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Rhinoplasty in Practice
Rhinoplasty in Practice
An Algorithmic Approach to Modern Surgical Techniques
by
Suleyman Taş, MD
TAS Aesthetic Surgery Clinic
Istanbul, Turkey
First edition published 2021
by CRC Press
6000 Broken Sound Parkway NW, Suite 300, Boca Raton, FL 33487–2742
and by CRC Press
2 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN
© 2022 Taylor & Francis Group, LLC
CRC Press is an imprint of Taylor & Francis Group, LLC
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The information or guidance contained in this book is intended for use by medical, scientific or health-care professionals and is
provided strictly as a supplement to the medical or other professional’s own judgement, their knowledge of the patient’s medical
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Library of Congress Cataloging‑in‑Publication Data
Names: Taş, Suleyman, author.
Title: Rhinoplasty in practice : an algorithmic approach to modern surgical techniques / by Suleyman Taş.
Description: First edition. | Boca Raton : CRC Press, 2021. | Includes bibliographical references and index.
Identifiers: LCCN 2021040459 (print) | LCCN 2021040460 (ebook) | ISBN 9781032004341 (hardback) |
ISBN 9781032004358 (paperback) | ISBN 9781003174165 (ebook)
Subjects: MESH: Rhinoplasty—methods
Classification: LCC RD119.5.N67 (print) | LCC RD119.5.N67 (ebook) | NLM WV 312 | DDC 617.5230592—dc23
LC record available at https://lccn.loc.gov/2021040459
LC ebook record available at https://lccn.loc.gov/2021040460
ISBN: 978-1-032-00434-1 (hbk)
ISBN: 978-1-032-00435-8 (pbk)
ISBN: 978-1-003-17416-5 (ebk)
DOI: 10.1201/9781003174165
Typeset in Times
by Apex CoVantage, LLC
Videos are available on the Companion Website: www.routledge.com/cw/tas

Dedicated to
My beautiful wife Sema for being an inspiration for everything in my life,
my amazing brother Ahmet for making possible everything I could ever ask for, and
my dear son Selim for giving me the energy to make this world a better place.
Contents ContentsContents
Preface�� xi
1 Patient Selection in Rhinoplasty�� 1

1.1 Patient Identification�� 1
1.2 Physical Examination�� 1
1.3 Psychological Evaluation�� 1
1.4 Functional Evaluation�� 1
1.5 Aesthetic Evaluation�� 2
1.6 Simulation Study�� 2
1.7 Revisit�� 2
Appendix A: Psychological Evaluation Form for Patients to Complete at Their Preoperative Consultation�� 3
2 Closed Atraumatic Rhinoplasty�� 5

2.1 Description and Explanation of the Closed Atraumatic Technique�� 5
2.1.1 Why Does This Philosophy begin with the Closed Technique?�� 5
2.2 Stages of the Closed Atraumatic Technique�� 6
2.2.1 Local Injection�� 6
2.2.2 Incisions�� 7
2.2.3 Dissection Plane�� 8
2.2.3.1 Room Concept��10
2.2.4 Preservation�� 14
2.2.5 Reshaping�� 15
2.2.6 Reconstruction�� 16
2.2.7 Structure�� 16
2.2.8 Redraping and Closure�� 16
2.3 Open and Closed Rhinoplasty Comparison�� 22
2.4 Submembranous—SubSMAS Dissection Plane Comparison�� 23
3 Dorsum Surgery�� 25
3.1 Osteotomy�� 25
3.1.1 Osteotomy Complications and Their Prevention�� 25
3.1.1.1 Rocker Deformity�� 25
3.1.1.2 Nasolacrimal Duct Damage�� 25
3.1.1.3 Airway Problems�� 26
3.2 Osteoplasty�� 26
3.3 Maxilloplasty�� 27
3.4 Dorsum Surgery�� 27
3.4.1 Excisional Approach to the Dorsum�� 28
3.4.1.1 The History of Dorsum Excision�� 28
3.4.1.2 Composite Hump Removal�� 28
3.4.1.3 Component Hump Removal�� 29
3.4.1.4 Dorsum Reconstruction�� 30
3.4.1.5 Bone Dust Technique�� 33
3.4.1.5.1 Surgical Technique�� 33
3.4.2 The Dorsum Preservation Approach�� 36
3.4.2.1 The History of Dorsum Preservation�� 36
3.4.2.2 Dorsum Preservation Techniques�� 40
3.4.2.2.1 Down Techniques�� 40
3.4.2.2.2 Dorsal Roof Technique�� 58
vii
viii Contents
3.4.3 Dorsum Algorithm in Reduction Rhinoplasty�� 65

3.5 Dorsum Augmentation�� 66
3.5.1 Ultradiced Cartilage Method�� 66
3.5.1.1 Surgical Technique�� 66
4 Nasal Tip Surgery�� 73

4.1 History of Tipplasty�� 73
4.2 Surgical Anatomy and Related Deformities in Tipplasty�� 73
4.2.1 The Tripod Concept�� 74
4.2.2 Supratip Break Point�� 75
4.2.3 Nostril Image�� 75
4.2.4 Lateral Crus Malposition�� 78
4.2.5 Medial Crus Malposition�� 78
4.2.6 Bifid Nose Deformity�� 79
4.3 Tipplasty�� 80
4.3.1 Lower Lateral Cartilage Flaps�� 82
4.3.2 Lateral Crural Flap�� 83
4.3.3 ST Flap (Superior-Based Transposition Flap)�� 84
4.3.4 Reverse ST Flap�� 90
4.3.5 Anatomic Strut Concept�� 91
4.3.6 Algorithm of the Columellar Strut Concept�� 93
4.3.7 Anatomic Columellar Septal Extension Graft�� 94
4.3.8 The Mystery of the Pitanguy Ligament�� 95
4.3.9 Deep SMAS Suture�� 98
4.3.10 Perichondrio-SMASectomy�� 102
4.3.10.1 What Is the Soft Tissue Hump: Where and How Does It Form?�� 102
4.3.11 Soft Tissue Redraping�� 105
4.4 Use of Electrocautery in Rhinoplasty�� 108
4.5 Blinking Nose Deformity and Its Treatment�� 109
4.5.1 Surgical Anatomy�� 109
4.5.2 Surgical Technique��110
5 Alar Base Surgery�� 115

5.1 Alar Excision��115
5.1.1 Algorithm��116
5.1.2 Surgical Technique��116
5.2 Alar Base Narrowing Suture�� 120
5.2.1 Surgical Technique�� 120
5.3 Providing Symmetry on Vertical, Horizontal, and Sagittal Planes�� 120
5.3.1 Alar Base Retraction�� 122
5.3.2 Algorithm�� 124
5.3.3 Releasing the Levator Alaeque Nasi Muscle�� 124
5.3.3.1 Surgical Anatomy�� 124
5.3.4 Releasing the Piriform Ligament�� 129
5.3.5 Maxillary Hypoplasia Treatment�� 130
5.4 Releasing the Depressor Septi Nasi Muscle��131
Contents ix
6 Revision Rhinoplasty�� 137

6.1 Dissection Plane in Revision Surgery�� 137
6.1.1 If the Subperichondrial Plane Was Preferred in the First Operation�� 137
6.1.2 What Should Be Done When Dissection Is Interrupted Due to Fibrosis from Microperforations
Induced by the Sutures?�� 138
6.1.3 If the SubSMAS Plane Was Preferred in the First Operation�� 138
6.2 The Closed Rhinoplasty Approach for Challenging Cases�� 139
6.2.1 Discussion: Should the Open or Closed Technique Be Used in This Case?�� 139
6.3 Saddle Nose Deformity��142
6.4 Using Rib Cartilage in Revision Rhinoplasty�� 144
6.4.1 Harvesting the Rib Cartilage�� 146
6.4.1.1 Thorax Anatomy�� 146
6.4.1.2 Anatomic Landmarks�� 146
6.4.1.3 Determining the Incision��147
6.4.1.4 Surgical Technique��147
6.5 Costal Reconstruction in Revision Cases with Cleft Lip-Nose Deformity�� 149
6.6 Using Auricular Cartilage Graft in Revision Surgery�� 152
6.7 Diced Cartilage Flap Technique�� 152
6.8 Restoring Tip Mobility in Revision Rhinoplasty Patients�� 153
6.9 Treatment of Over-Rotated Noses�� 154
6.10 Fisherman Suture�� 158
6.10.1 Surgical Technique�� 158
7 Advanced Rhinoplasty�� 161

