
alsohavea fibrousattachment
underside
of the nasalbonesthatmaintains
the smoothtransition
fromthe medialportionof the eyebrowto thetip of the nose.
Traumatic
of this attachment
disruptsthe smoothtrandisarticulation
sitionbetweenthe uooerand middlethirdsof the nose.

Anatomy

{rt
tit

Thejunctionbetweenthe upperlateralcartilage
andalarcartilages
is
oftena continuous
(thescroll). In somepeopletrimrollof cartilage
mingthe scrollreducesbulbousness
of the tip.

Chapter2
Photography
Goodphotographs
arewellworththe smalltimeand moneyinvestment.Theyare essential
for a surgeonto evaluatehis resultsand
perfecthistechnique.Theycan alsofacilitate
communication
with
patient,
provide
the
andthey
medicolegal
documentation.
The easiestwayto takeconsistent
photographs
is witha 35 mm
camerausinga portraitlens(90-105mm).The portraillensrenders
truefacialproportions,
whereasa 50 or 60 mm lensdistortsthe middle thirdof theface,especially
the nose. To keepheadsizeconpictures
stant,all
shouldbe takenat a distanceof 1 m. An tstop
rangeof 8-11givesa gooddepthof field.A background
of lightblue
photographic
paperprovidesgooddefinitionof the nasalprofilein
bothcolorand blackandwhitepictures.Consistent
flashpositionfor
pre-andpostoperative
viewswillyieldtrulycomparable
photographs.
Whentakinga profileview,the flashshouldbe positioned
suchthat
theshadowfallsbehindthe noseand is notvisibleon the backoround.
Standardization
of patientoositionis critical.

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19

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In a frontalviewthe baseol the noseis at the levelof the bottomof

the earlobe.Theverticalcenteris at the levelof the infraorbital
rim.

Photography

In the profileview,the top of thetragusis alignedwiththe infraorbital

rim,puttingthe patientin the Frankforthorizontalplane. Theview
findershouldbe on thatplaneat the lateralcanthus.Alignment
of
the eyebrowsindicates
thata truelateralpositionhasbeenobtained,

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/.---:\

In the viewfromthe baseof the nose(at a distanceof 60 cm,

insteadof 1 m),the tip is betweenthe medialcanthi,andthe dorsum
is justvisible.Thisviewshowstheshapeof the tip andthe dorsal
alignment.In mostcasesthreephotographic
views(frontal,
lateral,
andbasal)willprovideall necessary
information.

Chapter
Analysis
analysisis the cornerstone
of rhinoplasty.
Almostall
Preoperative
can
be
treated
with
deformities
severaldifferentsurgical
anatomic
the besttechnique
involvesmanyfactors,but
techniques.Choosing
is
important
one
a
clear
understanding
of the specif;c
most
the
involved.
deformities
anatomic
analysisincludesevaluation
of the profile,frontal,and
A systematic
basalviews.

The nasofrontal
angleshouldbe
at aboutthe levelof suoratarsal
(uppereyelid)crease.Studies
haveshownthatthe sizeof this
anglevariesgreatlyamongpeoplejudgedto be attractive.

A straightdorsalprofileis acceptable
in eithermalesor females,
although
a slighthumpmaylendmasculinity,
anda slightscoopfemininity.Thepatient's
wishesarediscussed
duringpreoperative
consultation.

Supratlp b,'eak--____-_.....Tip definingpoint -)

$,

Generally,
thetip leadsthedorsumby 1-2mm. A "doublebreak"
characterizes
a refinedtip. Thefirstbreakis in the supratiparea
wherethedorsumendsandthetip begins.Thisis usually
1-3mm
abovethe mostdistalpartof the tip (tip definingpoint). A second
breakis foundat thejunctionof the infratiplobuleandcolumella.

Analysis

4
L

(,

Theconceptsof tip projectionandtip rotationillustrated

aboveare
mostuseful in describing
relativepositions
of the nasaltip. Their
specificmeasurements
are notclinically
useful.A correlate
of tip
rotation,however,
is the nasolabial
anole.

The nasolabialangleshouldbe 90 - 105degreesin malesand95

to 110degreesin females.lf thisangleis too widethe tip appears
overrotated.
Oftena widenasolabial
angleis dueto a caudalseptal
give
excess,whichcan also
the appearance
of a shortupperlip.

Thealarrimshouldarch23 mm abovethe columella.

generally
ln men,chinprojection
approximates
a vertical
junctionof the lowerlip
linefromthe vermilion-cutaneous
whenthe headis oositioned
in the Frankfurt
horizontal
plane. In women,the chinmaybe slightlybehind
thisline.

Analysis

Evaluation
of the frontalview
startswiththe smoothlines
runningfromthe eyebrows
downthroughthe radix
alongthe lateraledgeof the
dorsum,diverging
slightlyat
thetip. Disarticulation
of the
upperlateralcartilages
or a
fractureof the nasalbones
candisrupt
thisline.

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In a deviatednosethe nasalbonesandthe upperlateralcartilages

pointin the samedirection.In a twistednosethe nasalbonesdeviale in one direction
whilethe upperlateralcartilages
returntoward
themidline.

Analysis

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lf the volumeof the lateralcrurais too largethetip is saidto be

bulbous. Surgicalreduction
is indicated.
(lowerlateralcartilages)
The alarcartilages
formprominences
in the
skinthatarecalled"highlights."
Highlights
definethe nose. Thick
skinnedpeoplehavelessdefinition
(lesswell-defined
highlights)
than
thinsklnned
oeoole.

Analysis

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'9,\
margin
Thealar-columellar
tormsa gentle"seagullin
flight"outlinealongthe
base.

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On baseview,the tip shouldbe triangular.Bulboustipsare

trapezoidal.

Thealarbasewidthshould
be within1 - 2 mmof the
intercanthal
distance.

