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Nasal Anatomy
A clear understanding of nasal anatomy is
important to successfully perform nasal
procedures and decrease the incidence of
complications.
Surface Anatomy
The terms used to describe the surface
anatomy of the nose are important in
Table 65-1
Giabella: the most forward projecting point of the forehead in the midline at the level of the
supraorbital ridges
Radix: the junction between the frontal bone and the dorsum of the nose
Rhinion: the anterior tip at the end of the suture of the nasal hones
Dorsum: the anterior surface of the nose formed by the nasal bones and the upper lateral
cartilages
Supratip break: the slight depression in the nasal profile at the point where the nasal dorsum
joins the lobule of the nasal tip
Infratip lobule: the portion of the tip lobule that is found between the tip-defining points
and the columellar-lobular angle
Tip-defining points: there are four tip defining points, which include the supratip break, the
columellar-lobular angle, and the most projected area on each side of the nasal tip formed
by the lower lateral cartilages
Alar sidewall: the rounded eminence forming the lateral nostril wall
Alar-facial junction: the depressed groove formed on the face where the ala joins the face
Columella: the skin that separates the nostrils at the hase of the nose
1346
Superior
Inferior
Blood Supply
Tbere is a ricb blood supply to tbe subdermal vascular plexus of the nose that
arises from branches of both tbe internal
and external carotid arteries. The blood
supply from the internal carotid artery
that supplies the external nose includes
the dorsal nasal artery and the external
nasal artery. The dorsal nasal artery is a
branch of the ophthalmic artery. The
Superficial Musculoaponeurotic
System and Nasal Musculature
The muscles of the nose are encased in the
nasal superficial musculoaponeurotic system (SMAS). This is a fibromuscular layer
that separates tbe skin and subcutaneous
tissue from the nasal cartilage and bone.
Tbe SMAS of the nose is in continuity
with the SMAS of the face. During rhinoplastic surgery the dissection is performed
Procerus muscle
Transverse
nasaiis muscie
Diiator naris
anterior muscle
Levator labii superioris
alaeque nasi muscle
Compressor
narium minor muscie
FIGURE 65-2 Nasal musculature. The muscles of the nose are grouped into the elevators (light blue),
the depressors (dark blue), the compressors (light gray), and the dilators (dark gray). Adapted from
fewett B. Anatomic considerations. In: Baker SR, editor. Principles of nasal reconstruction. St. Louis
(MO):Mosby: 2002. p 17.
Supraorbital artery
Supratrochlear
artery
Angular artery
Columellar branch
Septal branch
Facial artery
FIGURE 65-3 Arteries of the external nose. The arterial supply of the external nose comes from
branches of the external carotid artery (dark blue) and the internal carotid artery {light h\ue). Adapted from Jewett B. Anatomic considerations. In: Baker SR, editor. Principles of nasal reconstruction. St.
Louis (MO): Mosby; 2002. p. 18.
conclusion is that the primary blood supply to the nasal tip comes from the bilateral lateral nasal arteries that course in a
plane superficial to the alar cartilages in
the subdermal plexus approximately 2 to
3 mm above the alar groove. Thus a columellar incision does not compromise tip
blood supply. Also there are no significant
veins and minimal lymphatics in the columellar region.-''' Some surgeons believe
that external rhinoplasty remains more
edematous for longer postoperative periods than an endonasal rhinoplasty.
Sphenopalatine
artery
DesQending
palatine artery
Lesser
palatine artery
Greater
palatine artery
Branch of
angular artery
FIGURE 65-4 Arteries of the lateral nasal wall. The arterial supply of the lateral nasal wall arises from
branches of the external carotid artery (black) and the internal carotid artery (blue). Adapted from
Jewett B. Anatomic considerations. In: Baker SR, editor Principles of nasal reconstruction. St. Louis
(MO): Mosby; 2002. p. 23.