7.1 Male Nose��161
7.2 Female Nose�� 168
7.3 Algorithmic Approach in Reduction Rhinoplasty According to Skin Type��172
7.4 Rhinoplasty in Thin-Skinned Patients��172
7.5 Rhinoplasty in Thick-Skinned Patients��175
7.6 DUAL Plane Dissection�� 180
7.7 Asian Rhinoplasty��181
7.7.1 Nasal Tip Bulbosity��181
7.7.2 Septal Problems�� 182
7.7.3 Dorsal Augmentation�� 183
7.7.4 Wide Pyramidal Angle and Wide Base�� 183
7.8 African Rhinoplasty�� 184
7.9 Middle Eastern Rhinoplasty�� 185
Index�� 189

Preface PrefacePreface
After performing many extremity replantations and face recon- There is no other book like the one that you are holding
structions as a super-microsurgeon, I dedicated myself to rhi- because it is clear, informative, comprehensive, and algorith-
noplasty which had always attracted me with its aesthetically mic. In addition, tips and tricks from my years of practice on
challenging aspect. However, I struggled greatly to choose the thousands of cases are included for you to be able to master
right sources in order to master it. A simple PubMed/Google rhinoplasty in the best way possible. It is designed to be the
research can illustrate this task; there are more than 11,000 main and the optimum textbook of rhinoplasty, answering all
papers and 100 books on rhinoplasty. While this many sources your questions; thus one reading will not suffice and it should
may seem like a good thing, it comes with some disadvantages. be within your hands’ reach to revisit whenever you need it.
Information pollution, which is the emerging problem of this I hope this book will help you realize the motto “Happy
century, may be confusing and time-consuming for surgeons. Surgeon, Happy Patient” and light the way for those who con-
What we need is an algorithmic and holistic approach to be able stantly try to be ahead of their time.
to achieve the best rhinoplasty practice.
xi
1
Patient Selection in Rhinoplasty
Patient selection in rhinoplasty is much harder than choosing all published articles on the plastic surgery patient group in
the most beautiful contestant in a beauty pageant. Currently, order to manage preoperative patient identification, prepara-
there are a lot of application requirements in beauty contests, tion, and postoperative follow-up processes. A nose surgeon
but what are the conditions you need to meet for rhinoplasty? should analyze the patient like a psychologist/psychiatrist
Detecting the patient suitable for rhinoplasty is as vital as and have the necessary equipment to manage processes in a
knowing rhinoplasty itself. healthy way [5–6].
Patient selection can be investigated under seven subheads There are some critical questions that need to be answered—
[1]: whether the patient’s usual mode is depressive or high, whether
there are any underlying psychological processes (such as
1. Patient Identification a loss or divorce) to the decision to have an operation, and
2. Physical Examination whether there are any psychiatric diseases. The psychiatric
3. Psychological Evaluation diseases that need to be investigated before the operation are
as follows: body dysmorphic disorder, obsessive-compulsive
4. Functional Evaluation
disorder, and symmetry disease. The psychological evaluation
5. Aesthetic Evaluation form completed by patients before a consultation is shared in
6. Simulation Study Appendix A by the author.
7. Revisit
1.4 Functional Evaluation

1.1 Patient Identification
The functional importance of the nose cannot be ignored or
It is beneficial to know the patient’s job, social interactive separated from rhinoplasty. Today, aesthetic nasal surgery
status, intellectual status, economic status, academic status, includes a group of operations that are regarded as a contin-
etc. Even all these are not enough in today’s world; a patient’s uum with rhinoplasty, septoplasty, and concha surgery. The
social media status also provides very important information main issues that need to be determined are the duration of
about the patient. The questions are what the patient wants, for any functional problem, especially in which nostril it occurs,
how long she/he has wanted it, why she/he wants it, what is the at what times it disturbs the patient, and whether there is an
opinion of their relatives, etc. All these need to be addressed accompanying allergic disease or snoring.
before surgery. To evaluate the functioning of the airways, objective
methods such as rhinomanometry or acoustic rhinometry
and subjective scales such as NOSE (Nasal Obstruction
Symptom Evaluation) and VAS (Visual Analog Scale) can be
1.2 Physical Examination used. However, the evaluation of the airways with an office
Before examining the nose, the medical history should be taken endoscopy during examination by the surgeon and a physi-
in detail to rule out possible bleeding or healing problems after cal examination made in correlation with the comments of
the surgery [2–3]. Photographic and video documentation is a patients still remain among the most valuable functional
must in rhinoplasty because of simulation purposes, discuss- evaluation methods. The presence of allergic symptoms can
ing the aesthetic deformities and medico-legal reasons [4]. be seen in an endoscopic examination and can be supported
Inspection and palpation are the main methods during exami- with advanced investigations such as skin prick test. By
nation, which requires sensitivity; however, imaging studies knowing the optimum airway opening, pushing the concha
such as ultrasonography and computed tomography can be with the help of an elevator under endoscopy can help the
helpful in particular cases. surgeon understand how far current stenosis can relieve the
airway.
It is crucial to demonstrate the airways to patients and
explain what we will be doing during the operation. This
1.3 Psychological Evaluation approach helps patients to understand the problem and cooper-
It is an indisputable fact that psychological evaluation is ate with us. In addition, recording the airway and archiving the
extremely important in our profession. Therefore, the author records on a patient database will be beneficial in regard to any
has had a full-time psychologist in his clinic and has reviewed possible conflict that may emerge after the operation.
DOI: 10.1201/9781003174165-1 1
2 Rhinoplasty in Practice
second observation provides numerous advantages; the patient

1.5 Aesthetic Evaluation can be re-analyzed and reviewed as to whether their expecta-
tions are still the same, the right decision has been made, etc.
This begins with determining the points that visually dis- It is also very valuable since it provides opportunities to raise
turb patients. The objectivity of a patient’s statements can be any subjects not previously discussed and to answer any ques-
evaluated. The scenario making a patient happy should be tions arising in the patient’s mind after the first meeting.
learned from patients themselves. After getting answers to
these questions, surgeons should evaluate whether the expec-
tations of patient are realistic, before moving on to next step.
REFERENCES
Lastly, a facial analysis of the patient should be performed,
and it should be discussed to what extent the planned surgery 1. Taş S. Closed Atraumatic Rhinoplasty Course. Endorsed
will be aesthetically beneficial for the patient and whether it by RSE (Rhinoplasty Society of Europe) and ISAPS
should be combined with additional procedures for harmony (International Society of Aesthetic Plastic Surgery).
Istanbul, Turkey, Nov 16–17, 2019. https://drsuleymantas.
in the face.
com/course/ Accessed 11 Aug 2019.
2. Taş S, Top H. An Unexpected Complication after Periorbital
Tumor Surgery in a Patient Later Discovered to Have
1.6 Simulation Study Myelodysplasia. Arch Plast Surg. 2014 Mar; 41(2): 186–7.
doi: 10.5999/aps.2014.41.2.186. Epub 2014 Mar 12.
A simulation study is very helpful both for patients and sur- 3. Taş S. Severe Facial Dermatitis Following Rhinoplasty due
geons. By conducting a simulation study, we can have an to an Unusual Etiopathogenesis: Rosacea. Arch Plast Surg.
idea about what kind of change there will be on a patient’s 2015 May; 42(3): 362–4. doi: 10.5999/aps.2015.42.3.362.
face, whether a patient wants this change, and whether Epub 2015 May 14.
surgery will be worthwhile. It should be remembered that 4. Safaryan D, Santareno S, Taş S. Dynamic Video-
patients who are not satisfied with the simulation study will Photograph Studio: A New Rhinoplasty Documentation.
make the same statements to you after the operation; in Aesthetic Plast Surg. 2020 Mar 20. doi: 10.1007/s00266-
such conditions, it would be best for everyone that you do 020-01673-7. [Epub ahead of print].
not operate on them. 5. Taş S. Childhood Abuse, Body Shame, and Addictive
Plastic Surgery: The Face of Trauma. Aesthetic Plast
Surg. 2020 Dec; 44(6): 2328–9. doi: 10.1007/s00266-
020-01984-9.
1.7 Revisit 6. Constantian MB. Childhood Abuse, Body Shame,
Although all these evaluations are made in the first consulta- and Addictive Plastic Surgery: The Face of Trauma.
tion, the author suggests at least two visits before surgery. The Routledge; Newyork, 2019.
Appendix A: Psychological Evaluation Form for Patients
to Complete at Their Preoperative Consultation
Name and Surname:

Date:
1. Looking at the two nose photographs 14. Is there any movement that you need to repeat?
a. Which one is more beautiful? 15. If you were walking with a friend and a car hit your
b. Which one is more natural? friend and drove off, would you stay to help your
friend or would you run after the car to catch it?
c. Which one do you think was operated on by Dr.
Suleyman Taş? 16. Does the photograph below disturb you?
No: 1 No: 2
Examination Findings:
Planned Treatment:
2. How often do you visit a hairdresser?

