Volume 11 • Issue C7

RHINOPLASTY

Claude Jean Langevin, MD

Richard Y. Ha, MD

Cosmetic
 www.SRPS.org

Editor-in-Chief Jeffrey M. Kenkel, MD

Editor Emeritus F. E. Barton, Jr, MD

Contributing Editors R. S. Ambay, MD 30 Topics

R. G. Anderson, MD
S. J. Beran, MD
Grafts and Flaps
S. M. Bidic, MD
Wound Healing, Scars, and Burns
G. Broughton II, MD, PhD
J. L. Burns, MD Skin Tumors: Basal Cell Carcinoma, Squamous Cell
J. J. Cheng, MD Carcinoma, and Melanoma
C. P. Clark III, MD Implantation and Local Anesthetics
D. L. Gonyon, Jr, MD Head and Neck Tumors and Reconstruction
A. A. Gosman, MD Microsurgery and Lower Extremity Reconstruction
K. A. Gutowski, MD Nasal and Eyelid Reconstruction
J. R. Griffin, MD Lip, Cheek, and Scalp Reconstruction
R. Y. Ha, MD Ear Reconstruction and Otoplasty
F. Hackney, MD, DDS Facial Fractures
L. H. Hollier, MD Blepharoplasty and Brow Lift
R. E. Hoxworth, MD Rhinoplasty
J. E. Janis, MD Rhytidectomy
R. K. Khosla, MD Injectables
J. E. Leedy, MD Lasers
J. A. Lemmon, MD Facial Nerve Disorders
A. H. Lipschitz, MD Cleft Lip and Palate and Velopharyngeal Insufficiency
R. A. Meade, MD
Craniofacial I: Cephalometrics and Orthognathic Surgery
D. L. Mount, MD
Craniofacial II: Syndromes and Surgery
J. C. O’Brien, MD
Vascular Anomalies
J. K. Potter, MD, DDS
Breast Augmentation
R. J. Rohrich, MD
M. Saint-Cyr, MD Breast Reduction and Mastopexy
M. Schaverien, MRCS Breast Reconstruction
M. C. Snyder, MD Body Contouring and Liposuction
M. Swelstad, MD Trunk Reconstruction
A. P. Trussler, MD Hand: Soft Tissues
R. I. S. Zbar, MD Hand: Peripheral Nerves
Hand: Flexor Tendons
Senior Manuscript Editor Dori Kelly Hand: Extensor Tendons
Hand: Fractures and Dislocations, the Wrist, and
Business Manager Becky Sheldon Congenital Anomalies

Corporate Sponsorship Barbara Williams

Selected Readings in Plastic Surgery (ISSN 0739-5523) is a series of monographs

published by Selected Readings in Plastic Surgery, Inc. For subscription
information, please visit our web site: www.SRPS.org.
This blank page is included for proper presentation in two-page view.
 SRPS • Volume 11 • Issue C7 • 2015

RHINOPLASTY

Claude Jean Langevin, MD*

Richard Y. Ha, MD†

*Plastic and Reconstructive Surgery Center, Cedars-Sinai Medical

Center, Los Angeles, California
†Dallas Plastic Surgery Institute and University of Texas
Southwestern Medical Center at Dallas, Dallas, Texas

INTRODUCTION into English, rhinoplasty was finally introduced to the

Optimal results in cosmetic rhinoplasty demand much of
the surgeon. Detailed knowledge of the complex three-
dimensional anatomy of the nose, familiarity with all the
described techniques of rhinoplasty, and a well-developed
aesthetic sense are essential.
HISTORY
Cosmetic rhinoplasty evolved from and has contributed
to reconstructive nasal surgery. From its early origins as
an augmentation (reconstructive) operation, rhinoplasty
subsequently became a reduction (cosmetic) technique
and has progressed full circle to its current dual role for
both reconstructive and cosmetic purposes. Rogers1 and
Eisenberg2 presented comprehensive reviews of the history
of rhinoplasty.
Indian techniques for reconstructive rhinoplasty
began with Sushruta in 500 bce, continued and evolved
during the invasion of India by Alexander the Great in
327 bce, and subsequently waned after the Mohammedan
conquest in 997 ce. The Indian knowledge of rhinoplasty
is recorded in Sanskrit manuscripts, but Western scholars
were not aware of it until the British entered India in
the 18th century. The legendary clay potters of Satra,
India, practiced Sushruta’s methods for recreating noses,
and when these ancient techniques were translated
European medical community.
Two German surgeons, von Graefe and
Dieffenbach, substantially contributed to the advance
of rhinoplasty in the early 1800s. In 1887, John O. Roe
introduced the intranasal approach to rhinoplasty, and in
1891, Roe3 described cosmetic reduction of an entire nose
with removal of the bony and cartilaginous hump through
an intranasal approach.
In 1898, Jacques Joseph of Berlin pioneered modern
reduction rhinoplasty with the publication of his first
paper.4 His technique removed a V-shaped segment of the
nasal dorsum through an external incision; included in
the excision were skin, bone, cartilage, mucosal lining, a
full-thickness portion of ala, and a wedge from the lower
portion of the septum. Joseph analyzed and classified
various nasal deformities and introduced numerous
operative procedures for their correction. His monumental
two-volume textbook5 on plastic surgery of the nose was
published in 1931, and a few years later, his teachings were
brought to the English-speaking world by Safian6
and Aufricht.7
ANATOMY
Dingman and Natvig8 presented illustrations of the general
anatomy, skeletal elements, blood supply, and innervation

1
 SRPS • Volume 11 • Issue C7 • 2015

of the nose (Fig. 1). The skeletal framework of the nose
is highly variable and frequently asymmetrical. Natvig et
al.9 illustrated several cartilaginous configurations (Fig.
2). Bernstein10 and Broadbent and Woolf11 reviewed the
anatomy of the upper, middle, and lower third of the nose
and its clinical application in rhinoplasty.
The nasal bone is widest at the nasofrontal suture
(14 mm), is narrowest at the nasofrontal angle (10
mm), and then widens again to a maximum of 12 mm
approximately 9 to 12 mm inferior to the nasofrontal
angle.12 The nasal bone is thickest superiorly at the
nasofrontal angle (mean thickness, 6 mm) and thins
progressively toward the tip.

Paired nasal bones

Frontal process of maxilla
Lateral nasal cartilage
Nasal septum
Lateral crus
medial crus

Anterior ethmoid n. Terminal branches of

olfactory n.
Exterior branch of
Anterior ethmoid n.
Crista galli
Perpendicular plate
Sphenoid sinus of ethmoid bone
Septal cartilage
Vomer Medial branch of
nasopalatine
Incisal canal

Post. ethmoid artery

Post. septal artery

Anterior
Frontal sinuses
ethmoid
artery
Nasal bone
Sphenoid sinus

Supreme nasal concha Limen nasi

Nasopalatine
Superior nasal concha artery
Vestibule
Middle nasal concha

Inferior nasal concha

Figure 1. General anatomy of the nose. (Modified from Dingman and Natvig.8)

2

Cunningham Gray Spaltenholz
Sobotta Toldt Denecke/Meyer
Figure 2. Alar cartilages as depicted in various sources.
(Reprinted with permission from Natvig et al.9)
Daniel and Lessard13 noted the following:
• The critical, fixed anatomic landmark of the
nose is the medial canthal ligament, which
in many noses corresponds to the desired
level of the transverse fracture line.
• The soft-tissue coverage consists of skin
(thickest at the tip and thinnest at the
rhinion), subcutaneous tissue (most
prominent in the supratip area), and
muscles (ranging from 3.5–9.2 mm in
thickness).
• The nasofrontal suture is 10.7 mm above
the intercanthal line (Fig. 3),13 and the
intervening solid “bony triangle” is virtually
impossible to narrow by digital pressure or
to deepen by rasping.
• The keystone area of nasal bone overlapping
the upper lateral cartilage (ULC) extends
farther along the septum (7.6 mm) than
SRPS • Volume 11 • Issue C7 • 2015
laterally (3.8 mm).
• The dorsal hump is predominantly (57%)
cartilaginous rather than bony (43%).
• The dorsal border of the cartilaginous
septum progresses from a Y, with a
supraseptal depression at the keystone area,
to a T, and eventually to an I by the
septal angle.
• In most cases, the alar domes project far
above and caudal to the septal angle, thus
discounting direct septal support for the tip.
McKinney et al.14 confirmed fusion of the ULC and
nasal septum in the dorsal midline. Only at the level of
the septal angle are these structures separate (Fig. 4) and
merely connected to each other by fibrous tissue.
Accessory cartilages are interspersed in the
aponeurosis connecting the lateral crus to the piriform
aperture.15,16 A continuous, supporting ring of
cartilaginous and fibrous tissue circumscribes the nasal
lobule, with connections between the medial and lateral
crura and the floor,16 as follows:
•• The first accessory cartilage underlies the
alar crease.
•• The second accessory cartilage is attached to
the piriform aperture by the deep portion
of the alar nasal muscle arising from the
undersurface of the maxilla.
•• The third accessory cartilage has a definite
fibrous attachment to the nasal spine and
forms the internal nostril fold on the floor
of the nasal vestibule.
The ring consists of the caudal septum resting on the
nasal spine of the maxilla, the medial and lateral crura,
and a chain of three or four accessory cartilages. Rohrich
et al.17 described the pyriform ligament, which is a broad
dense fascial system spanning the pyriform rim from the
nasal bone to the anterior nasal spine and inserting onto
both the upper and lower lateral cartilage. It includes the
previously described lateral sesamoid complex ligament
and the ligament between the upper and lower
lateral cartilage.
3
 SRPS • Volume 11 • Issue C7 • 2015

management of the nose in the aging patient. With age,

the lower third of the face decreases in height secondary
to muscle atrophy of the orbicularis oris, fatty tissue
 Nasofrontal suture
10.7 mm

Nasofrontal groove
absorption, and maxillary alveolar hypoplasia (from tooth
 5.8 mm

loss and subsequent bony resorption). With advanced age,
Medial canthal ligament the nose lengthens and the nasal dorsum becomes more
Weak triangle (converse) convex as a consequence of downward rotation of the
K area (keystone) lobule and relative columellar retraction. The tip elongates
Upper lateral cartilidge and droops and the flow of air shifts superiorly, often
causing functional airway obstruction. Osteotomies are
recommended because of the fragile nature of the bony
Soft triangle (converse) nasal pyramid.
Daniel20 emphasized the importance of the three
Figure 3. Critical landmarks and relationships of the nose.
crura of the lower lateral cartilage—the medial, middle,
(Modified from Daniel and Lessard.13) and lateral crus—and of the three nasal tip angles—the
angle of tip rotation, angle of dome definition, and angle
of domal divergence (Fig. 5). The anatomy of the ULC
correlates strongly with tip aesthetics.
Histologically, the bulbous tip consists of
collagenous fibrous tissue and skeletal muscle; the adipose
tissue component is far less than expected.21 The tissue
makeup, blood supply, and lymphatic drainage are directly
related to postoperative edema and scar formation and
influence the resection that is performed for
tip modification.
Figure 4. Cross-section of the ULC-septal angle at three
levels. (Reprinted with permission from McKinney et al.14)

A. Angle of domal definition

Daniel and Letourneau16 found no deterioration of the B. Angle of rotation
C. Columella-lobular angle
cartilage with age and doubted that attenuation of the D. Angle of tip rotation
cartilage and fibrous supporting structures is responsible E. Angle of domal divergence

for the drooping nasal tip seen in the elderly. Rather, it

seems the drooping tip results from resorption of the
A
maxillary alveolar crest. Holden et al.18 analyzed the D
C
human nasal cartilage ultrastructure using scanning B E

electron microscopy. The authors reported a significant

difference between the cartilage of the nasal septum and
the lower lateral cartilage. The nasal septum has more
organized, layered, thicker collagen fibers, whereas the
lower lateral cartilage has a less organized pattern with Figure 5. Angles in the nasal lobule relevant to
smaller collagen fibers. rhinoplastic surgery.
Rohrich et al.19 discussed their approach to the

4

Copcu et al.22 described the interdomal fat pad as
a separate anatomic component not structurally attached
to the subcutaneous tissue. The fat pad consists purely of
adipocytes and varies in size from 1.2 × 2.4 mm to 3.6 ×
5.2 mm. Ultrasonography shows larger pads occupying the
interdomal space. Coskun et al.23 corroborated the finding
of this distinct interdomal fat pad in a cadaveric and
clinical radiological study.
Rohrich et al.24 studied the blood supply of the
nasal tip before and after transcolumellar incision in a
fresh cadaver model. The lateral nasal artery was present
in all specimens and was located in the subdermal plexus
2 to 3 mm superior to the alar groove. The columellar
branch of the superior labial artery was variable. Even after
transcolumellar incision, crossover flow was consistent
from the lateral nasal artery arcade to the distal aspect of
the transected columellar branches. The authors concluded
that external rhinoplasty does not compromise nasal tip
blood supply unless extensive tip defatting or extended alar
base resection above the alar groove is performed.
Toriumi et al.25 assessed the effect of external
rhinoplasty on the vascular anatomy of the nose. The
study involved pre- and postoperative clinical evaluation,
cadaver dissection, lymphoscintigraphy, and histological
evaluation. The major arterial, venous, and lymphatic
vessels course in or above the musculoaponeurotic layer
of the nose. The authors suggested that with the external
rhinoplasty approach, dissection in the areolar tissue plane
below the musculoaponeurotic layer will minimize tip
edema and protect against skin necrosis by preserving the
major vascular supply to the nasal tip. Loss of normal flow
of tracer occurred with the external approach, which used
dissection that disrupted the musculoaponeurotic layer
with supratip debulking.
To minimize injury to the external nasal
branch of the anterior ethmoidal nerve, Han et al.26
performed anatomic dissections in 10 fresh cadavers and
concluded that dissection deep to the nasal superficial
musculoaponeurotic system is safe. They recommended
keeping the dissection to within 6.5 mm of the midline
and limiting onlay graft widths at the rhinion to 13 mm.
Pitanguy et al.27 described a dermocartilaginous
ligament that might influence dorsum-tip relationships,
especially in patients with a bulbous tip and in black
patients in whom a convexity of the lower third of
SRPS • Volume 11 • Issue C7 • 2015
the nose is still apparent after classic modification of
the osseocartilaginous structures. Division and partial
resection of the dermocartilaginous ligament releases the
lower third of the nose, and the nasal tip moves upward.
Hwang et al.28 reported a close relationship between the
dermocartilaginous ligament and the depressor septi nasi
muscle and confirmed that it acts as a nasal tip depressor.
In a follow-up article, Pitanguy29 validated the presence
of this subseptal tip-anchoring structure and detached it
subcutaneously through an open browlift approach for the
aged, drooping nose. Saban et al.30 described the deep and
the superficial medial expansion of the nasal superficial
musculoaponeurotic system. The dermocartilaginous
ligament, previously described by Pitanguy, corresponds to
the deep medial expansion. Both the deep and superficial
components contribute in lowering the ligaments of
the nasal tip, and transection of these structures allows
cephalic rotation of the nasal tip.
Figallo31 described a dynamic structure in the nasal
tip, neither osseous nor cartilaginous, which he thought
to be a digastric muscle linking the nose to the upper
lip. This complex anatomic structure is joined through a
pulley to the anterior nasal spine and is thought to account
for the plunging tip. A distinction between this “new”
structure and the nasal depressor muscles is unclear. Figallo
and Acosta32 provided a detailed update on the muscles of
the nose.
Ozturan et al.33 used electromyography to study the
intrinsic nasal musculature as it relates to airway collapse
before and after rhinoplasty. The authors cautioned
against inadvertent disruption of the procerus, transverse
nasalis, and dilator nasalis muscles during rhinoplasty,
which would affect nasal movements postoperatively. They
emphasized remaining in the appropriate tissue plane
beneath the musculature and over the perichondrium to
achieve the best functional result.
In a cadaveric study, Ali-Salaam et al.34 found the
alar lobule to be an area where dermis interdigitates with
muscle throughout and down to the alar rim. The alar
groove is defined by a differential in fibrofatty bulging
anterior and posterior to it. The authors also studied the
soft triangle and described the anatomy of the insertion of
the dilator naris muscle down to the nostril rim.35
5
 SRPS • Volume 11 • Issue C7 • 2015
PHYSIOLOGY
Baker and Strauss36 reviewed the physiology of the nose
and noted that septal deviation and spur formation are
anatomic variants prevalent in normal populations.
The nasal cycle is a physiological response characterized
by alternate shrinkage and engorgement of the nasal
turbinates that repeats every 30 minutes to 4 hours. While
one side of the nasal airway is experiencing shrinkage
of its nasal turbinates and giving off secretions of serous
fluid and mucus, the opposite airway is involved in the
process of turbinate engorgement. This cycle occurs in
80% of individuals and its exact function is unknown.
Total airway resistance remains relatively constant despite
continuous changes in the size of the turbinates. Baker
and Strauss presented a discussion of the physiological
basis of nasal obstruction relative to pathological states
of the nasal turbinates. Rhinitis is classified as allergic,
vasomotor, atrophic, hyperplastic, medicamentosa, or
post-rhinoplastic. The differential diagnosis and treatment
of obstructive rhinitis were reviewed by Baker and Strauss.
On the basis of his vast experience treating patients
with nasal obstruction, Canady37 offered a relatively simple
algorithm (Fig. 6) to identify the causes and management
of nasal obstruction. He thought the algorithm might
allow the surgeon to recognize patients who will not be
satisfied, even with a technically good result, and thereby
avoid performing surgery on those patients.
Jesson and Malm followed 67 patients who were
38
considered candidates for septoplasty because of nasal
obstruction and deviated nasal septum. The patients did
not undergo surgery because their nasal airway systems
were discovered to be normal based on rhinometry. At
5 and 10 years of follow-up, 20% and 36% of patients,
respectively, showed improvement in relief of nasal
symptoms. The authors concluded that the majority
were in fact suffering from vasomotor rhinitis, which
tends to disappear with time, and recommended careful
evaluation to distinguish between anatomic obstruction
and physiological obstruction.
Deron et al.39 evaluated the influence of septal
deviation on eustachian tube function and concluded
that surgical correction improved tubal opening pressure
in both the deviated side and the non-deviated side.
Fomon et al.40 and Courtiss et al.41 stated that unless the
internal or external valves are adversely affected or unless a
6
simultaneous septal operation results in septal perforation,
aesthetic rhinoplasty does not affect nasal airflow.
Infracturing of the nasal bones takes place cephalad to the
internal nasal valves and presumably does not
impair airflow.
Ford et al.42 studied the effects of various osteotomy
techniques on the size of the airway in cadavers and
concluded that an interrupted transperiosteal osteotomy
preserving intervening strands of periosteum results in a
more stable nose with less compromise of the airway.
Guyuron43 studied the effect of osteotomy on the
airway of 48 patients (96 nasal bones). The length of the
nasal bones and the position of the inferior turbinates
were recorded preoperatively and correlated with the type
of osteotomy performed and extent of bone movement.
Each side was assessed independently. The high-to-
low osteotomies produced the least narrowing of the
nasal passages. Patients with short nasal bones had less
constriction of the airway than patients with either normal
or long nasal bones. Airway narrowing was more marked
when the inferior turbinates were positioned anteriorly.
The author concluded that nasal osteotomy does constrict
the nasal airway in most instances and to a degree varying
with length of the nasal bones, extent of nasal bone
repositioning, position of the inferior turbinates, and type
of osteotomy.
Grymer et al.44 studied the influence of placement
of the lateral osteotomy at levels above and below the
insertion of the inferior turbinates in 16 cadavers and
found no difference between noses that underwent high
lateral osteotomy and those that underwent low lateral
osteotomy. Both groups showed a 12% to 16% decrease
in mean cross-sectional area at the piriform aperture
after lateral osteotomies were performed. This reduction
was independent of osteotomy placement but was
probably caused by detachment of the bony box from the
underlying structures.
Becker et al.45 developed a rationale for selecting
the correct osteotome for endonasal lateral osteotomy.
The mean bony lateral wall thickness was measured by
computed tomography in 56 adult patients and was found
to be 2.47 ± 0.47 mm in men and 2.29 ± 0.40 mm in
women. The 4-mm osteotome caused intranasal mucosal
tears 95% of the time; the 3-mm osteotome created tears
in 34% and the 2.5-mm osteotome in 4%.

Figure 6. Algorithm for managing nasal obstruction. (Reprinted with permission from Canady.37)
Malm46 introduced the concept of acoustic
rhinomanometry, described the technical aspects of
the procedure, and listed clinical norms. Grymer47
used acoustic rhinomanometry to measure the internal
dimensions of the nasal cavity in 37 patients before and
after reduction rhinoplasty. A 22% reduction in minimal
cross-sectional area was noted at the nasal valve, and an
11% reduction in the cross-sectional area was noted at the
piriform aperture.
SRPS • Volume 11 • Issue C7 • 2015
Vomeronasal Organ
Moran et al.48 and Stensaas et al.49 independently
investigated the vomeronasal organ (Jacobson organ).
Interest in this vestigial structure stems from its similarity
to the vomeronasal system of other vertebrate species,
in which Jacobson organ plays a crucial reproductive
role by detecting pheromones. The authors collectively
evaluated 600 human study participants and found
paired vomeronasal pits in the anterior third of the nasal
7
 SRPS • Volume 11 • Issue C7 • 2015

septum in all individuals who had no underlying septal

pathological conditions. The pits signified the presence
of closed tubes that were 2 to 8 mm long and lined by
unique pseudostratified columnar epithelium, unlike any
other in the human body. Two potential receptors were RP
identified in the epithelial lining. The function of Jacobson CP
organ in humans is still in question, but it seems to be R

immune from injury by submucoperichondrial dissection

1/2 RT
of the septum.

T
ACJ
AESTHETICS AND FACIAL ANALYSIS
Implicit in a surgeon’s ability to correct nasal deformities
is an understanding of aesthetic proportions of the face,
not just the nose. Farkas and colleagues50−55 and Ricketts56
reviewed modern standards in facial aesthetics. Bernstein57
delineated relationships between facial shape and nasal
width, discussed nose-chin proportions, and listed
differences between male and female noses. According to NLCP
these authors, the aesthetically pleasing face is not divided
into equal thirds or fourths, but rather the lower face is
longer than the midface, which in turn is longer than the
upper face. Springer et al.58 reported that gender-related
differences in nasal shape appear to be subtle, with nasion
position being one of the main factors. According to their
judging panel, a nasal hump and a supratip break are Figure 7. Lateral view illustration shows ideal relations and
not desirable. proportions of the facial structures. RP, nasal root plane;
CP, corneal plane; R, nasal root; 1/2 RT, halfway between
Greer et al.59 reviewed the importance of the
the nasal root and the nasal tip; T, nasal tip; ACJ, alar crease
submental region in improving the perceived appearance
junction; NLCP, nose-lip-chin plane. (Modified from Byrd.61)
of the nose. They advocated neck-rejuvenating procedures
for improving results. Byrd and Hobar60 reported a
consistent relationship between vertical dimensions and determined by a line drawn through a point halfway
anteriorly projecting characteristics of the nose, lips, down the ideal nasal length and touching the upper lip
and chin. They proposed a dynamic system of analysis vermilion. In men, the chin projects to this line, but in
that describes key measurements of the nose relative women, it is 3 mm posterior to it. Other details of the
to other facial features and that maintains an overall facial analysis method are as follows:
proportion among the nose, the chin, and the rest of the 1. The MFH is measured from glabella to alar
face. According to their system, for any individual, the base plane. The lower face height (LFH) is
ideal nasal length (RTi) is determined by non-nasal facial measured from alar base plane to mentum.
measurements (Fig. 7).61 Specifically, RTi is equal to 67% MFH should be equal to or slightly less
of the midfacial height (MFH) and equal to the chin than 3 mm LFH. If it is not, reaffirm
vertical measurement (SMes). occlusion and look specifically for the
RTi = 67% MFH and RTi = SMes presence of long- or short-face syndrome
or microgenia.
Nasal tip projection equals 67% of the calculated
ideal length. The nose-lip-chin plane (NLCP) is MFH < LFH (≤3 mm)

8

2. Select the mid- or lower facial subunit as
the standard for determining ideal nasal
length. When the mandible is normal and
MFH and LFH are nearly equal, nasal
length should be planned on the basis of
chin vertical as measured from stomion
to mentum.
RTi = SMes
In cases of microgenia or maldevelopment
of the mandible, the ideal nasal length is
determined from the MFH.
RTi = 67% MFH
Similarly, when the midface is
overdeveloped and is not to be corrected
orthognathically, the nose should be
proportional to the midface rather than to
the smaller mandibular segment.
3. With the ideal nasal length established,
adjustments to the existing nasal length
and possibly the chin vertical should
approximate the ideal nasal length. The
treatment plan is ultimately determined by
safe and reliable surgical guidelines.
4. Multiply the ideal nasal length by 0.67 to
determine the ideal tip projection.
Ideal tip projection = 67% RTi
If actual tip projection is equal to or greater
than calculated value, tip projection is
adequate despite its appearance in relation
to the dorsum. If actual tip projection is less
than the calculated ideal, surgical steps to
increase tip support should be considered.
5. Measure the distance between corneal plane
and radix plane. The ideal radix projection
should be 28% of the ideal nasal length.
Ideal radix projection = 28% RTi
(9–14 mm)
If less than the calculated value and if a
dorsal hump is present, consider a radix
graft. If greater than 28% RTi and if the
radix breakpoint is poorly defined, consider
radix reduction.
SRPS • Volume 11 • Issue C7 • 2015
6. Note any difference in nasal length when
measured from supratarsal fold R and visual
radix breakpoint. If nasal length is normal
as measured from R but the nose appears
short because of a low breakpoint, it can
be corrected with a radix graft to raise the
visual break.
7. Mark a point on the dorsum of the nose
equivalent to one-half the ideal nasal length
as measured from R. Drop a line from
this point tangential to the vermilion of
the upper lip. The projecting point of the
chin should touch the line in men and lie
approximately 3 mm back of this plane
in women.
Chin projection = NLCP (men)
Chin projection = ≤3 mm
NLCP (women)
The aesthetically pleasing female face has an
MFH that is equal to or slightly less than
lower facial height (mean MFH, 61 mm).
Nasal length equals chin vertical distance
and averages 41 mm (Fig. 8).61
8. On lateral view, the mean distance between
nasal root plane and corneal plane is 11
mm or approximately 28% RTi. The nose
projects from the face at an angle of 30°
to 36°, whereas the nasolabial angle varies
from an average of 90° in men to 95° to
110° in women. A 2- to 3-mm segment of
columella should be seen below the rim of
the ala.
McKinney and Sweis62 sought to define the elements
of the ideally balanced white nose. Ideal dorsal length
was 2× rhinion height and tip projection. Ideal radix
height was 0.75× tip projection + rhinion height. In his
discussion of the McKinney and Sweis article, Daniel63
referenced the ideal nasion relative to its surrounding
anatomic landmarks: 15 to 20 mm from medial canthus; 9
to 14 mm anterior to corneal plane on profile; 4 to 6 mm
behind glabellar line; and at lower border of upper lid,
among others.
9
 SRPS • Volume 11 • Issue C7 • 2015
Gs
R STF
T in on the anatomic illustrations and are marked on the
ABP
S done surgically and the operative outcome.
SMEs
Figure 8. Frontal view illustration shows ideal relations and
proportions of the facial structures. (Modified from Byrd.61)
VISUAL DOCUMENTATION
Photography
Krugman64 reviewed photoanalysis and emphasized the
neoclassical facial proportions and holistic treatment
planning. Guyuron65 indicated the advantage of full-
scale, life-sized photography as an adjunct to soft-tissue
cephalometric analysis for rhinoplasty and described his
facial analysis system, which includes proportions, angles,
measurements, and recommended profile template.
Preoperatively, the system is used to confirm the treatment
plan and to serve as a baseline; postoperatively it can
help identify shortcomings in the rhinoplasty technique.
Schwartz and Tardy66 proposed a standardized system of
photodocumentation for rhinoplasty and made specific
recommendations regarding views, lighting,
and equipment.
Galdino et al. listed additional considerations
67
for maintaining detail and consistency in digital
photodocumentation of the nose. The authors discussed
various printing methods.
10
Anatomic Drawings
Gunter68 suggested a pictorial system to graphically record
intraoperative maneuvers during rhinoplasty. With this
system, a worksheet consisting of four views of the nose
and a checklist of possible surgical details and steps are
included in every patient’s chart. The type of rhinoplasty;
surgical approach; operations on the tip, lateral crura,
medial crura, dorsum, and nasal bones; use of grafts or
implants; and miscellaneous adjunctive procedures are all
recorded. The actual events during rhinoplasty are drawn
checklist. The value of this standardized graphic record lies
in the objective correlation it affords between what was
Computer Imaging
Computer imaging is another graphic tool that can
be used for preoperative evaluation and postoperative
assessment. Sophisticated hardware and software are
available in both PC and Macintosh platforms. The more
valuable systems can import undistorted, life-size images
and alter them by incremental differences in nasal length,
tip projection, angles, width, and shadowing.
For computer representations to be realistic, users
must project their true surgical skills. Computer imaging is
controversial because it is so powerful: Used as a marketing
tool, it can mislead patients into expecting a surgical result
that is impossible to achieve. Used properly, computer
imaging can offer a precise record of the deformity and its
proposed correction, a scaled surgical plan, and an exact
surgical record.
Mattison69 presented a review of facial video image
processing, with emphasis on image capture, software
modification, development of a surgical plan, and
comparison of pre- and postsurgical results. Schoenrock70
reported his 5-year experience with computer imaging.
Bronz71 recounted the predictability of surgical planning
with a computer imaging system in 100 primary
rhinoplasty cases.
Vuyk et al.72 used a patient questionnaire to assess
the role of computer imaging in facial plastic surgery. Most
patients (>80%) found computer imaging to be helpful
in communicating with the surgeon, both for expressing
their wishes and expectations and for facilitating the

