VIDEO+

The Five-Step Rhinoplasty Dead Space

Closure Technique
Ira L. Savetsky, M.D.

Summary: The creation of dead space in rhinoplasty creates a welcoming

Yash J. Avashia, M.D.
Rod J. Rohrich, M.D.
Dallas, Texas
Downloaded from http://journals.lww.com/plasreconsurg by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 03/29/2022
environment for erratic soft -tissue contraction. If rhinoplasty surgeons can
control and reliably predict skin contraction and wound healing, rhinoplasty
results will undoubtedly improve. Obliteration of dead space is a key com-
ponent in rhinoplasty as it minimizes soft-tissue contraction, resulting in a

more predictable outcome. In this article, the authors present a systematic

five-step dead space closure surgical plan.  (Plast. Reconstr. Surg. 149: 679e,
2022.)

T
he creation of dead space in rhinoplasty cre-
ates a welcoming environment for erratic
soft-tissue contraction. If rhinoplasty sur-
geons can control and reliably predict skin con-
traction and wound healing, rhinoplasty results
will undoubtedly improve. Obliteration of dead
space is a key component in rhinoplasty as it mini-
mizes soft-tissue contraction, resulting in a more
predictable outcome. Dead space closure is per-
formed in a systematic five-step manner (Table 1).
OPERATIVE TECHNIQUE
Step 1: Infratip Lobule Butterfly Graft
The infratip lobule butterfly graft is used to
obliterate the dead space above the lower lateral
cartilage after the cephalic margin of the lower lat-
eral cartilage is removed. This minimizes scarring
and retraction of the alar rim. It is a soft graft, typ-
ically obtained from the cephalic trim cartilage.
This graft also provides support and continuity
between the tip and alar lobule, which is other-
wise prone to collapse and contour irregularities
(Fig.  1).1 [See Video  1 (online), which demon-
strates a butterfly graft.]
Step 2: Supratip Spanning Suture
Closure of the supratip dead space with a mod-
ified spanning suture eliminates the soft-tissue
memory and further refines the supratip.2 [See
Video  2 (online), which demonstrates a supratip
spanning suture.] It is important to not make this
From the Dallas Plastic Surgery Institute.
Received for publication July 1, 2020; accepted June 3,
2021.
Copyright © 2022 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000008971
suture too tight, as significant tension may cause
skin necrosis.
Step 3: Membranous Septum Closure
Closure of the membranous septum after sep-
tal reconstruction [see Video  3 (online), which
demonstrates septal sutures] and closure around
the septal extension graft [see Video  4 (online),
which demonstrates Septal extension graft dead
space closure] are important in minimizing fluid
around the septum and septal extension graft.
Closure also eliminates the soft-tissue memory
caused by the deviated septum and further
Table 1.  Five-Step Dead Space Closure Technique
Step Closure Technique
Step 1 Infratip lobule butterfly graft
Step 2 Supratip spanning suture
Step 3 Membranous septum closure
Step 4 Splints (septal, external)
Step 5 Soft-tissue triangle Surgicel
Disclosure: Dr. Rohrich receives instrument royal-
ties from Eriem Surgical, Inc., and book royalties
from Thieme Medical Publishing, is a clinical and
research study expert for Allergan, Inc., Galderma,
and MTF Biologics and a medical monitor for Merz
North America, and owns Medical Seminars of Texas,
LLC. No funding was received for this article. Dr.
Savetsky and Dr. Avashia have no financial interests
to declare in relation to the content of this article.
Related digital media are available in the full-text
version of the article on www.PRSJournal.com.

www.PRSJournal.com 679e
Copyright © 2022 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.

Fig. 1. Infratip lobule butterfly graft. [Adapted from Rohrich RJ, Afrooz PN. The infratip lobule butterfly graft:
Balancing the transition from the tip lobule to the alar lobule. Plast Reconstr Surg. 2018;141:651–654.]
stabilizes the septal extension graft. This is per-
formed using horizontal absorbable mattress
sutures. It is also the senior author’s (R.J.R.) pref-
erence to leave a posterior unilateral drainage
port to allow any fluid to egress easily.
Step 4: Splints (Septal, External)
To further close the membranous septum dead
space, mupirocin-coated intranasal Doyle open
lumen splints are then placed and sutured in place.
[See Video 5 (online), which demonstrates Doyle
splints.] When needed, external splints, which are
used as a soft silicone bolster, provide external soft-
tissue support and control soft-tissue memory of
the ala and nasal sidewalls. [See Video 6 (online),
which demonstrates lateral splints.]
Step 5: Soft-Tissue Triangle Surgicel
Impregnated with Mupirocin Application
The soft-tissue triangle is never sutured closed,
given the high risk of poor wound healing and sub-
sequent alar notching and retraction. Therefore,
Surgicel (Ethicon US, Cincinnati, Ohio) impreg-
nated with mupirocin is placed inside the soft-tis-
sue triangle to eliminate dead space and support
this region. [See Video 7 (online), which demon-
strates Surgicel application.] This will autocoagu-
late in 3 to 5 days.
CONCLUSIONS
Obliteration of dead space is a key component
in rhinoplasty as it minimizes soft-tissue contrac-
tion, resulting in a more predictable outcome.
[See Figure, Supplemental Digital Content 1,
680e
Copyright © 2022 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Plastic and Reconstructive Surgery • April 2022
which shows a 22-year-old woman who pre-
sented to the senior author (R.J.R.) for rhino-
plasty. A Gunter diagram shows the autologous
grafts (green), excisions (red), and spreader flaps
(black). Subsequent images show anteroposterior,
oblique, lateral, and basal views of the patient.
(Left) The patient had nasal deviation, an asym-
metric narrow midvault, and distorted dorsal
aesthetic lines, as well as a dorsal hump, droopy
nasal tip, and alar retraction. (Right) The patient
is shown at her 3-year follow-up after undergoing
an open rhinoplasty with spreader flaps, septal
extension graft, extended alar contour grafts,
transection of lower lateral cartilages, and the
five-step dead space closure technique, http://
links.lww.com/PRS/E953.]
Rod J. Rohrich, M.D.
Dallas Plastic Surgery Institute
9101 North Central Expressway, Suite 600
Dallas, Texas 75231
rod.rohrich@dpsi.org
Facebook: @IraSavetksyMD
Instagram: @DrIraSavetsky
Twitter: @IraSavetskyMD
PATIENT CONSENT
The patient provided written informed consent for
the use of her images.
REFERENCES
1. Rohrich RJ, Afrooz PN. The infratip lobule butterfly graft:
Balancing the transition from the tip lobule to the alar lob-
ule. Plast Reconstr Surg. 2018;141:651–654.
2. Guyuron B, DeLuca L, Lash R. Supratip deformity: A closer
look. Plast Reconstr Surg. 2000;105:1140–1151.