Analysis

Dislocationof the caudalseptumoffthe premaxillary

spineis the
usualcauseof asymmetric
nostrils.Repositioning
of the caudalseptum al surgeryusuallyrestoressymmetry.

Finally,
a well-proportioned
largenoselooksbetterthanan ill-proportionedsmallone.In the drawingsbelow,the nasalbaseis exactlythe
samesize.

The illustrations
showthatan overprojecting
lowerthirdof the nose
mayactuallybe an opticalillusioncausedby relativeunderprojection
of the upperthird.The presenceof thisphenomenon,
calledlow
radix disproportion,indicates
a needfor surgicalaugmentation
of
the radix.

Analysis

To summarize
the analysis:
Fronlal
Basal
Profile
DorsalLine
Radix
Straightness
Bony-Cartilaginous Tip Definition
DorsalHeight
NostrilSymmetry
Tip Projection
Transition
Tip Bulbousness
AlarBaseWidth
Tip Rotation
Relation
Tio
Definition
AlarColumellar
Relation
NasoLabialAngle
Alar-Columellar
CaudalSeotum
ChinProjection

IE

Chapter4
Anesthesia
Septorhinoplasty
withthe patientunderlocalor
can be performed
generalanesthesia,
dependlng
on the preference
of the patientand
surgeon.
lf a localanesthesia
regimenis used,a mixtureof oxymetazoline
and
4% lidocaine
is oftensprayedintothe patient's
nosebeforearrivalin
the operating
roomto providevasoconstriction
andsomeanesthesia.

Forthe operation,
useof a "beach-chair"position(waistand knees
flexedandthe neckslightlyextended)
mitigates
lumbarfatigue.A
nasalcannulais placedin the patient'smouthto supplyoxygen.
(1% lidocaine
Injecting
with1:100,000
the localanesthetic
epinephrine)intothe nosepriorto preppinganddrapingallowstimefor vasoconstriction.
Anesthesia
and hemostasis
are maintained
for as lono
as necessary
by reinjection
every60 minutes.

iN
The entirefaceandone ear are preparedanddrapedto allowevaluationof facialbalanceand readyaccessto auricular
cartilage.A
small,clearadhesivedressing(suchas Tegaderm@1
securesan
OralRae@
endotracheal
tubein the mldlinewithoutdistorting
the
mouth.Theanesthetization
sequenceis begunby placingpledgets
soakedin oxymetazoline
and lidocaine
in the nose,especially
up
undernealh
the nasalbones.

Anesthesia

The infraorbital
nerveis then
blockedwith0.5 ml of local
injectedthrougha
anesthetic
puncture.
vestibular

Thisfacilitates
subseouent
needle
passagebetweenthe infraorbital
foramenand medialcanlhus.

is injectedintothe
Anesthetic
sidewallof the nosethroughan
puncture;
intercartilaginous
to
preventdistortion,
onlya minimalamountis used. Slightballooning(2 mm)of the dorsum
duringinjection
througha septal
anglepunctureimitates
the permanentpostoperative
softtissue
thickening
to be expected
anc
therebyfacilitates
accurate
removal.
humo

An injection
acrossthe baseof the
nosehelpsnumbthe tip priorto
placingfourseparateinjections
aroundthe lowermarginof the alar
cartilages.

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Anesthesia

whiledirectinjection
Judicious
ingthe needleoverthe alar
vasoconmaximizes
cartilages
tip
whileminimizing
striction
distortion.
Thefinalstepin externalanesthe
is blanching
thetization
of the
mucosaon the underside
nasalbones.

1 ml of
Forseptalanesthesia
is placed1 cm in
anesthetic
frontof the sohenoidrostrumto
andsuperior
blockthe posterior
branches
of the sphenopalatine
arteryand nerve.A 25-gauge
spinalneedle(bentat the hub)
is usedto permitoptimalvisualinjections
ization.Systematic
{rombackto f rontcompletethe
and preseptalanesthetization
the
ventbloodfromobscuring
view. Injections
are
surgeon's
alsomadeintothe inferior
turbinates.

Anesthesia

injection
maynecessitate
Severespursthatpreventposterior
transoralpterygopalatine
nerveblocking
throughthe greaterpalatine
foramina.Theforamenis identified
by locatingthe dimplejust medial to the thirdmolar.The needleshouldnotbe insertedmorethan
2.5cm intothe foramenbecauseof the possibility
of afiecting
the
proper
opticnerve.Considerable
resistance
injection
confirms
on
placement
in the pterygopalatine
suggests
canal. Minimalresistance
misdirection
of the needlebehindtheforamenintothe softtissues6f
the nasopharynx.
The mostcommonlyunderanesthetized
areasarethe posterior
plate,andunderneath
septum,highon the perpendrcular
the nasal
bones.A highseptaldeflection
mayrequireinjection
of the middle
Patients
may
turbinates.
shouldbe warnedthatthey
experience
a
sensation
of dysphagia
causedby anesthesia
of the pharynx;
some
becomeso numbthattheycannotfeelthe air passingthroughthe
noseandthroat.The injection
shouldbe donebeforethe surgical
preparation
anddrapingto allow15lo 20 minutesfor the onsetof
vasoconstriction.
Reinjection
on the outsideand underside
of the
prior
nasalbones15 minutes
eliminates
lo osteotomies
bleeding
patients
and pain. To preventstartling,
shouldbe toldbeforehand
willbe loud,butwillnot hurt.
thatthe osteotomies

Chapter5
Basic Technique
EndonasalRhinoolastyTechnique
preference
the orderof a septorhinoplasty.
Personal
determines
technique.
Manysurgeonshavehadsuccesswiththefollowing
A hemitransfixionincisionis madethroughthe mucosaon one
sideof the caudalseptumto provideaccessfor the septoplasty.

offthe premaxilIn patientsin whomthe caudalseptumis dislocated

the mucosa
full
incision
through
laryspine,however,
a
transfixion
on bothsidesjust in frontof the caudalseptumis madeto allowbetandsecuring
theseptumto the nasalspine.
ter accessfor repositioning

m and mucoperiosleum
are liftedoffthe entire
The mucoperichondriu
concavesideof the nasalseptumto provideoptimalvisualization.