decision for or against a particular surgical change. The
majority of the patients who participated in the study also
thought that computer imaging should be a routine part of
preoperative evaluation for plastic surgery. The predictive
value of computer tracings was approximately 80%.
Adelson et al.,73 in a retrospective study, objectively
evaluated the accuracy by which computer-simulated
rhinoplasty images reflect the surgical outcomes. No
significant difference was observed when comparing
computer-simulated images and 6-month postoperative
photographs when analyzing nasolabial angle, nasofrontal
angle, columellar:infratip lobule ratio, and tip projection.
The only measurement found to be significantly different
was the columella tip angle. The authors concluded that
computer-simulated images help educate and engage the
patient in a discussion in which desires and expectations
are assessed and controlled.
PATIENT SELECTION
Selection of the appropriate patient for rhinoplasty
depends on communication. The surgeon must listen and
understand the patient’s wishes and balance them against
his or her estimate of what can reasonably be
achieved surgically.
Thomson74 listed criteria to be used in the selection
and counseling of patients for rhinoplasty and cautioned
against certain recognizable types of individuals: those
who are super-secretive, are unable to identify their desires,
request urgent operation, are overly concerned with minor
deformities, have secondary motivations, are excessively
demanding, carry a number of photographs describing
their preferred nose, or are extremely indecisive and male
patients. Tardy et al.75 emphasized the importance of
preoperative interviews.
Goin discussed the psychology of rhinoplasty
76
patients. Honigman et al.77 reviewed the literature on
psychological outcomes after cosmetic surgery and
identified consistent predictors of a poor
psychosocial outcome.
In a retrospective study of 150 secondary
rhinoplasty patients, Constantian78 noted four anatomic
variants that are strongly predisposed to unfavorable
results: low radix and/or low dorsum, narrow midvault,
inadequate tip projection, and alar cartilage malposition.
SRPS • Volume 11 • Issue C7 • 2015
The triad of low radix, narrow midvault, and inadequate
tip projection was the most common combination (40%)
in patients seeking secondary rhinoplasty. More recently,
Constantian79 reviewed 100 consecutive cases of primary
rhinoplasty and reported inadequate tip projection in
67%, cephalic malrotation of the lateral crura in 46%, and
too prominent s tip in 23%.
Hellings et al.80 reported that long-term satisfaction
after revision rhinoplasty was obtained mainly in young
adult and middle-aged patients, without major differences
between male and female patients. Not surprisingly, an
inverse correlation was found between satisfaction and
number of previous rhinoplasties.
Male Rhinoplasty
Daniel81 acknowledged the validity of the SIMON
profile presented by Gorney82: Single, Immature Male,
Overly expectant, and Narcissistic. These patients
are psychologically unstable and poor candidates for
rhinoplastic surgery but reportedly constitute only
approximately 15% of men seeking rhinoplasty. Men’s
noses tend to be more variable in aesthetic measurements,
with wide ranges in level of nasion, height of nasion, and
relation between endocanthus and nasal base. Daniel’s goal
in male rhinoplasty is a “strong” profile and no
supratip break.
Rohrich et al.83 described male rhinoplasty patients
as typically nonspecific regarding their complaints, more
demanding, and less attentive during consultations. It
is important to avoid excessive dorsal reduction or tip
refinement in this patient cohort.
Timing
Septal cartilage and nasal bones have important roles in
the outgrowth of the midface. Therefore, rhinoplasty
should be postponed until growth affecting this region is
completed. van der Heijden et al.84 performed a systematic
review to determine the end of the nasofacial growth
spurt, which was defined as the age at which nasofacial
growth velocity curves have their steepest descending
slope. The authors concluded that rhinoseptoplasty can be
safely performed in girls after the age or 16 years and in
boys after the age of 17 years. Based on their retrospective
11
 SRPS • Volume 11 • Issue C7 • 2015
clinical study, Shandilya et al.85 outlined the indications
for nasal correction in the pediatric population: acute
nasal trauma, septal abscess, malignancies, severe septal
deviations causing nasal airway obstruction, benign
tumors, and nasal deformities associated with cleft lip.
ANESTHESIA
General anesthesia is recommended when operating on
an apprehensive patient, for procedures involving deep
septovomerine manipulation, and in some posttraumatic
deformities accompanied by intranasal scarring. A
prospective study conducted by Demiraran et al.86
evaluating postoperative analgesia and vasoconstriction
concluded that local infiltration of levobupivacaine 0.25%
plain was significantly more potent and longer lasting than
that achieved by lidocaine 2% with epinephrine in patients
undergoing nasal surgery. No significant difference was
noted between the study groups regarding the preoperative
and postoperative hemoglobin values.
Moscona et al.87 compared sedation techniques for
outpatient rhinoplasty in 859 cases. Patients were assigned
to one of two groups: those who received midazolam and
those who received midazolam plus ketamine. Sedation
scores showed that both groups were adequately sedated.
Patients in the midazolam plus ketamine group were
less likely to remember the injections and were more
satisfied with their surgical experience. Van Noord and
Cupp88 examined different types of systemic sedation-
analgesia in nasal surgery. The authors concluded that
intravenously administered conscious sedation is associated
with a lower risk of airway or ventilation problems when
compared with deep sedation and a lower risk of deep vein
thrombosis when compared with general endotracheal
anesthesia. A high level of patient satisfaction was noted
with intravenously administered conscious sedation.
Miller et al.89 recommended topical administration
of 4% to 5% cocaine solution to enhance anesthesia
and induce vasoconstriction while avoiding high
plasma concentrations of cocaine. Mixing cocaine with
epinephrine offers no advantage, and the toxic effects of
“cocaine mud” are well documented. Thevasagayam et
al.,90 in a prospective study, noted no significant difference
in blood loss or surgical field visualization between a group
infiltrated with lidocaine 2% with epinephrine 1:80,000
and another group infiltrated with lidocaine 2% plain. A
significant increase in systolic blood pressure was observed
12
in the group receiving epinephrine. The authors concluded
that the use of epinephrine with cocaine paste does not
improve hemostasis or surgical field visualization.
In a prospective, randomized study of 12
consecutive patients, Liao et al.91 tried to identify factors
that influenced the safe use of topical cocaine during
rhinoplasty. Group 1 received cotton pledgets soaked in
4 mL of 4% cocaine solution for 10 minutes; group 2
received 4 mL of 4% solution for 20 minutes; and group
3 received 4 mL of 10% solution for 20 minutes. Serum
cocaine concentrations were measured at intervals of 5,
10, 15, and 20 minutes. Of the total cocaine applied,
35% was absorbed systemically within 15 minutes of
application. This absorption rate was four times higher
than expected and led the authors to conclude that topical
use of 10% cocaine was to be avoided. Metzinger et al.92
recommended adding 1 part sodium bicarbonate to 5
parts local anesthetic to lessen the pain and irritation of
injections during rhinoplasty.
SURGICAL TECHNIQUES
The classic concept of “reduction rhinoplasty” presented
by Joseph5 and updated by Aufricht93 has evolved
substantially during the past 35 years. According to Rees,94
“...the highly styled retroussé nose of the
past has given way to emphasis on a more
natural look with higher dorsal profile, less
tip elevation, and less sculpturing of the
alar cartilages. The ‘operated look’ is to be
avoided at all costs.”
In 1977, Rees94 listed the trends in rhinoplasty
as follows:
•• less removal of tissue
•• more preservation of structures
•• a decided tendency toward “under-
operation” rather than “over-operation”
To this list, we can now add the following:
•• incisions designed to preserve lining and
soft tissue
•• resection of only the bare redundancy of the
ULC
•• correction of the nasal tip first, or at least
early in the procedure, before modifying
the dorsum
 SRPS • Volume 11 • Issue C7 • 2015

•• a tendency to avoid transecting the domes Intranasal Approach

or otherwise avoid interrupting the spring
The intranasal approach to rhinoplasty includes several
of the alar cartilages
routes of access to the nose (Fig. 9),108 as follows:
•• maximum preservation of the caudal border
of the septum •• intercartilaginous incisions between the
upper and lower lateral cartilages
•• resection of the nasal spine only in well-
defined, isolated cases •• transcartilaginous (cartilage-splitting)
incisions through the lower lateral cartilages
•• less frequent medial osteotomies
•• infracartilaginous incisions following the
•• rare outfracturing
caudal border of the lower lateral cartilages
The techniques presented by Anderson,95−97
Peck, Rees,99 Sheen and Sheen,100 and Goodman101 are
98 •• combinations of the above, with or without
representative of current concepts in rhinoplasty. Peck102 a transfixion incision through cartilaginous
described the preferred basic approach to rhinoplasty and or membranous septum caudally99,108
emphasized that the most important aesthetic goal is to Deformities requiring wide exposure, such as tip
create a pleasing tip that will stand out gracefully from the
asymmetries, high dorsal septal deviations, and severe
straight nasal bridge.
posttraumatic deformities, frequently are approached
Sheen’s original methods of nasal augmentation, through cartilage-delivery methods using infracartilaginous
along with his refinements of surgical techniques for or marginal incisions, singly or in conjunction with an
the correction of secondary nasal deformities,103−106 intercartilaginous incision. They can also be combined
further expanded modern rhinoplastic alternatives. In
with a transcolumellar incision and converted to an
a retrospective titled “Rhinoplasty: Personal Evolution
external approach. If the nasal tip morphology is normal,
and Milestones,” Sheen107 reviewed the milestones in this
one should avoid dissection of the tip structures as part of
evolution, as follows:
the exposure.
1) vestibular stenosis: diagnosis of a surgical
consequence
2) etiology and treatment of supratip
deformity: the dynamic relationship of
soft-tissue contour to skeleton
3) etiology and treatment of the tip with
inadequate projection: tip graft design
4) practical aesthetics of balance: the
augmentation-reduction approach
to rhinoplasty
5) support of the middle vault: functional and
aesthetic effects
6) malposition of the lateral crura: recognition
and management
7) significance of the middle crura: clinical
and aesthetic considerations
Figure 9. Rhinoplasty intranasal incisions. (Reprinted with
The review by Sheen and the techniques therein should be permission from Dingman and Natvig.108)
carefully studied by all rhinoplastic surgeons.

13
 SRPS • Volume 11 • Issue C7 • 2015
External (Open) Approach
The open approach to rhinoplasty consists of bilateral
marginal or rim incisions along the inferior border of
the alar cartilages that are connected in the midline by a
transcolumellar skin incision 5 to 7 mm long (Fig. 10);
it does not include the large skin incision presented by
Joseph.5 Aksu et al.109 compared two different columellar
incision designs in a retrospective study. The authors
concluded that the inverted-V incision results in a better
scar formation and less notching than does a transverse
columellar incision. The main difference between the
external and internal approaches is that the external
approach allows exposure of the tip-lobule complex
Figure 10. Incisions used in external approach
to rhinoplasty.
without disturbing intercrural and alar-septal attachments.
Adams et al.110 reviewed nasal tip support in open
and closed rhinoplasty. The mean loss of tip projection
with the open approach was 3.43 mm, versus 1.98 mm
for the closed approach. The difference was attributed to
greater ligamentous disruption and skin undermining with
the open approach. Septal manipulation was associated
with decreased tip support regardless of approach.
Rethi111 used a partial, high-transverse columellar
incision that failed to uncover the entire nasal skeleton.
Sercer112 extended the incision used by Rethi to expose
the entire osseocartilaginous framework of the nose.
14
Padovan113 further expanded the open rhinoplasty concept
and incorporated his treatment of the nasal septum. Bravo
and Schwarze.114 described a closed-open rhinoplasty
technique with extended lip dissection, which comprises
an alar base resection incision with complete undermining
of the area between the nasal base and the upper lip. The
approach allows full access to the entire osteocartilaginous
framework while avoiding a transcolumellar incision.
Goodman101 described his technique of external
rhinoplasty and reported his experience with 74
patients.115 Wright and Kridel116 endorsed the method
presented by Goodman and listed the following advantages
to the external rhinoplasty procedure:
•• better binocular visualization for teaching
and studying deformed anatomy
•• control of bleeding by electrocautery
•• more accurate diagnosis
•• more precise correction of deformities
The external approach offers all the advantages
of the cartilage-delivery technique plus simultaneous
bilateral visualization of the lower lateral cartilages in their
resting state without retraction. This additional exposure
can be of benefit when dealing with an asymmetric
tip or when correcting tip projection, for which it is
desirable to maintain the soft-tissue attachments117 while
simultaneously evaluating the unloaded support to the
tip complex.
On the other hand, the external approach implies
unnecessary degloving of the tip-lobule complex when tip
projection is normal. In this case, the increased exposure
gained by the open approach must be balanced against
the risk of altering tip support or tip definition while
dissecting the dome. Goodman118 noted the following
limitations and potential complications of the
open approach:
•• separation and secondary healing of the
transverse columellar incision
•• additional edema of the nasal tip persisting
for several months
•• increased operative time for incision closure
The indications for the external approach remain
arguable, even among current masters of rhinoplasty.

Anderson119 expressed some concern regarding the
resulting scar and suggested that the external rhinoplasty
technique might be most applicable in long-standing,
severe, posttraumatic nasal deformities. Friedman and
Gruber120 adopted the open rhinoplasty technique because
of the increased exposure it affords but concluded that it
probably is not necessary if the cartilaginous vault or tip
does not need much modification.
Constantian121 reviewed 100 consecutive patients
who underwent secondary rhinoplasty and reported that
36% had undergone open rhinoplasty at the previous
surgery. The patients’ symptoms were related to an over-
resected dorsum or tip and internal nasal valve collapse.
Excessive columellar length, hard columellar struts, alar
and/or nostril distortion, narrow nose, and external
valvular obstruction were more common in this group
than in patients undergoing primary closed rhinoplasty.
Surgical Approaches to the Tip
Most surgical approaches to the nasal tip are variations
of the retrograde technique, cartilage-splitting technique,
cartilage-delivery technique, or external approach.
Retrograde Technique
The retrograde or eversion technique presented by
Converse122 uses a single intercartilaginous incision
for access to the nasal dorsum, the cephalic portion of
the alar cartilage, and the inferior scroll of the ULC.
It also preserves an intact caudal rim of alar cartilage
after resection. The retrograde technique is indicated
for deformities requiring minimal cephalad resection
of the alar cartilages, minimal dome manipulation or
modification, and minimal cephalad rotation of the
lobule complex. Relative disadvantages of the retrograde
technique are a difficult dissection, less visibility, and
limited access to the dome-medial crural areas.
Cartilage-Splitting Technique
Anderson95 and Webster et al.123 used intracartilaginous
incisions paralleling the caudal border of the alar cartilages.
At the lateral aspect of the lateral crura, variable amounts
of cartilage are resected according to individual anatomy
SRPS • Volume 11 • Issue C7 • 2015
and degree of tip rotation desired (Fig. 11).123
The cartilage-splitting approach is best suited to
symmetrical tips that require cephalad resection of the alar
cartilages, with or without cephalad rotation of the lobule
complex, and to tips that require only minimal refinement.
If substantial asymmetry is present or the dome needs to
be modified, it might be better to use a different approach
to gain direct access to the area. Peck102,124 noted a
preference for the cartilage-splitting incision for
routine rhinoplasties.
The advantages of the cartilage-splitting technique
are as follows: 1) one incision with minimal trauma to
the cartilage and soft tissue, 2) no disruption or dissection
of the residual caudal alar segment, and 3) absence of an
incision through the “nasal valve” area at the junction of
the upper and lower laterals. Disadvantages include the
following: 1) limited visibility of the dome and medial
crura; 2) possible asymmetry if the incisions are not
precisely equal bilaterally; 3) decreased tip projection if
the incision at the dome is too far caudal, which alters
the pivot point of the lobule (Fig. 12);96 and 4) possible
collapse of the lateral crura and alar notching if the caudal
rim is weakened by over-resection.
Cartilage-Delivery Techniques
Techniques that deliver the alar cartilages for direct
visualization have been described by Sheen and Sheen,100
Becker,125 and Bernstein.126 Access to the lobule is by
combined intercartilaginous and infracartilaginous (alar
margin) incisions that offer greater visibility of the alar
cartilages. The entire lower lateral cartilage with attached
vestibular skin and mucosa is exteriorized as a bipedicled
chondrocutaneous flap. It is easier to manipulate the
dome areas under direct vision to correct secondary tip
deformities, and better postoperative tip symmetry can
be achieved because the surgeon can see the amount of
cartilage remaining and possibly contour the existing
cartilage without resection. The cartilage-delivery
technique is most appropriate for difficult nasal tip
deformities such as asymmetries and twisted, bulbous, box,
bifid, or over-projecting tips.127
Disadvantages of the cartilage-delivery technique
include increased trauma from the dissection, a worse scar
from two incisions, and the risk of injury to the caudal
15
 SRPS • Volume 11 • Issue C7 • 2015
Figure 11. Tip reduction by resection of variable amounts
of alar cartilage to produce cephalad rotation of the tip.
A, Complete strip excision. B, Rim strip excision. C, Lateral
crural flap. D, Complete curved strip excision. (Reprinted
with permission from Webster et al.123)
A B
Caudal end of septum
Pivot point of rotation
X
Lateral crus
Figure 12. Cartilage-splitting incisions have changed the
pivot point of tip rotation. Before (A) and after (B) splitting
the alar cartilages. (Modified from Anderson.96)
16
strip of the alar cartilage from the marginal incision. One
must be careful not to penetrate the soft triangle, because,
as noted by Sheen and Sheen,100 any incision in the soft
triangle could cause deformity of the tip.
THE OSSEOCARTILAGINOUS VAULT
Dorsal Reduction
The nasal dorsum can be lowered either before or after
the tip is modified. Rees,94 Anderson,96 and Peck128 noted
a preference for initial tip modification with subsequent
lowering of the dorsum to a level appropriate for the
revised tip. Safian129 and Sheen and Sheen,100 on the
other hand, noted a preference for initial reduction of the
dorsum and then tip modification.
When tip projection is adequate or excessive and a
small hump removal is anticipated, dorsal reduction might
best be performed before tip modification. A conservative,
controlled dorsal reduction using a sharp rasp is a safe way
to avoid over-reduction, according to Rees,94 Sheen and
Sheen,100 and Peck.128
When tip projection is marginal or inadequate, it
seems logical to maneuver the tip first to achieve as much
tip projection as possible and then lower the dorsum
(instead of first lowering the dorsum, perhaps excessively,
in an attempt to achieve a dorsal line below the level of
tip projection). Constantian130 described a notch that
tends to appear “at the midpoint of the nasal dorsum
when the bridge has been resected beyond the ability of
the soft tissues to contract. This notch, commonly seen in
secondary rhinoplasty patients, occurs at the cephalic end
of the supratip convexity and appears whether or not the
tip has been overresected.”130
Skoog131 performed composite resection of the bony
and cartilaginous dorsum, tailoring the removed unit and
replacing it as a dorsal osseocartilaginous composite graft.
The original indications for the operation included severely
deviated noses in which extensive dorsal reduction was
anticipated; any residual septal deformities could thus be
camouflaged by the dorsal autograft.
Regnault and Alfaro132 further refined the
procedure, and Lejour et al.133 used the Skoog technique
routinely when dorsal reduction was indicated. Although
hump reinsertion might seem overly aggressive by current

standards of practice, the technique should be considered
in patients with very short nasal bones for whom lateral
osteotomies would be risky and in select cases of septal
deviation in which septal modification could lead to total
collapse of nasal support. The disadvantage of the Skoog
technique for routine rhinoplasty is the potential for
displacement and resorption of the dorsal graft.
Often, the dorsal hump deformity consists more
of cartilage than of bone.13,94 The cartilaginous dorsum,
including the septum and ULC, can be reduced by
composite resection100 or by separating the ULC from
their junction with the septum dorsally and resecting
each separately.99
With small dorsal humps (most frequent),
composite resection maintains mucosal integrity without
formal extra-mucosal tunnel dissection and avoids the
risk of narrowing mucosal surfaces at the septum-ULC
junction as a result of scar contracture. With large hump
deformities, it is necessary to divide the ULC from the
septum extra-mucosally and to resect the attached and
potentially redundant mucosa to keep it from heaping
over the dorsal profile. When ULC have to be separated
from the dorsal septum to correct a markedly deviated
nose or for better septal exposure, submucosal tunnels or
extramucosal dissection from the underside of the septum-
ULC junction preserves mucosal integrity.
Rohrich et al.134 advocated a gradual approach to
dorsal reduction to avoid complications such as dorsal
irregularities, over-resection, inverted-V deformities, and
excessive narrowing of the midvault. The authors listed five
critical steps: 1) separation of the ULC from the septum,
2) incremental reduction of the cartilaginous septum,
3) dorsal bony reduction with rasps, 4) verification
by palpation, and 5) final modification. Bilateral
submucoperichondrial tunnels are created before releasing
the ULC from the septum to preserve the cartilages and
mucosa of the internal nasal valves.
Sheen and Sheen100 recommended oblique rasping
across the bones to minimize pull on the ULC from below.
This prevents accidental avulsion of the cephalic portions
of the ULC from their junction with the nasal bones
during rasp reduction of the bony dorsum. Guyuron135
recommended the use of a guarded power burr for
deepening the nasofrontal angle. In substantial reductions
of the nasofrontal junction, the burr is more effective than
SRPS • Volume 11 • Issue C7 • 2015
a rasp, electric saw, or osteotome.
Mommaerts et al.136 described a reduction
osteotomy in which the osteotome enters the vertical
frontonasal suture behind the nasal bones and in front of
the nasal spine of the frontal bone. In our view, reduction
of the nasofrontal junction presents two problems. One,
the soft-tissue response to bony removal is approximately
50%. Two, as the nasofrontal junction deepens, the
intercanthal bridge lines visibly widen. Successful bone
removal in this area, therefore, can be tempered by a
compromise in nasal aesthetics.
Sheen and Sheen100 recommended spreader grafts
for reconstruction of the middle roof in patients who have
a narrow nose with visible depression of the lateral walls
and abnormal valving on inspiration. Noses predisposed to
midvault collapse (e.g., noses with short bones, thin skin,
weak cartilages, or combinations of these) are too narrow
after resection of the roof and might benefit from
spreader grafts.
Byrd et al.137 described the use of an autospreader
flap when performing dorsal reduction. Autospreader
flaps consist of the transverse portion of the ULC, which
are rotated medially to function as a local spreader flap
while reducing the profile of the dorsum and preserving
the aesthetic lines (Fig. 13).137 Gruber et al.138 reported a
similar technique that uses spreader flaps to reconstruct
the middle third of the nose in primary rhinoplasty.
Skeletal Manipulation and the Soft Tissues
Guyuron139 studied the reaction of the soft tissues to
skeletal reduction over several zones of the nose (Table 1).
The author combined data on soft-tissue response with
preoperative records of the soft-tissue outline to formulate
a plan for precise nasal reduction.
Two factors influence the response rate: 1) the
thickness of the skin and soft tissues overlying the
skeleton; and 2) patient age, which modulates the
degree of movement of the soft tissues in several zones.
Unfortunately, in the clinical situation, the soft-tissue
response to skeletal reduction is not linear over the length
of the nose (i.e., a direct, regularly progressive soft-tissue
response does not hold throughout). As the degree of
skeletal reduction increases, the soft-tissue response
decreases because of redundancy and “memory” of the
17
 SRPS • Volume 11 • Issue C7 • 2015

Figure 13. Internally rotating the upper lateral cartilage maintains the nasal valve (green arrows). (Reprinted with permission
from Byrd et at.137)

soft-tissue envelope. Some studies140,141 indicated that
standard maneuvers in tip modification usually decrease
tip projection.
Statistical analysis of these changes led
Guyuron142,143 to the following conclusions:
•• Resection of the caudal septum, caudal
borders of the medial crura, or cephalic
portions of the lower lateral cartilage (LLC)
produces cephalad rotation of the tip, in
decreasing order of effectiveness.

•• Reduction of the nasion renders the
appearance of increased intercanthal
distance and a longer nose.
•• Reduction of the nasal bridge results in a
wider nose on frontal view and a tip rotated
upward on profile.
•• Augmentation of the bridge makes the nose
look narrower.
•• Resection of the alar base not only narrows
the nostrils but also moves the alar rims
caudally and reduces tip projection when
severe enough.
•• Resection of the nasal spine increases upper
lip length on profile and decreases tip
projection by weakening support for the
medial crura.

18

TABLE 1
Reaction of Soft Tissues to Skeletal Reduction139
Bony Reduction
Nasion and nasal spine
Proximal and midnasal bridge
Supratip
Tip-lobule angle and infratip
Pessa et al.144 used three-dimensional computed
tomographic scans of patients in two age groups to assess
skeletal remodeling of the nasal profile after rhinoplasty.
The authors reported continued, differential growth of
the craniofacial skeleton, with the piriform aperture area
changing the most. This ongoing posterior movement of
the maxilla manifested as a retruded nasal profile with age.
Dorsal Augmentation and the Nasofrontal Angle
The higher the nasal dorsum is, the smaller the nasal base
looks. Constantian145 recommended raising the nasal
bridge to offset the appearance of an augmented base.
This strategy limits the amount of nasal skeletal reduction
necessary, decreases the potential for postoperative change
and soft-tissue distortion, and increases the surgeon’s
control over the results.
Ortiz-Monasterio and Michelena146 presented
a review of techniques for nasal dorsal augmentation
with autogenous cartilage and bone grafts. The authors
preferred nasal septum as a graft material, sometimes
stacked two and three layers thick. The longitudinal graft
pieces are scored lengthwise on their external surface so
that they conform to the nasal bridge contour. When the
septum is not available in sufficient quantities, the authors
recommend use of composite cartilage-bone grafts from
the rib molded to the appropriate shape.
SRPS • Volume 11 • Issue C7 • 2015
Soft-Tissue Response (%)
25
60
43
40
Gunter and Rohrich147 described U- and A-shaped
modifications of septal cartilage grafts for nasal dorsal
augmentation to raise the nasofrontal angle. The authors
included descriptions of the indications and surgical
technique for these tailored septal grafts.
Dorsal surface irregularities can occur after
alteration of the osseocartilaginous vault. McKinney et
al.148 advocated use of a thin septal graft to reconstruct the
nasal dorsum after osteotomy. The authors noted, “nasal
hump resection converts a smooth, fused nasal ‘cap’ into
five separate components. This may unmask a twist in the
septum, expose sharp irregular edges, evidence an open
roof deformity, and/or develop a pinched middle third as a
result of removal of the spreader effect of the hump.” The
septal graft proposed by the authors is durable enough to
camouflage contour irregularities yet thin enough not to
raise the dorsum. If septum is not available, the authors
opt for a double layer of temporalis fascia rather than
synthetic material.
Endo et al.149 reviewed 1200 cases of augmentation
rhinoplasty with ear cartilage grafts, including replacement
of silicone prostheses in 40%. Complications developed
in 4% of the cases, the most common of which was graft
malposition. The infection rate in that series was 0.5%.
Crushed cartilage grafts have also been recommended for
use after reduction of the dorsum.
19
 SRPS • Volume 11 • Issue C7 • 2015
More recently, Gryskiewicz et al.150 proposed the
use of Alloderm (LifeCell Corporation, Branchburg,
New Jersey) for the correction of dorsal contour
irregularities and minimal dorsal augmentation. The
authors reported that Alloderm is stable (non-shifting),
soft, and natural-looking. A 2+-year follow-up of 20
patients disclosed partial graft absorption in 45%; three
patients required reoperation. The authors recommended
slight overcorrection in the nasal dorsum, which exhibits
the highest rate of resorption. A subsequent article151
assessed results in patients who had undergone secondary
rhinoplasty and confirmed 20% to 30% graft resorption
over the dorsum and 10% to 15% resorption over the tip.
Jackson and Yavuzer152 noted excellent outcomes
with Alloderm for camouflage of dorsal nasal irregularities.
Alloderm blocks adhesions between the osseocartilaginous
vault and overlying skin and helps conceal scars. The
authors found no substantial absorption or recurrence of
deformity in 15 patients who were followed for 6 to 24
months postoperatively.
Erol153 described an adjunctive procedure for dorsal
camouflage or augmentation in primary and secondary
rhinoplasty. The technique, called Turkish delight, involves
diced cartilage wrapped in Surgicel (Johnson & Johnson
Ethicon, Somerville, New Jersey) and shaped as a tube.
The roll is inserted in the nasal dorsum and molded to fit
the desired contour after closure of incisions. The author
reported a 0.7% complication rate in 2365 rhinoplasties,
with over-correction and partial resorption in 0.5%.
Elahi et al.154 used a modified Erol technique for
augmentation rhinoplasty in 67 patients and reported
good retention of the graft material for up to 24 months.
Subsequent studies by other authors using the technique
presented by Erol153 have yielded variable results. Daniel
and Calvert155 examined the use of diced cartilage wrapped
in Surgicel (group 1), wrapped in fascia (group 2), and
with no wrapping (group 3). Complete resorption of the
cartilage occurred in the Surgicel group and good survival
of the cartilage grafts occurred in the other two groups.
The authors reported that the Turkish delight technique
might be useful for minor camouflaging but question its
usefulness for marked dorsal augmentation.
Brenner et al.156 studied the survival of four kinds
of diced cartilage grafts implanted in dorsal skin pockets
of rats: cartilage and Surgicel, cartilage and fascia, fascia
20
alone, and Surgicel alone. The lowest cartilage viability
occurred in the cartilage wrapped with Surgicel group,
probably because of the inflammatory response elicited
by Surgicel.
Daniel157 reviewed three types of diced cartilage
grafts in rhinoplasty: diced cartilage, diced cartilage
wrapped in fascia that is sewn closed, and diced cartilage
covered with fascia after graft placement. Diced cartilage
without fascia is mostly reserved for the peripyriform
and radix area and for alongside structural rib grafts.
Good results were achieved with all three diced cartilage
techniques, and no revision surgery was needed. The most
common technical problems were overcorrection, visibility,
and junctional step-offs.
Nasal Osteotomies
Outfracture involves levering the nasal bones laterally
through a medial osteotomy to complete the cephalad
portion of the fracture of the nasal bones. The current
trend in rhinoplasty is away from this maneuver because it
can produce a “rocker” deformity.
The indications for nasal bone infracture continue
to be debated. Infracture is useful for accomplishing
either of two goals: 1) closure of an open roof after hump
removal to narrow the apex or roof of the nose, and 2)
narrowing the base of the bony cartilaginous pyramid.
Depending on the thickness of the septum and the dorsal
angle of the septum-ULC- junction, a certain amount
of the nasal dorsum can be removed without creating a
space between the septum and nasal bones or between the
septum and upper laterals (an open roof ). Removal of a
small dorsal hump deformity does not necessarily produce
an open roof, and infracture of the nasal bones only
narrows the base of the bony cartilaginous pyramid, not its
apex or roof.
Two questions should be asked before undertaking
an osteotomy: 1) Is there an open roof rendering a flat
appearance to the nasal dorsum? and 2) Is the base of
the bony pyramid excessively wide on frontal view such
that the aesthetic lines at the base of the pyramid do
not parallel the aesthetic lines from superciliary ridge
to nasal tip along the dorsum of the pyramid? Routine
or unnecessary nasal bone infracture in the absence of
a notable open roof or when the nasal bones are not