3. Do you always visit the same hairdresser?
4. When you visit the hairdresser, which treatments do
you get usually?
5. While cutting your hair, how do you describe it to the
hairdresser?
6. Does the hairdresser cut your hair as you wish?
7. If your hairdresser does not cut your hair as you
wish, how do you feel?
8. Have you ever dyed your hair before?
9. If yes, how did it make you feel?
10. Have you ever made any changes on your face or
body before?
11. For how long have you been planning to have an
operation?
12. Why did you decide to have an operation?
13. Can you tell us about your expectations from the
operation?
3
2
Closed Atraumatic Rhinoplasty Closed Atraumatic RhinoplastyRhinoplasty in Practice
This chapter aims to explain the meaning, philosophy, and • Have good knowledge of anatomy
technical details related to Closed Atraumatic Rhinoplasty. • Know which anatomic structures will be affected
with the surgical intervention and how
• Think about how the path of the desired maneuver
2.1 Description and Explanation of the should be done without disturbing any tissue
Closed Atraumatic Technique • Analyze the gain vs loss relationship
• Attempt the least risky maneuver first
With records of nose surgery dating back to 3000 bc, the term
rhinoplasty has evolved over the years. Until the 19th century, • Preserve the anatomy and the functions
reconstruction operations performed due to trauma and tis- • Attempt to minimize risk in order to minimize tis-
sue loss in the nose were known as rhinoplasty. After Roe [1] sue damage by aiming for longer-term results and
performed the first nasal cosmetic surgery in 1887, the term by identifying and supporting any weaker anatomic
rhinoplasty started to be attributed to aesthetic rhinoplasty, structures
whereas operations for trauma and tissue loss were called
reconstruction operations. While the concept of rhinoplasty, This list clearly shows that atraumatic means first, do
based on fundamental surgical principles and a deep scien- not harm; preserve anatomy and functions; strengthen weak
tific background, will continue to evolve, the important thing or weakened structures; and aim for long-lastin results [2–16].
is to understand is the philosophy behind these fundamental
principles. Without the philosophy, complication rates will not Atraumatic approach in rhinoplasty =
decrease and the results will satisfy neither the surgeon nor not only preserve but also support.
the patient. (S. Taş)
Generally known as “good practice”, these fundamental
principles mean doing the right thing, at the right time, with The plastic surgery tissue reconstruction ladder, created by
the right technique. If not followed, the unwanted result and examining these principles, is actually the best example to
side effects are not called complications but malpractice. understand this issue. The reconstruction ladder was designed
These principles are: according to the complexity of the construction, the risk of com-
plications, and the rate of possible revision. This algorithmic
• Determining the right diagnosis and appropriate ladder ranges from primary repair to more complex procedures
treatment option such as grafting, flap surgery, and free tissue transfers, and aids
• Ensuring a sterile environment during the procedure plastic surgeons in determining the best treatment options for
success. In the same manner, rhinoplasty should have a specific
• Patient monitoring and systemic follow-up before,
algorithmic ladder, since it is a nasal contouring surgery and
during, and after the procedure
is different from rhino-reconstruction surgery. This distinc-
• Using atraumatic techniques in surgery tion should be clearly made, and the surgeon should determine
• Ensuring the integrity of the body against external when and how to use each of these techniques. Surgeons should
factors by closing the incisions realize that rhinoplasty is a nose shaping surgery and should
• Early postoperative and follow-up to obtain optimal protect the structures encountered while shaping. If these struc-
wound healing tures cannot be protected, then they should be reconstructed.
In the following section, the ladder designed for rhinoplasty
Upon a literature review, it can be seen that all publications, surgery will be elaborated.
techniques, congresses, and speeches made since the 1800s
were attempts to improve one of these basic principles. It is
2.1.1 Why Does This Philosophy begin
critical for the surgeon to adopt these principles and follow
with the Closed Technique?
any progress made in these areas. Progress on techniques will
continue to evolve, but if the principles are not adopted, each There are two approaches for exposure in rhinoplasty: the
new improvement will be in vain. open and closed technique. Roe initially performed rhino-
The first and foremost principle of medicine is Primum non plasty without any external incisions in 1887 [1]. Following
nocere or “First, do not harm”. this, in 1929 Rethi [17] performed the same surgery using
Atraumatic in medicine means designing the surgical inter- an open technique, which became progressively popular and
vention aimed for minimizing tissue damage. In order to do mainstream since it provided superior exposure, visuality, and
that, one should: served better for educational purposes.
DOI: 10.1201/9781003174165-2 5
Although many incisions have been presented in the litera-

ture for the open approach (step incision, inverted V incision,
V incision, Swiss incision, etc.), decortication is basically
made by a full thickness incision on the columella, which is
then continued with dissection from tip to dorsum.
Anatomic and microscopic research have helped us better
understand the importance of the columella. The columella
is one of the main aesthetic units in the nose, consisting of
the columellar artery, vein, lymphatics, and the Pitanguy liga-
ment. When the columella is incised, those important struc-
tures are cut as well. If the surgeon can perform the surgery
using the closed technique, those structures will be preserved.
However, when the open technique is preferred:
• The incision can be repaired by primary suturing

• The Pitanguy ligament can be repaired back
• However, the columellar artery, vein, and lymphat-
ics are still not repairable today in practice. In the
literature, to address this point, Pshenisnov [18] tried
to repair the columellar artery by microsurgery
FIGURE 2.1 External vascular anatomy of the nose.
Therefore, before choosing the open technique, the irrevers-

ible losses should be kept in mind. The question arises: “Can
the surgeon perform this surgery with closed approach in order
to prevent these disadvantages?”
The Closed Atraumatic Technique will be summarized in
eight steps with review of every detail of rhinoplasty from
local injection to mucosal closure.
2.2 Stages of the Closed Atraumatic Technique

Closed Atraumatic Technique
1. Local injection
2. Incisions
3. Dissection
4. Preservation FIGURE 2.2 Internal vascular anatomy of the nose.
5. Reshaping
6. Reconstruction
7. Structure
8. Redraping and closure
2.2.1 Local Injection

The main reasons for bleeding in rhinoplasty procedure
include undiagnosed bleeding disorders, hypertension, and
insufficient local injection use on the septum.
A local injection to the external side of the nose has a mini-
mal effect on bleeding during rhinoplasty and disrupts the
planes. Therefore, local injection made only on the incision
lines with maximum 2 cc of anesthetic is recommended. In
this way, distortion of the nose is prevented and the external
appearance of the nose does not change. On the other hand,
the main blood supply of the nose lies within the septum area;
therefore control of this area using 7–8 ml of injection is also
suggested (Figures 2.1–2.3). FIGURE 2.3 Vascular anatomy of the septum and Kiesselbach plexus.
Closed Atraumatic Rhinoplasty 7
FIGURE 2.4 Divisions of trigeminal nerve.
Due to the septum’s rich blood supply, tachycardia and

hypertension may be seen, so the adrenergic injection should
be made slowly. If tachycardia occurs, then the trigeminal FIGURE 2.5 Inferior intracartilaginous incision.
reflex [19] can be stimulated. A local injector in the spine
may often suffice; however, in order to fully stimulate this
reflex, a 0.1 cc bilateral injection to the spine (Figure 2.4)
can be made, resulting in a 20–30 beat per minute decrease
in heart rate.
Video 2.1 details the local injection application favored by
the author: 0.1 cc of 1/100 adrenaline in 20 cc of prilocaine,
forming a 1/200,000 adrenaline solution.
2.2.2 Incisions
Incisions placed in the cartilage are better at withstanding scar
contracture forces that may occur during the wound healing
period and reduce the possibility of distortion and asymme-
try. These incisions are called intracartilaginous incisions
(Figure 2.5) and should be preferred if possible.
Each incision is made for a specific reason, allowing the sur-
geon access to a specific part of the nose. The nose resembles (a)
a house with many rooms when the outer soft tissue cover
and bone-cartilage relationship is examined. Surgery using
the open technique will require cutting into many walls to
reach each room, whereas with the closed technique, which
uses fewer cuts, the operation would be limited to one or more
selected regions. This anatomic aspect of the nose is presented
as the “Room Concept” [7].
Fundamental Closed Atraumatic Rhinoplasty Incisions