Basic Technioue

A 6 mm dorsdlcartilaginous
strutanda 1 cm caudalstrutarepreservedto supportthe externalnosewhenseptalcartilage
is usedin
(e.9.,for creationof a columellar
the rhinopolasty
strutor tip graftor
for dorsalaugmentation).

Thecartilage
lo be resectedis outlinedwitha Cottleor Freerknifeto
preventincisingthe contralateral
mucoperichondrium.

Basic Technique

b
:/2::
mucoperiA Cottleelevatoris thenusedto dissectthe contralateral
plate
perpendicular
ontothe
chondrium.Flapelevationis continued
of the ethmoidanddownalonothe vomerto the nasalfloor

plateof the ethmoidsuperiorly

andthe vomerinfeThe perpendicular
riorlvarecut withscissors.

Basic Technique

A Freerelevatoris placedbetweenthesecutsand usedto fracture

plateandvomer.
the perpendicular

GI

The harvested
septalcartilage-bone
complexis thenremovedwith
forceps,withcaretakento preserve
thethickcartilage
at the bonejunction
for tip grafting.ln casesin whichno graftsare
cartilage
needed,onlythe obstructing
cartilage
and boneare excised,thereby
preserving
After
autogenous
materialfor futuregraftingprocedures.
the septoplasty,
a lowfenestrais createdin oneflapto helpprevent
hematoma
formation.

Basic Technique

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Thehemitransfixion
incision
is closedandSilastic@
splintsor a quilting stitchare usedto holdthe flapstogetherin the midline.Some
surgeonsalsoperformoutfracture,
cauterization,
or partial(including
submucosal)
reseclion
of the inferiorturbinates
to ensurean adeouatearrwav.

The rhinoplasty
of the nose.
startswithdegloving

Bilateralintercartilaginous
incisions(between
the alar
and upperlateralcartilages)
are made1 mm abovethe
caudalmarginof the upper
lateralcartilage
and extended
mediallyabovethe nasal
valveandaroundthe septal
will
angle.Theseincisions
meetanyfulltransfixion
or
hemitransfixion
incisions
that
havebeenmade.

Basic Technique

Elevation
of softtissuesover
thecartilaginous
dorsumand
proupperlateralcartilages
ceedswithscissors
or knifein
plane.
thesupraperichondrial

Oncethe softtissuehasbeenelevatedoverthe cartilaginous

dorsum,a McKentyelevatoris inserted underthe periosteum
starting
justabovethe caudalmarginof the
nasalbones.The periosteum
is lifted withthe elevatorto allowintroductionof the instruments
necesfor
reduction.
sary dorsal
The
smallmidlineraph6of the periosteumis dividedat the rhinionwith
scissorsto allowinsertion
of a
Converse
or Aufrichtretractor.
Whenthe retractor
is in olace.
nasal
the entire
dorsumwill
be exoosed.

Basic Technique

Thesurgeonmaytheneitherremovethe hump(seechapter6) or
is
beginworkon thetip. Manysurgeons
thinkthattip projection
harderto controlthanhumpremovalandtherefore
workon the tip
judgehowmuchof the hump
firstso thattheycansusequently
shouldbe removedin relationto the finaltip projection.On the other
hand,surgeons
whoset tip projection
by usinga strutanda shield
prefer
perform
ofien
to removethe humpand
the necessary
osteotomies
beforebeginning
the delicatetip work.

Basic Technique

lf an endonasal
tip delivery
approachis used,bilateral
incisionsare madeat the lowermargin of the alarcartilages
(alar
marginalincisions).

The softtissueis elevatedoffthe

cartilages
withscissorsin the
plane.
supraperichondrial

Thisplaneis connected
withthe intercartilaginous
incisionallowing
the alarcartilages
to be delivered
andmodifiedas necessary.
Any
shapingstitches(seechapter9) areplacedaftertrimmingthe appropriatepartsof the alarcartilages.

Basic Technique

Osteotomies
arethenperformed.Theoutsideand
especially
the underside
of
the nasalbonesandthe
processof the
ascending
maxillaare injectedwith
15minutes
localanesthetic
priorto the osteotomies
to
preventpainand bleeding.

Medialosteotomiesare madeoarallelto the midline(whenthe nose

is crooked)or mayfadelaterally(if the noseis straight).The
osteotome
maybe introduced
transmucosally
withno untoward
effects.
Aftercompletion
of the medialosteotomies,
lateralosteotomiesare
performed.

Thevestibular
skinis punctured
with lrisscissorsto allowthe
osteotome
to be insertedwithout
bleeding.
Somesurgeons
elevatethe periosteum
on the sidewallof the nosepriorto performingthe osteotomy.

Basic Technique

Beginning
surgeonsprefer
guardedosleotomes
because
theyare easierlo localizealong
the sidewallof the nose.With
a 2- or 3-mm
experience,
osteotome
can be usedeffectivelyfor lateralosteotomies.

An osteotome
of the samesize
for percucanalsobe employed
lateral
osteotomles.
taneous
Aftermultipleperforations
have
in
beencreated the bone,digital
pressureis appliedto fractureit.
Thestabincisionon the outside
of the nosedisappears.
A lateralosteotomy
maybe
low
either or high.Mostsurgeonscreatelowosteotomies
becausethe sitesof high
osteotomies
maybe palpable
visible
andsometimes
postoperatively.

Basic Technique

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In general,osteotomies
are usedfor threereasons:
to close an
open roof createdby removinga hump;to straightena crooked
nose;andto flattenconvexnasalbones(intermediate
osteotomies).