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Nasal septal
cartilage
Posterior septal
branch ot
sphenopalatine
artery
Kiesselbach's plexus
Septal branch of
superior labial artery
FIGURE 65-5 Arteries of the nasal septum. The arterial supply of the nasal septum arises from
branches of the external carotid artery (black) and the internal carotid artery (blue). Kiesselbach's
plexus is formed by the sphenopalatine artery, greater palatine artery, superior labial artery, and anterior ethmoid arteries. It is a common site ofepistaxis. Adapted from Jewett B. Anatomic considerations. In: Baker SR, editor. Principles of nasal reconstruction. St. Louis (MO): Mosby; 2002. p. 23.
52%
20%
17%
11%
Nerves
The sensory nerve supply to the skin of
the external nose is supplied by the ophthalmic and maxillary divisions of the
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Cribriform plate
Perpendicular
plate of
ethmoid
bone
Nasal bone
Septal
cartilage
Upper lateral
cartilage
Vomer
Alar cartilage
Nasal crest of
maxilla
FIGURE 65-11 Anatomy of the nasal septum. The nasal septum is composed of the perpendicular plate
of the ethmoid, the vomer, and the quadrangular cartilage. Adapted from Jewett B. Anatomic considerations. In: Baker SR, editor. Principles of nasal reconstruction. St. Louis (MO): Mosby; 2002. p. 22.
trigeminal nerve. Branches of the supratrochlear and infratrochiear nerves supply the skin in the region of the radix and
rhinion. The lower half of the nose is
supplied by the infraorbital nerve and
the external nasal branch of the anterior
ethmoidal nerve (a branch of the
nasociliary nerve that arises from the
ophthalmic branch of the trigeminal
nerve) (Figure 65-12).
Lateral crus
intennedrate crus:
domal segment
lobular segment
Lateral crus
Intermediate crus
Medial crus
{columellar
segment)
Medial crus
(footplate
segment)
Lateral crus
Medial crus
B
Medial crus
FIGURE 65-10 A-C, Anatomy of the lower lateral cartilages. The lower lateral cartilages are often described as having a lateral crus, medial crus, and an intermediate
cms. Tlie intermediate cms is the most projected portion of the lower lateral cartilages and these form two of the tip-defining points seen on nasal tip analysis. Adapted
from Jewett B. Anatomic considerations. In: Baker SR, editor. Principles of nasal reconstruction. St. Louis (MO):Mosby; 2002. p. 21.
1350
Table 65-2
Cosmetic Evaluation
Parasympathetic innervation is derived
from branches of the pterygopalatine ganglion which are derived from cranial nerve
VII. Some sympathetic branches reach the
nasal cavity via the nasociliary nerve.^'''
Nasal Valve
The airflow through the nose is regulated
by the internal and external nasal valves.
The external nasal valve is comprised of
the lower lateral cartilage and the nasal
septum and floor. Collapse of the external
nasal valve can sometimes be noted when
the nares become occluded on even gentle
inspiration. This problem is seen in
patients with narrow nostrils, a projecting
nasal tip, and thin alar sidewalls. External
nasal valve collapse is usually seen in
patients who have had previous rhinoplasty surgery and excessive trimming of
the cephalic portion of the lower lateral
cartilages. It is also seen with increased
age and in facial nerve paralysis. The
external nasal valve collapse can be corrected by deprojecting the overprojected
nose, realigning the lateral crura into a
more caudal orientation, and placing alar
batten grafts to provide structural support
and prevent collapse.^
The internal nasal valve is formed by
the junction of the septum with the upper
lateral cartilages. The angle formed should
be a minimum of 10 to 15 to maintain
Supraorbital nerve
Supratrochlear
nerve
Infralrochlear nerve
Infraorbital nerve
FIGURE 65-12 Sensory nerves of the external nose. The sensory innervation of the nose is derived
from the V] (ophthalmic: colored hlackj and from 16 (maxillary: colored bluej divisions of the
trigeminal nerve. Adapted from Jewett B. Anatomic considerations. In: Baker SR, editor. Principles of
nasal reconstruction. St. Louis (MO): Mosby; 2002. p. 19.