(Figure 2.6a–b)
1. Inferior intracartilaginous incision

2. Superior intracartilaginous incision (b)
3. Hemitransfixion incision FIGURE 2.6 (a) Inferior and superior intracartilaginous incisions. (b)
4. Lateral osteotomy incision The hemitransfixion incision.
FIGURE 2.7 Classic rhinoplasty incisions.
FIGURE 2.9 The framework of the nose.
Classic Rhinoplasty Incisions (Figure 2.7)
1. Trans-cartilaginous incision
2. Inter-cartilaginous incision
3. Marginal incision
4. Trans-columellar incision
2.2.3 Dissection Plane

The blood supply of the nose is concentrated in the SMAS
layer. Except for the perforators transecting the bone and
the cartilage, there are no vessels between the cartilage and
its perichondrium nor between the bone and its periosteum.
Bone and cartilage tissue are nasal structures with the lowest
metabolism and receive their required nutrients by diffusion
from the membranes (Figures 2.8–2.9). Therefore, the sub-
FIGURE 2.8 The soft tissue envelope of the nose. membranous (subperichondrial and subperiosteal) dissection
FIGURE 2.10 How the perichondrium adheres tightly to the cartilage FIGURE 2.12 The subperichondrial plane is demonstrated without any
can be clearly observed; using special tools for dissection of the perichon- bleeding.
drium will eliminate the possibility of damage to the cartilage during this
procedure. The author designed TAŞ1® and TAŞ2® for this purpose [19].
FIGURE 2.13 The bloodless surgical plane created by the subperichon-

drial plane is observed on the upper lateral cartilage.
plane is the most bloodless surgical plane that can be achieved

FIGURE 2.11 Although the perichondrium is penetrated, see how the
(Figures 2.10–2.13).
perichondrium and cartilage still appear as the same anatomic unit. Second, Periosteal and perichondrial membranes wrap and secure
see the clean and bloodless surgical plane under the perichondrium, while the anatomic structures beneath them. If they are separated
a significant capillary network is observed over the perichondrium. from the underlying structures, damage to their membranes
(a)
FIGURE 2.15 The DUAL dissection plane described by the author is

demonstrated. There is a combined surgical dissection which includes a
subperichondrial dissection over the lower lateral cartilage, a subSMAS
dissection in the supratip area which has a thick soft tissue envelope,
and again a subperichondrial dissection in the keystone area where there
is a thin soft tissue envelope. Thus, the redistribution of the soft tissue
envelope in a homogeneous manner can be performed to achieve the best
redraping effect.
2.2.3.1 Room Concept

There is no continuous plane to follow through the entire nose,
as seen in cadaveric dissections. Regardless of the surgical
plane chosen, the areas of dissection are interrupted by what
resembles a wall-like structure. If the submembranous surgi-
cal plane is preferred, these walls will be thicker than the other
planes. Those walls need to be transected to continue the dis-
section. Each wall will be explained for each surgical plane
separately.
(b) • For the submembranous dissection plane:

FIGURE 2.14 (a) TAŞ1 and TAŞ2, surgical instruments invented by the 1. Scroll ligament: It exists bilaterally in the lat-
author, penetrate into the submembranous surgery plan atraumatically. eral borders between the tip and dorsum. This
(b) TAŞ1 has a sharper and more delicate tip and is designed to penetrate fibrous tissue wall is thicker in the submembra-
under the perichondrium. TAŞ2 has a blunt and hard tip to penetrate nous plane by the perichondrial layer of upper
under the periosteum. Its L-shaped tip fits into the border of the nasal and lower lateral cartilages.
bone, allowing the surgeon to cut the pyriform ligament and penetrate
under the periosteum in one move. In both tools, one side has a cutter and 2. Pyriform (pyramidal) ligament: It exists in the
the other side has a blunt surface to continue dissection. border between the cartilaginous and bony dor-
sum. This fibrous tissue wall is much stronger
in the submembranous plane than in the sub-
will be prevented during reshaping of the cartilage and bones SMAS plan because of the perichondrium of
(Figure 2.14a–b). All surgical stages of the submembranous the upper lateral cartilage. In fact, in the border
dissection plane are shown in Video 2.2 [10–11]. between the cartilaginous and bony dorsum,
However, this plane has some limitations in specific condi- the perichondrium of the upper lateral cartilage
tions. It creates a thick, soft tissue cover, which is an advan- is divided in two. While the superficial layer
tage for thin-skinned patients but a challenge for redraping in merges with the periosteum of the nasal bone,
thick-skinned patients. Therefore, the DUAL dissection plane the deep layer attaches under the nasal bone. The
is preferred for those cases (Figure 2.15). anatomic relationship of this “transition zone”
was shown in a clinical study published by the c omplete the dissection (rather than additionally using inci-
author (Figures 2.16–2.17) [10]. sions, as in the submembranous plane).
3. Pitanguy ligament: It exists in the central border The subSMAS plane is the generally accepted routine surgi-
between the tip and dorsum. This fibrous tissue cal plane in which it is easier to pass over the nasal bone from
wall is thicker in the submembranous plane than in the upper cartilage. But since it meets the supra-perichondrial
the subSMAS plane because of the perichondrial surgical plane on the nasal bones, an additional incision should
layer of lower lateral cartilages. Unlike other walls, be made to get through the subperiosteal plane, which is more
this wall is perpendicular to the dissection plane. bloodless (Figures 2.18–2.23).
• For subSMAS dissection plane:

The same anatomic structures (scroll ligament, Pitanguy
ligament, and pyriform ligament) form the nasal walls, but
compared to the submembranous plane these fibrous walls
in the SMAS plane are thinner; it requires pushing only to
FIGURE 2.16 The transition zone described by the author is schema-