A lateralosteotomy
actslike
a hinge,allowing
the upper
surfacesof the nasalbones
and upperlateralcartilages
to cometogetherin the midline. Theonlyareaactually
narrowed
is
by osteotomies
the dorsumof the nose.
Eventual
boneremodeling
at
piriform
the
aperturewillnullifyany immediate
narrowing
of the baseof the nose.

Basic Technique

Beginning
with
surgeonsunderstandably
approachosteotomies
pointsabouttheseprocedures
sometrepidation.Thefollowing
may
be helpful.
1 . Theinitialplacement
for a lateralosteotomy
of theosleotome
can

varyby 1-3mm withalmostno affeclon the finalappearance.

2 . Manysurgeons
areoverlyconcerned
aboutstartingthe lateral
sufficiently
lowon the piriformrimsincea highosteotoosteotomies
my sitemaybe palpable
andperhapsvisiblepostoperatively.
I prefer to starta littlehigheron the rim,wherethe boneis slightly
thinner,andthendropquicklyto a lowposition
alongthe sidewallof the
nose.A curvedosteotome
lendsmechanical
advantage
to
lf the medialosteotomy
approaching
thetop of the medialosleotomy.
fadesawayfromthe midline,
canbe usedfor
a straightosteotome
the lateralosteotomy.

is seated,
forcelul
facilitates
3. Oncetheosteotome
tapping
theprocemallet
is usedwhenDatients
dure.A sound-attenuated
areunder
localanesthesia.
At the endof the caseall the incisions
areclosedwithabsorbable
sutures.Precisereapproximation
of the mucosanearthe septal
anglepreventsscarringin the valvearea. Somesurgeonsleavethe
intercartilaginous
incisions
opento allowdrainage.
The noseis tapedand a castis applied.Administration
of steroids
maydecreaseswelling.Antibiotic
therapymaypreventinfection,
a
patients
prosthetic
in whomsplintsor
implants
specialconcernin
havebeeninserted.The nasalcastandsplintsare generally
removedon the seventhpostoperatlve
day.

kr

Basic Technique

External
Aoproach

An externalrhinoplasty
beginswith
bilateralincisions
starlingjust anterior to the medialcruraandextending
fromthe dometo the midcolumellar
regton.

Basic Technique

An inverted"v" incisionacrossthe columella

connectsthe incisions
on theside.

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Smallsharpscissorsarethenadvanced
acrossthe columella
betweenthe skinandanterioredgeof the medialcrura.Oncein
position,
incithe scissorsareopenedto spreadthetranscolumellar
sionand revealany remaining
thatmust
softtissueattachments
be divided.

Basic Technique

A smalldoublehookis usedto
retractthe columellar
flapwhilethe
scissorsare insertedoverthe lateral crura.

Onebladeof the scissorsis

placedin the pocketoverthe
lateralcrusandthe otherin the
vestibule
alongthe lowerrimof
the alarcartilage.
The marginal
incisionis thencompleted.

BasicTechnique

inferiorly
Thedomesare retracted
witha narrow7 mm doublehook.
flapis retracted
Thecolumellar
witha 2 mm doublehook.
is extended
to the
Dissection
.septalangleand alongthe nasal
dorsumup to the caudalendof
the nasalbones.

A McKentyelevatoris used
offthe
to liftthe periosteum
nasalbones.

can be performed
throughthe externalapproach,
Theseptoplasty
viewof the upperseptumthatis espewhichprovidesa panoramic
patients
or in revision
witha highseptaldeflection
ciallyhelpfulin
is harvested.Dividing
the
cartilage
casesin whichsomeremaining
to the septumassistsin
attachment
of the upperlateralcartilages
flapandexposureof the septum.
elevation
of the mucoperichondrial

lf a columellar
strutis to be
placed,smallscissorsare usedto
createa pocketbetweenthe medial crura.Thesofttissuein frontof
the nasalspineis preserved
to
lateralstrutdisolacement.
Drevent

Somesurgeons
securethe strutwith
4-0 gut sutureon a straightneedle
thattheypassthroughthe columellastrutcomplex;usuallytwo or three
stitchessuffice.Othersuse buried
nylonor polydioxanone
sutures.

"-\'1

Basic Technique

lf a sheildgraftis to be placed,the
sidesare beveledto preventvisible
sharpedges.The shieldgraftis
(PDSo)
securedwithpolydioxanone
or nvlonsutures.

'/''-.-

To promoteoptimalpositioning
of the graft,the suturesnearestthe
domesshouldbe placedbeforethoseclosestto the transcolumellar
incisionare inserted.

Basic Technioue

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jt

({_,

Replacement
of the skinoverthe strutandshieldcomplexmayproducea slightupwardrotationof the tip andconsequent
flaringof the
lateralcrura.Thiscan be prevented
by dividingthe domeand excising a smallsegmentof lateralcrus. The medialand lateralcruraare
thenreapproximated
withsutures.

Thetranscolumellar
incisionis closedwitha deeplyplaced6-0 polydioxanone
sutureandfineskinsutures.Absorbable
suturesare
usedto closethe incisions
alongthe alarmargin.The noseis taped
andsolinted.