Internai nasal
(anterior
ethmoidai)
1351
Nasal Analysis
Mediai
posterior
superior
Nasopaiatlne
Psychiatric Stability
In addition to analyzing tbe nose the surgeon needs to assess if the pafient is psychologically prepared for a cosmetic procedure.
Patients should have realistic expectations
and motivations. A patient who is internally
motivated (eg, wishes to improve their selfesteem) to have the procedure is a better
candidate tban one who desires the procedure for external reasons (eg, spouse wants
them to have it
General Assessment
Skin
The skin sbould be assessed for its tbickness, mobility, and sebaceous gland content. Any pigmentations or scars sbould
also be noted. Thick skin does not redrape well after rhinoplasty.
Symmetry
Any gross asymmetries in all views sbould
be noted.
Lateral View Nasofrontal Angle Tbe
nasofrontal angle is defined as the angle
formed from lines that are tangential to
the glabella and tbe nasal dorsum and
intersect tbrougb the radix as seen on a
profile view. The normal angle is between
125 and 135 (Figure 65-16).
'HA
A
FIGURE 65-14 Preoperative rhinoplasty. A, Preoperative frontal view shows the width of the nose and alar base. B, Preoperative lateral view shows the nasal profile and dorsum in relation to the nasofrontal angle and nasolabial angle. C, Preoperative three-quarter, or oblique view, is most natural and often revealing for
harmony of the orbital rims and gull wings that flow into the nasal dorsum. D, Preoperative basal view is either taken from above or below the patient and is a
good view of tip and base morphology.
1352
FIGURE 65-15 Postoperative rhinoplasty A, Postoperative frontal view shows the change in the width of the nose. This is the patient's most critical analysis. B,
Postoperative lateral view shows the change in dorsal reduction and tip position. C, Postoperative three-quarter, or oblique view, demonstrates the symmetry and
graceful balance of the nose with the face. D, Postoperative basal view shows the width of the nose and any tip deviation from the dorsal midline.
Radix
Nasal Tip Projection Nasal tip projection can be defined as the distance that
the tip (pronasale) projects anterior in
the facial plane.'"^ Perception of nasal tip
projection can be influenced by may factors: upper lip length, nasolabial angle,
nasofrontal angle, dorsal hump, and
chin projection. There are several methods to determine if the nasal tip projection is adequate. Most cosmetic rhinoplasty procedures are designed to
preserve tip projection.
The simplest method to remember is
Simons' method, which states that the lip-totip ratio is 1:1. Essentially the length of the
upper lip (from subnasale to labrale superioris) should equal the nasal projection
(measured from subnasale to pronasale).
This method may be invaUd because of the
wide variation in lip lengths.'^
The Goode method is another way of
determining nasal projection. Using the
Goode method a line is drawn from the
radix to the nasal tip. A second line is drawn
from the radbt to the alar columellar junction. A third line is drawn perpendicular to
this and passes through the nasal tip.
Goode's analysis states that if the nasofacial
angle is between 36 and 40, then the length
of the perpendicular line passing through
the nasal tip should be 0.55 to 0.6 of the
length ofthe nasal dorsum (Figure 65-18)."^
Rohrich describes another technique
of assessing nasal tip projection. If the
nasal dorsal length is appropriate, the tip
projection should be 0.67 times the ideal
nasal length. The ideal nasal length should
be equal to the distance from stomion to
menton or 1.6 times the distance from the
nasal tip to stomion. The tip projection is
measured from the alar facial junction to
the nasal tip.''' This method is subject to a
great deal of facial variation.
Additionally a vertical line drawn
from the most projected portion of the
upper lip should divide the nose in two
equal halves between the alar facial groove
and the nasal tip. If the anterior portion is
greater than 60%, then the nose is likely to
be overprojected (Figure 65-19).'''