tized. In the keystone area, the perichondrium is divided into two: the
superficial layer joins with the periosteum of the nasal bone, and the deep
layer goes under the nasal bone and covers the upper lateral cartilages
which overlap. Thus, if one prefers the subperichondrial plane, when the FIGURE 2.18 Room Concept: The nasal framework is divided into
dissection comes to that point, the superficial perichondrial layer should three different rooms by the soft tissue envelope: orange, nasal bones;
be dissected to go under the periosteum. On the other hand, if one prefers gray, upper and lower lateral cartilages; blue, pyramidal ligament; green,
the subSMAS plane, when the dissection passes the upper lateral carti- scroll ligament; red, deep SMAS attachments.
lage, the periosteum of the nasal bone must also be incised and switched
to the subperiosteal plane. The author termed this region the “transition
zone” due to its clinical and anatomic importance.
FIGURE 2.19 The nose of the cadaver was dissected through the sub-
membranous plane on the left side and the subSMAS plane on the right
side. While subSMAS dissection exposed the branches of the angular
FIGURE 2.17 A clean upper lateral cartilage-nasal bone passage can be artery (red arrow) on the right side, the vessel network (green arrow) was
achieved with atraumatic dissection performed by TAŞ 2. totally preserved by the submembranous plane on the left side.
FIGURE 2.20 The right side of the nose received subSMAS dissec- FIGURE 2.22 The right side of the nose received submembranous
tion and the left side received submembranous dissection. While the dissection and the left side received subSMAS dissection. Note how far
scroll ligament (blue arrow) and transition zone (red arrow) are clearly the perichondrium of the upper lateral cartilage (green arrow) keeps its
observed on the left side, there is no true ligament to pause the dissection existing relation to the nasal bone, although the upper lateral cartilage
in subSMAS plane, although the author noted the dissection was harder itself has ended, in comparison to the other side (yellow arrow). This
in those areas. finding again confirms the transition zone (red arrow) described by the
author. Detached scroll ligament (blue arrow).
FIGURE 2.23 The footprint of the scroll area (blue arrow) in SMAS
has ligamentous extensions (blue rectangle) as well as the transition zone
(red arrow). This observation is the same as for the retaining ligaments
on the face. Therefore, these ligaments were called by the author retain-
FIGURE 2.21 After dissecting the scroll area (blue rectangle) where ing ligaments of the nose. The importance of those retaining ligaments
the scroll ligament attaches, the thickness and route of the scroll ligament in clinical practice is as redraping issue. Ligamentous extension of the
can be clearly exposed (red arrow, transition zone). transition zone (red rectangle).
• For the sub-skin dissection plane: There is, however, a difference between face and nose
surgery here. In a face-lift, all retaining ligaments are dis-
Cadaveric studies have revealed that these walls are sected so the face can be effectively lifted. Unlike face-
similar to the subSMAS plane. lifts, nose surgery does not allow for the luxury of excessive
The nasal framework is divided into three rooms with skin and subcutaneous tissue removal. Therefore, it is man-
these ligaments: datory to redrape the excessive skin-subcutaneous tissue
in rhinoplasty. To prevent complications such as supratip
The upper room containing the nasal bones; deformity or postoperative droopy tip, these retaining liga-
The middle room including the upper lateral ments should be addressed (Figures 2.25–2.28). The sur-
cartilage; gical technical aspect of the concept will be elaborated in
The lower room including the lower lateral Chapter 4.
cartilage.
The upper room is separated from the middle room by the

pyramidal ligament and the middle room from the lower
room by the scroll and Pitanguy ligaments. The lower room
is further divided into two separate rooms by the Pitanguy
ligament.
So why are these walls, which are critical to preserve the
anatomy, dissected during rhinoplasty?
It seems illogical to cut them to complete a dissection as
they are responsible for the stabilization of the soft tissue.
They are strong or relatively weaker in not only one surgical
plane, but throughout them all. Thus, they are no different
from the retaining ligaments of the face (Figure 2.24). These
three ligaments (scroll, Pitanguy, and pyramidal) should also
be referred to as the “retaining ligaments of the nose” and as
such, directly affect the success of nose surgery. FIGURE 2.25 The retaining ligaments of the nose are demonstrated:
Pitanguy, scroll, and pyriform ligaments, respectively (red, green, and
turquoise); transition zone (gray-yellow transition in keystone area).
FIGURE 2.24 The retaining ligament has a body which forms a true
ligament, above which there are many extensions towards the skin; this
resembles a tree and its branches. FIGURE 2.26 The Room Concept is demonstrated in a patient.
FIGURE 2.29 SubSMAS dissection meets with the subperiosteal dis-

section after the dissection passed the nasal bones and reaches the maxil-
lary bone. (Blue arrow) Naked maxillary bone; (red arrow) nasal bone
periosteum; (green arrow) naked nasal bone; (yellow arrow) sutura
between the nasal and the maxillary bone.
bones, the dissection switches itself under the periosteum of

the maxillary bone. This shows that the periosteum of the
nasal bone is different from that of the maxillary bone and is
FIGURE 2.27 The retaining ligaments are demonstrated in a patient.
a fibrous layer that is more firmly attached to the wall of the
bone (Figure 2.29) [2].
2.2.4 Preservation
As much preservation as possible of all anatomic structures
during dissection and exposure is the key point of aesthetic
rhinoplasty procedures (Figures 2.30–2.33). Preservation
FIGURE 2.28 In this histological study of the author, it is clearly

observed how the perichondrium layer firmly adheres to the cartilage
tissue; in some areas their boundaries cannot be clearly selected as the
two tissues are intertwined. In contrast, the SMAS layer is loose fibrous
tissue, located at the right side. (Green arrow) The area where cartilage-
perichondrium border is clearly selected; (yellow arrow) the area where
cartilage-perichondrium border cannot be clearly selected; (purple
arrow) the hyper-intense area which refers to dense fibrous perichondrial
tissue; (turquoise borders) the localization of the perichondrial tissue.
Important Note: When dissecting the dorsum completely in

the subSMAS surgical plane and going over the periosteum of
the nasal bones, where the periosteum of the nasal bones ends
in a junction with the nasal process of the maxillary and nasal FIGURE 2.30 Subperichondrial dissection on the septal cartilage.
FIGURE 2.31 The lower lateral cartilage was exposed through the infe-
rior intracartilaginous incision with a submembranous dissection plane;
the dissection was terminated when it meets with the scroll ligament.
FIGURE 2.33 When one prefers to dissect the nasal dorsum from the
inferior intracartilaginous incision, the scroll ligament must be dissected:
(blue arrow) detached scroll ligament; (red arrow) the transition zone (not
yet penetrated).
2.2.5 Reshaping
Bone structures are the main support element of the nose; this
support is weakened when osteotomy is performed. Therefore,
it is very important to know the concept of osteoplasty. In the
first step, reshaping of the nasal and maxillary bones will be
a more conservative approach with osteoplasty techniques. If
osteoplasty is not enough, then osteotomy can proceed to get the
desired shape. When and how should osteoplasty be performed?
• With respect to the thickness of the nasal bones, they

can be flexed by osteoplasty in some specific cases, so
a more elegant structure can be achieved c ompared to
osteotomy. This may be a suitable method if a small
amount of narrowing without narrowing the volume
of the nasal cavity is desired.
• For nasal bones with C/S-shaped asymmetric bone
surfaces, using osteoplasty to obtain smoother bone
surfaces before an osteotomy will be more successful
in crooked noses (Video 2.3) [5, 9].
FIGURE 2.32 How the delivery technique can be applied by preserving
the scroll ligament (non-delivery technique).
• In patients with thick nasal bones, thinning the oste-
otomy line with osteoplasty before the osteotomy is a
good maneuver to prevent unexpected fractures dur-
ing osteotomy (Video 2.4).
of these structures allows the identification of underly- • The bone dust created when an osteoplasty is per-
ing variations and deformities, and thus makes their treat- formed with a manual rasp is also a very suitable graft
ment possible [20]. If the preservation of these structures material [9]. This dust is a special weapon providing the
does not allow for correction of the deformity, redesigning ability to handle secondary cases with an insufficient
these anatomic structures instead of excising them should primary graft source, without the need for more distant
be considered. graft sources such as rib and ear (Video 2.5).
2.2.6 Reconstruction 2.2.7 Structure

If it is not possible to preserve the anatomic structures and it Preservation alone is never enough; the nose should also
becomes necessary to use excision, it is mandatory to repair be supported after identifying the weak areas due to both
this area (Figure 2.34). The most logical and least harmful anatomic variations and maneuvers used during rhinoplasty.
course of action is to perform reconstruction using the tissues This approach is essential to achieve long-lasting anatomic
in that area (Figures 2.35–2.36) [6]. noses (Figure 2.37a–b) [4].
FIGURE 2.34 The endoscopic image recorded when all the anatomic
structures can be preserved.
FIGURE 2.37a Exposure of the lower lateral cartilages, while com-

pletely protecting the soft tissue on it, revealed the shape deformity of the
cartilage clearly. There is a concavity deformity due to weakness of the
lateral crus and a secondary flaring in the medial crus of the foot plates.
FIGURE 2.35 As a result of component excision from cartilage dor-

sum, the septal cartilage is exposed, the upper lateral cartilage is ready
for spreader flaps, and the nasal bone is ready for rasp/excision.
FIGURE 2.37b When the lateral crura are supported, the desired aes-
thetic triangular image in the lower crural ring is achieved, and the flar-
ing in the medial crus is also self-corrected since the actual problem was
treated.
2.2.8 Redraping and Closure