divergent can produce a pinched appearance to the upper
and middle third of the nose.
Osteotomies of the nasal bones are classified
as follows:
•• low-to-low lateral osteotomy with greenstick
fracture of the cephalic portion of the nasal
bones at their junction with the
frontal bones99
•• low-to-low osteotomy along the frontal
process of the maxilla and extending to
connect the cephalic portion of the lateral
osteotomy with the nasal dorsum at
the radix99
•• low-to-high osteotomy beginning low at
the frontal process of the maxilla caudally
and curving upward to pass lateral to the
dorsum at the radix100
•• high lateral osteotomy95 beginning along the
base of the nasal bones at the frontal process
of the maxilla caudally and curving toward
the dorsum at the radix158
•• medial osteotomies passing vertically
between the septum and the nasal bones
and extending cephalad to the nasal process
of the frontal bone
Sheen and Sheen listed the advantages of the low-
100
to-high osteotomy as follows: 1) the residual cephalic nasal
bone bridge is narrow and can be fractured with minimal
digital pressure; 2) bony continuity is maintained when
the remaining cephalic segment is greenstick fractured;
and 3) outfracture, infracture, and disarticulation of the
nasal bones are unnecessary.
In cases in which the bony pyramid has an
excessively wide base and bony apex but the dorsal
projection is normal, a lateral osteotomy is indicated.
Care must be taken to circumscribe the abnormally wide
portion of the skeleton with the osteotomy. Laterally,
periosteal elevation and soft-tissue undermining should be
kept to a minimum to maintain soft-tissue attachments
to the lateral portion of the nasal bones. The soft-tissue
attachments keep the bones from collapsing into the
piriform aperture when mobilized.41,102 Arfaj et al.159
recommended performing lateral osteotomy without
SRPS • Volume 11 • Issue C7 • 2015
periosteal elevation to minimize postoperative periorbital
ecchymosis despite the higher chance of disrupting blood
vessels and causing bleeding. The intact periosteum acts as
a barrier, preventing the blood from extravasating to the
adjacent periorbital subcutaneous tissue. Infracture alone
will not succeed in narrowing the apex, however, so that a
medial osteotomy and frequently a medial ostectomy are
necessary to displace the osteotomized segment medially.
Rees99 and Sheen and Sheen100 caution that an
excessively high osteotomy performed laterally along
the nasal bone can produce a visible ridge or stair-step
deformity at the base of the bony pyramid. To avoid this
problem, the authors proposed technical modifications
that leave a narrow residual cephalic segment that is
reportedly easier to greenstick fracture without direct or
medial osteotomy.
Wright160 in 1961 and later Daniel and Lessard13
evaluated the effects of various types of hump removal,
osteotomy, and nasal dorsal dissection using cadavers. The
authors concluded the following:
•• saw cuts produce less comminution than
chisel cuts (but this seems to be more of a
disadvantage than an advantage)
•• rasping is safest and simplest for
hump reduction
•• closure of an open roof necessitates medial
movement of the bony vault that is greater
at its caudal end
•• the length of the hump, especially its
cephalic extent, determines how medial
movement will occur
•• after excision of a hump that extends above
the inter-canthal line, medial fracture or
osteotomy might be required
•• in smaller humps that end below the inter-
canthal line, a transverse fracture is required
•• the most satisfactory infracture method
is that presented by Becker125 (lateral
osteotomy with greenstick fracture at the
cephalad portion of the bones); the small
spur on the residual superior portion of the
nasal bone at the nasofrontal junction can
be rasped
21
 SRPS • Volume 11 • Issue C7 • 2015
•• the bony triangle above the intercanthal line
is virtually impregnable, and narrowing it
requires rongeuring the bony web
•• medial osteotomy with outfracture of the
superior attachment of the nasal bones
is not desirable because it produces an
unintended angling of the open dorsum
and curved fracture lines following a
curved osteotomy; if the fracture line at
its cephalad end does not reach the nasal
dorsum, a bony bridge can persist and cause
a rocker effect, levering outward after the
nasal bones are moved inward
•• with infracture of the nasal bones
after lateral osteotomy without medial
osteotomy, the bones do not spring back
into their original position as long as the
site of greenstick fracture is the thin upper
portion of the nasal bones and not the
upper heavier portion; transverse fractures
pass through the body of the nasal bones
and not through the naso-frontal suture line
•• potential problems of the low-to-low
osteotomy with greenstick fracture are
incomplete fracture or spicule formation
in the cephalad portion; if this does not
fracture readily, a 2-mm osteotome can
be inserted through a stab incision in the
glabellar or canthal area to complete the
fracture line
•• if the low-to-low osteotomy leaves a wide
cephalic portion of nasal bone, direct
transverse osteotomy with a small osteotome
through a stab incision is more precise
than medial osteotomy and outfracture or
greenstick fracture
Rohrich et al.161 found that the external perforated
osteotomy technique produced consistent results in
rhinoplasty with minimal postoperative complications.
The osteotomies should be designed to cut through
intermediate or transitional zones of bony thickness, such
as along the lateral nasal wall. A comparative, endoscopic
study in cadavers162,163 confirmed the superiority of
external osteotomies in minimizing intranasal trauma:
22
mucosal tears were seen in 11% of external perforated
osteotomies versus 74% of internal
continuous osteotomies.
Harshbarger and Sullivan164 studied the bony
thickness and fracture patterns of the medial nasal
osteotomy. The authors drilled 1-mm holes along the left
nasal bones in 17 cadavers and found that bone thickness
gradually increased from caudal to cephalic and from
lateral to medial, leaving a natural cleavage plane. The
right hemi-noses had medial osteotomies at 0° or 15° from
the midline and were combined with low-to-low lateral
osteotomies and then digital greenstick infracture. The 0°
osteotomies produced contour irregularities and rocker-
like deformities. The 15° medial osteotomy produced
reliable, controlled infracture with adequate narrowing.
Gruber et al.165 provided a classification of broad
nasal bones that emphasizes the distinction between dorsal
and nasal base width. The authors reported that reduction
of the nasal dorsal width is facilitated by a medial oblique
osteotomy alone without lateral osteotomy if it is placed at
the lateral aspect of the apex of the open roof after
a humpectomy.
Gryskiewicz and Gryskiewicz166 studied 75 patients
who underwent rhinoplasty and required nasal osteotomy.
The authors compared the perforating method of nasal
osteotomy with a 2-mm straight osteotome versus the
continuous technique with a 4-mm curved, guarded
osteotome. Each patient received one technique on one
side of the nose and the other technique on the opposite
side. The osteotomies were performed through an
internal transnasal or an external percutaneous approach.
Evaluation at 3, 7, and 21 days after surgery showed
that ecchymosis and edema were less on the side with
perforating lateral osteotomies with the 2-mm straight
osteotome than on the side with the continuous osteotomy
with the curved osteotome.
Gryskiewicz167 also found that scars resulting from
external percutaneous osteotomies were imperceptible in
94% of patients but that on a few occasions, a small visible
scar was apparent. The author emphasized the importance
of thorough cleaning of the chisel between cases to avoid
traumatic tattooing.
Castro et al.168 recommended use of a modified
Joseph saw on a reciprocating handpiece for basal and

superior nasal osteotomies. A fixator anchors the saw on
a single axis that allows sawing without resistance and
averts multiple bone cuts. Giampapa and DiBernardo169
reported their preference for a dual-plane, curved
reciprocating saw for low-to-high osteotomies to make
precise lateral transverse osteotomies and avoid a medial
osteotomy. Kim and Kim170 described their technique for
endoscopically assisted osteotomies with a reciprocating
saw through bilateral intraoral incisions in the gingival
sulcus. It is anecdotally known that despite these advances
in instrumentation, most rhinoplastic surgeons still prefer
to use osteotomes in the nose.
TIP-LOBULE COMPLEX
The size, shape, and position of the alar cartilages relative
to the ULC, septum, and soft-tissue envelope determine
the conformation of the tip-lobule complex. When the
tip-defining points of the dome fall at or below the profile
line of the nasal dorsum, analysis of the facial and nasal
measurements is needed to determine the status of the tip.
When tip projection is adequate, reduction of the dorsum
satisfies the aesthetic requirements. When tip projection
is inadequate, attempts to increase tip projection are
appropriate.
The most difficult aspect of rhinoplasty is to
surgically manipulate the tip-lobule complex so as to
achieve predictable results. Primary deformities of the
tip and supratip area are formidable problems initially,
and secondary deformities resulting from inappropriate
surgical manipulations are even more difficult to correct.11
A carefully planned and executed operation
preserves the normal anatomy of the nose as much as
possible. Techniques for the correction of various tip
deformities were detailed by Rees,99 Sheen and Sheen,100
Janeke and Wright,117 Peck,127 Petroff et al.,140 and Rich
et al.141 Janeke and Wright emphasized the importance of
preserving tip support during rhinoplasty by safekeeping
the following:
•• the dense connective tissue between the
lateral crura and the sesamoid cartilages
•• the junction of the medial crura with the
caudal septum
•• the aponeurosis between the upper and
SRPS • Volume 11 • Issue C7 • 2015
lower lateral cartilages
•• the interdomal ligament formed by a
congregation of dense connective tissue
between the domes of the lower laterals
A minimum of 5 mm of intact lateral crural cartilage must
be left in place at the caudal margin to support the weight
of the soft tissues and maintain tip projection.171
The most important elements of nasal tip projection
are the medial crura, their attachments to the caudal
septum, and the presence of additional cartilage grafts
between the medial crura themselves or beneath the
crural feet. Petroff et al.140 evaluated 51 patients who
underwent primary rhinoplasty. Tip projection was
measured preoperatively, intraoperatively, and 6 months
postoperatively. Nasal tip projection increased an average
1.5 mm after injection of local anesthetic solution. When
either a cartilage-delivery or cartilage-splitting approach
was used, most of the support mechanism of the nasal
tip was weakened or totally disrupted. Lowering the
cartilaginous dorsum and shortening the caudal septum
had a profound effect on the postoperative position of the
nasal tip. Regardless of the preoperative goal, actual nasal
tip projection decreased postoperatively in a majority of
patients unless steps were taken to increase the length and
strength of the medial crural segment. Of these, 70% had
full transfixion with excision of various amounts of caudal
septum. Disruption of the caudal septal attachments
not only correlated with a higher incidence of decreased
tip projection, but the quantitative loss was 2.8 mm,
compared with an overall average of 1.8 mm. When the
preoperative goal was to maintain nasal tip projection,
the success rate was 28%. When the preoperative goal
was to increase nasal tip projection, the overall success
rate was 57%, but most underwent procedures that
increased the strength of the medial crural segment. When
the preoperative goal was to decrease tip projection, the
success rate was 87%.
Rich et al.141 reviewed 100 cases of nonaugmenting
rhinoplasty to measure the effect of lower lateral cartilage
excision on nasal tip projection. Three technical variants
were used: 1) cephalic resection of the LLC, 2) vertical
dome division, and 3) suture approximation of the medial
crura (modified Goldman tip) when the cartilage was
sectioned. Despite overall good to excellent results, the
authors noted a measurable loss of tip projection in all
23
 SRPS • Volume 11 • Issue C7 • 2015
except one patient.
Byrd et al.172 presented a report of a subset of
patients who were retrospectively identified as being at
high risk of losing tip projection, shape, and rotation
during rhinoplasty. Their noses were characterized by a
weak midvault, a plunging tip with pollybeak deformity,
retracted alae, and weak lower lateral cartilages. These
patients had been treated with a floating columellar strut,
yet 19 of the 20 patients lost nasal tip projection. Armed
with this information, a second group of 20 patients
who had similar features were treated prospectively with
septal extension grafts, and nasal tip projection was
either maintained or increased in all except one. The
authors recommended anterior septal extension grafts for
controlling projection, shape, and rotation of the nasal tip
during open rhinoplasty in these high-risk patients.
Hubbard173 reported similar techniques using
direct fixation of the medial crura to the septum or septal
extension grafts to secure the nasal tip. He noted minimal
variance postoperatively. Rohrich and Griffin174 presented
a classification of asymmetric deformities of the columella
and nasal tip and recommended methods of surgical
correction (Fig. 14).
These reports prompted the following questions.
Does the loss of nasal tip projection during rhinoplasty
account for the poor correlation between dorsal resection
and overlying soft-tissue response? Can we create the
appearance of tip projection after rhinoplasty by lowering
the dorsum and rotating the tip despite a measured
reduction of true projection? Are we really achieving
the desired nasal tip projection, or are we modifying the
dorsum simply to create the desired tip-dorsal profile line?
Suturing Techniques
Many of the supporting structures to the tip are
interrupted during standard rhinoplasty, and it frequently
is necessary to increase tip definition at time of surgery.171
Kridel et al.175 reported a tongue-in-groove technique in
which the medial crura are advanced upward and back
and the denuded caudal septum is placed into a surgically
created space between them. This method corrects
excessive columellar show and maintains correction
after straightening a caudally deviated septum. It is also
indicated for controlling nasal tip rotation and projection
24
while preserving the integrity of the lobular cartilaginous
complex. The technique can be combined with either the
external or endonasal rhinoplasty approach.
Kridel et al.171 showed the value of sutures in
enhancing nasal tip rotation and projection and illustrated
the correction of wide, bulbous, amorphous tips in 50
patients using a suture technique they called lateral
crural steal (LCS) through an open rhinoplasty approach.
The concept behind LCS is to increase the length of
the medial crura at the expense of the lateral crura. The
suture technique depends on a stable nasal base, which
is created by securing the medial crura to each other,
proceeding from the base of the columella to the nasal
tip. If the medial crura are buckled or weak, a strut of
septal cartilage is placed in the columella for additional
strength. Plumping grafts are inserted to achieve the
desired nasolabial angle. Once the middle crural complex
is stabilized, the lateral crura are advanced medially and
each is sutured first to its medial crus and then to its
counterpart on the opposite side with a mattress suture
across the tip complex (Fig. 14).174 As the lateral crura are
shortened, the tip is relocated superiorly and anteriorly.
If tip rotation is not desired, the lateral crus can be freed
from its lateral fibrous attachments and vestibular skin so
that it can move independently.
Foda and Kridel176 evaluated the effect of two
cartilage-modifying techniques on their effects on nasal
tip projection and rotation. With the LCS technique,
the lateral crura are advanced onto the medial crura,
resulting in an increase in length of the medial crura and
shorter lateral crura. With the lateral crural overlay (LCO)
technique, the lateral crura are shortened by vertically
transecting them and overlapping the cut edges. Computer
imaging was performed on 30 patients seeking primary
rhinoplasty mainly for nasal tip repositioning. The external
approach was used in all cases. LCS resulted in an increase
in both nasal tip projection and rotation. LCO resulted
in substantially greater tip rotation but decreased tip
projection. The authors concluded that LCS is indicated
when a moderate increase in nasal tip projection and
rotation is desired and that LCO is reserved for patients
with severe tip under-rotation associated with
over-projection.
Tardy et al.177 reviewed long-term outcomes of
transdomal suture techniques on the nasal tip. The

Figure 14. Algorithm for surgery of the asymmetric nasal tip. (Reprinted with permission from Rohrich and Griffin.174)
techniques preserve the integrity of the nasal tip (e.g., an
intact caudal segment or complete strip of alar cartilage)
while reorienting its elements. The transdomal suture is
indicated for broad, trapezoidal nasal tips with which the
alar cartilages typically are firm and strong, with a broader
than normal arch to the dome segment connecting the
intermediate and lateral crura. The triad of anatomic
findings—firm, broad, divergent alar cartilages; thin skin;
and delicate alar sidewalls—should suggest the option of
transdomal suture for nasal tip sculpturing.
Tebbetts178,179 placed sutures to shape and stabilize
the tip by controlling the multiple “force vectors” that
influence the tip complex. He reported maintaining the
SRPS • Volume 11 • Issue C7 • 2015
structural integrity of the alar rim strips; shaping and
positioning the lateral and medial crura in a reversible,
nondestructive manner; minimizing variables by
decreasing the need for a visible graft to shape the tip
complex; applying sutures judiciously and precisely; and
specific sequences for every maneuver.
Regalado-Briz180 studied 52 patients who underwent
an open rhinoplasty technique that used a modification of
the suture technique presented by Tebbets.178 The cephalic
portion of the lateral crus was preserved, and lateral crural
resection was limited to the most medial aspect. Suture
shaping was used to stabilize and control tip morphology.
Byrd181 emphasized the importance of controlling the
25
 SRPS • Volume 11 • Issue C7 • 2015

projection and rotation of the domes to establish an Resection Techniques

aesthetic tip-dorsum relationship.
Daniel 182,183
presented a two-part review of a
simplified three-stitch, open-tip suture technique for
primary and secondary rhinoplasty. The technique consists
of the following: 1) a strut suture to affix the columellar
strut between the crura, 2) bilateral dome-creation sutures
to create tip definition, and 3) a dome equalization suture
to narrow and align the domes.
Hugo et al.184 presented a suture technique for
replanting the medial crura in the hooked nose. The
medial crura are detached from the septum and from each
other, the tip is elevated and rotated to increase projection,
and the medial crura are reattached to the septum.
Behmand et al.185 tracked the evolution of the major
tip suture techniques. Guyuron and Behmand186 discussed
the sequencing and multiplanar effects of nine tip
suture techniques.
Daniel187 analyzed the large nostril-to-small
tip disproportion “deformity.” He argued against the
traditional basal view and the “ideal” ratio of two-
thirds to one-third, proposing instead a lateral view
analysis and a nostril:tip length ratio of 55:45 or 60:40.
He recommended a three-suture tip technique with
columellar strut graft and alar base resections to restore
this relationship. In his discussion of the Daniel article,
Sheen188 stated that he prefers tip augmentation with
cartilage grafts to achieve the same end.
Goldman190 reported that he divides the lateral crus lateral
to the dome to narrow the lobule and to add projection
to the tip. The method borrows from the lateral crus to
augment the height of the medial crus (Fig. 15).171
With the modification presented by McLure,191 no
vestibular skin is included with the segment of the lateral
crus that is rolled medially and a septal cartilage strut
is added between the medial crura for support. A small
separation is maintained between the repositioned lateral
crura to simulate a double nasal dome.
The effects on the nasal tip of resecting the alar
cartilages in the dome, intermediate crus, and medial crus
are illustrated in Figure 16. These are radical solutions to
the problem of the drooping nasal tip, and in thin-skinned
individuals, they are apt to leave visible irregularities.
Kamer and Cohen192 presented a method of excising
a central horizontal strip of alar cartilage to elevate the
tip, increase tip projection, and rotate the tip superiorly
while preserving structural integrity of the arch. The
defect created during the resection is closed by rotating
the caudal segment of the lateral crus cephalad and
affixing it to the still-stable cephalic margin. The authors
recommended the technique for noses that have a wide
dome and a drooping tip.

Scoring or Crushing Techniques

McCollough and English189 discussed various
modifications of the alar cartilages designed to increase
tip projection, all of which involve weakening by scoring
or crushing the portion of the lateral crus immediately
lateral to the dome and the middle or intermediate crus
immediately below the dome. A horizontal mattress suture
is used to pull the tip-defining points centrally and to
carry the alar cartilages medially, narrowing the lobule and
increasing the vertical height of the tip-defining points.
These maneuvers are most applicable when the tip-lobule
complex is broad and the excess width can be aesthetically Figure 15. Suture technique for increasing projection of the
converted into vertical projection. nasal tip. (Modified from Kridel et al.171)

26
 SRPS • Volume 11 • Issue C7 • 2015

Resection lateral crus

Dome resection
A
Might:
1. Allow medial advancement of dome
a. Increase tip projection
b. Centralize dome projection points
2. Cause pinched tip
3. Cause collapse of nostral arch

Might:
1. Narrow wide or boxed tip
Might: 2. Decrease tip projection
1. Increase cephalad rotation of tip 3. Maintain inter-domal distance
2. Weaken support of nostral arch 4. Create loss of tip definition, tip irregularities, and tip asymmetries
3. Allow lateral advancement of lateral crus
a. When dormal segment morselized or
scored, elimates wide or boxed tip
b. Decreases tip projection Resection intermediate crus
B

Figure 16. Effect on tip projection from resection of the

lateral crura at two points.
1. Decreases tip protection
2. Customizes dome projection points
3. Shortens distance from columellar-lobule
angle to tip

Resection medial crus

Massiha193 described a similar technique involving C
elliptical horizontal excision and repair of the alar
cartilage in open rhinoplasty to correct cartilaginous tip
deformities. With this technique, an elliptical excision is
made in the central segment of the lower lateral cartilage
in a horizontal correction and the upper and lower edges
of the remaining cartilage are repaired with 5-0 nylon Decreases tip protection
sutures. The technique seems to be identical to that
presented by Kamer and Cohen.192 Figure 17 illustrates the
potential effects on the nasal tip of resecting the cephalic Figure 17. Effect of tip projection from resection of the
border of the alar cartilages and caudal septum. lateral crura at the dome (A), the intermediate crura (B), and
Adamson et al.194 presented a report of 116 the medial crura (C).
consecutive patients who underwent open rhinoplasty
and vertical dome division. Patients undergoing surgery
early in the series underwent cartilage resection and suture
reapproximation, whereas those undergoing surgery later Grafts to the Tip
underwent dome division, overlap, and suturing. Vertical
Grafts to the lobule complex can improve tip projection
dome division is recommended for the correction of lobule
when manipulation of the existing cartilage alone fails. A
asymmetry, retrodisplacement, wide domal arch, and a
cartilage graft is inserted within a limited soft-tissue pocket
hanging infratip lobule. An important consideration with
the cartilage-overlap technique is reduction in nasal tip under some degree of tension to produce angulation at
projection. If a loss of tip projection is not desired, tip the columella-lobule junction,195 projection and angularity
grafts or other methods to enhance tip projection at the dome area,127,195 or support of the medial crura-
are needed. columella to prevent settling.81,82

27
 SRPS • Volume 11 • Issue C7 • 2015
Sheen195 reviewed his 20-year experience with grafts
to the nasal tip, which he thinks are best suited for primary
rhinoplasties. He divided his experience into three parts,
paralleling the evolution of nasal tip grafting to current
standards. Over the years, sources of graft materials have
included the septum, ear, rib, vomer, and ethmoid. Septal
cartilage grafts have evolved from a single columella-lobule
contour graft to multiple small septal cartilage fill grafts,
sometimes crushed or bruised to avoid angularities and
to improve definition. Ear cartilage is a distant second
choice to septal cartilage because of its tendency to shatter
when manipulated. Sheen reserved rib cartilage grafts for
cases involving complex reconstruction of the entire nasal
skeleton. Because of progressive resorption of vomer and
ethmoid bone grafts for the tip, Sheen used them only as
buttresses to hold overlying septal cartilage grafts.
The most persistent complications of tip grafts in
the series presented by Sheen195 were malposition and
undesirable angularities. Tip grafts can shift their position
and cause a number of problems. Grafts that are displaced
laterally cause asymmetry; those that migrate upward
cause tip blanching or over-projection; and if displaced
downward, they protrude from the columella. Oversized
grafts can also compromise the vascular supply to the skin
of the lobule. Sheen emphasized the need for thorough
preparation and precise wound closure to keep infections
to a minimum.
Cárdenas-Camarena and Guerrero196 reported an
8-year experience with cartilage grafts in nasal surgery,
encompassing 83% from the nasal septum, 12% from
the ear, 3% from the alar cartilages, and 2% from the rib.
Grafts were placed between the medial crura in 64%, as
Sheen tip grafts in 28%, in the nasal dorsum in 19%, as
spreader grafts in 8%, as Peck grafts in 8%, and in the
rim in 3%. Reoperation to achieve the desired result was
required in 8%.
Bateman and Jones197 reviewed outcomes of
augmentation rhinoplasty using autologous cartilage grafts
in 103 patients followed for an average of 3 years. The
revision rate during the follow-up period was 15.5%. The
same surgeons’ revision rate in 311 rhinoplasties without
grafts during the same period was 4%. The authors
concluded that rhinoplasty with cartilage graft is associated
with a significantly higher revision rate than when no graft
is required.
28
Constantian198 noted that 77% of patients
undergoing primary rhinoplasty and 80% of patients
undergoing secondary rhinoplasty in his practice
required grafting mainly to improve lobular contour,
not tip projection. He described the distant effects of
dorsal grafts and tip grafts in rhinoplasty and outlined
his techniques for achieving the effects. Grafts affect
nasal length, symmetry, ethnicity, and dorsum-tip
relations. Constantian199 subsequently elaborated an
alternative cartilage-bearing tip graft technique with
which small amounts of autologous donor material are
used to augment only those lobular segments that require
increased contour or support. The technique evolved in
response to the high number of patients with inadequate
donor cartilage for traditional shield-type grafts and
in response to the observation that by enlarging the
lobule, tip grafts can create undesirable postoperative
disproportions in some patients. The revision rate in 405
rhinoplasties (40% primary, 60% secondary) was 14%.
Peck200 reported using rectangular onlay grafts of
septal or auricular cartilage that are placed overlying the
domes. A tight pocket helps keep the graft in position,
but, if necessary, the graft can be stabilized with a pullout
suture. Much like Sheen tip grafts, Peck onlay grafts can
displace, distort, or partially resorb, and it is difficult to
judge intraoperatively the appropriate degree of projection
desired. The result is that the tip often is over- or
undercorrected.
Peck et al.201 described an 18-year experience with
the umbrella graft in rhinoplasty. The graft consists of a
vertical cartilaginous strut between the medial crura and
a horizontal onlay graft overlying the alar domes. The
umbrella graft was used in 22% of 1252 mostly secondary
rhinoplasties. The revision rate for the umbrella graft
was 5%, and the most common complication was visible
cartilage. In his discussion of the article by Peck et al.,
Rohrich202 stated that nasal tip support usually depends
equally on the length and strength of the paired lower
lateral cartilages, which in turn are supported by the
suspensory ligaments connecting the domes and the fibers
that connect them with the ULC.
Baker and Courtiss203 noted that parchment-thin
skin is a common problem associated with secondary
rhinoplasty. The authors suggested that an onlay graft
of temporalis fascia is the most satisfactory method of

covering the underlying osseocartilaginous framework
or cartilage grafts in patients who exhibit this condition.
The surgical results in six patients with temporalis fascia
grafts are reviewed. A biopsy of the temporalis fascia and
cartilage graft confirmed the long-term viability of the
fascia and its underlying cartilage.
Anderson96 reported a preference for a strut of
cartilage from the septum placed between the medial
crura, from the level of the upper border of the nostrils
downward, almost to the premaxilla. Millard204
recommended anterior septum-columellar struts extending
from the premaxillary area to the nasal tip. Dibbell205
described the use of a Bowie knife-shaped strut to increase
tip angularity and projection, particularly in noses
associated with cleft lip. The potential disadvantages of
strut grafts are a widened columella, a tent-pole effect with
blanching at the nasal tip, leaning of the tent pole, and
visibility of the graft through the skin.
Arden and Crumley206 reviewed their clinical
experience with and indications for combined placement
of columellar struts, shield grafting, and caudal septal
grafts. Patients most likely to require combination grafts
are those with lobular hypoplasia or tip under-projection.
The authors advocated a columellar strut sutured to
the medial crura and septal midline when a transfixion
incision is required. They noted that shield grafts are
particularly useful in highlighting tip architecture in the
Asian, Hispanic, Mestizo, or black nose and in revision
rhinoplasties with which tip scarring or existing alar
cartilage structures prohibit natural skin redraping. For
lengthening the nose, caudal septal grafts are used, but the
limiting factor is the amount of available lining. Porter et
al.207 advocated a contoured auricular projection graft for
nasal tip projection in Asian and black noses.
Orak et al.208 presented a report on an extra-
supported tip graft for the treatment of bulbous nasal tips.
The technique involves an A-shaped tip graft supported
with a columellar strut, both inserted into small separate
pockets (Fig. 18).
Gunter and Rohrich introduced alar spreader
209
grafts for correction of the pinched nasal tip. The grafts
are shaped like bars or flat triangles and are carved from
autogenous septal or auricular cartilage. The spreader
graft is inserted between and deep into the remaining
lateral crura to force them apart, propping up the caved-in
SRPS • Volume 11 • Issue C7 • 2015
segment of the pinched tip.
De Carolis210 reported using an infradome graft to
improve dome reshaping in rhinoplasty. The technique
places under the domes two parallel strips prepared from
the resected alar cartilages. The grafted cartilages block the
plication suture, which averts excessive pinching of the
domes and enhances stability.
McCollough and Fedok211 described the technique
of lateral crural turnover graft for correction of the concave
lateral crus. Adham and Teimourian212 reported mobilizing
and advancing the lateral crura toward the alar rim. The
alar cartilages are reshaped, and the domes are grafted
with stacked disks of cartilage (individual dome-projecting
grafts). Adham213 later modified the procedure by
camouflaging the stacked disk grafts with LLC trimmings
(from the cephalic edge) to avoid a boxy look.
Hamra214 noted that he prefers crushed cartilage
grafts to alar domes after reduction rhinoplasty via the
open approach. The tip is reduced through dome division
and suture reconstruction. Contour deformities are
avoided by overgrafting the divided domal segments with a
crushed onlay graft.
Cephalad resection
lateral crus
Will:
1. Reduce tip fullness and increase
definition of dome projecting points
2. Rotate tip cephalad
Might:
1. Decerase tip projection
2. Hitch or raise alar margin
3. Weaken support of nostril arch
Figure 18. Effect on tip support and projection from
resection of a cephalic strip of lateral crura.
29
 SRPS • Volume 11 • Issue C7 • 2015
Guyuron et al.215 introduced a subdomal graft for
management of the pinched nasal tip. The graft is placed
into a subdomal pocket extending from one dome to
another (8–10 mm long × 1.5 mm wide × 1.5 mm thick).
The technique was successfully applied in 53 primary
rhinoplasties and eight secondary cases of pinched nasal
deformity or asymmetric domes.
Hamra216 opted for dome excision, side-to-side
cartilage repair, and crushed cartilage overlay graft to
improve tip contour. This is a simple method with which
to treat tip deformities and reduce tip projection when the
angle of divergence is normal.
Bujia217 studied the viability of chondrocytes
in crushed, uncrushed, and cut cartilage grafts. More
cartilage cells (70%–90%) are damaged by crushing than
by cutting, which leaves most cells viable and able
to proliferate.
Pereira et al.218 assessed the availability of block
conchal cartilage for total reconstruction of the ala in
a cadaveric model. “…from the lamina tragi, isthmus,
and cavum conchae, en bloc resection is possible with
characteristics of form and dimension similar to those of
the homolateral alar cartilage.”
Fanous and Webster219,220 recounted their experience
with Mersilene tip implants (Ethicon, Somerville, NJ) or
the correction of tip deformities in 98 patients. Indications
were recession, boxiness, asymmetry, thick or thin skin,
upward or downward turn, and a bifid tip. Mersilene mesh
is soft, pliable, and easily shaped and can be invaded by
surrounding connective tissue, which affixes the implant
firmly in place and prevents displacement.220
Despite this favorable report, readers should be
circumspect in their use of alloplastic materials in the nasal
tip. Aside from the potential for tissue ingrowth and scar,
an alloplast rejection reaction would have catastrophic
consequences in this critical area of the nose. Autogenous
sources of tip grafts, such as nasal septum and ear cartilage,
are undeniably superior in nasal reshaping.
Broad or Boxy Tip
A nasal tip that looks boxy or bulbous rather than
triangular from the basal view is the product of either
an increased angle of divergence of the medial crura
or a wide arc in the dome segment of the lateral crura.
Tasman and Helbig221 measured the distance between the
30
domes and the skin thickness over the LLC before and
after transdomal suture tip plasty. The distance between
the cartilaginous domes correlated with tip width before
surgery. After surgery, the degree of tip refinement
correlated with preoperative skin thickness but not with
interdomal distance. These data provide further evidence
that tip definition surgery is limited by thick soft tissues.
Rohrich and Adams222 proposed an algorithm for
the management of nasal tips: type I, angle of divergence is
>30°; type II, domal arc between tip-defining points is >4
mm; type III, both conditions are present (Fig. 19). The
technique involves limited domal and cephalic trimming
and then transdomal and/or interdomal suturing. The
endpoint is reached when the distance between tip-
defining points is 5 to 6 mm. Gruber and Friedman223
presented a discussion of the rationale for use of sutures
in the correction of broad or bulbous tips: the transdomal
suture (to narrow the individual domes); the interdomal
suture (to bring symmetry, to add tip strength, and
sometimes to narrow the tip complex); the lateral crural
mattress suture (to reduce lateral crural convexity); and the
columella-septal suture (to prevent tip droop and to adjust
tip projection).
Division Techniques
Goldman190 narrowed the square tip by completely
transecting the lateral crura and vestibular skin. A
modification of this approach divides the lateral crura
outside the dome area, with or without division of
vestibular skin.224 The medial crura can then be sutured
near the dome, or the lateral crura can be rotated
medially and sutured to gain further projection anteriorly.
McKinney and Stalnecker225 described their modification
of the Goldman technique for bulbous tips in thick-
skinned individuals with both normal and overly
projecting dome points. Unless the skin of the nose is very
thick, transection techniques produce a more triangular
tip at the expense of a single dome point, the distinct
possibility of pinching or kinking the alar rim, and visible
asymmetries.
Scoring Techniques
Unlike transection, scoring usually maintains the integrity
of the cartilage and hence support of the tip, with less
visibility of the cut cartilage edges. McCollough and