Chapter6
TheHump

Rhinoplasty
hasbeencalledthe'Justonething"operation.At the
endof the one-yearpostoperative
visitthe patientwillsmileandsay
"doctor,I lovemy nose,butthere'sjustonething...." Theythen
maypointto a verysmallresidualhump(calledswellingup to now)
andask,"Willthisgo away?"Duringthe rhinoplasty,
the profileof
thispatienthad lookedperfectto thesurgeon.A studyof preoperativeand postoperative
xeroradiographs,
howevelrevealspermanent
postoperative
softtissuethickening
occursat the rhinion.As mentionedearlier,injectinganesthetic
directlyoverthe dorsumduringthe
(1
operation
willproducea mimicking
of thispostoperative
thickening
judgments
to 2 mm)andallowsmoreaccurate
to be madeaboutthe
amountof boneand cartilage
thatshouldbe removed.In addition,
the softtissuesat the radixswellquicklyaltertheyare elevated.At
surgery,
thisswelling,
whichincreases
withthe lengthof the case,
mustbe pushedout by applyingpressure
to the radixareaimmediatelybeforethe profileis assessed.Finally,
becausethe dorsal
humpseemslargerin a patientwitha low radixdisproportion
or a tip
projection,
withinadequate
it shouldbe remembered
thatmodifying
thesefeatureswilldecreasethe amountof humpto be removed.
Thereare manywaysto removea hump. Somesurgeonsraspthe
boneandthenusea scalpelto shavedownthe cartilage.Othersur
geonscutthe cartilage
firstandthenremovethe bonewithan
prefer
osteolome.A few
to usepowerraspsanddrills.
Forbeginning
surgeons,it is safestto usea raspon the bonyconvexityandthenshavethe remaining
cartilaginous
dorsumwitha
scalpel.A raspengagesa progressively
largersurfaceareaof bone
as humpremovalproceeds,
therebyslowingdownthe processas the
idealprofile is approached.lt is impossible
to gougethe dorsum
unintentionally.
Engaging
the cartilage
witha bladecansubsequently
be somewhat
difficultbecauseof thesurrounding
bone,but mostsurgeonslearnto do it.

Somesurgeons
stabthroughthe cartilaginous
convexity
at the bonejunctionwitha scalpel,drawthe instrument
cartilage
downtoward
theseptalangle,andthenremovethe bonyhumpwithan osteotome.
Thismethodcan resultin overreduction
if the osteotome
is not
directedsuperficially,
sincethe instrument
willbe deflected
downwardby the flatcortexof the underside
of the nasalbones.
However,
manyexperienced
surgeonspreferthistechniquebecause
it is faster.

In a moreconservative
approach,
the
desiredlevelon the sideof the cartilaginousconvexity
is firstmarkedwith
a blade.The bladeis thenadvanced
junctionby
to the bone-cartilage
meansof progressive
sweepsacross
the dorsum.An osteotome
or a rasp
is usedto removethe remaining
bonyconvexjty.
Almostall surgeonssmooththe bony
dorsumwitha raspandemploysome
formof incremental
cartilage
shaving
to makefinaladjustments
to the dorsal profile.

The Hump

Becauseopticalillusionsare
in the postoperative
important
of the profile,use
appearance
of a radixgraftmay reducethe
amountof humothat mustbe
the need
removedor eliminate
hump
removal
entirely.
for

Increasing
the tip projection
(witha shield,strut,or both)
mavhavethe sameeffect.

Chapter7
TheCrookedNose

noseis one in which

A "deviated"
the nasalbonesand upperlateral
pointawayfromthe
cartilages
midline.

$,

nose,the
In a "twisted"
nasalbonespointin one
butthe upperlater
direction,
returnto the
al cartilages
A systematic
midline.
correcsimplifies
approach
tionof eitherabnormality.

Second,
is performed.
First,if the septumis crooked,a septoplasty
to
fromtheirattachment
aredisarliculated
the upperlateralcartilages
the septum.

Disarticulation
can be oerformed
transmucosally
or submucosally.
lf the transmucosal
approachis
- I1I'
preused,caremustbe takento
servea smallrimof mucosaat
the nasalvalve. Medialand lateralosteolomies
arethen
oerformed.

The CrookedNose

Afterthe septoplasty,
releaseof
the upperlateralcartilages,
and
osteotomies,
the nosewill usuallybe straight.However,
the
extension
of the perpendicular
plateof the ethmoidup underneaththe nasalbones,(the
"centralcomplex")may
remaincrooked.lf so, it should
be digitallyIractured.

Beginning
surgeonsshouldnot letthe dramaticnatureof this maneuver producea reluctance
to do it. In fact,fracturing
rarelyhasany
complications.

The CrookedNose

9,\- ' \ /'@

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V
- tl

L,

G-'
_,,-,--:-\
-=7-

f6
\

"t.

rl

,!-<--.>-1

lf the noseis stillcrookedafterthe centralcomplexfracture,camougraftsshouldbe placedalongthe sidewalls

flagingcrushedcartilage
of the nose.

Tosummarize
for a crookednose:
1.
2.
3.
4.
5.

Septoplasty.
Disarticulation
of the upperlateralcartilages.
Osteotomies.
Digitalfractureof the centralcomplex.
grafts.
Camouflaging
crushedcartilage

Patientsshouldneverbe guaranteed
an absolutely
straightnose,
and mostunderstand
thatsuchan assurance
is notoossible.With
useof goodtechnique,
however,improvement-though
not perfectionoccursin nearlvall cases.

Chapter8
Saddle Nose
Mostsaddlenoserepairsincludeaugmentation
of the nasaldorsumwith
previously
autogenous
septalcartilage.lf theseptumhas
beenharvested,cartilage
fromthe auricular
conchacan be used. Autogenous
septum andconchaarewelltolerated
andwillnotbecomeinfectedor be
reabsorbed.
Otherautogenous
materials
thatcan be usedincludesplil
calvarialbone,althoughit tendsto be stiffand havesomewhat
sharp
edges(whlch,however,
can be smoothed
witha burr),and rib,which
resorbsor waros.
somet;mes
lf autogenous
materialis notavailable
(eg,in a patientwho has hadmultiplerevisions),
the dorsummaybe augmented
withan alloplast.Many
prosthetic
plastic
materials
havebeenusedin
surgeryprocedures,
with
varyingdegreesof success.Polyamide
meshis reabsorbed
by the
body.Solidsiliconehasthe abilityto get infectedand extrudeeven
yearsafterbeingplaced.Polypropylene
meshhasbeenusefulin some
polyethylene
cases. Porous
allowssofttissueingrowth,
but is somewhat
stifi.
The mostpromising
alloplastic
materialappearsto be expandedpolyte(ePTFE),
trafluoroethylene
whichis nonabsorbable,
biocompatible,
soft,
conformable,
and allowssofttissueingrowth.Severalauthorshave
reportedinitialsuccesswithePTFE,whichmaybecomethe alloplastic
materialof choiceif long-term
dataon the materialare as goodas the
earlyresults.
Manysurgeonscontinueto believe,however,
thatthe useof anyformof
graftmaterialin the nasaldorsumrepresents
nonautogenous
an invitationto the eventualdevelopment
of problems
causedby mobility,
infection.andextrusion
of the imDlant.