Nasal tip Rotation The nasal tip rotation
is evaluated by the nasolabial angle and the
columellar-lobular angle. Nasolabial angle is
defined as the angle formed by lines that are
tangential to the columella of the nose
36-40'
FIGURE 65-18 Goode method of nasal projection. This method is sometimes used to determine adequacy of nasal projection. If the
nasofrontal angle is between 36 to 40, then the
length of a perpendicular line through the nasal
tip should be 0.55 to 0.6 the length ofthe nasal
dorsum. x - nasal length. Adapted jrom Austermann, K., Rhinoplasty: planning techniques and
complications. In: Booth PW, Hausamen JE, editors. Maxillofacial surgery. New York: Churchill
Livingstone; 1999. p. 1380.
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Functional Considerations
Although the patient desires cosmetic correction of their nose, the functional significance of the nose should be closely considered. Nasal airflow through both the
internal and external nasal valves should be
evaluated. The septum should be evaluated
for deviation and perforations. The septum
is often a good site for harvesting autogenous cartilage for grafting. The turbinates
should be evaluated for hypertrophy.
Rhinoscopy with a nasal speculum can be
performed both before and after the
administration of a topical decongestant.
Photographs
The examination is not complete without
standardized facial photographs. The
standard facial photographs should
include frontal, right, and left lateral
views; right and left oblique views; and a
high and low basal view. Close-up views
are taken if warranted. The photographs
are beneficial from a medicolegal standpoint, and they also allow the surgeon to
Anesthesia
Proper anesthesia of the nose is important
to ensure minimal distortion of the tissues
as well as to provide adequate hemostasis.
Prior to injecting the nose, cottonoids or
cotton-tipped applicators soaked in 4%
cocaine or oxymetazoline are placed in
each nostril to constrict the mucous membranes of the turbinates. If the rhinoplasty
is to be performed under sedation, then
cocaine is preferred because of its anesthetic properties. If the procedure is performed under general anesthesia, then
oxymetazoline is sufficient.
Three cottonoids are placed in each
nostril: one along the middle turbinate,
one along the superior nasal vault, and
one along the inferomedial septum.
Local anesthesia is achieved with 2%
lidocaine with 1:100,000 epinephrine. In
an endonasal rhinoplasty the following
areas are injected:
0.5 cc deposited at the junction of
each upper and lower lateral cartilage
(intercartilaginous area)
0.5 cc deposited in the region of each
marginal incision
3 cc along the nasal dorsum and lateral nasal bones (hugging periosteum)
1 cc along the nasal septum
0.5 cc at each alar base
1 cc at each infraorbital nerve
1 cc at the nasal tip
For external rhinoplasty the following
additional area is injected:
1 cc to the coiumeila
Incisions/Sequencing
There are multiple incision techniques
used to gain access to the cartilage and
bone support of the nose.
Complete Transfixion
FIGURE 65-20 Columella-to-lobule ratio. The
columella-to-lobule ratio should be 2:1.
Partial Transfixion
This incision is similar to the complete
transfixion incision except that it stops at
the level of the medial footpads of the
lower lateral cartilages. The advantage of
this incision is that the attachments of the
medial footpads of the lower lateral cartilages to the caudal septum are not disrupted (see Figures 65-7 and 65-21B).
Hemitransfixion
This incision is a complete transfixion incision that is performed on only one side of
the membranous septum. It does not traverse both mucosal surfaces and therefore
some attachments of the medial crura to
the caudal septum are maintained. Access
to the nasal septum is good with this incision; however, delivery of the lower lateral
cartilage on the side opposite to the incision
is difficult (see Figures 65-7 and 65-21C).
Killian Incision
This incision is seldom used in rhinoplasty.
It is a useful incision to gain access to the
nasal septum if only a septoplasty is to be
performed. The incision is made several
millimeters cephalad to the caudal edge of
the septum. It can be extended onto the
nasal floor if needed.
Intercartilaginous Incision
This incision is made at the junction of the
upper and lower lateral cartilages. The
nare is elevated superiorly with a double
skin hook. A no. 15 blade should pass
below the lower lateral cartilage and above
the upper lateral cartilages. This incision is
typically made after a transfixion incision.