FIGURE 2.36 In cases where the dorsum cannot be preserved, the dor- The dictionary definition of “redrape” is to pull the skin tightly
sum is reconstructed. The cartilage dorsum was repaired with spreader during plastic surgery procedures. In most plastic surgery
flaps and the bony dorsum was repaired with bone dust instead of oste-
operations, the skin cover can be pulled tightly by excision of
otomies since the case had a narrow base. Thus, the bone defect was
repaired with bone and the cartilage defect was repaired with cartilage,
the excessive skin; however, this is not possible in rhinoplasty.
which are the same type of tissue. It should be remembered that the best Even if it were possible, it would not be done as it could cause
reconstruction in plastic surgery is reconstruction of the gaps with the the loss of three-dimensional definition of the nose. So how
same type of tissue. can redraping in the nose be done?
This issue is especially important in reduction rhino- infections, bleeding, edema, and late-term complications
plasties. Rhinoplasty only allows for elliptic alar skin exci- such as retraction and hypertrophic scarring (Figure 2.38).
sions. Unfortunately, this type of excision cannot be used for Likewise peroperative care—innovations which provide post-
redraping in reduction procedures as excessive skin occurs operative intensive and high quality care—should be followed
in the central part of the nose (dorsum and tip). In addition, as state of the art [21–24].
skin reduction in lateral rooms—going back to the Room As a result, using closed rhinoplasty with the atraumatic
Concept—does not affect the central rooms of the nose. philosophy will aid the surgeons in achieving a natural look-
The contraction capacity of the skin is also another issue. If ing, fast healing, long-lasting, functional, and highly aesthetic
one prefers the submembranous plane for dissection, no skin result (Figures 2.39–2.42, Videos 2.8–2.10).
contraction will be seen since the soft tissue cover is fully pro-
tected with the perichondrium-periosteum layer which cannot
shrink or stretch. In such cases, it is logical to use the DUAL
dissection plane (detailed in Chapter 7).
If redraping can be achieved by the redistribution of the
soft tissue cover without excision, this should be prioritized
(Video 2.6). However, if the skin cover is too thick, then peri-
chondrio-SMASectomy, as described in Chapter 4, should be
performed as a further step.
After these steps, the soft tissue cover will have a more
homogeneous distribution in thickness. However, redraping
can continue if the ligaments are preserved or repaired again.
According to the Room Concept, the excessive skin in the lower
third of the nose can be adapted to the nasal skeleton using the
Pitanguy and scroll ligaments, and the excess skin at the upper
two-thirds with the pyramidal ligament (Video 2.7).
Proper closure of the skin and mucosa incisions is essen-
tial to prevent short-term complications such as wounds,
(a)
(b)
FIGURE 2.39 (a, b) In a patient who underwent rhinoplasty with

FIGURE 2.38 In the operation of a secondary case with soft triangle a closed atraumatic approach, although she had thick skin and an alar
retraction, following the incision, many hair follicles were found in the excision was performed, she made a speedy recovery with a low level of
retracted side. edema and no bruising on the postoperative seventh day.

(a) (b)

(c) (d)
FIGURE 2.40 (a–d) Before and five years after the closed atraumatic rhinoplasty.
(a) (b)
(c) (d)
(e) (f)

(g) (h)
FIGURE 2.41 (a–h) Before and three years after the closed atraumatic rhinoplasty.

(a) (b)
FIGURE 2.42 (a–h) Before and four years after the closed atraumatic rhinoplasty.
(c) (d)
(e) (f)
(g) (h)
FIGURE 2.42 (Continued)

TABLE 2.1
2.3 Open and Closed Rhinoplasty Comparison Comparison of Surgical Approaches in Rhinoplasty
The outcome of an operation performed by ignoring the rela- Disadvantages of Disadvantages of Open
tionship of the soft tissue between the framework is unpredict- Closed Technique Technique
able. In the end, the patient will see her external nose in the It is more difficult to Columellar scar
mirror, not her inner framework. As described, a closed and learn and perform
atraumatic approach including choosing maneuvers carefully, Columellar artery/vein/lymphatic damage
following the given shape intensively during surgery, redrap-
If alar excisions are performed, there will be
ing the excess skin, and adjusting the thickness of the skin can no remaining main lymphatic vessel for
be the most efficient and logical way [2–3, 25]. drainage
Instead of the classic debate of the closed vs open technique, the The possibility of impairment in the tip
point here is to go a step further to see the big picture. In order for circulation when alar excisions are
a surgeon to fully evaluate this, one must have full experience in performed with defatting procedures
both techniques over a long time to see what is sufficient or insuf- The columella loses its chance of being a
ficient and what actually determines the result. It is this experi- single aesthetic unit when a columellar
ence that will be explained throughout this book (Figure 2.43). incision is performed in the open technique
Table 2.1 provides an objective comparison of the advan- Since the route of the dissection has to be from
tages and disadvantages of the open and closed techniques. the tip incision to the back, all walls of the
To best understand the advantages of the closed technique, soft tissue enveloped in the framework have to
refer to the tertiary rhinoplasty case with a total septal perfo- be dissected (remember the Room Concept)
ration and Binder syndrome for whom a reconstruction using Redraping is harder since it is more extensively
the closed technique, despite its technical difficulties, was pre- dissected than in the closed technique
ferred (see Chapter 6, Figures 6.4–6.9). The columella should be sutured back many
times in order to evaluate the shape given
during the surgery
Longer recovery period
FIGURE 2.43 Left, 11 years previously the author performed rhinoplasty surgery with open technique in a comfortable posture. Right, 7 years
previously the author performed rhinoplasty surgery with a closed technique, with postural difficulty for the neck and back of the surgeon. However,
postural difficulties should not discourage the surgeon from performing closed surgery.
TABLE 2.2 Rhinoplasty Society), ISAPS (International Society of