Figure 19. Management algorithm for the boxy nasal tip. *, Domal resection and suture reshaping in excessively wide domal
arch (>6 mm); resilient lateral crura included. (Reprinted with permission from Rohrich and Adams.222)
English189 discussed an alternative to the Goldman
technique that consists of scoring the cartilage medial and
lateral to the dome and bringing the lateral crus medially
with horizontal mattress sutures. This centralizes the dome
segment while avoiding the break or step-off that typifies
the Goldman tip. The technique is recommended for use
in wide, bulbous, or under-projecting tips.
Peck127 reported achieving a triangular tip through
wide mobilization of the lateral crura with resection of
their distalmost segment and scoring of the dome area.
Sheen and Sheen100 described narrowing the broad or
boxy tip by interdigitating partial scoring cuts in the
dome and medial crura. Hamra226 modified the technique
for repositioning the lateral crus described by Sheen by
creating a subcutaneous pocket and suturing the medial
crura together. The dissection is simpler, undermining is
easier, and the procedure can be done through an open or
closed approach. The technique is indicated for patients
SRPS • Volume 11 • Issue C7 • 2015
who have cephalically positioned lateral crura showing the
“parentheses” deformity on frontal view. In these cases the
tip frequently is flat and broad, the alar rim is notched,
and the basilar view shows a square perimeter.
Over-projecting Tip
Over-projection of the nasal tip—the “Pinocchio
nose”—results from excessive length of the medial and
lateral crura. Procedures designed to reduce the over-
projecting tip involve full-thickness resection of either the
medial227,228 or lateral6,100,127 crura or scoring of the dome-
medial crura junction, with or without resection of the
lateral crura.100,127 Goldman190 and Tardy et al.229 analyzed
the over-projecting tip. They found that overdevelopment
of the caudal quadrangular cartilage tends to “tent” the tip
away from the face and can tether the upper lip, producing
an indefinite nasolabial angle. This can occasionally create
31
 SRPS • Volume 11 • Issue C7 • 2015

abnormal exposure of the maxillary gingiva, especially
during smiling. Correction begins by lowering the
cartilaginous profile, releasing the tip from the abnormal
influence. Almost every case required weakening tip
support and overall reduction of the overdeveloped
components. After complete transfixing incision, the tip
immediately settled back.
Any procedure that transects the rim of the alar
cartilage can alter the smooth arch of the nostril and
produce sharp edges, a notch, or step deformity. To
minimize the potential complication, it is essential to
precisely realign and suture the transected cartilage ends
and to keep intact as much of the nasal lining as possible.
Neu230 reported that he addresses the Pinocchio tip
by rolling the lateral crura medially and creating new, less
prominent domes while preserving the natural bowing of
the alar arch. If necessary, any extra length can be excised
The nasolabial angle is directly influenced by the
configuration of the nasal spine and caudal septum.
When a person is smiling, the upper lip pulls back and
the caudal border of the septum and nasal spine appear to
protrude downward, sharpening the columella-lip angle.
Aston and Guy233 reviewed techniques for resection of the
caudal border of the septum and the nasal spine. Figure 20
illustrates the effects of these maneuvers on the columella-
lip angle.233
Dorsal wedge resection caudal septum
1. Shortens nose
a. Cephalad rotation of tip
b. Increases nostral show
2. Obtuse columella-lip angle
3. No effect on upper lip length

at the footplates, which causes caudal rotation of the tip.

Smith and Smith231 reported reducing the over-
projecting tip through an open rhinoplasty technique that
transects and raises a columellar flap, which carries the
crura of the alar cartilage within. Tip sculpting is limited
to cephalic trimming of the lateral crura. Caudal septal resection
1. Shortens nose
Gryskiewicz232 described resecting columellar skin a. Tip moves cephalad
b. Columella-lip angle changes minimally
to avert an iatrogenic hanging columella after reducing 2. Raises columella relative to alar margin
3. Lengthens upper lip
an over-projected tip. The optimal indication for this
technique is when tip setback is >3 mm.

Surgery on the Columella, Nasal Spine, and Lip

The columella-lip angle is critical to the aesthetic
appearance of the nose. According to Aston and Guy,233 Nasal spine resection
1. Lengthens lip
the desired septolabial angle is 90° to 95º in men and 2. Deepens columella-lip angle
100º in women. Lewis,234 on the other hand, proposed 3. Retrudes columella base
4. May decrease lip projection
that the ideal uptilt of the columella should be 5° to 15º
(or 95−105º) in men and 12° to 25º (or 102–115º) in
women. He suggested that tall patients, patients with long
faces, and those with receding foreheads or chins should
have less of a “tilt-up,” whereas patients with straight
foreheads or prominent chins should have even wider
columella-lip angles. We disagree. In our opinion, tilting-
up of the nasal tip creates a shorter nose that becomes Figure 20. Effect on the columella-lip angle of resection of
further disproportionate with a prominent chin. Instead, the caudal septum and nasal spine. (Modified from Aston
nasal length should vary directly with chin vertical length. and Guy.233)

32

Over-resection of the caudal septum or nasal spine
can produce an excessively obtuse septolabial angle (“pig
nose”), an acute septolabial angle with a plunging tip
(“witch’s nose”), a retracted columella, or a flat upper lip
that seems excessively long (“ape lip”). Webster et al.235,236
discussed the anatomy of the columella and analyzed
the aesthetics of the nose regarding surgical techniques
for correcting deformities of the lip-columella junction,
including tissue subtraction, tissue addition, and
sliding procedures.
Cachay-Velasquez237 advocated a Rowen-Boyd
resection of the depressor septi nasi muscles to correct the
rhinogingivolabial syndrome: drooping nasal tip, short
upper lip, and increased exposure of the maxillary gums,
particularly when smiling. Resection is continued through
an extension of the transfixion incision and frequently is
accompanied by partial resection of the caudal septum and
nasal spine. The postoperative results reflect the change
induced in the columella-lip angle and between the tip
and upper lip.
Rohrich et al.238 studied the role of the depressor
septi nasi muscle in rhinoplasty and described three
anatomic variations. An active depressor septi muscle can
accentuate a drooping nasal tip by shortening the upper lip
on animation. The authors recommended muscle release
and transposition through a sublabial intraoral incision
during rhinoplasty to improve the tip-upper
lip relationship.
De Benito and Fernandez Sanza239 reported
resecting the columella and nasal depressor muscles to
improve the nose-lip relationship and the smile. The
resection eliminates the downward movement of the nasal
tip with smiling.
Lawson and Reino240 described reduction
columelloplasty, which involves full-thickness excision
of a diamond-shaped piece of tissue from between the
feet of the medial crura. The incision is continued down
through the skin, depressor septi muscle, and adjacent
soft tissue. When the defect is closed, the splayed medial
crura are brought together, increasing the nasolabial
angle, modifying the shape of the nares, and increasing
projection of the nasal tip.
Pessa241 suggested selective resection of the levator
alae (levator labii superioris alaqui nasi) muscle to correct
SRPS • Volume 11 • Issue C7 • 2015
the acute nasolabial angle and prominent nasolabial
folds and to improve asymmetries in nasal base position.
Cadaveric dissections have shown that the levator alae
muscles originate at the frontal process of the maxilla and
insert into the lateral alae and orbicularis oris muscles.
The angular artery and vein lie medial and superficial to
the muscle and serve as a reliable guide to its position.
The infraorbital nerve is lateral to the levator alae muscle
and lies beneath the levator labii superioris muscle,
approximately 7 mm below the orbital rim. The principal
action of the levator alae muscle is to elevate the alar base,
producing a sneer or snarl. As the alar base is elevated, the
nasolabial angle becomes acute and the medial nasolabial
fold becomes accentuated. The muscle is approached
through a subciliary incision, a skin-muscle flap is elevated,
the orbicularis oculi muscle is dissected inferiorly to free
it from the orbital rim, and dissection proceeds medially
to the groove between the maxilla and nasal bones, where
the levator alae muscle is located and identified. A 0.5- to
1-cm-long segment of muscle is resected. Alternatively,
muscle resection can be accomplished through a buccal
sulcus incision.
Foda242 reviewed his results after a minimum of 1
year in 360 consecutive “droopy tip” rhinoplasties using
three alar cartilage modification techniques. He found
LCS to be most effective for under-projected tips. LCO
worked best in cases of over-projected tips. The tongue-in-
groove technique was best suited for tips with
adequate projection.
Guyuron243 studied abnormalities of the footplate
of the medial crura and how their surgical correction
influences the outcome of rhinoplasty. In a prospective
series of 20 consecutive primary rhinoplasties, the author
found the distance between the medial footplates to be
7.5 to 15 mm (average, 11.4 mm). The length of the
footplates was 4 to 7.5 mm (average, 5.8 mm).
In a retrospective review of 295 consecutive
rhinoplasties, footplates were altered in 76 cases. In
cases of over-projecting tip and divergent footplates, the
lateral portion of the footplates was partially resected
and then approximated. If the tip was under-projecting
or had normal projection, the divergent footplates were
approximated without resection. When the subnasale
and the base of the columella protruded, the soft tissue
between the footplates was removed. When the footplates
33
 SRPS • Volume 11 • Issue C7 • 2015

diverged, the columellar base and nasal spines were

retracted but the soft tissues were left undisturbed so as to
narrow the columella and advance it caudally.

A
Lengthening the Short Nose
The short nose is characterized by lower-than-normal
distance from the nasofrontal angle to the tip-defining
points and an overly wide nasolabial angle with increased
nostril show.244 Gunter and Rohrich244 described a
technique that lowers the tip-defining points by detaching
the lateral crura from their attachments to the ULC,
suspensory ligament, and septum (Figs. 21 and 22). The
release effectively rotates the alar cartilages caudally, lowers
the dome, decreases projection of the tip, and lengthens
the distance between the nasofrontal angle and the tip-
defining points. As tip projection decreases, the illusion
of nasal length increases. The technique is best suited for
patients who have a short nose with an over-projecting tip.
Lee et al.245 described lengthening the postoperative
short nose with a combination gull-wing conchal
composite graft and rib costochondral dorsal onlay graft B
as a replacement for the missing nasal lining and cartilage
and to reinforce the framework, respectively. Wide
degloving of the outer skin envelope is recommended to
cover the entire nasal length without tension.
The problem with this method of reconstruction
is the failure to differentially project the nasal tip above
the plane of the reconstructed dorsum. The outcome of
this technique is a somewhat under-projecting tip with
pollybeak deformity fullness. A more aesthetic result can
be obtained by incorporating columellar support to raise
the nasal tip above the plane of the dorsum.
Naficy and Baker246 illustrated five techniques for
lengthening the short nose:
•• the flying buttress graft, which is made up
of a single spreader graft or paired spreader
grafts secured to the columellar strut
•• caudal septal grafts
•• tip grafts of various shapes Figure 21. A, Aesthetically short nose. NFA, nasofrontal
angle; TDP, tip-defining point. B, Lengthening an
•• radix grafts to elevate the nasion
aesthetically short nose with inferior rotation of the lower
•• interposition grafts between the upper and lateral cartilages. (Reprinted with permission from Gunter
lower lateral cartilages and Rohrich.244)

34

Figure 22. A, Lower lateral cartilages released from their
attachments to the upper lateral cartilages, suspensory
ligament, and septum. B, Direction of rotation of lower
lateral cartilages after release of all attachments. (Reprinted
with permission from Gunter and Rohrich.244)
Ha and Byrd247 revisited their experience with
septal extension grafts: extended spreader grafts, paired
batten grafts (below the junction of the septum and
ULC), and direct extension grafts (directly affixed to the
anterior septal angle when cartilage supply is limited).
Despite the tremendous versatility of the grafts in
primary and secondary rhinoplasty, the authors cautioned
against supratip and/or midvault widening and excessive
lengthening from “over-extension.”
Guyuron and Varghai248 reported lengthening the
nose with a tongue-and-groove technique and three pieces
of appropriately shaped septal cartilage. The technique
combines bilateral spreader grafts beyond the septal angle
with a columellar strut while avoiding rigidity of the
tip. The authors presented a report of 20 of 23 patients
enjoying good to excellent results during 12.5 years but
warned that the technique is labor-intensive and requires
sufficient cartilage.
SRPS • Volume 11 • Issue C7 • 2015
Juri249 recommended conchal cartilage grafts in the
nasal tip in conjunction with wide cutaneous undermining
and wide mucosal lining undermining for the treatment
of the iatrogenically retracted tip and short nose. In the
article, he detailed the method of precisely shaping the
cartilage grafts.
Hamra250 treated 15 patients with surgically
shortened noses by means of infratip cartilage grafts. A
two- or three-tier cartilage graft from septal or conchal
donor site is sutured to the caudal edge of the medial
crura. According to the author, the success of this
operation was partly because of increased inelasticity of
skin among the older patients in the series.
To lengthen the nose, Gruber251 suggested releasing
the septal mucoperichondrial lining and ULC from the
LLC. A batten graft is attached to the septum, which in
turn holds the tip cartilages in a more caudal position. The
most common complication is inadequate lengthening.
Wolfe252 recommended using a nasofrontal
osteotomy with mobilization of previous fractures for
lengthening posttraumatic foreshortened noses. To
lengthen congenitally short noses, Wolfe preferred a
perinasal osteotomy. He presented his experience with
nine cases.
Tension Nose
Excessive growth of the quadrilateral cartilage results
in a high nasal dorsum with anterior and sometimes
inferior displacement of the nasal tip cartilages: a tension
nose.253 Johnson and Godin253 reviewed 50 consecutive
primary rhinoplasty candidates and noted that 46% had
some manifestation of tension deformity. The authors
recommended an open approach to reduce the excessive
elements of septal cartilage and anterior nasal spine.
Cartilage grafts and sutures can then be used to re-project
the domes. Tardy et al.229 offered a different perspective on
the same anatomic deformity.
PHYSIOLOGICAL AIRWAY
Howard and Rohrich254 summarized the nasal anatomy
and physiology in nasal airway obstruction. Primary
air flow is through the middle meatus (Fig. 23).254
Resistance to air flow is structurally related to hypertrophic
35
 SRPS • Volume 11 • Issue C7 • 2015

Figure 23. Primary inspiratory current is an arched pathway

through the middle meatus. (Reprinted with permission from
Howard and Rohrich.254)

turbinates, valvular incompetence, septal deviation, and

intranasal masses. Constricted points along the way
increase the velocity of air flow and can generate negative
B
pressures that collapse the internal and external nasal valves
(Fig. 24).254 The appropriate treatment of the obstructed
nasal airway depends on its cause. Medical management
often is recommended for nonstructural rhinitis. When
the airway obstruction is caused by turbinate disorders, a
deviated septum, or incompetent internal or external nasal
valves, surgical treatment is required.

TURBINATES
Jackson and Koch255 reviewed controversies in the
management of hypertrophic inferior turbinates, with
emphasis on surgical treatment. Ophir256 analyzed the
results of total inferior turbinectomy after 1 to 7 years Figure 24. A and B, Two views of the boundaries of the
in 38 patients: 84% reported subjective relief of nasal internal and external valves. Internal nasal valve angle is
obstruction, and 92% had wide clean nasal airways shown normally 10° to 15°. (Reprinted with permission from Howard
by rhinoscopy. Objective airflow measurements in 32 and Rohrich.254)
patients showed increased patency in all, including three
patients who still complained of nasal obstruction. No
atrophy of the nasal mucosa or chronic infection occurred. earlier. They found no incidence of dry nose syndrome and
The author recommended total inferior turbinectomy for concluded that bilateral subtotal resection of the inferior
patients with obstructing inferior turbinates. turbinates is the treatment of choice for nasal obstruction
caused by hypertrophied turbinates.
Courtiss and Goldwyn257 looked for undesirable
long-term sequelae in 25 patients who had resection Surgery on the inferior turbinates should be
of obstructing inferior nasal turbinates at least 10 years considered along with septal straightening when

36
 SRPS • Volume 11 • Issue C7 • 2015

attempting to relieve nasal obstruction. Pollock and and cartilage grafting through an open approach. The
Rohrich258 reported their experience with 408 patients valves were reconstructed with spreader grafts, lateral
with obstructed airways who were successfully treated crural spanning grafts, crural onlay and sidewall grafts,
with adjunctive inferior turbinate resection. The authors and columellar struts used singly or in combination (Figs.
preferred performing full-thickness excision of the anterior 25−27).262 Treatment was successful in 24 of 27 patients.
one-third to one-half of the inferior turbinate. Long-term The authors suggested strategies to prevent nasal valve
follow-up revealed no evidence of atrophic rhinitis or
collapse during rhinoplasty.
untoward sequelae.
Rohrich et al.259 reported a preference for
submucous resection (SMR) of hypertrophic inferior
turbinates, which, in their series, was associated with
fewer complications of bleeding, mucosal crusting or
desiccation, or recurrent obstruction. The anterior one-
third to one-half of the bony segment is resected with this
technique. No atrophic rhinitis was reported.
Smith et al.260 reported a technique describing
resection of the pyriform aperture in patients with residual
obstructive symptoms after inferior turbinate resection
with or without septal surgery. The medial aspect of the
prominent nasal process of the maxilla at the pyriform
aperture is removed via an endonasal approach. The
authors reported a subjectively substantial improvement
Figure 25. Site and number of cartilage grafts used in
in nasal airways, including resolution of inspiratory alar
reconstructing the nasal valve area. (N = 27). (Reprinted
collapse, with this technique.
with permission from Teichgraeber and Wainwright.262)

NASAL VALVES
Constantian261 analyzed the functional effects of alar
cartilage malposition. Rhinoplasty with resection of the
cartilaginous dorsal roof or alar cartilages is the most
common cause of acquired incompetence at the internal
and external valves. The external nasal valve is presumed
to be the mobile nasal ala at the introitus of the vestibule
that is normally supported by the lateral crus. External
valvular incompetence ensues from malposition of the alar
cartilage. Graft support to the lateral wall of the nostril is
recommended to minimize this complication.
Teichgraeber and Wainwright262 presented a report
of 27 patients with nasal obstruction who were treated
over a 3-year period. Of these, 14 had involvement of the Figure 26. Bilateral spreader grafts (septal cartilage),
internal valve only, two had involvement of the external columellar strut (septal cartilage), resection of the cephalad
valve alone, and 11 had involvement of both valves. 1 mm of the lower lateral cartilages, lateral crural spanning
The cause of the obstruction was previous surgery in 13 graft (septal cartilage), and bilateral turbinoplasties.
patients, trauma in eight, and a congenitally narrow nose (Reprinted with permission from Teichgraeber and
in four. Surgery consisted of nasal valve repositioning Wainwright.262)

37
 SRPS • Volume 11 • Issue C7 • 2015
Figure 27. Bilateral spreader grafts (homograft irradiated
cartilage), columellar strut (homograft irradiated cartilage),
right lower lateral cartilage graft (ear cartilage), and lateral
crural spanning graft (septal cartilage). (Reprinted with
permission from Teichgraeber and Wainwright.262)
Stucker and Hoasjoe263 reviewed the treatment of 56
patients who had nasal valve obstruction. Follow-up
duration ranged from 18 months to 13 years. Treatment
consisted of open rhinoplasty with valve and sidewall
stabilization with a dorsal conchal cartilage graft bridging
the ULC and alar cartilage. Rhinomanometry in 24
patients showed objective improvement postoperatively.
Sheen106 noted that internal valvular incompetence
occurs when the angle between the caudal edge of the
ULC and the septum is <15°, such as after resection of the
midvault roof. Sheen recommended the use of spreader
grafts placed submucosally between the dorsum and ULC
to widen the ULC-septum angle. Byrd et al.137 presented
their algorithm for the use of spreader graft options in
patients at risk for internal nasal valve dysfunction: high
and narrow dorsum, weak middle vault, short nasal bones,
or preoperative internal valve dysfunction (Fig. 28).
Schlosser and Park264 quantified changes in a
cross-sectional area of the nasal valve after placement of
spreader grafts and flaring sutures in six cadaver heads.
The average minimal area increased by 5.4% with spreader
grafts, by 9.1% with flaring sutures, and by 18.7% with
combined spreader grafts and flaring sutures. On a scale
of 1 (complete obstruction) to 10 (complete patency), the
38
mean nasal patency scores improved from 3.4 to 6.5 with
the combination of spreader grafts and flaring sutures.
A follow-up article by Park265 emphasized the clinical
application of flaring sutures to enhance the repair of
dysfunctional nasal valves.
Guyuron et al.266 introduced the upper lateral splay
graft to widen a narrow internal valve. The splay graft
spans the dorsal septum but is deep to the left and right
ULC. Excessive widening of the caudal portion of the
dorsum is possible with imprudent use of the technique.
Sen and Iscen267 described the spring graft, which is a
modification of the splay graft. Two alar resected cartilage
grafts are sutured together and placed deep to the ULC
as a strengthened spring to prevent midvault collapse and
internal valve incompetency. In contrast to the splay graft,
the spring graft does not cause excessive widening of the
caudal portion of the dorsum. Al-Qattan and Robertson268
reviewed acquired nostril stenosis with related airway
obstruction occurring secondary to a shortage of vestibular
lining and discussed techniques designed to replace the
vestibular lining and widen the introitus.
Menger269 described an endonasal procedure for
widening and strengthening the lateral component of the
external nasal valve area. The technique consists of placing
permanent submucosal spanning sutures between the
piriform aperture and the distal part of the lower lateral
cartilage, providing superolateral rotation of the lateral
crura and additional support for the lateral nasal wall.
NASAL SEPTUM
Deformities of the nasal septum sometimes produce
internal nasal obstruction without external deformity,
external deformity without airway obstruction, or internal
airway obstruction and external deformity. The surgical
correction of internal or external septal deformities must
strike a balance between preserving dorsal support of
the nose on the one hand and obliterating the visible or
functional abnormality on the other. The correction of
complex deformities often necessitates both SMR and
some form of septoplasty.
Episodes of staphylococcal bacteremia resulting in
metastatic infection have occurred in association with nasal
septoplasty, suggesting the possible need for antimicrobial
prophylaxis. Silk et al.270 reviewed the records of 50

Figure 28. Algorithm for the use of spreader graft options. (Reprinted with permission from Byrd et al.137).
healthy patients who had blood cultures drawn before and
during the procedure. Although 50% had colonization
of the nasal mucosa by Staphylococcus aureus, none of
the blood cultures showed bacterial growth. The authors
concluded that staphylococcal bacteremia during nasal
septoplasty is a rare occurrence that does not warrant
antimicrobial prophylaxis.
Yoder and Weimert271 analyzed the infection rate
in 1040 patients who underwent septal surgery without
prophylactic antibiotics. Minor nasal infections developed
postoperatively in five patients (0.48%), and all responded
to orally administered antibiotic therapy. The authors
concluded that the risk of infection after nasal surgery
without antibiotic coverage is minimal.
SRPS • Volume 11 • Issue C7 • 2015
SMR
SMR of an obstructive septal deformity was first described
by Killian272 in 1905. Currently, the basic principles
of subperichondrial dissection and resection of the
obstructing cartilage remain largely unchanged. Dingman
and Natvig273 noted that the Killian SMR is seldom
indicated. They stated that if performed, it should preserve
at least 1 cm of the dorsal margin and 1 cm of the caudal
portion of the septal cartilage.
Bernstein274 presented a list of indications for
SMR, including midseptal obstructive deformities. After
conservative excision of the most severely obstructing
portions of the septum by SMR, the remaining cartilage
usually is realigned by septoplasty techniques.
39
 SRPS • Volume 11 • Issue C7 • 2015
Septoplasty
Edwards275 reviewed the rationale for septoplasty. Simple
midseptal deflections (which can be successfully managed
by SMR) comprise only 25% of cases, whereas caudal
dislocations account for approximately 65%. Complicated
deformities make up the rest. According to Edwards, SMR
results in inadequate correction of these more complicated
deformities, three-fourths of which are best treated
by septoplasty.
In 1950, Converse276 recommended vertical
scoring of the residual dorsal strut of the septum to
correct persistent deviations of the dorsum. Fry277 later
described “interlocking stresses” in nasal septal cartilage
that could be relaxed by scoring the cartilage. Numerous
modifications of scoring techniques have since evolved,
along with procedures combining resection and scoring.
Gruber and Lesavoy278 advocated closed septal
osteotomy to realign the bony septum (perpendicular
plate of the ethmoid, vomer, and vomerine ridge). An
intranasal fracture is created with a long nasal speculum.
All 32 patients in their series had fracture of the vomer and
perpendicular plate of the ethmoid. The vomerine ridge
(premaxilla area) was fractured in 69%. This resulted in
dramatic straightening of the bony septum in 82%
of patients.
Combined SMR and Septoplasty
Noting that a timid surgical attack of the deviated
septum can result in persistent deformity, Johnson and
Anderson279 recommended a more aggressive approach
consisting of resection of an inferior strip of septum next
to the nasal spine so that the septum can swing freely
toward the midline. The authors advocated total or near-
total transection of the dorsal strut to correct a deviation
while preserving intact mucoperichondrium on the convex
side. The septal strut is stabilized with transseptal mattress
sutures to prevent collapse after division. Medial and
lateral osteotomies to reposition the nasal bones complete
the procedure. Any residual deformities of the dorsum can
be camouflaged with morcellized autogenous
cartilage grafts.
Byrd et al.280 proposed an algorithm for correction
of the crooked nose through an open approach. Anatomic
correction consists of total release of the cartilaginous
40
septum from the LLC and ULC and cartilaginous
and bony septal resection to free the dorsal and caudal
septum. Scoring is avoided, and the curvature is corrected
by repositioning the septum and control sutures aided
by batten and extended spreader grafts. The nasal tip
routinely is secured with a combination of batten and
spreader grafts to preserve tip projection. Osteotomies are
modified to deal with specific deformities in the
bony skeleton.
de la Fuente and Martin del Yerro281 stated that
they prefer bilateral mucoperichondrial-mucoperiosteal
dissection of the septum from its caudal edge to the most
posterior deviated part. They reported that it provides easy
septal resection in a good surgical field. A dorsocaudal
L strut is preserved when possible, but if involved in the
deviation, it can be resected and reconstructed with dorsal
and columellar grafts.
Cannistrá et al.282 advocated an endonasal technique
with full release of the septum from the ULC. Rees283
noted that when a high bony deviation is associated
with marked distortion of the cartilaginous septum, the
surgeon is challenged to completely alleviate the septal
deformity and simultaneously correct the external bony
vault deflection without totally excising the septum. For
severely deviated noses, Rees recommends total removal of
the entire bony and cartilaginous septum extramucosally
and replacement as a free graft. This is a somewhat risky
procedure if the lateral osteotomy and infracture turn out
to be less than perfect.
In 1995, Gubisch284 described complete removal
of the septum with subsequent replantation after
correction of deformity in 1012 patients. All septal
replants healed primarily. The complication rate was 2.2%.
The main problem with the technique was difficulty in
reconstructing the dorsum and stabilizing the replant.
Sheen and Sheen100 noted that a midline septum can
be irrelevant to the objectives of septal surgery (i.e., patent
airways and a nose that appears straight). Sheen reported
that he opts for a conservative approach involving careful
resection of portions of the obstructing septum, which are
subsequently crushed and replaced as camouflage grafts
to mask the deviations. Constantian285 described resecting
the dorsum in the area of deviation until the dorsal edge
is close enough to the midline to disguise the remaining
asymmetry.
 SRPS • Volume 11 • Issue C7 • 2015

Jugo286 advocated total septal reconstruction or interrupting the anatomic continuity of the L-shaped
through an external approach. He reported gaining access septal strut.
to the septum between the alar cartilages along the nasal
Conservative approaches to septal deviation use
dorsum. After removal of the entire septum, the straight
onlay grafts to mask the deformity, but subsequent
cartilage from the center is used to reconstruct the ventral-
resorption or displacement of the grafts can produce
caudal and ventral-cranial septum. The deformed cartilage
dorsal irregularities. In turn, radical procedures for septal
is straightened by crushing and is replaced back into the
straightening risk losing dorsal support to the nose,
posterior septal space. Five girls and 19 boys, ages 5 to 14
with subsequent collapse of the nasal bridge and saddle
years, were treated this way, and the author reported no
deformity. A thorough knowledge of nasal anatomy and
alterations of growth necessitating reoperation.
physiology is the key to proper correction.
Gunter and Rohrich287 reviewed the management of
the deviated nose and advocated simultaneous correction
of the septum and bony pyramid when both structures are
involved. The authors proposed extensive alteration of the
septum but a conservative approach to the external nasal
framework. Total septal reconstruction entails mobilization
of all deviated structures, including the ULC, and
reconstruction of the deviated L strut along the dorsum, if
necessary. The mucoperichondrial attachments should be
disturbed as little as possible to preserve dorsal support to
the nose. Planned precise osteotomies are performed on
the nasal bones.
Rohrich et al.288 grouped nasal deviations into
three basic types: caudal septal deviations, concave
dorsal deformities, and S-shaped dorsal deformities with
deviation of the bony pyramid. Management includes
open exposure of all deviated structures, release of all
involved attachments, straightening the framework while
maintaining a sturdy L-strut, restoring long-term support
with buttressing septal batten or spreader grafts, turbinate
reduction, if necessary, and precise osteotomies
(Fig. 29).288
Guyuron and Behmand289 discussed the
diagnosis and management of caudal nasal deviation by
independently assessing the components of the caudal
nasal structures: septal deviations, asymmetric growth of
the lower lateral cartilages, anterior nasal spine tilting,
and medial crural footplate asymmetry. The authors
recommended specific techniques to address each of these
Figure 29. Operative plan is component dorsal reduction,
potential sources of deviation.
septal cartilage resection, and septal L-strut straightening
Boccieri and Pascali290 addressed the crooked nose with inferior full-thickness 50% cuts. Suturing the L-strut
with septoplasty, full-thickness incisions, and a unilateral to the upper lateral cartilages restores support. Bilateral
cartilage spreader graft, referred to as a crossbar graft, that low-to-low percutaneous osteotomies can be performed
splints the concave surface of the deviated septum. The to narrow the nasal base. (Reprinted with permission from
surgeon must avoid degloving the contralateral surface Rohrich et al.288).