The intercartilaginous incision is then
Rim/Marginal Incision
Complete transfixion
Transcolumellar Incision
Partial transfixion
Hemitransfixion
Septoplasty
In rhinoplasty surgery there are several rea-
FIGURE 65-21 Transfixion incisions. A, A complete transfixion incision is made caudal to both the
medial crura and through the membranous septum. B, A partial transfixion incision is similar exceptsons to access the nasal septum: (1) to corthe incision stops short of the medial foot pads of the medial crura. C, A hemitransfixion incision is a rect nasal airflow obstruction, (2) to assist
complete transfixion incision that is performed only on one side, therefore the other medial crura andin the correction of asymmetries, and (3)
footpad is not violated.
Intracartilaginous Incision
This incision is made through hoth the
vestibular nasal mucosa and a portion of
the lower lateral cartilages. This incision is
similar to the intercartilaginous incision
except that it is made 3 to 5 mm posterior
to the junction of the upper and lower lateral cartilages. This incision in effect performs a complete cephalic strip of the
lower lateral cartilages without the need
for delivering the cartilage. The disadvantage is that the lower lateral cartilage is not
directly visualized and it may therefore be
difficul to achieve symmetry between the
right and left sides.
1355
1356
1.
2.
3.
4.
5.
6.
7.
8.
9.
!0.
11.
Local anesthesia
Partial transfixion incision
(see Figure 65-7)
Intercartilaginous incision
(join with partial transfudon)
(see Figures 65-8, 65-9, 65-21,
and 65-22)
Septoplasty (if needed)
(see Figures 65-24 and 65-25)
Dorsal reduction (see Figures
65^28-65-30)
Lateral nasal osteotomies
(see Figure 65-31)
Marginal incision
(see Figure 65-23)
Delivery of lower laterai cartilages
(see Figure 65-37)
Tip modification (ie, cephalic
strips/cartilage grafting/suture
techniques)
Alar base modification
(see Figure 65-41)
Closure, taping, and splinting
tightly bound at the junction of the septum and the maxillary crest.
Once tbe septum is exposed it can be
treated in four ways: (1) resection, (2)
morselization, (3) segmental transection,
and (4) swinging door flaps.'^ Submucosal resection allows a significant portion of
cartilage to be barvested for grafting. At
least 1 cm sbould be maintained superiorly and anteriorly in an L-shaped configuration to provide support for the nose
(Figure 65-26). In order to resect the cartilage a Cottle elevator is used to cut the cartilage. Fomon scissors may be used to
make tbe superior and inferior cuts
4.
5.
6.
7.
8.
9.
10.
11.
12.
Local anesthesia
Bilateral marginal incisions
(see Figure 65-23)
Columellar incision
(see Figure 65-23)
Skeletonization of upper and lower
lateral cartilages and nasal dorsum
Dorsal reduction
Dome division if access is needed
to the septum for septoplasty or
graft harvest
Septopiasty (if needed)
Turbinate reduction
Lateral nasal osteotomies
Tip modification (ie, cephalic
strips/cartilage grafting/
suture techniques)
Alar base modification
Closure, taping, and splinting
1 cm
L-shaped strut
Removal of deviated
septum or cartilage
obtained for grafting
FIGURE 65-26 Resection of cartilage/bone from the nasal septum. This may be done to harvest cartilage
for grafring procedures or for removal ofgrossly deviated septum. It is important to maintain 1 cm dorsally and caudally for nasal support.
Septum
FIGURE 65-27 Septal repositioning. A deviated nasal septum can be repositioned by removing the
obstruction inferiorly (A) and cross-hatching the cartilage to allow the deviated portion to he repositioned (B). Adapted from Robinson RC. Functional septorhinoplasty. In: Waite PD, editor. Atlas of the
oral and maxillofacial surgery clinics of North America: rhinoplasty. Philadelphia (PA): WB. Saunders; 1995. p. 35.
be required for 1 week. In all septal procedures a 4-0 gut on a straight needle is routinely used to perform a mattress suture
through the septum and mucosa. This
decreases the likelihood of a septal
hematoma formation and circumvents the
need for nasal packs.