Comparison of Surgical Planes in Rhinoplasty Aesthetic Plastic Surgery) and RSE (Rhinoplasty Society
of Europe). Istanbul, Turkey, Nov 28–29, 2020. https://
Disadvantages of the Disadvantages of the drsuleymantas.com/course/ Accessed 28 July 2020.
Subperichondrial Plane SubSMAS Plane 4. Taş S. Response to Commentary on: Dorsal Roof Technique
It is more difficult to get to this plane Bleeds more for Dorsum Preservation in Rhinoplasty. Aesthetic Plast
Prevents shrinking effect in thick Swells more Surg. 2020 Mar 4. doi: 10.1007/s00266-020-01656-8.
skinned patients [Epub ahead of print].
In thick-skinned patients, additional Bruises more (if subSMAS 5. Taş S. The Alignment of the Nose in Rhinoplasty: Fix Down
debulking or plication procedures are dissection also prefers over Concept. Plast Reconstr Surg. 2020 Feb; 145(2): 378–89.
required to adapt the non-shrinking the bone) doi: 10.1097/PRS.0000000000006523. Epub 2019 Nov 19.
tissue to the framework
6. Taş S. Dorsal Roof Technique for Dorsum Preservation in
There will be more scarring
Rhinoplasty. Aesthet Surg J. 2020 Feb 17; 40(3): 263–75.
(in the reduction rhinoplasty
this can be preferred; see doi: 10.1093/asj/sjz063. Epub 2019 Feb 25.
DUAL Plane Dissection in 7. Taş S. Superior-Based Transposition Flap: A Novel
Chapter 7) Technique in Rhinoplasty. Aesthet Surg J. 2019 June 21;
It causes limited debulking in 39(7): 720–32. doi: 10.1093/asj/sjy197. Epub 2018 Aug 10.
thick-skinned patients 8. Taş S. The Pearls of Closed Rhinoplasty: “Atraumatic
Approach” Advanced Aesthetic Rhinoplasty and Face
Contouring Meeting. St Petersburg, Russia, Oct 24–27, 2019.
9. Taş S. The Use of Bone Dust to Correct the Open Roof
Deformity in Rhinoplasty. Plast Reconstr Surg. 2018 Sep;
2.4 Submembranous—SubSMAS 142(3): 629–38. doi: 10.1097/PRS.0000000000004706.
Dissection Plane Comparison 10. Taş S, Celik N. New Instruments for Submembranous
Both surgical planes have their cons and pros, and the surgeon Dissection in Rhinoplasty. Aesthet Surg J. 2017 July 1;
37(7): NP73–NP8. doi: 10.1093/asj/sjx084.
has to master them and know which one is more appropriate
11. The Name of the Invention. Apparatus Used in Nose
in certain cases. Table 2.2 provides an objective comparison
Surgery, Inventor: Süleyman Taş. Turkish Patent Institution
of the advantages and disadvantages of the submembranous
Registration Number: 2016/05472.
(subperichondrial-periosteal) and subSMAS planes.
12. Taş S. The Closed & Atraumatic Technique. Baku
Rhinoplasty Days: Baku-Azerbaijan, Aug 31–Sep 1, 2018.
VIDEOS 13. Taş S. The Closed Atraumatic Technique. Innovation in
Rhinoplasty 2: Istanbul, Turkey, June 3–4, 2018.
2.1 Local injection in closed rhinoplasty. 14. Taş S. A New and Simple Way to Hold Tendon Stumps
2.2 Surgical stages of the submembranous dissection plane. Atraumatically. J Hand Surg Am. 2013 Aug; 38(8): 1659.
2.3 Using osteoplasty to obtain smoother bone surfaces. doi: 10.1016/j.jhsa.2013.05.029.
2.4 Thinning the osteotomy line with osteoplasty. 15. Taş S. A New Way for Supporting Tip Projection in Closed
Rhinoplasty: Using the Medial Deep SMAS Layer. Plast
2.5 Harvesting bone dust.
Reconstr Surg. 2014 Jan; 133(1): 76e–7e. doi: 10.1097/01.
2.6 Redraping achieved by the redistribution of the soft prs.0000436809.88659.e0.
tissue cover. 16. Santareno S, Taş S. Concept of Anatomic Columellar Strut
2.7 Redraping with bone suture. Grafting in Rhinoplasty: An Algorithmic Approach. Aesthet
2.8 Result with closed rhinoplasty 1. Surg J. 2020 Jan 29; 40(2): NP65–NP71. doi: 10.1093/asj/sjz272.
17. May H. The Réthi Incision in Rhinoplasty. Plast Reconstr
2.9 Result with closed rhinoplasty 2.
Surg. (1946) 1951 Aug; 8(2): 123–31.
2.10 Result with closed rhinoplasty 3. 18. Pshenisnov KP. Commentary on “Comparison of Various
Rhinoplasty Techniques and Results of Long-Term”.
Aesthetic Plast Surg. 2015 Aug; 39(4): 478–82.
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3
Dorsum Surgery Dorsum SurgeryRhinoplasty in Practice
3.1 Osteotomy area while the open roof gets closed; thus, the phenomenon is
known as rocker. To prevent the occurrence of this complica-
The surgery used to cut bone is known as an osteotomy. tion, medial osteotomies that lie higher than the radix should
Performing this type of surgery smoothly and without creating not be made, or the edges of the lateral and medial osteotomies
additional fractures requires great skills, patience, and good should be determined with transverse osteotomies.
equipment. Osteotomies used to be performed with hand saws
in the 1900s; however, due to emerging bone defects through
their use, they were then performed with a chisel, then with 3.1.1.2 Nasolacrimal Duct Damage
4 mm guarded osteotomies, and then with 2 mm guarded oste- The canaliculi arising from the upper and lower lacrimal punc-
otomies. Today, power tools facilitate this stage and two spe- tum drain to the lacrimal sac formed by the frontal process
cific ones come to mind: ultrasonic devices and micromotors of the lacrimal bone and maxillary bone behind the orbital
(Videos 3.1–3.2). rim at the level of the medial canthus. The lacrimal sac and
Success in this classical osteotomy technique is based on post-lacrimal sac are a bone canal lined with a thin mucosa.
the sharpness of the device, hand sensitivity of the surgeon, This canal is called the nasolacrimal duct, and it moves down
and coordination with the nurse. However, all these potential 1.5–2 cm in the maxilla and opens to the lower meatus. Its
risks can be eliminated with the use of power instruments opening is approximately 16 mm inside from the front end of
(Figure 3.1) [1]. the lower concha and 3 cm inside from the nostrils and has a
mucosal fold (the valve of Hasner) [3–6].
3.1.1 Osteotomy Complications Various procedural routes such as “low to low”, “low to
and Their Preventions high”, “high to low”, and “high to low to high” have been
described for the lateral osteotomy line. However, the nasal
3.1.1.1 Rocker Deformity
When the middle line goes too high during medial osteotomy,
a condition called rocker deformity appears since the nasal
bone released through a lateral osteotomy is medialized using
the fingers at the level of the apertura pyriformis. This defor-
mity is a version of the open roof deformity occurring more
in the cephalic rather than the keystone area (Figure 3.2) [2].
Why is it known as rocker deformity? The word “rock”
means “to bewilder” in English. When osteotomies are done
too close to the roof after removing the hump, it is “bewilder-
ing” that a new open roof deformity appears in the cephalic
FIGURE 3.1 The correction of a severely crooked nose with asymmet-

ric osteotomies. FIGURE 3.2 Rocker deformity, red arrow.
DOI: 10.1201/9781003174165-3
25
closed with the lower concha lateralization, the tear drainage

to the nasal cavity is interrupted and if the patient bleeds from
the osteotomy line after the operation, this blood flows retro-
gradely to the eye from the lower punctum and may emerge
from it. This is quite a dramatic scene for the cosmetic rhino-
plasty patient.
The Following Should Be Done in These Cases
1. The eye should immediately be covered with a strip

and wet gauze since blood will cause irritation in the
eye. The patient should be monitored until discharge,
although the bleeding generally stops the next day by
the hemostasis mechanism of the body. If bleeding
continues, antibiotic eye creams and keeping the eyes
closed are recommended.
2. The surgeon should review their knowledge on lat-
eral osteotomy and anatomy.
If the nasolacrimal duct is damaged, or if there was already

an underlying nasolacrimal duct problem exaggerated by
rhinoplasty, silicone tube intubation is primarily made. This
procedure is sufficient in most patients and successful results
are obtained, but it may rarely be necessary to perform a
dacryocystorhinostomy.
FIGURE 3.3 Webster triangle, blue; valve of Halser; nasolacrimal duct;
and lowest level for safe lateral osteotomy.
3.2 Osteoplasty
baseline is solitary and is not an anatomical suture but a
bone groove that progresses between the frontal process of the If there is a convexity deformity on the lateral walls, it can be
maxillary bone and the main buttress of the maxilla. In low repaired by shaping the bone. Power burrs are very successful
osteotomies, the lowest it can get coincides with this line. The in this regard. However, maximum care must be taken to avoid
nasolacrimal duct is in the maxillary bone further lateral to this thinning the bone too much. The parameter here is that the
line. The point where the duct is closest to the nasal baseline bone should be left thick enough to perform a safe osteotomy
is at the level of medial canthal ligament, but here, it is 2 mm (Figure 3.4). If the convexity deformity is not very severe,
lateral to the medial canthal ligament (Figure 3.3). power rasps can be used for this purpose (Video 3.3).
3.1.1.3 Airway Problems

For the lateral osteotomy line not to cause airway problems, it
is recommended that it should begin a bit higher than the nasal
baseline in the piriform apertura. The reason is the Webster
triangle (see Figure 3.3), and the protection of this area is a
common method for the prevention of airway problems due
to the narrowing induced by the lateral osteotomy [7]. In fact,
if the adhesion point of the lower concha bone stays on the
lateral osteotomy line, the airway narrows significantly. In the
scenario where the lower concha is included in the lateral oste-
otomy, there is also a risk of damage in the nasolacrimal duct
since it opens to the lower meatus.
Thus, if a lateral osteotomy line is formed which does not
pass beyond the medial canthal lateral above and does not
include the lower concha in the osteotomy line, the nasolac-
rimal duct is preserved, and the airway does not clog. It is
important for the surgeon to stay in this safe zone to prevent
severe osteotomy complications.
Important Notice: In cases where the osteotomy line is not
formed in this way, blood may seep from the patient’s eye after
the operation! How? If the valve of Hasner is damaged or it is FIGURE 3.4 Reshaping of the convex lateral nasal walls with osteoplasty.
Dorsum Surgery 27
If power instruments are not available, TAŞ3® can be used

for the shaping of lateral surfaces, and it also enables the accu-
mulation of bone powders that arise during this shaping with
the reservoir in the middle.
3.3 Maxilloplasty
Maxillary hypoplasia is the condition in which one of the
alar bases is more displaced than the other in such a way as
to include the upper part of the nasolabial fold in the sagittal
plane (Figure 3.5). If the maxillary hypoplasia is lesser than
2 mm, then the opposite maxilla can be deepened with a power
burr. Symmetry with the hypoplasic side is ensured and the
risks of grafting are not taken; thus, a more symmetrical and
successful result can be obtained (Video 3.4) [8]. If the maxil-
lary hypoplasia is more than 2 mm, then maxillary augmenta-
tion should be performed (detailed in Chapter 5).
It is always useful to check the osteotomy lines after the
osteotomy with palpation or endoscopically as roughness in
these lines can be smoothed and perfected using the maxil-
loplasty method (Video 3.5).
In crooked noses, the maxilloplasty technique can also be
used to prepare a groove for the nose to sit on after rotation to
reduce the difference between the maxilla on both sides (see
fix down technique).
FIGURE 3.6 (a) The historical categorization of dorsum surgery.