Chapter

geometric
rotation,
formanddefinition
createa
Goodprojection,
pleasingtip.
Proiection
projected
whenit leadsthe dorsum
In general,the tip is adequately
in somepersons,it appearsadequateif it is
by 1-2mm,although,
alignedwiththe dorsum.
IncreasingTip Projection
projection
A systematic
approach
to a tip wlthinadequate
eliminates
confusion.

lf only1-2mm of additional
projection
is needed,a supradomal
gralt or a shieldgraft can be placedin a pocketin the tip.

The Tip

lf stillmoreprojection
is required,
a strutof autogenous
septalcartilagecan be suturedbetween
the medialcrura.

Formaximalprojection
botha sirutanda shieldgraftaresuturedinto
place. Useof an externalapproach
facilitates
thisprocedure,
whichis
calledan "open-structured
rhinoplasty".

Somesurgeonsplacean
intercrural
strut,dividethe
domes,andthensewthe
medialcrurato the strut.

projection,
but
This"dome-division"techniquecan maximize
the
skin
of
cartilage
are
visible
through
sometimes
the cut edges
postoperatively
(bossaeformation).The methodmaythereforebe
patients,
whoare notas likelyas thlnmostusefulin thick-skinned
andalarnotching.
skinnedpatients
to havebossaeformation

ln summary,
tip
a systematic
approach
to increasing
projection
involves:
1.
2.
3.
4.

gra{t.
A shieldor supradomal
A columellar
strut.
graft.
A strutand a shieldor supradomal
A strutanddomedivision.

DecreasingTip Proiection
resultscan be difficult,
achieving
acceptable
tip projectlon,
In decreasing
aroundthe new,
maybe lostwhenthe skincontracts
sincedefinition
an overprojected
remember
that
lt
is
important
to
smallerframework.
lowerthirdof the noseis oftenan opticalillusioncausedby a low radix
the need
In suchcases,useof a radixgraftcan eliminate
disproportion.
to decrease
tip projection.

largenoseis
A well-proportioned
preferred
overan ill-proportioned
smallone.

The Tip
of the tripodmodelof tip supportwillhelpin planning
Consideralion
procedures
or rotatethe tip.
to deproject
to thismodel,eachlateral
According
one legof a tripod,with
crusrepresents
cruraand caudal
medial
conjoined
the
septumformingthe thirdleg.
any of the
or lengthening
Shortening
movea corresponding
legsproduces
mentof thetip. Pushinggentlyon an
tip will revealthe originof
overprojected
mostof itssupport.lf the tip is supportby the crura,it willfeel
ed primarily
lf
its
supportis derivedchiefly
springy.
f romthe septum,the septalanglewill
be palpable.
maneuver
is the creationof a comThe mostsubtletip-deprojection
pletetransfixion
incisionthatallowsthe tip to slidebackalongthe
substantial
margin
caudal
of the septum.lf the septumis providing
supportfor the tip,the septalanglewillbe lowered.lf the tip is overprojected
becauseof the lengthandstrengthof the medialand lateral crura.the crurawillbe modified.

A segmentof the lateralcruraor a segmentof the medialcruracan

be excisedor overlapped
fixationby sutures.This
withsubsequent
technioue
maintains
the naturalshaoeof thetiDat the domes.

The Tip
Excision
of the domesthemselves
canalsobe done,butthe procedure
willchangetheirshape.

ffi
ffi
In patientsin whomthe tip is substantially
(especially
deprojected
thickskinnedpatients),
the skinsleevemaybe too largeto drapewellover
procedure.A
thesmallerframeworkresulting
f romthe deprojection
shieldgraft(suturedor placedin a pocket)can helpfillthe skinenvelope,addingdefinition
withoutaddingprojection.

In summary,
to decreasetip projection:
1. Fulltransfixion
incision.
2. Lowerseptalangle
3. Shortencrura(addshieldgraftfor definition).

Botation
IncreasingTip Rotation
The mostsubtlewayto increaseappar
enttip rotationis to removethe
hump.The
firstdirectmaneuverfor
augmenting
tip rotationis excisionof a
pieceof the caudalseptum,
triangular
withthe baseof the triangleat the top.

Anotherfrequently
employeddirectmaneuver
is shortening
the lateral
crura. Useof this procedure
is basedon thetripodtheoryol tip suppon.

the lateralcrura
ln casesin whichthereis concernthatshortening
graft,which
projection,
many
surgeons
use
a
shield
mightdecrease
increased
tip rotation.
oftencreatesthe illusionof dramatically
withautogenous
cartilage
or ePTFE
Augmentation
of the premaxilla
willenhance
thatillusion.

In summary,
to increaseiip rotation:
1.
2.
3.
4.
5.

Removehumpif present.
Shortencaudalseptum.
Shortenlateralcrura.
Shieldgraft.
Premaxillary
augmentation.

The Tip

\$.

DecreasinqTip Rotation
Tip rotationmayseemexcessive
in patientswithhypertrophy
of
thecaudalseDtumnearthe
nasalspinethatresultsin a
largenasolabial
angleandan
apparently
shortupperlip.

K
s-

Trimming
the caudalseptumnearthe nasalspinedecreases
the
nasolabial
angle,createsan apparentderotation
of the tip,and may
relievetensionon the upperlip.Tip rotationmayalsobe visually
decreased
by dorsalaugmentation.
In summary,
to decreasetip rotation:
1. Trimcaudalseptumnearspine.
2. Augment
thedorsum.