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Turbinectomy
Although the focus of this chapter is the
cosmetic rhinoplasty, some mention needs
to be made on maintaining function. Inferior turbinate hypertrophy is a problem
that can result in nasal obstruction after
cosmetic rhinoplasty, if the problem is not
recognized preoperatively. Hypertrophy of
the inferior turbinates is the most common cause of nasal airway obstruction.'^'^"
Hypertrophy can be caused by numerous
factors. Most commonly it is related to
allergic symptoms. Hypertrophy caused by
allergy should be managed medically with
antihistamines and topical corticosteroids.
If this fails, then surgical management can
be considered.^' In cases of a deviated
nasal septum the turbinate on the side at
which the nasal passage is enlarged can
become hypertrophic with time. In
patients with anatomic enlargement ofthe
turbinate, the problem needs to be recognized so that the nasal passage does not
become obstructed when the septum is
straightened.
Management of inferior turbinate
hypertrophy is controversial and outside
the scope of this chapter. The surgical procedures used to treat this problem have
included corticosteroid injection, turbinate
out-fracture, electrocautery, cryosurgery,
laser reduction, partial turbinate resection,
total turbinate resection, submucous
turbinate resection, and vidian neurectoj^y 20-24 g(-|^ Qf these procedures has various advantages and disadvantages and the
procedure chosen depends on the patient.
The most common complications from
turbinate surgery are hemorrhage, atrophic
rhinitis, and ozena.
Nasal Dorsum
Reduction
One of the most dramatic changes that
can be achieved in rhinoplasty surgery is
correction of a dorsal hump. There are
many ways to remove the hump. Some
surgeons use a scalpel and osteotome,
whereas others use rasps, and a few use
power rasps. The authors recommend to
first incise the cartilaginous convexity
below the nasal bones and then to use a
Rubin osteotome to remove the bony
hump (Figures 65-28-65-31). Care must
be taken to keep the osteotome directed
superficially, since it can defiect downward and result in over-reduction. After
removing the gross hump, sequential
Augmentation
Augmentation is indicated when there has
been excessive reduction from previous
rhinoplasty or from a post-traumatic
defect. Several techniques are used to augment the nasal dorsum.
Autogenous Augmentation In the setting of acute trauma, cranial bone grafts
can be used to provide support. These are
cantilevered off the frontal bone with a
miniplate. The graft must be properly
Nasal bones
Upper lateral
cartilages
FIGURE 65-28 Removal of a dorsal hump. A, Vie dorsal hump is removed by first using a scalpel to incise
through the upper lateral cartilages. B, Next, a Rubin osteotome is used to reduce the bony prominence.
Care is needed to keep the osteotome from being directed too far posteriorly thereby over-reducing the dor
sum. AdaptedfromAustermann, K., Rhinoplasty: planning techniques and complications. In: Booth PW,
Hausamen JE, editors. Maxillofacial surgery. New York: Churchill Livingstone; 1999. p. 1389.
Osteotomies
Nasal Tip
Understanding the mechanisms of nasal
tip support is critical when performing
rhinoplasty. The surgeon must understand both the desired and undesired
changes that occur from the surgical
approach or technique.^^
The three major tip support mechanisms include the following:
1. The size, shape, and strength of the
lower lateral cartilages
2. The attachment of the medial crura to
the caudal septum
3. The attachment of the lower lateral cartilages to the upper lateral cartilages
The minor tip support
include the following:
mechanisms
1359
1360
Tip Projection
Increasing Tip Projection Nongrafting techniques to increase
nasal projection include the following:
1. Suturing of divergent medial crura: For
this technique to be effective there must
be diverging medial crura. Intervening
soft tissue may require excision prior to
suturing with mattress sutures.*'
2. Lateral crural steal: The lower lateral
cartilage is skeletonized and the lateral
crura cartilages are sutured with a
mattress suture so that the lateral
crura now contributes to the medial
crura (Figure 65-32). This results in
increased projection and some rotation as
Grafting techniques to increase projection
include the foUowing:
1. Collumellar strut: This technique
involves the placement of a strut of septal cartilage between the feet of the
medial crura and abutted against the
nasal spine. The medial crura are elevated superiorly with double skin hooks
and the cartilage strut is sutured to the
medial crura via mattress sutures. Only
a minor amount of tip projection can
be increased with this method.