41
 SRPS • Volume 11 • Issue C7 • 2015
Septal Perforations
Teichgraeber and Russo291 described the management of
septal perforations performed in 25 patients, 22 of whom
were treated surgically. The perforations ranged from 1.5
to 2.5 cm and were located on the posterior border of the
quadrilateral cartilage near the vomer-ethmoid junction.
Operative correction included external rhinoplasty with
septal and intranasal mucosal flaps and an autograft of
mastoid periosteum or temporalis fascia and was successful
in 19 (86%) of the 22 patients.
Kridel et al.292 used acellular human dermal allograft
in the repair of septal perforations in 12 patients. Eleven
had complete closure of the perforation. The repair was
considered successful if, at examination 3 months later, the
right and left mucoperichondrial flaps were entirely healed.
The authors stated that this technique yields satisfactory
results similar to those obtained with temporalis fascia,
mastoid periosteum, or pericranium.
Schultz-Coulon293 reported bilateral closure using
bridge flap techniques in 54 patients, with an overall
success rate of 93.7%. Closure was supplemented with
autologous cartilage from residual septum, rib, or auricle.
Morre et al.294 reported a similar technique with equally
good results. A “cross-stealing” technique for closure
of septal perforations was presented by Mladina and
Heinzel.295 The surgery consists of turn-in flaps based on
the margins of the septal perforation from either side of
the septum.
Romo et al.296 proposed a graduated approach to the
repair of nasal septal perforations tailored to the size and
location of the perforation:
•• Perforations up to 2 cm in diameter were
closed in 93% of patients by an extended
external rhinoplasty and bilateral posteriorly
based mucosal flaps.
•• Larger perforations (2–4.5 cm) were closed
in 82% of patients by a two-stage technique
and midfacial degloving to immediately
advance posteriorly based, expanded
mucosal flaps. A 1 × 3 cm tissue expander
was first inserted in a submucoperiosteal
pocket on the nasal floor.
Foda297 reported a one-stage repair of septal
perforations up to 4 cm in diameter, which he performed
42
in 20 patients. The repair consisted of bilateral intranasal
mucosal advancement flaps bridged by a connective
tissue interposition graft through an external rhinoplasty
approach. Complete closure of the perforation was
achieved in 90%, and 80% experienced resolution of
preoperative symptoms. Ribeiro and da Silva298 reviewed
their experience repairing septal perforations with bilateral
intranasal submucoperichondrial and submucoperiosteal
advancement flaps with an interpositional sandwich
graft. This method was successful in 257 of 258 cases for
correcting perforations ranging from 1.0 to 3.5 cm in
diameter. The graft consisted of temporal deep fascia with
cartilage folded over in a sandwich fashion.
Guyuron and Michelow299 proposed an algorithm
for the management of intraoperative nasal septal tears
and perforations based on their experience with 98
patients. Small, nonopposing perforations are allowed to
heal spontaneously. Opposing tears ranging from 1 to 2+
cm are repaired on one side by inserting a straight piece
of septal cartilage, and then the mucoperichondrium is
repaired on the other side.
ALAR RIM
The alar rim is a common site of patient dissatisfaction,
either because of preoperative deformity or postoperative
complication. Gunter et al.300 described the ideal alar-
columella relationship and classified discrepancies in
these proportions. In aesthetically pleasing noses, the
highest point of the alar rim is located midway between
the transverse levels of the columella-lobule angle and the
tip-defining points. As seen on a lateral view, the nostril
is oval; the alar rim forms the superior nostril border and
the roll of the columella forms the inferior border (Fig.
30).300 Abnormal variants can have a hanging or retracted
columella, a hanging or retracted ala, or a combination
of these.
In profile, the nostril rim should be cephalad and
parallel to the columella. When this balance is disturbed,
or if raising the columella will shorten the nose excessively,
the alar rim(s) might have to be raised, too. Matarasso
et al.301 reported diagnosing a hanging columella when
the septal mucosa is visible on profile, with or without a
retracted caudal alar rim and regardless of the nasolabial
angle. When unusually wide medial crural cartilages
 SRPS • Volume 11 • Issue C7 • 2015

Gunter and Friedman305 described the lateral crural

strut graft (Figs. 31 and 32) for use in patients with alar
rim retraction (Fig. 33), alar malposition, alar collapse
(Fig. 34), concave lateral crura (Fig. 35), and/or boxy tip
(Figs. 36 and 37). This versatile cartilage graft typically is
placed in anatomic position between the lateral crura and
the vestibular lining. The authors described their technique
and provided illustrative examples of the
clinical indications.

Figure 30. In a normal alar-columellar relationship, the

greatest distance from the long axis of the nostril to either
the alar rim or the columella should be 1 to 2 mm (AB = BC
= 1 to 2 mm). (Reprinted with permission from Gunter et al.300)

contribute to the deformity—as was the case in 15%

of their series—balance can be restored by excising a
C-shaped crescent of cartilage from the cranial border of Figure 31. Lateral crural strut graft. The graft is sutured
the medial crura through a direct approach. to the deep surface of the lateral crus. (Reprinted with
McKinney and Stalnecker302 discussed three permission from Gunter and Friedman.305)
techniques for achieving a proper columella-ala
relationship: 1) excising the skin of the nose, 2) trimming
the lateral crura along the cephalic or caudal border, and
3) resecting nasal lining. Decisions relating to these choices
are discussed in the article.
Ellenbogen and Blome303 advocated raising the
high point of the alar rim by 3 to 5 mm from the caudal
margin of the columella. Indications for raising the alar
rim are a cleft nose with anterior webbing, asymmetric
nostrils, small or round nostrils, and a hanging sigmoid
ala. In the event of a hanging columella, the alar rim might
have to be lowered to correct the high-arched nostril.
Ellenbogen304 also reintroduced the concept of lowering
the alar rim by incising the alar margin along its free
length and unfurling vestibular mucosa caudally. A graft Figure 32. Left, Area of vestibular skin undermining
of septal or auricular cartilage is placed between the two for placement of the lateral crural strut graft. Right,
layers of mucosa at the proposed new alar height and held Relationship of graft to undermined region. (Reprinted with
in place with through-and-through sutures. permission from Gunter and Friedman.305)

43
 SRPS • Volume 11 • Issue C7 • 2015
Figure 33. Alar retraction. Correction with the lateral crural
strut grafts and lateral crural repositioning. (Reprinted with
permission from Gunter and Friedman.305)
Figure 34. Alar rim attenuation with resultant collapse.
Correction with lateral crural strut grafts. (Reprinted with
permission from Gunter and Friedman.305)
Figure 35. Concave lateral crura. Correction with lateral
crural strut grafts. (Reprinted with permission from Gunter
and Friedman.305)
44
Figure 36. Boxy nasal tip. Left, Medial displacement of the
lateral margin of the lateral crus after suture correction of
the nasal tip. Right, Compromise of the vestibular airway
caused by medial displacement of the lateral crus. (Reprinted
with permission from Gunter and Friedman.305)
Figure 37. Boxy nasal tip. Correction of the lateral crural
displacement using lateral crural strut grafts. (Reprinted with
permission from Gunter and Friedman.305)
Rohrich et al.306 presented a review of alar rim deformities
and the surgical options for their correction (Table 2).
The authors advocated the use of alar contour grafts or
nonanatomic alar rim grafts (septal cartilage) for patients
with mild to moderate congenital alar retraction, for those
undergoing primary rhinoplasty who have a propensity for
alar notching, for those undergoing secondary rhinoplasty
patients who have minimal or no vestibular lining loss,
and for those with malposition of the lower lateral
cartilages. The authors included details of the surgical
technique (Fig. 38).
 SRPS • Volume 11 • Issue C7 • 2015

TABLE 2
Surgical Indications and Options for Alar Deformities306

Technique Degree of Alar Retraction Graft Location Efficacy for

Corrected (mm) Lining Loss

Alar contour graft ≤2 Alar rim +

2−4 Between lower lateral cartilage domes +

Lateral crural <4 Beneath lower lateral cartilage medially to ++

strut graft pyriform aperture laterally

Composite graft >4 Variable (alar rim area) +++

Guyuron307 discussed his approach to various

alar rim abnormalities, such as convexity, concavity, A
retraction, and hanging ala. He utilized lateral crural
spanning sutures, posterior transaction of the lateral crura,
or transdomal sutures to correct convexity. Concavities
are corrected with lateral crural strut or alar rim grafts.
Mild alar retraction is also corrected with alar rim grafts.
Guyuron proposed an internal V-Y advancement flap
for severe retraction and provided technical details. For
hanging alar deformity, the author reported a preference
for vestibular lining excisions.
Other authors have suggested different methods
for correction of alar retraction. Tardy and Toriumi308
proposed composite grafting of the alar rim. Tellioglu
and Cimen309 suggested a turn-in folding of the cephalic
portion of the lateral crus to support the alar rim.
Constantian310 also advocated liberal use of composite
B
auricular cartilage grafting for alar rim deformities in
patients undergoing secondary and tertiary rhinoplasty,
based on his experience in 100 consecutive patients.
He described an “axially oriented” auricular cartilage
graft spanning the alar base and sill for the correction
of vestibular stenosis with alar collapse. Gruber311,312
described the use of an intercrural batten graft that extends
Figure 38. A, Open approach with stairstep columellar
from the caudal edge of the ULC to the cephalic margin of
incision and infracartilaginous incision. B, Proper placement
the LLC to push the lateral crus and alar rim caudally.
and shape of the alar contour graft immediately above the
Tardy et al.313 described a technique for alar alar rim and spanning the alar notched area are key to a
reduction and sculpture that is based on a detailed successful outcome. (Reprinted with permission from Rohrich
analysis of the anatomy of the alae and nostril floor. et al.306)

45
 SRPS • Volume 11 • Issue C7 • 2015
Alar modifications are indicated when there is flaring,
bulbosity, or excessive width of the nasal base or when
tip retroposition at surgery produces excessive alar flare.
Of importance is the site and angle of insertion of the
alae into the face. A cephalic location of the alar-facial
junction can create a high-arched appearance to the alae,
exposing an excessive amount of columella. In extreme
cases, this variant produces a snarl-like appearance. Caudal
insertions of the alae into the face create the appearance
of a disproportionately large and bulbous lobule and
sometimes alar hooding. The authors give indications for
internal nasal floor reduction, alar wedge excision, alar
flap, and sliding alar flap.
Millard314 presented a discussion of alar margin
sculpturing techniques through external incisions. Planas
and Planas315 reviewed the use of external excisions
for correcting variations in the shape of the nostrils in
rhinoplasty. Matarasso316 approached alar rim excision
through an “internal technique” to core out excess alar
tissue through an alar base incision. Subsequently, the
author limited the indications for this approach to
deformities of the lower third of the rim.317
Oktem et al.318 described a lower cartilage Z-plasty
for treating alar cartilage malposition. The alar cartilage
is divided obliquely into anterior and posterior segments
at a point located 15 mm lateral to the nasal dome. The
posterior crural segment, which is secured to the pyriform
aperture, is transposed cephalically in a Z-plast manner
to attain the desired position of the anterior lateral
crural segment. This technique has the advantage of not
requiring additional cartilage and does not violate the
posterior alar rim, which allows for preservation of the fine
movements of the alar muscles. In addition, tip projection
can be adjusted by fixing the anterior crural segment
in a posterior and overlapping manner if nasal tip over-
projection is present or in an anterior position with no
overlapping in under-projection cases.
SECONDARY RHINOPLASTY
The incidence of postsurgical nasal deformities requiring
secondary correction varies from 5% (the best that
experienced surgeons achieve, according to Rees et al.319)
to 12% (Smith320 presented a report of 221 patients).
Rogers321 offered a comprehensive discussion of post-
46
rhinoplasty deformities and the procedures for their
correction. The reader is also referred to a review of
techniques presented by Webster,322 a retrospective
presented by Peck,323 and a chapter on secondary
rhinoplasty written by Sheen and Sheen.100 Sheen and
Sheen100 asserted that the key to effective secondary
rhinoplasty is accurate diagnosis of the deformity. He listed
five “ground rules” for the management of postsurgical
nasal anomalies, as follows:100,103
•• Defer surgery until there is final resolution
of tissue edema (at least 1 year).
•• Have a well-defined aesthetic concept.
•• Make a proper diagnosis.
•• Limit the dissection.
•• Use only autogenous material.
In general, surgical correction of secondary
deformities must be more conservative than the primary
operation. The surgeon should resist the temptation to
repeat errors of over-reduction. In the words of Millard,324
“Once the nose goes wrong, too often an irreversible chain
reaction is set in motion-as the surgeon frantically excises
again and again.”
Sheen103 discussed the secondary correction of
supratip fullness, total disharmony of all nasal parts, a
dorsum that is too low after grafting, a snub nasal tip
from over-resection of the dorsum and under-resection of
the caudal septum, and residual high septal deviation. He
presented a technique for grafting the nasal tip104 that is
also helpful in secondary rhinoplasty. For cases in which
the middle vault has been excessively narrowed and the
caudal borders of the nasal bones are visible through the
skin, Sheen106 recommended spreader grafts to reestablish
an open angle between the ULC and the dorsal septum.
The author correlated reconstruction of the middle nasal
vault with improvement in nasal physiology and enhanced
airway capacity.
Peck323 discusses some common deformities in
secondary rhinoplasty, as follows:
•• Lack of tip projection from lack of alar
cartilage-dome projection
•• Lack of tip projection from lack of septal
support of the nasal tip-pyramid complex

•• Saddle deformity
•• Supratip deformity
•• Alar deformities
•• Deformities of the ULC and nasal bones
•• Deformities of the columella and short nose
•• Deformities of the nasolabial angle
•• Thick, rigid tip
•• Persistent Pinocchio tip
Peck323 reported using a conchal cartilage tip graft
when there is lack of tip projection from inadequate dome
projection and a conchal cartilage intercrural graft when
the lack of tip projection is due to insufficient dorsal
support. Peck’s choice for reconstructing the septum in
saddle nose deformity is first, a layered septal cartilage graft
and second, a bone graft harvested from the ilium, rib, or
calvarium. Marin et al.325 preferred rib cartilage grafts for
correction of contour deformities and functional problems
caused by previous operations. The authors argued that
that it has a lower resorption rate and higher strength
compared with auricular cartilage, irradiated cartilage, and
alloplastic materials. A detailed description of their rib
cartilage harvesting techniques is described.
Based on his experience, Peck323 determined that
the supratip deformity is most commonly caused by a
high supratip septal cartilage. For correction, the author
recommended lowering the dorsum as a unit to include
the septum and the left and right ULC. The second
most common cause of supratip deformity is inadequate
removal of the fibrofatty tissues. The third most common
cause is inadequate sculpting of the alar cartilages. A
supratip deformity can also result from overzealous
lowering of the nasal pyramid in the presence of thick,
rigid skin, in which case a columellar strut or dome-tip
graft might be indicated.323
Guyuron et al.326 noted supratip fullness in 9%
of patients undergoing primary rhinoplasty and in
36% undergoing secondary rhinoplasty. With primary
rhinoplasty, the deformity was caused by inadequate
tip projection (pseudo-deformity), an over-projecting
caudal dorsum, a combination of both, or cephalically
oriented LLC. With secondary rhinoplasty, the deformity
was caused by under-resection or over-resection of the
SRPS • Volume 11 • Issue C7 • 2015
caudal dorsum, over-resected midvault, under-projected
tip (pseudo-deformity), or any combination of these.
The authors concluded that it might be possible to
prevent supratip deformity by properly resecting the
caudal dorsum, avoiding dead space, restoring adequate
projection to the nasal tip, and approximating the supratip
subcutaneous tissues to the underlying cartilage with a
supratip suture.
Alar notch deformities most often occur secondary
to resection of vestibular lining or transection of the alar
cartilages. Deformities of the ULC and bone generally are
corrected by onlay grafts of septum or conchal cartilage.322
According to Peck,323 the most common cause of a
crowded lip is a septum that is too long and has literally
grown onto the upper lip. Resection of the caudal end of
the septum usually is all that is needed for correction.
The recessed nasolabial angle is corrected by
insertion of a septal or conchal cartilage graft to build
up the base and open the angle. A tight frenulum can be
corrected by V-Y advancement of the frenulum.323
The thick, rigid tip generally is associated with
sebaceous skin that will not drape or contour onto
the skeletal framework. In these instances, Peck323
recommended augmentation of the tip. He corrected the
persistent Pinocchio tip by amputation of the cartilages
and reconstruction with onlay graft from the concha.
Parkes et al.327 analyzed their experience with 1221
consecutive rhinoplasties, 170 (14%) of which were
revision procedures. Most secondary problems occurred
in the lower third of the nose: polly beak (33%), bossa
(26%), and excessive dorsal resection (24%).
On the basis of his experience with 56 cases of
secondary deformity after primary open rhinoplasty,
Daniel328 recommended a closed technique when
augmentation is the solution and an open approach when
structural correction is required. The risks of skin necrosis
and poor scarring are similar with either technique.
The stigmata of open primary rhinoplasty include the
following: 1) a depressed and visible scar, 2) destruction
of the soft-tissue facets in the nostril apices, 3) columellar
deformities with associated nostril asymmetry, and 4)
excessive tip or supratip defatting. These can and should
be avoided, and Daniel offered suggestions for
eliminating them.
47
 SRPS • Volume 11 • Issue C7 • 2015
Neu329 described a “segmental” approach to
secondary rhinoplasty for mild to complete loss of alar
cartilages and a treatment algorithm based on the severity
of the deformity. His technique of cartilage grafting in
these difficult cases is detailed and illustrated in the article.
Turegun et al.330 used a thin saddle-shaped porous
polyethylene implant to overcome aesthetic and functional
deformities in secondary rhinoplasty. The rigid structure of
this implant allows functional improvement of the airway
and correct surface asymmetry by filling the defects. No
extrusion was noted in this study.
SADDLE NOSE DEFORMITY
Stuzin and Kawamoto331 used cranial bone grafts to
correct the post-rhinoplasty saddle nose deformity. The
subperiosteal pocket extends well into the piriform
aperture and along the lateral nasal walls and nasal floor.
Mucosal advancement is sometimes indicated. In addition,
patients with nasal foreshortening often require a strong
cantilever bone graft to augment the dorsum, lengthen the
nose, increase tip projection, and support the columella.
Erol153 elevated the nasal dorsum with a pliable graft
of diced cartilage wrapped in Surgicel. Although the graft
seems more suitable for fill than for structural support, the
author reported achieving good results in 2365 patients
over 10 years.
In the event of end-stage deficiency of the nasal
skeleton, Posnick et al.332 recommended full-thickness
cranial bone grafts and rigid internal fixation through
a coronal incision. The dorsal graft often must extend
down to the tip for a well-chiseled contour and good tip
definition. The authors warned against grafts that are too
wide and that excessively broaden the nasal dorsum and
urged care in sculpting the nasofrontal junction.
Powell and Riley333 analyzed the 4-year results of
850 calvarial bone grafts to the nose in 170 patients.
Most graft sites showed partial resorption ranging from
insignificant to 30%. Areas of maximum resorption and
contour change were at the nasal dorsum and lateral
posterior mandible. Excellent contour was achieved and
maintained in all except a few cases. Although the authors
endorsed the use of calvarial bone grafts in facial skeletal
reconstruction and in the nasal dorsum, their study
showed the nose to be a site of potentially greater bone
48
resorption than other areas of the face.
Jackson et al.334 reviewed the long-term outcomes
of 363 cranial bone grafts used in nasal reconstruction.
Split-thickness grafts were applied in 85% of the cases
and full-thickness grafts in the remainder. The authors
reported satisfactory results in the vast majority of cases.
Shipchandler et al.335 described a technique creating
an L-shaped strut graft from a split calvarial bone that
provides dorsal support while increasing tip projection.
The results showed maintenance of the tip projection
and absence of graft infection, resorption, and migration.
Hodgkinson336 argued that bone grafts should not extend
to the nasal tip but stop at the septal angle; augmentation
of the nasal tip should be accomplished with cartilage
grafts from other sites. We agree with this view; differential
support of the tip produces aesthetic projection of the tip
above the dorsal plane.
Kridel and Konior337 reviewed the fate of 306
irradiated costal cartilage homografts to the nose, 122
of which were used on the nasal dorsum, 40 for primary
rhinoplasty, and 82 for revision rhinoplasty. Complications
included infection around the graft in 3% to 4%, graft
resorption in 3% to 4%, graft mobility in 4%, and
cartilage warping in 3%. The overall complication rate
was approximately 10%. Four patients in the primary
rhinoplasty group eventually needed revisional nasal
surgery for additional augmentation. To date, this is
the largest published series of irradiated costal cartilage
homografts specifically used for nasal reconstruction.
Daniel338 described the use of an osseocartilaginous
autologous rib graft for dorsal contour in combination
with a rigid cartilaginous strut to support the tip and
reinforce the columella. The method of harvest and
reconstruction are well illustrated. In a discussion of the
article by Daniel, Byrd339 described his technique for
carving portions of the 10th and 11th ribs as nasal grafts
(Fig. 39). In a cadaveric study, Kim et al.340 confirmed that
meticulous concentric carving results in less warping than
does eccentric carving.
Waldman341 reported his experience with Gore-Tex
for augmentation of the nasal dorsum in 17 patients when
autogenous sources were not available. The Gore-Tex grafts
were inserted during open rhinoplasty, and all patients
received some type of columellar support. During follow-
up examinations from 12 to 36 months, Waldman noted
 SRPS • Volume 11 • Issue C7 • 2015

no operative or postoperative complications. One implant and reported, “Postoperative follow-up has revealed a
was removed 5 months after insertion because of stable implant material with no complications relating to
excessive augmentation. the graft material.”
Godin et al.342 analyzed the postoperative course Jang et al.345 investigated the histological changes
of 137 patients—69 primary rhinoplasties, 68 revision associated with Gore-Tex removed during aesthetic
rhinoplasties—who received augmentation with Gore-Tex revision rhinoplasty. Gore-Tex samples implanted for long
patches. Follow-up duration was from 6 to 80 months periods of time were associated with decreased thickness,
(average, 25 months). The authors reported that three structural changes, micro-calcifications, foreign body
(2.2%) of 137 grafts became infected and were removed. reactions, and, surprisingly, tissue ingrowth beginning as
One graft was removed 5 months postoperatively early as 1 week after insertion.
because of excessive augmentation. None of the patients
who underwent implant removal required subsequent Straith346 reviewed the long-term (average, 15
augmentation. All 137 patients were pleased with their years) outcome of Silastic implants for the correction of
results. Technical points that were thought to be important saddle-nose deformity in five patients. A careful dissection,
to the success of the procedure are as follows: watertight closure, antibiotic irrigation, and implant
design that avoids pressure on thin vestibular membranes
•• For dorsal grafts, the implant usually was
are credited for the good results.
boat shaped.
Peled et al.347 conducted a meta-analysis of the
•• All implant edges were carefully beveled.
The graft was cut to the width of the nasal use of alloplastic materials in rhinoplasty. The authors
bones at the nasion, gradually widened concluded that alloplastic implants have acceptable
toward the rhinion, and tapered to a sharp complication rates and can be used when autogenous
point at its caudal end. materials are unavailable or insufficient. They also reported
that Medpor or Gore-Tex might offer a slightly better
•• The dissected pocket should easily accept outcome than silicone.
the graft without rolling or bunching.
•• The graft should run the entire length of the
dorsum to avoid steps or notches in profile.
•• The graft is soaked in saline containing a
broad spectrum antibiotic and is secured
with 5-0 polypropylene suture.
•• Overcorrection is not necessary considering
that resorption of Gore-Tex implants has
not been observed.
An update343 of the series presented by Godin et
al.342 included 309 consecutive patients with 52% primary
and 48% secondary rhinoplasty cases. During follow-up
of 5 months to 10 years, the graft infection rate was 3%
overall: 1% primary and 5% revision. The grafts became
infected in three patients with perforated nasal septums
and had to be removed. The authors considered septal
perforation to be a contraindication for nasal Figure 39. Eleventh rib rotated 90° so that inferior border
Gore-Tex implantation. becomes convex dorsum. Bony portion split and out-
fractured to create the bony dorsum. Cartilaginous portion
Owsley and Taylor344 reviewed their use of Gore-Tex of tenth rib serves as columellar strut. (Reprinted with
for nasal augmentation in 106 patients (87 on the dorsum) permission from Byrd.339)

49
 SRPS • Volume 11 • Issue C7 • 2015
Jung et al.348 reported their extensive experience
with silicone nasal augmentation. Silicone implants
were noted to induce calcification when inserted
for a prolonged period of time, causing long-term
morphological changes.
Daniel349 proposed a new saddle nose classification
based on the presenting deformities and method of
treatment. He presented a new subgroup, which he
designated the septal saddle deformity secondary to
weakening or loss of septal cartilage instead of the classical
dorsal over-resection.
The forgotten element in successful correction of
posttraumatic saddle nose is nasal lining. For an in-depth
discussion of this topic, the reader is referred to SRPS
volume 10, number 12.350
ADJUNCTIVE PROCEDURES
Resection of the Alar Base
Sheen and Sheen100 classified alar bases according to
relative proportions of vestibular and external skin. Weir,351
in 1892, corrected excessively flaring or wide nostrils by
resecting the alar bases. Sheen and Sheen100 later modified
the technique presented by Weir by retaining a medial
flap on the wedge excision. This refinement provided a
more natural, continuous nostril sill and reduced the alar
notching produced by the scar of the Weir procedure.
Paranasal Augmentation
Guerrerosantos352 reviewed augmentation of the paranasal
and anterior maxillary area with autogenous fascia and
cartilage. Graft designs and positions were detailed. The
procedure is recommended as an adjunct to orthognathic
surgery and for primary and secondary rhinoplasties.
Mentoplasty
In 1965, Millard204 discussed adjunctive procedures in
corrective rhinoplasty, including wedge excision of the
alar bases and resection of the alar margins to narrow
the width of the nose and correct alar flare, insertion
of a columellar strut graft of septal cartilage to elevate
the tip, and introduction of a chin implant through an
intraoral approach. According to Millard, augmentation
50
mentoplasty is indicated in approximately 15% of
rhinoplasty cases.
Rish353 proposed a simple and effective method for
determining who would benefit from chin augmentation.
Using photographs of the patient in profile with the
Frankfort line parallel to the floor, a vertical line is
dropped perpendicular to the Frankfort horizontal plane
and through the lower lip. If the chin does not reach this
line, the patient is probably a candidate for augmentation
mentoplasty.
Davis354 classified chin deformities as macrognathic,
retrognathic, and microgenic. Microgenia and occasionally
retrognathia are the only conditions in which chin
augmentation is appropriate. He uses primarily Silastic
chin implants and stresses proper placement over the
pogonion, as low as possible over the point of the chin,
where the bone is dense and less likely to resorb than if the
implant is placed higher on the mandible. If augmentation
>8 mm is required, a simple chin implant is unlikely to
provide satisfactory results, in which case a mandibular
osteotomy or sliding genioplasty is indicated.
Two studies355,356 documented resorption of the
mandibular cortical surface after placement of solid chin
implants. Although essentially a radiographic finding and
usually self limiting, this cortical resorption nevertheless
has prompted the development of softer prostheses.
Simons357 reviewed the history of mentoplasty.
The author described an extraoral surgical approach and
discussed other adjuncts to rhinoplasty, including chin
reduction, orthodontia, makeup, and hair styling.
Endoscopic Sinus Surgery
Slafani and Schaefer358 examined the effect of concurrent
endoscopic sinus surgery on the postoperative course of
cosmetic rhinoplasty. The findings suggested that the
presence and treatment of sinonasal disease prolongs the
patient’s recovery from cosmetic rhinoplasty and correlates
closely with the degree of preoperative sinus disease. The
authors recommended a two-team approach and that
the endoscopic sinus surgery be performed first. The
cosmetic rhinoplasty should be performed only if excellent
hemostasis is present and violation of the anterior skull
base or medial orbit on the part of the sinus surgeon is not
of concern.