The Tip
Shape
Whenviewedfromthe baseof the nose,thetip shouldappeartrianare bulbousor thedomesarewide,the
gular. lf the alarcartilages
tip lookstrapezoidal.

In patientswithV-shaped
domes,placement
of a suturebetweenthe
medialcrurawillnanowthe interdomal
distanceandcreatea more
triangular
tip.

The Tip

the domesform
Often,however,
moreof an archthana V. ln
suchcases,boththe medialand
lateralcruracan be includedin
a horizontal
or verticalmattress
suture("double-dome"or
"interdomal"stitch). Thismay
be supplemented
by scoringthe
at the domesto weakcartilage
en its inherentspring.

Somesurgeonsmodifythe tip by placingsutures

in eachdomeseparately
to createthe properlndividualdomeshape.A separatestitchallowsprecisecontrolof the interdomal
distance.

For maximalnarrowing,
the
domesthemselves
can be divided andthe medialcrurasewn
together(thedome-division
technique).Mostsurgeonspreservethe continuity
of the
vestibular
skinwhendividingthe
previousdomes.As mentioned
ly,sharpedgesof the cartilage
mayshowthroughthe skincreatingbossae.In thick-skinned
patients,
however,
thisis less
likely.

Tipbulbousness
can be
by excising
decreased
the cephalicportionof
the lateralcrura. To preventalarnotchingand
collapsefromthis procedure,a stripof cartilage
at least6 mm wide
shouldbe leftintact.

In summary,
to narrowthetip:
1.
2.
3.
4.

A stitchbetweenthe medialcrura.
A stitchbetweenthe domes.
A stitchbetweendomeshapingstitches.
Domedivisionwithcoaotation
of the medial
crura.

The Tip
Definition
Tipde{inition
dependson the visibleridges(highlights)
createdby cartilageunderthe skin. Becausetheseridgesare lessnoliceable
in thickpersons,resection
skinnedthanin thin-skinned
of cartilageunderneath
thickskinwouldcompromise
definition.Conversely,
augmentation
with
grafts(supradomal
patientscreates
cartilage
or shield)in thick-skinned
highlights,
makingthe skinappearthinnerandthe tip of the nosemore
welldefined.Any excessive
fat in the supratiparea
subcutaneous
shouldbe removedduringthisprocedure.
Placinga tip graftaddsvolumeto the totalamountof tip cartilage
and
canactuallyincreasebulbousness
by causingflaringof the lateralcrura.
just lateralto the dome
Excising
a smallsegmento1the alarcartilage
withreapproximation
of the remaining
lateralcruswillallowan increase
projection
in definition
and
withoutan increasein bulbosity.

/t

tu_D

l\

(_D

Thealarbaseshouldbe no morethan1-2mmwiderthanthe inter

canthaldistancewhenthe noseis viewedfromits base.
alar baseresections,
Whennanowingthe alarbase,by performing
preserved
medially
at the baseof the
a smallflapof tissueis always
to changethe sizeratherthantheshapeof the nostril.
columella

nostrils
Asymmetric
are usuallythe resull
of the
of dislocation
caudalseptumoffthe
premaxillary
spine.
Repositioning
the caudalseptumrestores
symmerry.

Chapter10
NasalFractures
Patients
withnasalfracturesusuallypresentto the emergency
room
withsubstantial
swelling.Management
includesthe usualprocedures
employedin anytraumacase(e.9.,maintenance
of an airway)andevaluationof anyassociated
fractures.Patients
withan isolatednasalfracturecan be treatedwithicefor 24 hours,as wellas decongestants,
analgesics,and antibiotics.Whenthe swellinghasgonedown(fiveto seven
days),theyshouldreturnfor evaluation.Photographs
obtainedin the
pertaining
emergency
roomwill providedocumentation
to the natureof
the injury.Nasalradiographs
do notchangemanagement.
Thetraditional
treatment
for nasalfractureis closedreduction,
the results
of whichwillsatisfy65%to 85%of patients.Experienced
surgeons,
however,
photograph
treatthis injurymoreaggressively.
A prefracture
is
obtained,
if possible,
for preoperative
Afterdiscussion
assessment.
with
the surgeon,the patientusuallygrantspermission
for an openreduction
andseotalreconstruction.
Whenthe septumis fracturedanda closedreduction
is attempted
the
nosewilloftendriftbackoff midlineevenbeforethe castis aoolied.In
thesecasesa septalreconstruction
is performed.Minimalcartilage
is
junctionis
resected,
butdisarticulation
of the septalbony-cartilaginous
necessary.
Any bonyor cartilaginous
spuris removed.The nasalbones
are reducedagainand if theystayin placewithoutpackingor splinting
thentheincisions
areclosedanda splintis applied.
Occasionally,
the nosecontinues
to deviateafterthe septoplasty.
In
suchcases,medialand lateralosteotomies
areperformed,
whichusually
straighted
the nosein patientsin whomthe upperlateralcartilages
were
straightbeforethe initialfracture.lf the nosecontinues
to deviateafter
the osteotomies,
the upperlateralcartilages
aredividedfromtheir
attachment
to the septum.Osteotomies
anddisarticulation
of the upper
lateralcartilages
can be donewithoutdegloving
the nose. Subsequently,
the surgeonfollowsthe sameprocedures
usedto repaira crookednose
including
digitalcentralcomplexfractureandcamouflaging
crushedcartilagegrafts(Chapter7).