2. Peck graft: This is an onlay graft in the
region of the nasal tip. Layers of cartilage are placed in the domal region to
FIGURE 65-32 Lateral crural steal A, B, A horizontal mattress suture is placed in the lateral crura in
order to increase nasal projection and narrow the nasal tip. Adapted from Taylor CO. Surgery of the
nasal tip. In: Waite PD, editor. Atlas of the oral and maxillofacial surgery clinics of North America:
rhinoplasty Philadelphia (PA): W.B. Saunders; 1995. p. 61.
FIGURE 65-33 Peck graft. This involves the placement of layers of cartilage grafts in the region of the
nasal tip to increase nasal projection. Adapted from
Taylor CO. Surgery of the nasal tip. In: Waite PD,
editor. Atlas of the oral and maxillofacial surgery
clinics of North America: rhinoplasty. Philadelphia (PA): W.B. Saunders; 1995. p. 62.
6-8 mm
10-12 mm
FIGURE 65-35 Shield graft. A, B, This is a grafting technique used to redefine the tip-defining points
of the nose. The graft is typically 6 to 8 mm wide superiorly, 5 mtn wide inferiorly, and 10 to 12 mm
long. Adapted from Taylor CO. Surgery of the nasal tip. In: Waite PD, editor. Atlas of the oral and maxillofacial surgery clinics of North America: rhinoplasty Philadelphia (PA): W.B. Saunders; 1995. p. 62.
1361
1362
Overlapped cartiiage
FIGURE 65-37 Delivery of lower lateral cartilage. The lower lateral cartilage is best delivered
by a marginal incision or exposed through an
open rhinoplasty for direct visualization and
surgical manipulation.
Tip refinement
is
improved in this case by complete tip reduction
to reduce the volume of the tip.
Maintain
6 mm width
Excised
cartilage
Area of skin
to be excised
FIGURE 65-40 Coldman tip. This is an interrupted strip technique in which the lateral crura
are divided lateral to the tip-defining points. Tlic
medial segments are then sutured together to
increase nasal tip projection and to narrow the
nasal tip. Adapted from Willis AE, Costa LE. Surgical management of the nasal base. In: Waite
PD, editor. Atlas of the oral and maxillofacial
surgery clinics of North America: rhinoplasty.
Philadelphia (PA): W.B. Saunders; 1995. p. 61.
Postoperative Management
Nasal Base Alar Reduction
The alar base should approximate the
intercanthal distance and be no more than
1 to 2 mm wider than this. The nostrils
should have a symmetric appearance.
Asymmetry of the nostril is often due to a
deviated nasal septum and this should be
reevaluated prior to consideration of an
alar base resection.
The primary procedure to reduce the
alar base width is an alar base resection.
Alar modification is often considered in
cases where the nose has to be deprojected or to balance the anatomy in certain
ethnic types. It is mandatory to be conservative when performing alar reduction
since it is difficult to correct an overreduction. If there is any doubt, the surgeon should delay the alar base reduction
until a later date.^^
The procedure is performed by excising a small wedge of vestibular mucosa
FIGURE 65-41 Alar base reduction (Weir's excision). A, This is med to narrow an overly wide
nostril. B, A small amount of vestibular mucosa
and skin is excised and sutured together. The
excision is usuaUy 1 to 2 mm wide
References
1. Rohrich RJ, Huyn B, Muzaflar AR, et al. Importance of the depressor septi nasi muscle In
rhinoplasty: anatomic study and clinical
application. Ptast Reconstr Surg 2000;105:
.'576-83; discussion 384-8.
2. Hollinshead W. Anatomy for surgeons: the
head and neck. 3rd ed. Philadelphia (PA):
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