COMPLICATIONS
In 1964, Klabunde and Falces359 surveyed 300 unselected
cases of cosmetic rhinoplasty and noted an overall
complication rate of 18%, although 95% of patients
were satisfied with the results. Intraoperative or early
postoperative complications included the following:
•• operative hemorrhage
•• septal perforation
•• anesthesia-related problems
•• postoperative hemorrhage
•• postoperative infection
Late complications consisted of the following:
•• persistence of edema or ecchymosis
•• excessive scar
•• vestibular webbing
•• hypesthesia
A later retrospective study of 200 rhinoplasties,
conducted by McKinney and Cook,360 disclosed
considerably lower incidences of infection, hemorrhage,
and secondary revisions in the intervening 17 years. The
overall complication rate was approximately 6% (4% if
chin complications were excluded), and 12% of patients
required revisions. Despite the improved surgical outcome,
patient satisfaction declined to 90%. Dissatisfied patients
were more likely to be female, in their 40s, and not
physician referrals.
Teichgraeber et al.361 reviewed 259 consecutive
rhinoplasties and noted a 5% incidence of serious
complications, defined as hemorrhage (five cases),
perforation (four cases), infection (three cases), and
pneumocephalus (one case). All these patients had
undergone concomitant septal or turbinate surgery.
Padovan and Jugo362 reviewed the complications
of external rhinoplasty in their practice over a 14-year
period. Intraoperative complications included excessive
bleeding (>250 mL) in 1%, and cuts on the caudal
border of the LLC and tears of the columellar skin, which
occurred rarely but were annoying. The most common
early postoperative complication was transient epiphora
occurring in 13%. Transient anosmia occurred in 5%
and prolonged edema in 3%. The most common late
SRPS • Volume 11 • Issue C7 • 2015
postoperative complication was failure to achieve the
desired aesthetic or functional goal in 5% of patients,
approximately half of whom requested secondary
correction. The authors recommend the following
measures to avoid complications in open rhinoplasty:
•• meticulous surgical technique
•• proper set of instruments
•• hypotensive anesthesia
•• careful screening for coagulation disorders
•• no surgery during the menstrual period or
during times of aspirin intake
•• careful patient selection and increased
caution in hypertensive patients
•• routine use of broad-spectrum antibiotics
and steroids
•• careful placement of nasal packs only in the
anterior half of the nasal cavity
•• no narrow, straight osteotomes
Andrews et al.363 performed a prospective
randomized study comparing the efficacy of
prophylactic versus postoperative antibiotics in cases
of septorhinoplasty. The authors found no significant
difference in infection rates between the prophylactic
and postoperative groups, strengthening the evidence for
antibiotic administration before nasal surgery.
Piltcher et al.364 conducted a randomized clinical
trial. They concluded that hypopharyngeal packing is
ineffective in preventing nausea and vomiting after
nasal surgery.
Corticosteroids
Hoffman et al.365 noted certain advantages to the use of
steroids during rhinoplasty. In a randomized double-
blind study of 29 patients, the authors documented less
postoperative edema of the eyelids and nose and fewer
ecchymoses when steroids were administered. Patients who
received steroids also had less discomfort postoperatively.
In a randomized double blind prospective study of
20 male patients, all of whom had undergone osteotomies
as part of their rhinoplasties, Berinstein et al.366 measured
51
 SRPS • Volume 11 • Issue C7 • 2015
the effect of a single preoperative dose of 10 mg of
dexamethasone on postoperative edema. Contrary to
expectations, these patients experienced more edema than
those who did not receive the corticosteroid.
Shafir et al.367 reported the case of a 37-year-old
woman who underwent rhinoplasty, including septal
correction, with injection of small amounts of long-acting
Depo-Medrol to either side of the nasal bridge. Within
seconds of the last injection, the patient lost vision in the
ipsilateral eye and had no pupillary reflex. A diagnosis of
central retinal embolus and choroidal occlusion was made,
and routine treatment for vascular occlusion of the bulb
was immediately initiated. Despite these measures, the
patient remained blind in that eye.
In a review of the literature in 1981, Mabry368 found
10 cases of blindness occurring after steroid injections.
In 1994, the author reported zero visual complications
in his own series of 13,000+ intranasal steroid injections.
The pathomechanism is thought to be microemboli of the
steroid suspension that occlude one or more of the retinal
or choroidal vessels.
A prospective study conducted by Ozdel et al.369
showed no significant difference in psychological well
being between a group receiving 10 mg of dexamethasone
preoperatively and a control group. In addition, the
authors reported that periorbital edema was significantly
reduced for the first 2 postoperative days in the group
receiving steroid.
Gürlek et al.370 conducted a prospective controlled
randomized double blind study of the effects of different
regimens of corticosteroids on 40 patients undergoing
open rhinoplasty with osteotomies. A clinically
statistically significant difference in ecchymosis and
edema was noted between the placebo and the high-dose
methylprednisolone groups.
Totonchi and Guyuron371 compared arnica, an
herbal medication, and steroids in the management of
post-rhinoplasty ecchymosis and edema. Their prospective
study suggested that both arnica and steroids can be
effective in reducing edema. However, arnica does not
provide any benefit when evaluating the extent and
intensity of ecchymosis.
Nasal Packing, Stents, Splints, and Dressings
Guyuron372 assessed the role of nasal packing in
52
septorhinoplasty and concluded that patients who received
packing were less likely to develop recurrent septal
deviation and synechiae and more likely to experience
an improved nasal airway postoperatively. Significant
improvement in airflow was documented in 96% of the
patients who received nasal packing compared with 64%
of those who did not (P < 0.05).
Reiter et al.373 disagreed with Guyuron.372 On the
basis of their analysis of 75 consecutive nasal procedures
completed without packing, Reiter et al. recommended
through-and-through suturing of the entire septal
flap, small caliber osteotomy, meticulous closure of all
intranasal incisions, and proper application of conforming
dressings as alternatives to packing.
Camirand et al.374 reviewed the course of 812
patients who had neither internal packing nor external
immobilization after rhinoplasty. None showed early
bone or septal displacement, and swelling, bruising, pain,
epistaxis, and synechiae was not increased compared with
patients who received packing. It is not clear from their
report whether any patient in their series had undergone
turbinate surgery, which would have increased the risk of
synechiae. Submucosal hematoma and septal necrosis were
nonexistent. Nevertheless, it is anecdotally known that
most rhinoplasty surgeons thing that external conforming
dressings are of benefit in controlling postoperative edema.
A randomized prospective trial by Lubianca-Neto
et al. evaluated the time of nasal packing in relation to
375
hemorrhagic complications after nasal surgery. Of 104
patients in the study, half had packing for 24 hours and
the other half for 48 hours. No statistical difference was
observed between the two groups in terms of hemorrhagic
complications. Hypertension was the only prognostic
factor for postoperative bleeding.
Guyuron and Vaughan376 evaluated the efficacy of
septal stents for maintaining patency of the airway after
septorhinoplasty. Subjective ratings of airway improvement
were very similar regardless of whether patients had
received stents. The number of patients who complained
about discomfort in this small sample was higher in the
nasal stent group, as were the rates of partial, residual, and
recurring septal deviation.
Awan and Iqbal377 conducted a prospective
randomized study comparing the incidence of

postoperative complications in patients undergoing
septoplasty with and without nasal packing. The authors
found that patients within the nasal packing group
experienced significantly more postoperative pain,
headache, epiphora, dysphagia, and sleep disturbance.
When examined 7 days postoperatively, no significant
difference between the two groups was noted in the
incidence of bleeding, septal hematoma, adhesion
formation, or local infection. The authors concluded that
nasal packing is not only unnecessary but is a source of
patient discomfort, especially during its removal.
Airway Changes
Constantinides et al.378 studied the long-term outcome
of open cosmetic septorhinoplasty and its effect on nasal
airflow in 27 patients. Plethysmographic findings showed
improvement in 23 patients and worsening in four.
Subjective impressions of nasal patency did not correlate
well with objective measurements. The authors concluded
that patients with normal nasal resistance values might
suffer long-term asymptomatic increases in nasal resistance
values after cosmetic open septorhinoplasty.
Risk of Nasal Fracture
Guyuron and Zarandy379 noted an incidence of nasal bone
fracture after rhinoplasty of 0.624 fractures per year (24 of
1121 cases over 8 years). In contrast, the National Center
for Health Statistics cites a 0.021% annual rate of nasal
bone fracture. It is clear that the incidence of nasal bone
fracture occurring after rhinoplasty is higher than that of
nasal bone fracture in the general population.
Sense of Smell
Kimmelman380 evaluated the olfactory capacity of
93 patients before and after nasal surgery, including
ethmoidectomy, polypectomy, Caldwell-Luc, reduction of
nasal fracture, and septorhinoplasty. The author reported
improvement in 61 patients and decline in 32. No
correlation was shown with age, sex, type of operation,
or anesthetic. Shemshadi et al.381 reported that 87.5% of
the patients undergoing open rhinoplasty had anosmia
at 1 week postoperatively, with the remaining exhibiting
at least moderate levels of hyposmia. At postoperative
SRPS • Volume 11 • Issue C7 • 2015
week 6, 85% of the patients experienced some degree of
hyposmia. The authors concluded that a time interval
of 6 weeks to 6 months is required to revert to baseline
olfactory function after open rhinoplasty.
Pade and Hummel382 conducted a prospective
study to analyze the outcome of olfactory function after
nasal surgery in 775 patients. The authors observed an
improvement in the sense of smell in 13% and 23% of
patients undergoing septal and sinus surgery, respectively.
A postoperative decrease in olfactory function was
identified in 7% and 9% of patients undergoing septal and
sinus surgery, respectively. Decrease in olfactory function
occurred mostly in patients with good sense of smell
preoperatively; therefore, this group should be counseled
appropriately regarding the potential risks of nasal surgery.
Toxic Shock Syndrome
Reports of toxic shock syndrome (TSS) occurring after
nasal surgery383−385 deserve special attention. Between 1980
and 1983, the incidence of TSS after nasal surgery was
16.5 per 100,000 patients, which is proportionately higher
than for the general population of menstruating women.
In all cases, the onset of symptoms was rapid and consisted
of fever, nausea, vomiting, diarrhea, erythroderma, and
hypotension; the wound did not appear grossly infected.
The causative organism was a species of Staphylococcus
capable of producing a potent exoprotein, TSS toxin-1
(TSST-1). Topical and systemic antibiotics did not
seem to offer any protection against the disease.383 No
predisposing factors were identified, and there was only
a weak correlation with surgical technique.383−385 Patients
who develop TSS tend to receive splints more often, and
all have nasal packing, but so do 98% of all nasal surgery
patients. In short, to this day, we do not know why some
patients contract TSS after rhinoplasty and most do not.
THE NON-WHITE NOSE
The basic approach to the non-white nose involves
elevation (augmentation) and narrowing of the dorsum,
increasing tip projection and definition, and narrowing
of the wide nasal base and alae. Hoefflin386 reported his
experience with geometric sculpting of the thick and
poorly defined nasal tip common in Black, Hispanic, and
Asian patients. Tip definition and refinement to create the
53
 SRPS • Volume 11 • Issue C7 • 2015
illusion of a thinner nose can be accomplished through
the following procedures: 1) geometric tip defatting on
the central and lateral areas; 2) triangular alar cartilage
reduction; 3) placement of an ultra-supportive, peapod-
shaped graft in the nasal tip; and 4) alar base reduction.
The Asian Nose
Most rhinoplasty surgeons find that their Asian and white
patients share similar concepts of the ideal nose. Asian
noses frequently lack adequate tip projection, nasal length,
and dorsal height and projection. Widened alar bases,
caudal tip rotation, short columella, and thickened alae are
also common findings. Suh et al.,387 using reconstructed
computed tomography, objectively evaluated the size of
the internal nasal valve in Asians. The study found that the
internal nasal valve in Asians measures 21.6° ± 4.5° and is
substantially larger that what has been reported for white
patients. The following points should be considered when
contemplating rhinoplasty on an Asian patient:
•• Thick, sebaceous nasal tip and columellar
skin can limit the amount of lobule
refinement that can be achieved.
•• Patients tend to prefer intranasal or
closed approaches.
•• The scars of transcolumellar incisions might
remain visible, with notching
or hypertrophy.
•• Patients generally opt for procedures
without grafts because of their aversion to
external scars.
•• Septal cartilage availability is questionable.
•• Flat or absent nasal dorsa might require
extensive dorsal augmentation.
Alloplastic augmentation through closed techniques has
been advocated over more traditional open rhinoplasty
techniques with autogenous materials. The safety and
efficacy of alloplastic materials remains controversial.
Falces et al.388,389 presented a review of specific
techniques designed to create Western features in Asian
and Black noses. Flowers390 addressed rhinoplasty in Asian
noses and listed indications and limitations of alloplastic
materials for dorsal augmentation.
54
Parsa391 reported the use of autogenous split calvarial
grafts for nasal augmentation in Asian noses based on his
experience with 62 patients followed for up to 8 years.
Most noses could be satisfactorily augmented with a
single-layer split calvarial graft, but some required multiple
layers. The complication rate was 8%, including three
minor seroma-hematomas at the graft donor site, one
complete bone resorption, and one overcorrection that
necessitated secondary revision.
Endo et al.149 used ear cartilage grafts for
augmentation of the nasal dorsum in 1263 Japanese
patients. Follow-up duration ranged from 6 to 20 months.
Complications occurred in 4% of patients, and the most
frequent and severe problem was graft malposition. Local
infection developed in six patients but was controlled with
antibiotics. The authors concluded that ear cartilage graft
is the best alternative for dorsal nasal augmentation in
Japanese patients.
Deva et al.392 reported a 10-year experience with
silicone augmentation rhinoplasty. A dorsal-columellar
strut prosthesis was most commonly used. Of 422 patients
(412 of whom were of Asian ethnicity), 5.5% experienced
major complications requiring removal of the implant
within the first 30 days. The causes of implant removal
were displacement, hemorrhage, prominence, and supratip
deformity. An additional 4.3% of patients required later
removal, mainly for excessive prominence or displacement.
Only two (0.5%) patients had implants removed because
of extrusion. No infections occurred. The satisfaction
rate was 84%, and those who were dissatisfied wanted
further augmentation of the nose. The authors purported
that the main cause of extrusion is over-augmentation,
that an augmentation threshold exists beyond which
the complication rate rises dramatically. They discussed
implant selection in relation to nasal morphology and
desired augmentation and maintained that silicone nasal
rhinoplasty is safe for selected patients.
Zeng et al.393 reported 406 cases of silicone
augmentation rhinoplasty. Complications were related to
depth of implantation and character of overlying tissue.
The authors concluded that subperiosteal implantation
is superior to subfascial implantation. The published
complication rates in other series of dorsal nasal
augmentation with silicone implants vary.394−396
Clark and Cook397 described their technique of

immediate nasal reconstruction with irradiated homograft
costal cartilage after extrusion of alloplastic nasal implants
in 18 patients. One complication (warping) required graft
removal. The authors stated that the procedure might be a
reasonable alternative to staged reconstruction because it
avoids soft-tissue scarring and contracture. They discussed
typical sites of extrusion for Silastic (nasal tip), Supramid,
and Gore-Tex (nasal valves, nasal sidewall, rhinion)
implants. Jung et al.398 recommended autogenous cartilage
grafts from the seventh rib over alloplastic materials for
dorsal augmentation >8 mm.
Jang et al.399 reviewed their experience of combining
crushed cartilage and processed fascia lata (Tutoplast) for
dorsal augmentation in 113 Asian patients. With a mean
follow-up period of 26.6 months, complications were
encountered in four patients (3.5%). The complications
included overcorrection, graft resorption, and dorsal
irregularities. A patient satisfaction rate of 85% was
reported, and eight patients (7%) underwent revision
rhinoplasty secondary to dissatisfaction with the nasal
tip shape, graft resorption, and overcorrection of the
nasal dorsum.
In a retrospective study, Park et al.400 analyzed
post-rhinoplasty deformities in Asian noses. The authors
reported that 89% of revision rhinoplasty is performed
to correct upper-third deformities, which predominantly
result from inadequate insertion or dislocation of the
augmentation graft material. Most of the upper-third
deformities were treated with a rasp, camouflage graft, and
expanded polytetrafluoroethylene augmentation.
Other autogenous and alloplastic materials
for dorsal augmentation are discussed in the “Saddle
Nose Deformity” and “Dorsal Augmentation and the
Nasofrontal Angle” sections presented earlier in
this monograph.
The Black Nose
Ofodile et al.401 analyzed 201 black American noses and
noted three distinct groups on the basis of anatomic
features: the African (44%), the Afro-Caucasian (37%),
and the Afro-Indian (19%). The nasal dorsal contour
went from mostly concave in the African group to
predominantly convex in the Afro-Caucasian and Afro-
Indian groups. African noses were shortest and widest,
SRPS • Volume 11 • Issue C7 • 2015
Afro-Caucasian narrowest, and Afro-Indian longest. The
alar cartilages tended to be small and thin in the African
group and large and thick in Afro-Indian noses.
Rees,99,402 Bernstein,403 Kamer and Parkes,404
Santana,405 and Song et al.406 reviewed techniques of
rhinoplasty in blacks. Santana405 advocated correction
of alar base flaring without alar base excision. Through a
Caldwell-Luc incision, the soft tissues in the middle third
of the face are undermined subperiosteally and sutures are
placed across the alar line and are tightened in the midline.
This narrows the alar bases somewhat and elevates the
columella. The authors report no recurrence of flaring.
Song et al.406 discussed the use of cantilevered costal
cartilage grafts for nasal dorsal augmentation in 19 black
patients. They detailed the techniques for graft harvest,
design, and placement.
Rohrich and Muzaffar407 presented a discussion
of the classic anatomic features of black noses (Table 3).
The authors rejected the notion that the alar cartilages are
smaller or weaker than in white noses and attributed the
lack of tip projection to the relatively obtuse angle between
the medial and lateral crura with underdevelopment of
the nasal spine. The many techniques for increasing tip
projection, increasing tip definition, dorsal augmentation,
and correction of alar base abnormalities are reviewed. The
authors advised liberal use of tip grafts, alar base excision,
and dorsal augmentation, with cautious use of
nasal osteotomies.
Porter and Olson408 offered an anthropometric
analysis of the black female nose, with a classification
of nostril morphology and norms. For example, the
columella-to-lobule ratio is 1.5:1, the nasolabial angle is
86°, and the alar width-to-intercanthal distance ratio
is 5:4.
The Hispanic Nose
Ortiz-Monasterio and Olmedo409 described an approach to
rhinoplasty in Mestizo noses and later, Ortiz-Monasterio
and Michelena146 reviewed the use of augmentation
techniques in non-white noses. The authors’ preferred
source of graft material for augmenting the dorsum was
septal cartilage; rib cartilage was a second choice. Septal
cartilage was also favored over auricular concha for grafts
to the nasal tip. Most patients require augmentation of the
55
 SRPS • Volume 11 • Issue C7 • 2015
dorsum, columella, and tip and alar base resection.
Daniel410 proposed a classification system for
Hispanic nasal morphology, as follows (Table 4):
•• Type I (Castilian): high radix and dorsum
and relatively normal tip projection
•• Type II (Mexican-American): low radix and
bony dorsum, normal cartilaginous dorsum,
and depressed tip
•• Type III (Mestizo): low radix, normal
dorsum, decreased tip projection, and
thickened nasal ala/tip
The author’s surgical approach to rhinoplasty varied with
the type of deformity: a functional reduction rhinoplasty
for Type I noses; a “finesse” rhinoplasty for Type II; and a
“balanced” rhinoplasty for Type III. He also emphasized
conservative dorsal reduction for Type II and III noses,
radix grafting for Type II, and lobular soft-tissue reduction
with alar base and/or sill excisions for Type III.
The Middle Eastern Nose
This ethnic group possesses characteristic morphological
features that exist on a spectrum between the black and
white noses. Rohrich and Ghavami411 retrospectively
analyzed the morphological traits in patients of Middle
Eastern origin. Their findings identified a combination of
specific nasal traits, including thick sebaceous skin (excess
fibrofatty tissue), high wide dorsum with cartilaginous
and bony humps, ill-defined nasal tip, weak thin lateral
crura relative to the skin envelope, nostril-tip imbalance,
acute nasolabial and columellar-labial angles, and a
hyperdynamic (droopy) nasal tip. The authors presented
an open rhinoplasty approach to address the nasal
imbalance. The approach requires soft-tissue debulking;
substantial cartilaginous framework modification; tip
56
refinement, rotation, and projection; low osteotomies; and
depressor septi nasi muscle transection and transposition.
THE COCAINE NOSE
Slavin and Goldwyn412 noted the potential problem of
cocaine users presenting for rhinoplasty. In their series
of 13 patients who had used cocaine, fewer than half
were properly identified as cocaine users during initial
consultation. The preoperative rhinoscopic findings
that should alert a physician to cocaine use are visible
perforation, microscopic evidence of granulomas,
inflammation, and necrosis. Surgical complications
related to cocaine use include localized septal collapse,
delayed mucosal healing, and inadequate correction of
septal deflection. The authors concluded that SMR and
septoplasty should be avoided in patients with a known
history of intranasal cocaine use.
Millard and Mejia413 discussed their approach to
reconstruction of cocaine-damaged noses. Cocaine causes
vasoconstriction of the intranasal mucosal blood vessels
and, with continuing ischemia, mucosal necrosis ensues.
The exposed cartilage can succumb to chondritis and
septal perforation to varying degrees. The authors support
the use of local mucosal flaps for smaller perforations. For
more severe deformities, including complete midvault
and/or tip collapse, staged reconstruction is required. The
authors recommended the use of bilateral nasolabial flaps
for soft-tissue reconstruction and then staged rib cartilage
grafting of the tip and dorsum 3 months later.
Guyuron and Afrooz414 reviewed the different
surgical methods with which to correct cocaine-related
nasal defects. They emphasized that reconstruction of
massive septal perforation is unnecessary because the nasal
shape can be restored without repair of this defect as long
as infection is avoided.
 SRPS • Volume 11 • Issue C7 • 2015

TABLE 3
White and Black Noses407

White Nose Black Nose

Skin Thin Thick

Fibrofatty layer Thin Thick

Alar cartilage
Size Large Large
Support Strong Strong

Alar base Slight alar flaring Excess alar flaring, increased intermalar distance

Nasal pyramid
Nasal bones Long Long and flattened
Base Narrower Wide
Dorsum Thin Broad and depressed

TABLE 4
Anatomic Characteristics and Recommended Surgical Procedures for Hispanic Noses410

Type I Type II Type III

Castilian Mexican American Mestizo

Radix High to normal Low Low

Dorsum

Bony High Low Normal

Cartilaginous High Normal Normal

Tip

Projection Normal Decreased (−1) Decreased (−1)

Volume Increased (+1) Normal Increased (+3)

Width Wide (+1) Normal Very wide (+3)

Skin Variable (+1/−1) Variable (+1/−1) Thick (+3)

Base Variable Normal Wide

Operation Functional reduction rhinoplasty Finesse rhinoplasty Balanced rhinoplasty

57
 SRPS • Volume 11 • Issue C7 • 2015
REFERENCES
1. Rogers BO. Early historical development of corrective
rhinoplasty. In, Millard DR (ed): Symposium on Corrective
Rhinoplasty. St. Louis: CV Mosby; 1976.
2. Eisenberg I. A history of rhinoplasty. S Afr Med J
1982;62:286–292.
3. Roe JO. The correction of angular deformities of the nose
by a subcutaneous operation. Med Rec 1891;40:57.
4. Joseph J, Aufricht G. Operative reduction of the size of a
nose (rhinomiosis). Plast Reconstr Surg 1970;46:178–183.
5. Joseph J. Nasenplastik und sonstige Gesichtsplastik nebst
einen Anhang ueber Mammaplastik. Leipzig: Verlag von Curt
Kabitzsch; 1931.
6. Safian J. Corrective Rhinoplastic Surgery. New York: Paul B.
Hoeber; 1935.
7. Aufricht G. Dental molding compound cast and
adhesive strapping in rhinoplastic surgical procedure. Arch
Otolaryngol 1940;32:333–338.
8. Dingman RO, Natvig P. Surgical anatomy and aesthetics in
corrective rhinoplasty. Clin Plast Surg 1977;4:111–120.
9. Natvig P, Sethner LA, Gingrass RP, Gardner WD.
Anatomical details of the osseous-cartilaginous framework
of the nose. Plast Reconstr Surg 1971;48:528–532.
10. Bernstein L. Applied anatomy in corrective rhinoplasty.
Arch Otolaryngol 1974;99:67–70.
11. Broadbent TR, Woolf RM. Basic anatomy: Clinical
application in rhinoplasty. Ann Plast Surg 1984;13:76–89.
12. Sullivan PK, Varma M, Rozzelle AA. Optimizing bone-
graft nasal reconstruction: A study of nasal bone shape and
thickness. Plast Reconstr Surg 1996;97:327–335.
13. Daniel RK, Lessard ML. Rhinoplasty: A graded aesthetic-
anatomical approach. Ann Plast Surg 1984;13:436–451.
14. McKinney P, Johnson P, Walloch J. Anatomy of the nasal
hump. Plast Reconstr Surg 1986;77:404–405.
15. Lessard ML, Daniel RK. Surgical anatomy of
septorhinoplasty. Arch Otolaryngol 1985;111:25–29.
16. Daniel RK, Letourneau A. Rhinoplasty: Nasal anatomy.
Ann Plast Surg 1988;20:5–13.
17. Rohrich RJ, Hoxworth RE, Thornton JF, Pessa JE. The
pyriform ligament. Plast Reconstr Surg 2008;121:277–281.
18. Holden PK, Liaw LH, Wong BJ. Human nasal
cartilage ultrastructure: Characteristic and comparison
using scanning electron microscopy. Laryngoscope
2008;118:1153–1156.
19. Rohrich RJ, Hollier LH Jr, Janis JE, Kim J. Rhinoplasty with
advancing age. Plast Reconstr Surg 2004;114:1936–1944.
20. Daniel RK. The nasal tip: Anatomy and aesthetics. Plast
Reconstr Surg 1992;89:216–224.
21. Garramone RR Jr, Sullivan PK, Devaney K. Bulbous nasal
tip: An anatomical and histological evaluation. Ann Plast
Surg 1995;34:288–290.
58
22. Copcu E, Metin K, Ozsunar Y, Culhaci N, Ozkök S. The
interdomal fat pad of the nose: A new anatomical structure.
Surg Radiol Anat 2004;26:14–18.
23. Coskun N, Yavuz A, Dikici MB, Sindel T, Islamoglu K,
Sindel M. Three-dimensional measurements of the nasal
interdomal fat pad. Aesthetic Plast Surg 2008;32:262–265.
24. Rohrich RJ, Gunter JP, Friedman RM. Nasal tip blood
supply: An anatomic study validating the safety of the
transcolumellar incision in rhinoplasty. Plast Reconstr Surg
1995;95:795–799.
25. Toriumi DM, Mueller RA, Grosch T, Bhattacharyya TK,
Larrabee WF Jr. Vascular anatomy of the nose and the
external rhinoplasty approach. Arch Otolaryngol Head Neck
Surg 1996;122:24–34.
26. Han SK, Shin YW, Kim WK. Anatomy of the external nasal
nerve. Plast Reconstr Surg 2004;114:1055–1059.
27. Pitanguy I, Salgado F, Radwanski HN, Bushkin SC. The
surgical importance of the dermocartilaginous ligament of
the nose. Plast Reconstr Surg 1995;95:790–794.
28. Hwang K, Kim DJ, Hwang G. Relationship between
depressor septi nasi muscle and dermocartilaginous
ligament; anatomic study and clinical application. J
Craniofac Surg 2006;17:286–290.
29. Pitanguy I. Revisiting the dermocartilaginous ligament.
Plast Reconstr Surg 2001;107:264–266.
30. Saban Y, Andretto Amodeo C, Hammou JC,
Polselli R. An anatomical study of the nasal superficial
musculoaponeurotic system: Surgical applications in
rhinoplasty. Arch Facial Plast Surg 2008;10:109–115.
31. Figallo E. The nasal tip: A new dynamic structure. Plast
Reconstr Surg 1995;95:1178–1184.
32. Figallo EE, Acosta JA. Nose muscular dynamics: The tip
trigonum. Plast Reconstr Surg 2001;108:1118–1126.
33. Ozturan O, Ozcan C, Miman MC. Intrinsic nasal muscles
and their electromyographic evaluation after external
septorhinoplasty. Otolaryngol Head Neck Surg 2001;125:
332–338.
34. Ali-Salaam P, Kashgarian M, Davila J, Persing J.
Anatomy of the Caucasian alar groove. Plast Reconstr Surg
2002;110:261–266.
35. Ali-Salaam P, Kashgarian M, Persing J. The soft triangle
revisited. Plast Reconstr Surg 2002;110:14–16.
36. Baker DC, Strauss RB. The physiologic treatment of nasal
obstruction. Clin Plast Surg 1977;4:121–130.
37. Canady JW. Evaluation of nasal obstruction in
rhinoplasty. Plast Reconstr Surg 1994;94:555–559.
38. Jessen M, Malm L. The spontaneous course of nasal
obstruction in patients with normal nasal airway resistance.
Clin Otolaryngol Allied Sci 1991;16:302–304.
39. Deron BJ, Clement PA, Derde MP. The influence of
septal deviation and septal surgery on tubal function. Acta
Otorhinolaryngol Belg 1991;45:311–313.