NasalFractures

witha nasalfracturewanta previously

Somepatients
existinghump
during
the
surgery
for
removed
the fracture.Althoughsomesurgeonsthinkthatraspingfracturednasalbonesmightavulsethem
fromtheirsuperiorattachments,
a smallhumpcan usuallybe
if it is donewithcare. lf the fractureis severelycomremoved,
minuted,however,
humpremovalmaynotbe advisable
untilafter
healinghasoccurred(threeto six months).Moreover,
tip workis
rarelydonein patientswithan acutelracturebecauseof the presenceof swelling.
worksbestwhenperlormed
withintwo weeksof the
Openreduction
racture.
After
three
weeks,
f
the development
of fibroustissue
makesrepositioning
betweenfragments
moredifiicult,
evenwith
passed
Therefore,
if
osteotomies.
threeor moreweekshave
since
the injury,the patientis usuallyscheduled
for a septorhinoplasty
to
performed
be
threeto six monthsafterthe fracturewassustained.

In summary,
a systematic
approach
to treatment
of the fracnose
tured
involves:
1.
2.
3.
4.
5.
6.

Closedreduction.
Septoplasty.
Osteotomies.
Divislonof upperlateralcartilages
fromthe septumCentralcomplexfracture.
grafts.
Camouflaging
crushedcartilage

Conclusion
Manytechnicalprinciples
of rhinoplasty
havebeenpresented
in this
philosophical
principles
book. lt onlyremainsto sharea few
aboutthe
orocedure.
Thefirstgoalof any rhinoplasty
is to establish
and maintain
the airway.
Thiscan be donein severalways. First,the septumis straightened
and,
if necessary,
the turbinates
are reduced.Duringstraightening
of the
septum,adequatedorsalandcaudalcartilages
are preserved
to provide
supportfor the externalnasalskeleton.Whenconcernaboutvalvecollapseexists(especially
in casesof shortnasalbones),spreadergrafts
are oftenplaced.Adequatealarcartilage
is preserved
to preventalar
co aose.
Following
theseprinciples
of airwaypreservation
alsoservesanother
purpose:providing
as muchskeletalsupportas possibleto minimize
longtermchangesrnthe noseresulting
fromsofttissuecontraction.
Oncethe airwayandskeletalsupportareadequate,
attention
maybe
turnedto thefirstcosmeticgoalof rhinoplasty,
the creationof a balanced-appearing
nose. Interestingly,
featureof any
the mostattractive
faceis the eyes. Thusthe nosemustnotdrawattention
to itself,but
allowattention
to be drawnto the eyes. (Haveyou everheardanyone
otherthana professional
colleague
say,"whata beautiful
nose!"?)
Oncebalancehas beenachieved,
refinemenl
andbeautybecomethe
goals.Thesemustneverbe achieved
at the costof compromise
ol the
airuvay
or skeletalsupport,anda prioricannotbe achievedat the price
of balance.
Occasionally,
a surgeonwillhaveto makea choicebetweencreatinga
perfectprofileand makingthe noselookbetterfromthe front.Thiscan
happenwhenchoosing,
for example,
whetherto usethe lastpieceol
cartilage
on the sideof the nosefor straightening
or in the tip for added
projection.In general,the noseshouldbe madeto lookgoodfromthe
frontbeforecreationof the perfectprofile.Thisis simplybecause
patientsareviewedfromthe frontfar moreoftenthanin profile.
patients
Perhapsevenmoreimportant,
viewthemselves
fromthe frontin
a mirroreveryday andveryrarelyseetheirprofile.
Manybeginning
surgeonsbecomeconfused
becauseof the emphasis
in
the literature
on techniques
andapproaches.
Alwaysremember
thatthe
question
underlying
for any rhinoplasty
is, 'Whatneedsto be doneto this
noseto makeit workwellandlookright?"Oncethe operative
maneuvers

Conclusion

"whichapproachis
havebeendecidedon,the questionbecomes,
perform
the easiestfor me to useto
thesemaneuvers?"
technically
Forexample,if I needto securea strutandshieldgraftwithsutures,
I preferan externalapproach.However,
somesurgeonsusean
approach,
withequallygoodresults.Likewise,
if a shield
endonasal
graftcan provideadequateprojection
anddefinition
by beingplaced
in a pocket,thenan externalapproachbecomessuperfluous.
The
arguments
common
concerning
transcolumellar
scarsand operative
limesare irrelevanl.
rhinoplasty
is a challenging
Finally,
andfun operation,
butthe stakes
vety
high
are
becauseof the visibility
of the results.Anysurgeon
whoundertakes
rhinoplasty
shouldgivehisor herpatientsthe benefitsof continued
dedication
to self-education.
records
Graohical
maneuvers
showingoperative
on standardized
nasaldrawingsare
the easiestwayto keeptrackof whatwasdoneat surgery.These
records,coupledwithgoodclinicalphotographs,
formthe basisfor
understanding
the failureor successof one'sowntechniques.
Persistence
in self-education
willvieldfruitfulresults.

SuggestedReading

FarriorRT. Rhinoplasty.
In: NaumannH, ed. Headand necksurgery:
lndications,techniques,andpitfalls. Vol.7. Philadelphia:
Saunders,
1980;173-218.
GunterJP. A graphicrecordof intraoperative
maneuvers
in rhinoplasty:
The missinglinkfor evaluating
rhinoplasty
results.P/asfReconstrSurg
1989;82:2O5-212.
GuyutonB. Precision
rhinoplasty.
Partll: Prediction.PlastReconstr
Surg1988;81
:500-505.
JohnsonCM Jr, ToriumiDM. Openstructurerhinoplasty.1990.
McCollough
EG. Nasalplasticsurgery.Philadelphia:
Saunders,
1994.
PeckGC. Techniques
in aestheticrhinoplasty,2nd
ed. Philadelphia:
Lippincott,
1990.
SheenJH, SheenAP Aestheticrhinoplasty,
2nd ed. St. Louis: Mosby,
1987.
StaffelG, ShockleyW. Nasallmplants.Otolaryngol
Clin NorthAm
1995;28:295-308.
TardyME. Rhinoplasty.
In: Cummings
CW,ed.Otolaryngology-head
andnecksurgery,
2nd ed. 51.Louis:Mosby,1993;807-856.