40. Fomon S, Sayad WY, Schattner A, Neivert H. Physiological
principles in rhinoplasty. AMA Arch Otolaryngol
1951;53:256–276.
41. Courtiss EH, Gargan TJ, Courtiss GB. Nasal physiology.
Ann Plast Surg 1984;13:214–223.
42. Ford CN, Battaglia DG, Gentry LR. Preservation of
periosteal attachment in lateral osteotomy. Ann Plast Surg
1984;13:107–111.
43. Guyuron B. Nasal osteotomy and airway changes. Plast
Reconstr Surg 1998;102:856–860.
44. Grymer LF, Gregers-Petersen C, Baymler Pedersen H.
Influence of lateral osteotomies in the dimensions of the
nasal cavity. Laryngoscope 1999;109:936–938.
45. Becker DG, McLaughlin RB Jr, Loevner LA, Mang A. The
lateral osteotomy in rhinoplasty: Clinical and radiographic
rationale for osteotome selection. Plast Reconstr Surg
2000;105:1806–1816.
46. Malm L. Rhinomanometric assessment for rhinologic
surgery. Ear Nose Throat J 1991;71:11–16.
47. Grymer LF. Reduction rhinoplasty and nasal patency:
Change in the cross-sectional area of the nose evaluated by
acoustic rhinometry. Laryngoscope 1995;105:429–431.
48. Moran DT, Jafek BW, Rowley JC III. The vomeronasal
(Jacobson’s) organ in man: Ultrastructure and frequency of
occurrence. J Steroid Biochem Mol Biol 1991;39:545–552.
49. Stensaas LJ, Lavker RM, Monti-Bloch L, Grosser BI,
Berliner DL. Ultrastructure of the human vomeronasal
organ. J Steroid Biochem Mol Biol 1991;39:553–560.
50. Farkas LG, Hreczko TA, Kolar JC, Munro IR. Vertical and
horizontal proportions of the face in young adult North
American Caucasians: Revision of neoclassical canons. Plast
Reconstr Surg 1985;75:328–338.
51. Farkas LG, Sohm P, Kolar JC, Katic MJ, Munro IR.
Inclinations of the facial profile: Art versus reality. Plast
Reconstr Surg 1985;75:509–519.
52. Farkas LG, Munro IR. Anthropometric Facial Proportions in
Medicine. Springfield, Illinois: Charles C. Thomas; 1986.
53. Farkas LG, Kolar JC, Munro IR. Geography of the nose: A
morphometric study. Aesthetic Plast Surg 1986;10:191–223.
54. Farkas LG, Kolar JC. Anthropometrics and art in the
aesthetics of women’s faces. Clin Plast Surg 1987;14:599–616.
55. Daniel RK, Farkas LG. Rhinoplasty: Image and reality. Clin
Plast Surg 1988;15:1–10.
56. Ricketts RM. Divine proportion in facial esthetics. Clin
Plast Surg 1982;9:401–422.
57. Bernstein L. Esthetics in rhinoplasty. Otolaryngol Clin
North Am 1975;8:705–715.
58. Springer IN, Zernial O, Nölke F, Warnke PH, Wiltfang J,
Russo PA, Terheyden H, Wolfart S. Gender and nasal shape:
Measures for rhinoplasty. Plast Reconstr Surg 2008;121:629–
637.
59. Greer SE, Matarasso A, Wallach SG, Simon G, Longaker
SRPS • Volume 11 • Issue C7 • 2015
MT. Importance of the nasal-to-cervical relationship to
the profile in rhinoplasty surgery. Plast Reconstr Surg
2001;108:522–531.
60. Byrd HS, Hobar PC. Rhinoplasty: A practical guide for
surgical planning. Plast Reconstr Surg 1993;91:642–654.
61. Byrd HS. The dimensional approach to rhinoplasty:
Perfecting the aesthetic balance between the nose and
chin. Presented at the 14th Annual Dallas Rhinoplasty
Symposium. Dallas, 1997.
62. McKinney P, Sweis I. A clinical definition of an ideal nasal
radix. Plast Reconstr Surg 2002;109:1416–1418.
63. Daniel RK. Discussion of “A clinical definition of an ideal
nasal radix” by P. McKinney and I. Sweis. Plast Reconstr Surg
2002:109:1419–1420.
64. Krugman ME. Photoanalysis of the rhinoplasty patient.
Ear Nose Throat J 1981;60:328–330.
65. Guyuron B. Precision rhinoplasty: Part I. The role of life-
size photographs and soft-tissue cephalometric analysis.
Plast Reconstr Surg 1988;81:489–499.
66. Schwartz MS, Tardy ME Jr. Standardized
photodocumentation in facial plastic surgery. Facial Plast
Surg 1990;7:1–12.
67. Galdino GM, DaSilva AD, Gunter JP. Digital photography
for rhinoplasty. Plast Reconstr Surg 2002;109:1421–1434.
68. Gunter JP. A graphic record of intraoperative maneuvers
in rhinoplasty: The missing link for evaluating rhinoplasty
results. Plast Reconstr Surg 1989;84:204–212.
69. Mattison RC. Facial video image processing: Standard
facial image capturing, software modification, development
of a surgical plan, and comparison of presurgical and
postsurgical results. Ann Plast Surg 1992;29:385–389.
70. Schoenrock LD. Five-year facial plastic experience with
computer imaging. Facial Plast Surg 1990;7:18–25.
71. Bronz G. Predictability of the computer imaging system
in primary rhinoplasty. Aesthetic Plast Surg 1994;18:175–181.
72. Vuyk HD, Stroomer J, Vinayak B. The role of computer
imaging in facial plastic surgery consultation: A clinical
study. Clin Otolaryngol Allied Sci 1998;23:235–243.
73. Adelson RT, DeFatta RJ, Bassischis BA. Objective
assessment of the acuracy of computer-simulated imaging
in rhinoplasty. Am J Otolaryngol 2008;29:151–155.
74. Thomson HS. Preoperative selection and counseling
of patients for rhinoplasty [editorial]. Plast Reconstr Surg
1972;50:174–177.
75. Tardy ME Jr, Dayan S, Hecht D. Preoperative rhinoplasty:
Evaluation and analysis. Otolaryngol Clin North Am
2002;35:1–27.
76. Goin MK. Psychological understanding and
management of rhinoplasty patients. Clin Plast Surg
1977;4:3–7.
77. Honigman RJ, Phillips KA, Castle DJ. A review of
psychosocial outcomes for patients seeking cosmetic
59
 SRPS • Volume 11 • Issue C7 • 2015
surgery. Plast Reconstr Surg 2004;113:1229–1237.
78. Constantian MB. Four common anatomic variants that
predispose to unfavorable rhinoplasty results: A study based
on 150 consecutive secondary rhinoplasties. Plast Reconstr
Surg 2000;105:316–331.
79. Constantian MB. The two essential elements for
planning tip surgery in primary and secondary rhinoplasty:
Observations based on review of 100 consecutive patients.
Plast Reconstr Surg 2004;114:1571–1581.
80. Hellings PW, Nolst Trenité GJ. Long-term patient
satisfaction after revision rhinoplasty. Laryngoscope
2007;117:985–989.
81. Daniel RK. Rhinoplasty and the male patient. Clin Plast
Surg 1991;18:751–761.
82. Gorney M. Malpractice. In, Courtiss EH (ed): Aesthetic
Surgery: Trouble: How to Avoid It and How to Treat It. St. Louis:
CV Mosby; 1978:180.
83. Rohrich RJ, Janis JE, Kenkel JM. Male rhinoplasty. Plast
Reconstr Surg 2003;112:1071–1085.
84. van der Heijden P, Korsten-Meijer AG, van der Laan BF,
Wit HP, Goorhuis-Brouwer SM. Nasal growth and maturation
age in adolescents: A systematic review. Arch Otolaryngol
Head Neck Surg 2008;134:1288–1293.
85. Shandilya M, Den Herder C, Dennis SC, Nolst Trenité G.
Pediatric rhinoplasty in an academic setting. Facial Plast Surg
2007;23:245–257.
86. Demiraran Y, Ozturk O, Guclu E, Iskender A, Ergin MH,
Tokmak A. Vasoconstriction and analgesic efficacy of locally
infiltrated levobupivacaine for nasal surgery. Anesth Analg
2008;106:1008–1011.
87. Moscona RA, Ramon I, Ben-David B, Isserles S. A
comparison of sedation techniques for outpatient
rhinoplasty: Midazolam versus midazolam plus ketamine.
Plast Reconstr Surg 1995;96:1066–1074.
88. Van Noord BA, Cupp CL. Safety of surgeon-directed
conscious sedation in nasal surgery. Arch Facial Plast Surg
2008;10:282–284.
89. Miller SH, Dvorchik B, Davis TS. Cocaine concentrations
in the blood during rhinoplasty. Plast Reconstr Surg
1977;60:566–571.
90. Thevasagayam M, Jindal M, Allsop P, Oates J. Does
epinephrine infiltration in septoplasty make any difference?
A double blind randomized controlled trial. Eur Arch
Otorhinolaryngol 2007;264:1175–1178.
91. Liao BS, Hilsinger RL Jr, Rasgon BM, Matsuoka K, Adour
KK. A preliminary study of cocaine absorption from the
nasal mucosa. Laryngoscope 1999;109:98–102.
92. Metzinger SE, Bailey DJ, Boyce RG, Lyons GD. Local
anesthesia in rhinoplasty: A new twist? Ear Nose Throat J
1992;71:405–406.
93. Aufricht G. Joseph’s rhinoplasty with some
modifications. Surg Clin North Am 1971;51:299–316.
60
94. Rees TD. Current concepts of rhinoplasty. Clin Plast Surg
1977;4:131–144.
95. Anderson JR. A new approach to rhinoplasty. Trans Am
Acad Ophthalmol Otolaryngol 1966;70:183–192.
96. Anderson JR. New approach to rhinoplasty: A five-year
reappraisal. Arch Otolaryngol 1971;93:284–291.
97. Anderson JR. A reasoned approach to nasal base
surgery. Arch Otolaryngol 1984;110:349–358.
98. Peck G. Rhinoplasty surgery. In, Millard DR (ed):
Symposium on Corrective Rhinoplasty. St. Louis; CV Mosby:
1976:8.
99. Rees TD. Aesthetic Plastic Surgery. Philadelphia:
Saunders; 1980.
100. Sheen JH, Sheen AP. Aesthetic Rhinoplasty. 2nd ed. St.
Louis; CV Mosby: 1987.
101. Goodman WS. External approach to rhinoplasty. Can J
Otolaryngol 1973;2:207–210.
102. Peck GC. Basic primary rhinoplasty. Clin Plast Surg
1988;15:15–27.
103. Sheen JH. Secondary rhinoplasty. Plast Reconstr Surg
1975;56:137–145.
104. Sheen JH. Achieving more nasal tip projection by the
use of a small autogenous vomer or septal cartilage graft: A
preliminary report. Plast Reconstr Surg 1975;56:35–40.
105. Sheen JH. A new look at supratip deformity. Ann Plast
Surg 1979;3:498–504.
106. Sheen JH. Spreader graft: A method of reconstructing
the roof of the middle nasal vault following rhinoplasty.
Plast Reconstr Surg 1984;73:230–239.
107. Sheen JH. Rhinoplasty: Personal evolution and
milestones. Plast Reconstr Surg 2000;105:1820–1852.
108. Dingman RO, Natvig P. The infracartilaginous incision
for rhinoplasty. Plast Reconstr Surg 1982;69:134–135.
109. Aksu I, Alim H, Tellioglu AT. Comparative columellar scar
analysis between transverse and inverted-V incision in open
rhinoplasty. Aesthetic Plast Surg 2008;32:638–640.
110. Adams WP Jr, Rohrich RJ, Hollier LH, Minoli J, Thornton
LK, Gyimesi I. Anatomic basis and clinical implications for
nasal tip support in open versus closed rhinoplasty. Plast
Reconstr Surg 1999;103:255–261.
111. Rethi A. Operation to shorten an excessively long nose.
Rev Chir Plast 1934;2:85–87.
112. Sercer A. Dekortication der nase. Chir Maxillofac Plast
(Zagreb) 1958;1:149.
113. Padovan T. External approach in rhinoplasty
(decortication). Symp Otorhinolaryngol 1966;4:354–360.
114. Bravo FG, Schwarze HP. Closed-open rhinoplasty with
extended lip dissection: A new concept and classification of
rhinoplasty. Plast Reconstr Surg 2008;122:944–950.
115. Goodman WS, Charbonneau PA. External approach to
rhinoplasty. Laryngoscope 1974;84:2195–2201.

116. Wright WK, Kridel RW. External septorhinoplasty: A
tool for teaching and for improved results. Laryngoscope
1981;91:945–951.
117. Janeke JB, Wright WK. Studies on the support of the
nasal tip. Arch Otolaryngol 1971;93:458–464.
118. Goodman WS. Septorhinoplasty: Surgery of the nasal
tip by external rhinoplasty. J Laryngol Otol 1980;94:485–494.
119. Anderson JR. Discussion of “External approach to
rhinoplasty” by W. S. Goodman and P. A. Charbonneau.
Laryngoscope 1974;84:2195.
120. Friedman GD, Gruber RP. A fresh look at the open
rhinoplasty technique. Plast Reconstr Surg 1988;82:973–982.
121. Constantian MB. Differing characteristics in 100
consecutive secondary rhinoplasty patients following
closed versus open surgical approaches. Plast Reconstr Surg
2002;109:2097–2111.
122. Converse JM. Corrective surgery of the nasal tip.
Laryngoscope 1957;67:16–65.
123. Webster RC, White MF, Courtiss EH. Nasal tip correction
in rhinoplasty. Plast Reconstr Surg 1973;51:384–396.
124. Peck GC. Techniques in Aesthetic Rhinoplasty. New York:
Thieme-Stratton; 1984.
125. Becker OJ. Principles of Otolaryngologic Plastic Surgery.
2nd ed. Rochester, Minnesota: American Academy of
Ophthalmology and Otolaryngology; 1958:48.
126. Bernstein L. A basic technique for surgery of the nasal
lobule. Otolaryngol Clin North Am 1975;8:599–613.
127. Peck G. The difficult nasal tip. Clin Plast Surg
1977;4:103–110.
128. Peck GC. Rhinoplasty. In, Goldwyn RM (ed): Long-Term
Results in Plastic and Reconstructive Surgery. vol 2. Boston:
Little, Brown; 1980:558.
129. Safian J. The split-cartilage tip technique of rhinoplasty.
Plast Reconstr Surg 1970;45:217–220.
130. Constantian MB. The middorsal notch: An
intraoperative guide to overresection in secondary
rhinoplasty. Plast Reconstr Surg 1993;91:477–484.
131. Skoog T. A method of hump reduction in rhinoplasty:
A technique for preservation of the nasal roof. Arch
Otolaryngol 1966;83:283–287.
132. Regnault P, Alfaro A. The Skoog rhinoplasty: A modified
technique. Plast Reconstr Surg 1980;66:578–590.
133. Lejour M, Duchateau J, Potaznik A. Routine reinsertion
of the hump in rhinoplasty. Scand J Plast Reconstr Surg
1986;20:55–59.
134. Rohrich RJ, Muzaffar AR, Janis JE. Component
dorsal hump reduction: The importance of maintaining
dorsal aesthetic lines in rhinoplasty. Plast Reconstr Surg
2004;114:1298–1308.
135. Guyuron B. Guarded burr for deepening of nasofrontal
junction. Plast Reconstr Surg 1989;84:513–516.
SRPS • Volume 11 • Issue C7 • 2015
136. Mommaerts MY, Van Butsele BL, Abeloos JS, De Clercq
CA, Neyt LF. Rhinoplasty with nasal bone disarticulation to
deepen the nasofrontal groove: Experimental and clinical
results. J Craniomaxillofac Surg 1995;23:109–114.
137. Byrd HS, Meade RA, Gonyon DL Jr. Using the
autospreader flap in primary rhinoplasty. Plast Reconstr Surg
2007;119:1897–1902.
138. Gruber RP, Park E, Newman J, Berkowitz L, Oneal R. The
spreader flap in primary rhinoplasty. Plast Reconstr Surg
2007;119:1903–1910.
139. Guyuron B. Precision rhinoplasty: Part II. Prediction.
Plast Reconstr Surg 1988;81:500–505.
140. Petroff MA, McCollough EG, Hom D, Anderson JR. Nasal
tip projection: Quantitative changes following rhinoplasty.
Arch Otolaryngol Head Neck Surg 1991;117:783–788.
141. Rich JS, Friedman WH, Pearlman SJ. The effects of
lower lateral cartilage excision on nasal tip projection. Arch
Otolaryngol Head Neck Surg 1991;117:56–59.
142. Guyuron B. Dynamics of rhinoplasty. Plast Reconstr Surg
1991;88:970–978.
143. Guyuron B. Dynamics in rhinoplasty. Plast Reconstr Surg
2000;105:2257–2259.
144. Pessa JE, Desvigne LD, Zadoo VP. The effect of
skeletal remodeling on the nasal profile: Considerations
for rhinoplasty in the older patient. Aesthetic Plast Surg
1999;23:239–242.
145. Constantian MB. An alternate strategy for reducing the
large nasal base. Plast Reconstr Surg 1989;83:41–52.
146. Ortiz-Monasterio F, Michelena J. The use of
augmentation rhinoplasty techniques for the correction of
the non-Caucasian nose. Clin Plast Surg 1988;15:57–72.
147. Gunter JP, Rohrich RJ. Augmentation rhinoplasty:
Dorsal onlay grafting using shaped autogenous septal
cartilage. Plast Reconstr Surg 1990;86:39–45.
148. McKinney P, Loomis MG, Wiedrich TA. Reconstruction
of the nasal cap with a thin septal graft. Plast Reconstr Surg
1993;92:346–351.
149. Endo T, Nakayama Y, Ito Y. Augmentation rhinoplasty:
Observations on 1200 cases. Plast Reconstr Surg 1991;
87:54–59.
150. Gryskiewicz JM, Rohrich RJ, Reagan BJ. The use of
AlloDerm for the correction of nasal contour deformities.
Plast Reconstr Surg 2001;107:561–570.
151. Gryskiewicz JM. Waste not, want not: The use of
AlloDerm in secondary rhinoplasty. Plast Reconstr Surg
2005;116:1999–2004.
152. Jackson IT, Yavuzer R. AlloDerm for dorsal nasal
irregularities. Plast Reconstr Surg 2001;107:553–558.
153. Erol OO. The Turkish delight: A pliable graft for
rhinoplasty. Plast Reconstr Surg 2000;105:2229–2241.
154. Elahi MM, Jackson IT, Moreira-Gonzalez A, Yamini D.
Nasal augmentation with Surgicel-wrapped diced cartilage:
61
 SRPS • Volume 11 • Issue C7 • 2015
A review of 67 consecutive cases. Plast Reconstr Surg
2003;111:1309–1318.
155. Daniel RK, Calvert JW. Diced cartilage grafts in
rhinoplasty surgery. Plast Reconstr Surg 2004;113:
2156–2171.
156. Brenner KA, McConnell MP, Evans GR, Calvert JW.
Survival of diced cartilage grafts: An experimental study.
Plast Reconstr Surg 2006;117:105–115.
157. Daniel RK. Diced cartilage grafts in rhinoplasty surgery:
Current techniques and applications. Plast Reconstr Surg
2008;122:1883–1891.
158. Hilger JA. The internal lateral osteotomy in rhinoplasty.
Arch Otolaryngol 1968;88:211–212.
159. Al-Arfaj A, Al-Qattan M, Al-Harethy S, Al-Zahrani K.
Effect of periosteum elevation on periorbital ecchymosis in
rhinoplasty. J Plast Reconstr Aesthet Surg 2009;62:e538–539.
160. Wright WK. General principles of lateral osteotomy
and hump removal. Trans Am Acad Ophthalmol Otolaryngol
1961;65:854–861.
161. Rohrich RJ, Krueger JK, Adams WP Jr, Hollier LH Jr.
Achieving consistency in the lateral nasal osteotomy during
rhinoplasty: An external perforated technique. Plast Reconstr
Surg 2001;108:2122–2130.
162. Rohrich RJ, Minoli JJ, Adams WP Jr, Hollier LH Jr.
The lateral nasal osteotomy in rhinoplasty: An anatomic
endoscopic comparison of the external versus the internal
approach. Plast Reconstr Surg 1997;99:1309–1312.
163. Rohrich RJ, Janis JE, Adams WP, Krueger JK. An update
on the lateral nasal osteotomy in rhinoplasty: An anatomic
endoscopic comparison of the external versus the internal
approach. Plast Reconstr Surg 2003;111:2461–2462.
164. Harshbarger RJ, Sullivan PK. The optimal medial
osteotomy: A study of nasal bone thickness and fracture
patterns. Plast Reconstr Surg 2001;108:2114–2119.
165. Gruber R, Chang TN, Kahn D, Sullivan P. Broad nasal
bone reduction: An algorithm for osteotomies. Plast
Reconstr Surg 2007;119:1044–1053.
166. Gryskiewicz JM, Gryskiewicz KM. Nasal osteotomies: A
clinical comparison of the perforating methods versus the
continuous technique. Plast Reconstr Surg 2004;113:
1445–1456.
167. Gryskiewicz JM. Visible scars from percutaneous
osteotomies. Plast Reconstr Surg 2005;116:1771–1775.
168. Castro A, Jackson IT, Rademaker B. Rhinoplasty saw: A
modified design. Ann Plast Surg 1991;26:600–601.
169. Giampapa VC, DiBernardo BE. Nasal osteotomy:
Utilizing dual plane reciprocating nasal saw blades: A 6-year
follow-up. Ann Plast Surg 1993;30:500–502.
170. Kim JT, Kim SK. Endoscopically assisted, intraorally
approached corrective rhinoplasty. Plast Reconstr Surg
2001;108:199–205.
171. Kridel RW, Konior RJ, Shumrick KA, Wright WK.
62
Advances in nasal tip surgery: The lateral crural steal. Arch
Otolaryngol Head Neck Surg 1989;115:1206–1212.
172. Byrd HS, Andochick S, Copit S, Walton KG. Septal
extension grafts: A method of controlling tip projection
shape. Plast Reconstr Surg 1997;100:999–1010.
173. Hubbard TJ. Exploiting the septum for maximal tip
control. Ann Plast Surg 2000;44:173–180.
174. Rohrich RJ, Griffin JR. Correction of intrinsic nasal tip
asymmetries in primary rhinoplasty. Plast Reconstr Surg
2003;112:1699–1712.
175. Kridel RW, Scott BA, Foda HM. The tongue-in-groove
technique in septorhinoplasty: A 10-year experience. Arch
Facial Plast Surg 1999;1:246–256.
176. Foda HM, Kridel RW. Lateral crural steal and lateral
crural overlay: An objective evaluation. Arch Otolaryngol
Head Neck Surg 1999;125:1365–1370.
177. Tardy ME Jr, Patt BS, Walter MA. Transdomal suture
refinement of the nasal tip: Long-term outcomes. Facial
Plast Surg 1993;9:275–284.
178. Tebbetts JB. Open rhinoplasty: More than an incisional
approach: Rethinking the logic, sequence, and techniques
of rhinoplasty. Presented at the Tenth Annual Dallas
Rhinoplasty Symposium, Dallas, March 1993:67–86.
179. Tebbetts JB. Shaping and positioning the nasal tip
without structural disruption: A new, systematic approach.
Plast Reconstr Surg 1994;94:61–77.
180. Regalado-Briz A. Aesthetic rhinoplasty with maximum
preservation of alar cartilages: Experience with 52
consecutive cases. Plast Reconstr Surg 1999;103:671–680.
181. Byrd HS. Discussion of “Aesthetic rhinoplasty with
maximum preservation of alar cartilages: experience with
52 consecutive cases” by A. Regalado-Briz. Plast Reconstr
Surg 1999;103:681–682.
182. Daniel RK. Rhinoplasty: A simplified, three-stitch,
open tip suture technique: Part I. Primary rhinoplasty. Plast
Reconstr Surg 1999;103:1491–1502.
183. Daniel RK. Rhinoplasty: A simplified, three-stitch, open
tip suture technique: Part II. Secondary rhinoplasty. Plast
Reconstr Surg 1999;103:1503–1512.
184. Hugo NE, Mattson-Gates G, Sultan MR. Unhooking the
hook: Sculpting the nasal tip by replanting the medial crura.
Plast Reconstr Surg 1993;91:1344–1348.
185. Behmand RA, Ghavami A, Guyuron B. Nasal tip sutures:
Part I. The evolution. Plast Reconstr Surg 2003;112:
1125–1129.
186. Guyuron B, Behmand RA. Nasal tip sutures: Part II. The
interplays. Plast Reconstr Surg 2003;112:1130–1145.
187. Daniel RK. Rhinoplasty: Large nostril/small tip
disproportion. Plast Reconstr Surg 2001;107:1874–1881.
188. Sheen JH. Discussion of “Rhinoplasty: Large nostril/
small tip disproportion” by R. K. Daniel. Plast Reconstr Surg
2001;107:1882–1883.

189. McCollough EG, English JL. A new twist in nasal tip
surgery: An alternative to the Goldman tip for the wide or
bulbous lobule. Arch Otolaryngol 1985;111:524–529.
190. Goldman IB. The importance of the mesial crura in
nasal-tip reconstruction. AMA Arch Otolaryngol 1957;65:
143–147.
191. McLure TC. A modified Goldman nasal tip procedure for
the drooping nasal tip. Plast Reconstr Surg 1991;87:254–260.
192. Kamer FM, Cohen A. Median horizontal split tip.
Otolaryngol Head Neck Surg 1985;93:35–40.
193. Massiha H. Elliptical horizontal excision and repair
of alar cartilage in open-approach rhinoplasty to
correct cartilaginous tip deformities. Plast Reconstr Surg
1998;101:177–182.
194. Adamson PA, McGraw-Wall BL, Morrow TA,
Constantinides MS. Vertical dome division in open
rhinoplasty: An update on indications, techniques, and
results. Arch Otolaryngol Head Neck Surg 1994;120:373–380.
195. Sheen JH. Tip graft: A 20-year retrospective. Plast
Reconstr Surg 1993;91:48–63.
196. Cárdenas-Camarena L, Guerrero MT. Use of
cartilaginous autografts in nasal surgery: 8 years of
experience. Plast Reconstr Surg 1999;103:1003–1014.
197. Bateman N, Jones NS. Retrospective review of
augmentation rhinoplasties using autologous cartilage
grafts. J Laryngol Otol 2000;114:514–518.
198. Constantian MB. Distant effects of dorsal and tip
grafting in rhinoplasty. Plast Reconstr Surg 1992;90:405–418.
199. Constantian MB. Elaboration of an alternative
segmental, cartilage-sparing tip graft technique: Experience
in 405 cases. Plast Reconstr Surg 1999;103:237–253.
200. Peck GC. The onlay graft for nasal tip projection. Plast
Reconstr Surg 1983;71:27–39.
201. Peck GC Jr, Michelson L, Segal J, Peck GC Sr. An 18-year
experience with the umbrella graft in rhinoplasty. Plast
Reconstr Surg 1998;102:2158–2165.
202. Rohrich RJ. Discussion of “An 18-year experience
with the umbrella graft in rhinoplasty” by G. C. Peck Jr, L.
Michelson, J. Segal, and G. C. Peck Sr. Plast Reconstr Surg
1998;102:2166–2168.
203. Baker TM, Courtiss EH. Temporalis fascia grafts in open
secondary rhinoplasty. Plast Reconstr Surg 1994;93:802–810.
204. Millard DR. Adjuncts in augmentation mentoplasty and
corrective rhinoplasty. Plast Reconstr Surg 1965;36:48–61.
205. Dibbell DG. A cartilaginous columellar strut in cleft lip
rhinoplasties. Br J Plast Surg 1976;29:247–250.
206. Arden RL, Crumley RL. Cartilage grafts in open
rhinoplasty. Facial Plast Surg 1993;9:285−294.
207. Porter JP, Tardy ME Jr, Cheng J. The contoured auricular
projection graft for nasal tip projection. Arch Facial Plast Surg
1999;1:312–315.
208. Orak F, Yücel A, Aydin Y. A new extrasupported tip graft
SRPS • Volume 11 • Issue C7 • 2015
in the treatment of bulbous nasal tip. Aesthetic Plast Surg
1998;22:259–266.
209. Gunter JP, Rohrich RJ. Correction of the pinched
nasal tip with alar spreader grafts. Plast Reconstr Surg
1992;90:821–829.
210. De Carolis V. The infradome graft: A new technique to
improve dome reshaping in rhinoplasty. Plast Reconstr Surg
1998;102:864–871.
211. McCollough EG, Fedok FG. The lateral crural turnover
graft: Correction of the concave lateral crus. Laryngoscope
1993;103:463–469.
212. Adham MN, Teimourian B. Treatment of alar cartilage
malposition using the cartilage disc graft technique. Plast
Reconstr Surg 1999;104:1118–1125.
213. Adham MN. New technique for nasal tip cartilage graft
in primary rhinoplasty. Plast Reconstr Surg 2002;110:
693–696.
214. Hamra ST. Crushed cartilage grafts over alar dome
reduction in open rhinoplasty. Plast Reconstr Surg
1993;92:352–356.
215. Guyuron B, Poggi JT, Michelow BJ. The subdomal graft.
Plast Reconstr Surg 2004;113:1037–1040.
216. Hamra ST. Crushed cartilage grafts over alar dome
reduction in open rhinoplasty. Plast Reconstr Surg
2000;105:792–795.
217. Bujía J. Determination of the viability of crushed
cartilage grafts: Clinical implications for wound healing in
nasal surgery. Ann Plast Surg 1994;32:261–265.
218. Pereira MD, Marques AF, Ishida LC, Smialowski EB,
Andrews JM. Total reconstruction of the alar cartilage en
bloc using the ear cartilage: A study in cadavers. Plast
Reconstr Surg 1995;96:1045–1052.
219. Fanous N. Mersilene tip implants in rhinoplasty: A
review of 98 cases. Plast Reconstr Surg 1991;87:662–671.
220. Fanous N, Webster R. Supramid tip implants in
rhinoplasty: Review of 98 cases. Arch Otolaryngol Head Neck
Surg 1987;113:728–736.
221. Tasman AJ, Helbig M. Sonography of nasal tip
anatomy and surgical tip refinement. Plast Reconstr Surg
2000;105:2573–2579.
222. Rohrich RJ, Adams WP Jr. The boxy nasal tip:
Classification and management based on alar cartilage
suturing techniques. Plast Reconstr Surg 2001;107:
1849–1863.
223. Gruber RP, Friedman GD. Suture algorithm for
the broad or bulbous nasal tip. Plast Reconstr Surg
2002;110:1752–1764.
224. Simons RL. The difficult nasal tip. Curr Ther Otolaryngol
Head Neck Surg 1983:122.
225. McKinney P, Stalnecker M. Surgery for the bulbous
nasal tip. Ann Plast Surg 1983;11:106–113.
226. Hamra ST. Repositioning the lateral alar crus. Plast
63
 SRPS • Volume 11 • Issue C7 • 2015
Reconstr Surg 1993;92:1244–1253.
227. Lipsett EM. A new approach to surgery of the lower
cartilaginous vault. AMA Arch Otolaryngol 1959;70:42–47.
228. Fredericks S. Tripod resection for “Pinocchio” nose
deformity. Plast Reconstr Surg 1974;53:531–533.
229. Tardy ME Jr, Walter MA, Patt BS. The overprojecting
nose: Anatomic component analysis and repair. Facial Plast
Surg 1993;9:306–316.
230. Neu BR. Reduction of nasal tip projection with medial
rotation of alar cartilages. Plast Reconstr Surg 2001;108:
763–770.
231. Smith RA, Smith ET. A new technique in nasal-tip
reduction surgery. Plast Reconstr Surg 2001;108:1798–1804.
232. Gryskiewicz JM. The “iatrogenic-hanging columella”:
Preserving columellar contour after tip retroprojection. Plast
Reconstr Surg 2002;110:272–277.
233. Aston SJ, Guy CL. The nasal spine. Clin Plast Surg
1977;4:153–162.
234. Lewis JR Jr. Rhinoplasty and the nasolabial area. Clin
Plast Surg 1988;15:115–124.
235. Webster RC, Davidson TM, Smith RC. Importance of the
columellar-labial junction in rhinoplasty. Head Neck Surg
1979;1:423–434.
236. Webster RC, Smith RC, Kazda G. Columella-labial
changes in solution of rhinoplastic problems. Laryngoscope
1985;95:629–643.
237. Cachay-Velásquez H. Rhinoplasty and facial expression.
Ann Plast Surg 1992;28:427–433.
238. Rohrich RJ, Huynh B, Muzaffar AR, Adams WP Jr,
Robinson JB Jr. Importance of the depressor septi nasi
muscle in rhinoplasty: Anatomic study and clinical
application. Plast Reconstr Surg 2000;105:376–383.
239. De Benito J, Fernandez Sanza I. Rhinoplasty and the
aesthetic of the smile. Aesthetic Plast Surg 1995;19:79–81.
240. Lawson W, Reino AJ. Reduction columelloplasty: A
new method in the management of the nasal base. Arch
Otolaryngol Head Neck Surg 1995;121:1086–1088.
241. Pessa JE. Improving the acute nasolabial angle and
medial nasolabial fold by levator alae muscle resection. Ann
Plast Surg 1992;29:23–30.
242. Foda HM. Management of the droopy tip: A
comparison of three alar cartilage-modifying techniques.
Plast Reconstr Surg 2003;112:1408–1417.
243. Guyuron B. Footplates of the medial crura. Plast
Reconstr Surg 1998;101:1359–1363.
244. Gunter JP, Rohrich RJ. Lengthening the aesthetically
short nose. Plast Reconstr Surg 1989;83:793–800.
245. Lee Y, Kim J, Lee E. Lengthening of the postoperative
short nose: Combined use of a gull-wing concha composite
graft and a rib costochondral dorsal onlay graft. Plast
Reconstr Surg 2000;105:2190–2199.
64
246. Naficy S, Baker SR. Lengthening the short nose. Arch
Otolaryngol Head Neck Surg 1998;124:809–813.
247. Ha RY, Byrd HS. Septal extension grafts revisited: 6-year
experience in controlling nasal tip projection and shape.
Plast Reconstr Surg 2003;112:1929–1935.
248. Guyuron B, Varghai A. Lengthening the nose with
a tongue-and-groove technique. Plast Reconstr Surg
2003;111:1533–1539.
249. Juri J. Surgical treatment for secondary retracted nose.
Plast Reconstr Surg 1990;86:1202–1207.
250. Hamra ST. Lengthening the foreshortened nose. Plast
Reconstr Surg 2001;108:547–549.
251. Gruber RP. Lengthening the short nose. Plast Reconstr
Surg 1993;91:1252–1258.
252. Wolfe SA. Lengthening the nose: A lesson from
craniofacial surgery applied to posttraumatic and
congenital deformities. Plast Reconstr Surg 1994;94:78–87.
253. Johnson CM Jr, Godin MS. The tension nose: Open
structure rhinoplasty approach. Plast Reconstr Surg
1995;95:43–51.
254. Howard BK, Rohrich RJ. Understanding the nasal
airway: Principles and practice. Plast Reconstr Surg
2002;109:1128–1146.
255. Jackson LE, Koch RJ. Controversies in the management
of inferior turbinate hypertrophy: A comprehensive review.
Plast Reconstr Surg 1999;103:300–312.
256. Ophir D. Resection of obstructing inferior turbinates
following rhinoplasty. Plast Reconstr Surg 1990;85:724–727.
257. Courtiss EH, Goldwyn RM. Resection of obstructing
inferior nasal turbinates: A 10-year follow-up. Plast Reconstr
Surg 1990;86:152–154.
258. Pollock RA, Rohrich RJ. Inferior turbinate surgery: An
adjunct to successful treatment of nasal obstruction in 408
patients. Plast Reconstr Surg 1984;74:227–236.
259. Rohrich RJ, Krueger JK, Adams WP, Marple BF. Rationale
for submucous resection of hypertrophied inferior
turbinates in rhinoplasty: An evolution. Plast Reconstr Surg
2001;108:536–544.
260. Smith W, Lowe D, Leong P. Resection of pyriform
aperture: A useful adjunct in nasal surgery. J Laryngol Otol
2009;123:123–125.
261. Constantian MB. Functional effects of alar cartilage
malposition. Ann Plast Surg 1993;30:487–499.
262. Teichgraeber JF, Wainwright DJ. The treatment of nasal
valve obstruction. Plast Reconstr Surg 1994;93:1174–1182.
263. Stucker FJ, Hoasjoe DK. Nasal reconstruction with
conchal cartilage: Correcting valve and lateral nasal
collapse. Arch Otolaryngol Head Neck Surg 1994;120:
653–658.
264. Schlosser RJ, Park SS. Surgery for the dysfunctional
nasal valve: Cadaveric analysis and clinical outcomes. Arch
Facial Plast Surg 1999;1:105–110.

265. Park SS. The flaring suture to augment the repair
of the dysfunctional nasal valve. Plast Reconstr Surg
1998;101:1120–1122.
266. Guyuron B, Michelow BJ, Englebardt C. Upper lateral
splay graft. Plast Reconstr Surg 1998;102:2169–2177.
267. Sen C, Iscen D. Use of the spring graft for prevention of
midvault complications in rhinoplasty. Plast Reconstr Surg
2007;119:332–336.
268. Al-Qattan MM, Robertson GA. Acquired nostril stenosis.
Ann Plast Surg 1991;27:382–386.
269. Menger DJ. Lateral crus pull-up: A method for collapse
of the external nasal valve. Arch Facial Plast Surg 2006;8:
333–337.
270. Silk KL, Ali MB, Cohen BJ, Summersgill JT, Raff MJ.
Absence of bacteremia during nasal septoplasty. Arch
Otolaryngol Head Neck Surg 1991;117:54–55.
271. Yoder MG, Weimert TA. Antibiotics and topical surgical
preparation solution in septal surgery. Otolaryngol Head
Neck Surg 1992;106:243–244.
272. Killian G. The submucous window resection of the nasal
septum. Ann Otol Rhinol Laryngol 1905;14:363.
273. Dingman RO, Natvig P. The deviated nose. Clin Plast
Surg 1977;4:145–152.
274. Bernstein L. Submucous operations on the nasal
septum. Otolaryngol Clin North Am 1973;6:675–692.
275. Edwards N. Septoplasty: Rational surgery of the nasal
septum. J Laryngol Otol 1975;89:875–897.
276. Converse JM. Corrective surgery of nasal deviations.
AMA Arch Otolaryngol 1950;52:671–708.
277. Fry H. Nasal skeleton trauma and the interlocked
stresses of the nasal septal cartilage. Br J Plast Surg
1967;20:146–158.
278. Gruber R, Lesavoy M. Closed septal osteotomy. Ann
Plast Surg 1998;40:283–286.
279. Johnson CM Jr, Anderson JR. The deviated nose: Its
correction. Laryngoscope 1977;87:1680–1684.
280. Byrd HS, Salomon J, Flood J. Correction of the crooked
nose. Plast Reconstr Surg 1998;102:2148–2157.
281. de la Fuente A, Martin del Yerro JL. Management of the
septum during rhinoplasty. Aesthetic Plast Surg 1995;19:
455–461.
282. Cannistrá C, Guerrieri L, Iannetti G. Deviated nose:
Technical proposition for prevention of recurrences.
Aesthetic Plast Surg 1998;22:206–210.
283. Rees TD. Surgical correction of the severely deviated
nose by extramucosal excision of the osseocartilaginous
septum and replacement as a free graft. Plast Reconstr Surg
1986;78:320–330.
284. Gubisch W. The extracorporeal septum plasty: A
technique to correct difficult nasal deformities. Plast
Reconstr Surg 1995;95:672–682.
SRPS • Volume 11 • Issue C7 • 2015
285. Constantian MB. An algorithm for correcting the
asymmetrical nose. Plast Reconstr Surg 1989;83:801–811.
286. Jugo SB. Total septal reconstruction through
decortication (external) approach in children. Arch
Otolaryngol Head Neck Surg 1987;113:173–178.
287. Gunter JP, Rohrich RJ. Management of the deviated
nose: The importance of septal reconstruction. Clin Plast
Surg 1988;15:43–55.
288. Rohrich RJ, Gunter JP, Deuber MA, Adams WP Jr.
The deviated nose: Optimizing results using a simplified
classification and algorithmic approach. Plast Reconstr Surg
2002;110:1509–1523.
289. Guyuron B, Behmand RA. Caudal nasal deviation. Plast
Reconstr Surg 2003;111:2449–2457.
290. Boccieri A, Pascali M. Septal crossbar graft for the
correction of the crooked nose. Plast Reconstr Surg
2003;111:629–638.
291. Teichgraeber JF, Russo RC. The management of septal
perforations. Plast Reconstr Surg 1993;91:229–235.
292. Kridel RW, Foda H, Lunde KC. Septal perforation repair
with acellular human dermal allograft. Arch Otolaryngol
Head Neck Surg 1998;124:73–78.
293. Schultz-Coulon HJ. Experiences with the bridge-flap
technique for the repair of large nasal septal perforations.
Rhinology 1994;32:25–33.
294. Morre TD, Van Camp C, Clement PA. Results of the
endonasal surgical closure of nasoseptal perforations. Acta
Otorhinolaryngol Belg 1995;49:263–267.
295. Mladina R, Heinzel B. “Cross-stealing” technique for
septal perforation closure. Rhinology 1995;33:174–176.
296. Romo T III, Sclafani AP, Falk AN, Toffel PH. A graduated
approach to the repair of nasal septal perforations. Plast
Reconstr Surg 1999;103:66–75.
297. Foda HM. The one-stage rhinoplasty septal perforation
repair. J Laryngol Otol 1999;113:728–733.
298. Ribeiro J, da Silva GS. Technical advances in the
correction of septal perforation associated with closed
rhinoplasty. Arch Facial Plast Surg 2007;9:321–327.
299. Guyuron B, Michelow BJ. Management of
intraoperative nasal septal tears and perforations. Aesthetic
Plast Surg 1994;18:61–63.
300. Gunter JP, Rohrich RJ, Friedman RM. Classification and
correction of alar-columellar discrepancies in rhinoplasty.
Plast Reconstr Surg 1996;97:643–648.
301. Matarasso A, Greer SE, Longaker MT. The true hanging
columella: Simplified diagnosis and treatment using a
modified direct approach. Plast Reconstr Surg 2000;106:
469–474.
302. McKinney P, Stalnecker ML. The hanging ala. Plast
Reconstr Surg 1984;73:427–430.
303. Ellenbogen R, Blome DW. Alar rim raising. Plast Reconstr
Surg 1992;90:28–37.
65
 SRPS • Volume 11 • Issue C7 • 2015
304. Ellenbogen R. Alar rim lowering. Plast Reconstr Surg
1987;79:50–57.
305. Gunter JP, Friedman RM. Lateral crural strut graft:
Technique and clinical applications in rhinoplasty. Plast
Reconstr Surg 1997;99:943–952.
306. Rohrich RJ, Raniere J Jr, Ha RY. The alar contour graft:
Correction and prevention of alar rim deformities in
rhinoplasty. Plast Reconstr Surg 2002;109:2495–2505.
307. Guyuron B. Alar rim deformities. Plast Reconstr Surg
2001;107:856–863.
308. Tardy ME Jr, Toriumi D. Alar retraction: Composite graft
correction. Facial Plast Surg 1989;6:101–107.
309. Tellioglu AT, Cimen K. Turn-in folding of the cephalic
portion of the lateral crus to support the alar rim in
rhinoplasty. Aesthetic Plast Surg 2007;31:306–310.
310. Constantian MB. Indications and use of composite
grafts in 100 consecutive secondary and tertiary rhinoplasty
patients: Introduction of the axial orientation. Plast Reconstr
Surg 2002;110:1116–1133.
311. Gruber RP. Malposition of the lower lateral crus:
Recognition and treatment. Perspect Plast Surg 2001;
15:33–45.
312. Gruber RP. Discussion of “Alar rim deformities” by B.
Guyuron. Plast Reconstr Surg 2001;107:866–867.
313. Tardy ME Jr, Patt BS, Walter MA. Alar reduction and
sculpture: Anatomic concepts. Facial Plast Surg 1993;9:
295–305.
314. Millard DR Jr. Alar margin sculpturing. Plast Reconstr
Surg 1967;40:337–342.
315. Planas J, Planas J. Nostril and alar reshaping. Aesthetic
Plast Surg 1993;17:139–150.
316. Matarasso A. Alar rim excision: A method of thinning
bulky nostrils. Plast Reconstr Surg 1996;97:828–834.
317. Matarasso A. Cosmetic follow-up: Alar rim excision:
A method of thinning bulky nostrils. Plast Reconstr Surg
2001;108:1425–1427.
318. Oktem F, Tellioğlu AT, Menevşe GT. Cartilage Z plasty on
lateral crus for treatment of alar cartilage malposition. J Plast
Reconstr Aesthet Surg 2010;63:801–808.
319. Rees TD, Krupp S, Wood-Smith D. Secondary
rhinoplasty. Plast Reconstr Surg 1970;46:332–340.
320. Smith TW. As clay in the potter’s hand: A review of 221
rhinoplasties. Ohio State Med J 1967;63:1055–1057.
321. Rogers BO. Rhinoplasty. In, Goldwyn RM (ed): The
Unfavorable Result in Plastic Surgery: Avoidance and
Treatment. Boston: Little, Brown; 1972:283.
322. Webster RC. Revisional rhinoplasty. Otolaryngol Clin
North Am 1975;8:753–782.
323. Peck GC. Secondary rhinoplasty. Clin Plast Surg
1988;15:29–41.
324. Millard DR. Secondary corrective rhinoplasty. Plast
66
Reconstr Surg 1969;44:545–557.
325. Marin VP, Landecker A, Gunter JP. Harvesting rib
cartilage grafts for secondary rhinoplasty. Plast Reconstr Surg
2008;121:1442–1448.
326. Guyuron B, DeLuca L, Lash R. Supratip deformity: A
closer look. Plast Reconstr Surg 2000;105:1140–1151.
327. Parkes ML, Kanodia R, Machida BK. Revision
rhinoplasty: An analysis of aesthetic deformities. Arch
Otolaryngol Head Neck Surg 1992;118:695–701.
328. Daniel RK. Secondary rhinoplasty following open
rhinoplasty. Plast Reconstr Surg 1995;96:1539–1546.
329. Neu BR. A problem-oriented and segmental
open approach to alar cartilage losses and alar length
discrepancies. Plast Reconstr Surg 2002;109:768–779.
330. Turegun M, Acarturk TO, Ozturk S, Sengezer M.
Aesthetic and functional restoration using dorsal saddle
shaped Medpor implant in secondary rhinoplasty. Ann Plast
Surg 2008;60:600–603.
331. Stuzin JM, Kawamoto HK. Saddle nasal deformity. Clin
Plast Surg 1988;15:83–93.
332. Posnick JC, Seagle MB, Armstrong D. Nasal
reconstruction with full-thickness cranial bone grafts and
rigid internal skeleton fixation through a coronal incision.
Plast Reconstr Surg 1990;86:894–902.
333. Powell NB, Riley RW. Facial contouring with outer-
table calvarial bone. Arch Otolaryngol Head Neck Surg
1989;115:1454–1458.
334. Jackson IT, Choi HY, Clay R, Bevilacqua R, Terkonda S,
Celik M, Smith AW. Long-term follow-up of cranial bone
graft in dorsal nasal augmentation. Plast Reconstr Surg
1998;102:1869–1873.
335. Shipchandler TZ, Chung BJ, Alam DS. Saddle nose
deformity reconstruction with a split calvarial bone
L-shaped strut. Arch Facial Plast Surg 2008;10:305–311.
336. Hodgkinson DJ. Cranial bone grafts for dorsal nasal
augmentation [letter]. Plast Reconstr Surg 1999;104:
1570–1571.
337. Kridel RW, Konior RJ. Irradiated cartilage grafts in the
nose: A preliminary report. Arch Otolaryngol Head Neck Surg
1993;119:24–30.
338. Daniel RK. Rhinoplasty and rib grafts: Evolving a flexible
operative technique. Plast Reconstr Surg 1994;94:597–609.
339. Byrd HS. Discussion of “Rhinoplasty and rib grafts:
Evolving a flexible operative technique” by R. K. Daniel. Plast
Reconstr Surg 1994;94:610–611.
340. Kim DW, Shah AR, Toriumi DM. Concentric and
eccentric carved costal cartilage: A comparison of warping.
Arch Facial Plast Surg 2006;8:42–46.
341. Waldman SR. Gore-Tex for augmentation of the nasal
dorsum: A preliminary report. Ann Plast Surg 1991;26:
520–525.
342. Godin MS, Waldman SR, Johnson CM Jr. The use of

expanded polytetrafluoroethylene (Gore-Tex) in rhinoplasty:
A 6-year experience. Arch Otolaryngol Head Neck Surg
1995;121:1131–1136.
343. Godin MS, Waldman SR, Johnson CM Jr. Nasal
augmentation using Gore-Tex: A 10-year experience. Arch
Facial Plast Surg 1999;1:118–121.
344. Owsley TG, Taylor CO. The use of Gore-Tex for nasal
augmentation: A retrospective analysis of 106 patients. Plast
Reconstr Surg 1994;94:241–248.
345. Jang TY, Choi JY, Jung DH, Park HJ, Lim SC. Histologic
study of Gore-Tex removed after rhinoplasty. Laryngoscope
2009;119:620–627.
346. Straith RE. Five long-term case reports (average 15
years) of saddlenose correction using cast Silastic implants.
Plast Reconstr Surg 1991;88:1064–1075.
347. Peled ZM, Warren AG, Johnston P, Yaremchuk MJ. The
use of alloplastic materials in rhinoplasty surgery: A meta-
analysis. Plast Reconstr Surg 2008;121:85e–92e.
348. Jung DH, Kim BR, Choi JY, Rho YS, Park HJ, Han WW.
Gross and pathologic analysis of long-term silicone implants
inserted into human body for augmentation rhinoplasty:
221 revision cases. Plast Reconstr Surg 2007;120:1997–2003.
349. Daniel RK. Rhinoplasty: Septal saddle nose deformity
and composite reconstruction. Plast Reconstr Surg
2007;119:1029–1043.
350. Thornton JF, Griffin JR. Nasal reconstruction. Selected
Readings in Plastic Surgery 2006;10:1−39.
351. Weir RF. On restoring sunken noses without scarring
the face. Plast Reconstr Surg 1970;45:382–390.
352. Guerrerosantos J. Nose and paranasal augmentation:
Autogenous fascia and cartilage. Clin Plast Surg 1991;18:
65–86.
353. Rish BB. Collected letters of the International
Corresponding Society of Ophthalmology and
Otolaryngology. Int Corr Soc Ophthalmol Otolaryngol
1974;19:3.
354. Davis PK. Chin augmentation with rhinoplasty: A
tutorial dissertation. Br J Plast Surg 1983;36:204–209.
355. Robinson M. Bone resorption under plastic chin
implants: Follow-up of a preliminary report. Arch
Otolaryngol 1972;95:30–32.
356. Jobe R, Iverson R, Vistnes L. Bone deformation beneath
alloplastic implants. Plast Reconstr Surg 1973;51:169–175.
357. Simons RL. Adjunctive measures in rhinoplasty.
Otolaryngol Clin North Am 1975;8:717–742.
358. Sclafani AP, Schaefer SD. Triological thesis: Concurrent
endoscopic sinus surgery and cosmetic rhinoplasty:
Rationale, risks, rewards, and reality. Laryngoscope
2009;119:778–791.
359. Klabunde EH, Falces E. Incidence of complications in
cosmetic rhinoplasties. Plast Reconstr Surg 1964;34:192–196.
360. McKinney P, Cook JQ. A critical evaluation of 200
SRPS • Volume 11 • Issue C7 • 2015
rhinoplasties. Ann Plast Surg 1981;7:357–361.
361. Teichgraeber JF, Riley WB, Parks DH. Nasal surgery
complications. Plast Reconstr Surg 1990;85:527–531.
362. Padovan IF, Jugo SB. The complications of rhinoplasty.
Ear Nose Throat J 1991;70:454–456.
363. Andrews PJ, East CA, Jayaraj SM, Badia L, Panagamuwa
C, Harding L. Prophylactic vs postoperative antibiotic
use in complex septorhinoplasty surgery: A prospective,
randomized, single-blind trial comparing efficacy. Arch
Facial Plast Surg 2006;8:84–87.
364. Piltcher O, Lavinsky M, Lavinsky J, de Oliveira Basso PR.
Effectiveness of hypopharyngeal packing during nasal and
sinus surgery in the prevention of PONV. Otolaryngol Head
Neck Surg 2007;137:552–554.
365. Hoffmann DF, Cook TA, Quatela VC, Wang TD,
Brownrigg PJ, Brummett RE. Steroids and rhinoplasty:
A double-blind study. Arch Otolaryngol Head Neck Surg
1991;117:990–993.
366. Berinstein TH, Bane SM, Cupp CL, DeMarco JK,
Hunsaker DH. Steroid use in rhinoplasty: An objective
assessment of postoperative edema. Ear Nose Throat J
1998;77:40–43.
367. Shafir R, Cohen M, Gur E. Blindness as a complication
of subcutaneous nasal steroid injection. Plast Reconstr Surg
1999;104:1180–1182.
368. Mabry RL. Visual loss after intranasal corticosteroid
injection: Incidence, causes, and prevention. Arch
Otolaryngol 1981;107:484–486.
369. Ozdel O, Kara CO, Kara IG, Sevine D, Oguzhanoglu NK,
Topuz B. Does corticosteroid usage in rhinoplasty cause
mood changes? Adv Ther 2006;23:809–816.
370. Gürlek A, Fariz A, Aydoğan H, Ersöz-Oztürk A, Evans GR.
Effects of high dose corticosteroids in open rhinoplasty. J
Plast Reconstr Aesthet Surg 2009;62:650–655.
371. Totonchi A, Guyuron B. A randomized, controlled
comparison between arnica and steroids in the
management of postrhinoplasty ecchymosis and edema.
Plast Reconstr Surg 2007;201:271–274.
372. Guyuron B. Is packing after septorhinoplasty
necessary? A randomized study. Plast Reconstr Surg
1989;84:41–44.
373. Reiter D, Alford E, Jabourian Z. Alternatives to packing
in septorhinoplasty. Arch Otolaryngol Head Neck Surg
1989;115:1203–1205.
374. Camirand A, Doucet J, Harris J. Nose surgery
(rhinoplasty) without external immobilization and without
internal packing: A review of 812 cases. Aesthetic Plast Surg
1998;22:245–252.
375. Lubianca-Neto JF, Sant’anna GD, Mauri M, Arrarte JL,
Brinckmann CA. Evaluation of time of nasal packing after
nasal surgery: A randomized trial. Otolaryngol Head Neck
Surg 2000;122:899–901.
67
 SRPS • Volume 11 • Issue C7 • 2015
376. Guyuron B, Vaughan C. Evaluation of stents following
septoplasty. Aesthetic Plast Surg 1995;19:75–77.
377. Awan MS, Iqbal M. Nasal packing after septoplasty: A
randomized comparison of packing versus no packing in 88
patients. Ear Nose Throat J 2008;87:624–627.
378. Constantinides MS, Adamson PA, Cole P. The long-term
effects of open cosmetic septorhinoplasty on nasal air flow.
Arch Otolaryngol Head Neck Surg 1996;122:41–45.
379. Guyuron B, Zarandy S. Does rhinoplasty make the
nose more susceptible to fracture? Plast Reconstr Surg
1994;93:313–317.
380. Kimmelman CP. The risk to olfaction from nasal surgery.
Laryngoscope 1994;104:981–988.
381. Shemshadi H, Azimian M, Onsori MA, Azizabadi
Farahani M. Olfactory function following open rhinoplasty:
A 6-month follow-up study. BMC Ear Nose Throat Disord
2008;8:6.
382. Pade J, Hummel T. Olfactory function following nasal
surgery. Laryngoscope 2008;118:1260–1264.
383. Jacobson JA, Kasworm EM. Toxic shock syndrome after
nasal surgery: Case reports and analysis of risk factors. Arch
Otolaryngol Head Neck Surg 1986;112:329–332.
384. Wagner R, Toback JM. Toxic shock syndrome following
septoplasty using plastic septal splints. Laryngoscope
1986;96:609–610.
385. Tobin G, Shaw RC, Goodpasture HC. Toxic shock
syndrome following breast and nasal surgery. Plast Reconstr
Surg 1987;80:111–114.
386. Hoefflin SM. Geometric sculpturing of the thick nasal
tip. Aesthetic Plast Surg 1994;18:247–251.
387. Suh MW, Jin HR, Kim JH. Computed tomography versus
nasal endoscopy for the measurement of the internal nasal
valve angle in Asians. Acta Otolaryngol 2008;128:675–679.
388. Falces E, Wesser D, Gorney M. Cosmetic surgery of the
non-Caucasian nose. Plast Reconstr Surg 1970;45:317–325.
389. Matory WE Jr, Falces E. Non-Caucasian rhinoplasty: A
16-year experience. Plast Reconstr Surg 1986;77:239–252.
390. Flowers RS. The surgical correction of the non-
Caucasian nose. Clin Plast Surg 1977;4:69–87.
391. Parsa FD. Nasal augmentation with split calvarial grafts
in Orientals. Plast Reconstr Surg 1991;87:245–253.
392. Deva AK, Merten S, Chang L. Silicone in nasal
augmentation rhinoplasty: A decade of clinical experience.
Plast Reconstr Surg 1998;102:1230–1237.
393. Zeng Y, Wu W, Yu H, Yang J, Chen G. Silicone implants in
augmentation rhinoplasty. Ann Plast Surg 2002;49:495–499.
394. Tham C, Lai YL, Weng CJ, Chen YR. Silicone
augmentation rhinoplasty in an Oriental population. Ann
Plast Surg 2005;54:1–5.
395. McCurdy JA Jr. The Asian nose: Augmentation
rhinoplasty with L-shaped silicone implants. Facial Plast Surg
68
2002;18:245–252.
396. Ham KS, Chung SC, Lee SH. Complications of Oriental
augmentation rhinoplasty. Ann Acad Med Singapore
1983;12:460–462.
397. Clark JM, Cook TA. Immediate reconstruction of
extruded alloplastic nasal implants with irradiated
homograft costal cartilage. Laryngoscope 2002;112:968–974.
398. Jung DH, Choi SH, Moon HJ, Chung IH, Im JH, Lam SM.
A cadaveric analysis of the ideal costal cartilage graft for
Asian rhinoplasty. Plast Reconstr Surg 2004;114:545–550.
399. Jang YJ, Song HM, Yoon YJ, Sykes JM. Combined use
of crushed cartilage and processed fascia lata for dorsal
augmentation in rhinoplasty for Asians. Laryngoscope
2009;119:1088–1092.
400. Park CH, Kim IW, Hong SM, Lee JH. Revision rhinoplasty
of Asian noses: Analysis and treatment. Arch Otolaryngol
Head Neck Surg 2009;135:146–155.
401. Ofodile FA, Bokhari FJ, Ellis C. The black American nose.
Ann Plast Surg 1993;31:209–218.
402. Rees TD. Nasal plastic surgery in the Negro. Plast
Reconstr Surg 1969;43:13–18.
403. Bernstein L. Rhinoplasty for the negroid nose.
Otolaryngol Clin North Am 1975;8:783–795.
404. Kamer FM, Parkes ML. The conservative management
of the Negro nose. Laryngoscope 1975;85:551–558.
405. Santana PS. Treatment of the Negroid nose without
nasal alar excision: A personal technique. Ann Plast Surg
1991;27:498–507.
406. Song C, Mackay DR, Chait LA, Manders EK, Kelly
MA. Use of costal cartilage cantilever grafts in Negroid
rhinoplasties. Ann Plast Surg 1991;27:201–209.
407. Rohrich RJ, Muzaffar AR. Rhinoplasty in the African-
American patient. Plast Reconstr Surg 2003;111:1322–1339.
408. Porter JP, Olson KL. Analysis of the African American
female nose. Plast Reconstr Surg 2003;111:620–626.
409. Ortiz-Monasterio F, Olmedo A. Rhinoplasty on the
Mestizo nose. Clin Plast Surg 1977;4:89–102.
410. Daniel RK. Hispanic rhinoplasty in the United States,
with emphasis on the Mexican American nose. Plast Reconstr
Surg 2003;112:244–256.
411. Rohrich RJ, Ghavami A. Rhinoplasty for Middle Eastern
noses. Plast Reconstr Surg 2009;123:1343–1354.
412. Slavin SA, Goldwyn RM. The cocaine user: The potential
problem patient for rhinoplasty. Plast Reconstr Surg
1990;86:436–442.
413. Millard DR, Mejia FA. Reconstruction of the nose
damaged by cocaine. Plast Reconstr Surg 2001;107:419–424.
414. Guyuron B, Afrooz PN. Correction of cocaine-related
nasal defects. Plast Reconstr Surg 2008;121:1015–1023.
 We thank the
Aesthetic Surgery Journal
and
Plastic and Reconstructive Surgery
for their support.

Now Indexed in MEDLINE!

Submit Your Manuscript Today
Aesthetic Surgery Journal (ASJ) is a peer-reviewed international
journal focusing on scientific developments and clinical techniques
in aesthetic surgery. An official publication of the 2200-member
American Society for Aesthetic Plastic Surgery (ASAPS), ASJ is also
the official English-language journal of twelve major international
societies of plastic, aesthetic, and reconstructive surgery representing
South America, Central America, Europe, Asia, and the Middle East,
and the official journal of The Rhinoplasty Society.
Submit your manuscript!
www.aestheticsurgeryjournal.com

Order Today:
(800) 818-7243 (US & Canada)
(805) 499 9774 (Other countries) Published by
www.aestheticsurgeryjournal.com
This is your life.
Whether you’re performing a routine
cosmetic procedure or a difficult
burn repair, having the right tool for
unexpected complications is critical.

This is your website.

The new Plastic and Reconstructive
Surgery Online
The intuitive, all-new, next-generation electronic journals
platform from Lippincott Williams & Wilkins comes loaded
with personalized options for its journal subscribers, including
customizable state-of-the-art capabilities, self-service
options tailored to your information preferences, rich media
content, improved search options, better article readability
in HTML and better tools to help you manage content that’s
vital to your practice and patient care.

Register online at prsjournal.com

Not a subscriber? Visit prsjournal.com to subscribe and
find out more