(b) The current categorization of dorsum surgery..
TABLE 3.1
The Current Techniques for Dorsum Surgery
Dorsum Preservation Dorsum Reconstruction
Techniques Techniques
1 Push down Excision + primer
suturation/osteotomies
2 Let down Spreader graft
3 Skoog technique Spreader flap
4 Retractable roof technique Camouflage surgery
5 Fix down Bone dust technique
6 Dorsal roof technique
and proposed closed roof techniques, popularizing the push

FIGURE 3.5 Maxillary hypoplasia, red arrow. down technique. Therefore, dorsum surgery historically
divides into the two main categories of open roof or closed
roof (Figure 3.6a) [9].
However, dorsum surgery today is categorized into those
that excise the dorsum and those that preserve it (Table 3.1).
This classification is not much different than the historical dis-
3.4 Dorsum Surgery
crimination of dorsum surgery. The only difference is that the
Looking back 70 years, dorsum surgery fell into two main cat- techniques that excise the dorsum now try to close the open
egories. The first was the hump removal technique which was roof that it formed, through osteotomies as well as spreader
popularized, well-described, and generalized by Joseph. Then, grafts/flaps. On the other hand, dorsum preservation tech-
Cottle showed that this technique caused open roof deformity, niques continue to use the push down modifications.
The new perspective here should be “not only to preserve as internal valve collapse and open roof syndrome occurred in
but also to support”, as required by the atraumatic philosophy. this period; however, nothing was proposed other than oste-
Dorsum preservation techniques do not mean that spreader otomies to close the open roof deformity that formed after
grafts, flaps, or other structural grafts are not required. Cartilages removal of the dorsum. In 1954, Cottle [9] began to replace
might have been thin before the operation or they might have the materials that were removed from the roof similar to an
enlarged due to performed modification, and in this case, thin onlay graft. After Sheen [13–14] described spreader grafts in
regions should be supported, and the preserved dorsum should 1978, these issues started to be overcome in earnest. Then, in
be remodified (Figure 3.6b) [10]. In the next pages of this chap- 1997, Ahmet Seyhan [15] started to use spreader flaps in an
ter, the following will be discussed: placing spreader grafts and attempt to eliminate roof issues occurring after excision. In
flaps on the totally preserved dorsum, suturing ethmoid grafts the 2000s, the composite removal of the dorsum gave way to
on the septum, combining other structural methods with preser- component excision, and roof repair became a routine pro-
vative methods, and various new structural methods. cedure after the removal of the hump [16]. Therefore, the
Important Note: Remember that in plastic surgery, if you history of dorsum excision shows that a practice that started
cannot create a surface that is aesthetically pleasing to the eye with only the removal of the dorsum turned into its removal
with lights and shadows, it does not matter whether you pre- and repair.
served anatomy or not. You cannot tell a patient that you have There have been numerous publications on dorsum surgery
preserved their dorsum but that no other modifications can be for asymmetrical and crooked noses describing various oste-
made or that you preserved their dorsum and their hump is gone otomy and shaping methods. Additionally, camouflage tech-
but their nose has expanded. Thus, when removing a hump, you niques were also improving during this period and the diced
must be careful to ensure others do not think the patient looked cartilage technique, which is now the most commonly used
better before the surgery. That is why it is important not only technique for this purpose, started to be used in plastic surgery
to preserve but also to attempt to obtain the best possible result in the 1940s [17]. In the 1950s, it found a wide application area
(Videos 3.6–3.9). The priority should be the frontal image of from ear reconstruction to bone defect and hernia repair. In
the patient, followed by the side and the base views. 1954, Peer [18] wrote a well-received publication on the use
of diced cartilage. In this, diced cartilage obtained from rib
cartilage is placed on an ear-shaped mold made from vital-
3.4.1 Excisional Approach to the Dorsum
lium with a perforated structure for the blood vessels to enter.
3.4.1.1 The History of Dorsum Excision This is then subcutaneously placed in the abdomen of the
The first hump removal surgery was executed by Roe [11] in patient and left there for five months, after which it is removed.
1891; all stages of the classical operation were detailed by The fibrosis and diced cartilage, which have taken the shape of
Joseph [12] in 1930 (Figure 3.7). Serious complications such the cartilage skeleton of the ear, are then used to form the skel-
eton of the atretic ear. In 1961, Limberg [19] designed a special
injector to inject diced cartilage and began to use it on the nose
for saddle nose repair. However, as the obtained results were
not ideal, this application was abandoned for quite some time.
Onur Erol’s [20] publication in 2000 related to a diced carti-
lage application known as the “Turkish Delight” attracted the
attention of surgeons to this interesting technique, causing it to
be frequently used in rhinoplasty and also to have more than
100 articles written about it.
In conclusion, dorsum excision is a surgical procedure which
may later require structural repair and camouflage techniques.
The most common technique is component hump removal,
which minimizes the amount of excision to be made on the
dorsum, followed by repair with a spreader flap, graft, or oste-
otomies. If any roughness is observed on the surface after the
reconstruction, the surface can be repaired with camouflage
techniques.
3.4.1.2 Composite Hump Removal

This is the removal of the hump with the mucosa under it
as one piece. In this case, the septum that forms the key-
stone region, upper lateral cartilage, and nasal bone with
the mucosa that covers it are removed (Figure 3.8a–b). It is
an outdated technique since it causes open roof syndrome,
FIGURE 3.7 The classical hump removal technique demonstrated by a deformity characterized by discoloration, pain, malforma-
Joseph. tion, and gap emergence as a result of direct skin contact with
Dorsum Surgery 29
FIGURE 3.9 Component excision material.
FIGURE 3.8 (a) The anatomy of the dorsum and internal vault. (b) Left,
component hump excision. Right, composite hump excision.
the mucosa and the skin after the operation on the skin of the
dorsum [9].
3.4.1.3 Component Hump Removal

This modification is quite important for reducing the amount
of tissue extracted to treat an arched or projected appearance
on the dorsum. First, the mucosa is preserved by forming tun-
nels into it on the surface of the upper lateral cartilages that
face the nasal cavity. Then, the upper lateral cartilages are
separated from the septum and the groove where they adhere
anatomically; the overlapping where the upper lateral carti-
lages progress under the nasal bone is preserved from the total
excision. Thus, only the septum and nasal bone protrusion that
causes the hump is revealed in the midline and it is excised
(Figure 3.9). After the dorsum descends to the intended level,
the upper lateral cartilages, which are relatively longer than
the new dorsum, are used as spreader flaps in closing the bone
roof thanks to the overlapping that progresses under the carti-
lage roof and partially under the nasal bone [16] (Figure 3.10).
The remaining gap in the bone roof is closed with medial and
lateral osteotomies. If the dorsum has not descended enough
to form a spreader flap, or in cases of asymmetry and trauma,
spreader flaps obtained from the septal cartilages are used to
close the gap on the dorsum (Figure 3.11). Sheen called this FIGURE 3.10 Spreader flap.
3.4.1.4 Dorsum Reconstruction

Reconstruction methods are often used when an excisional
approach is performed on the dorsum, when the dorsum needs
to be strengthened, or in cases where dorsum preservation meth-
ods are insufficient for nose shaping methods (Figure 3.12).
Dorsum repair with the spreader graft and flaps is essential
in rhinoplasty, and surgeons must know them well. Tips for
this technique are as follows:
• Reconstruction should be eased by minimizing the

defect to be formed while making the excision
• The complete volume of the defect should be esti-
mated and a graft/flap suitable to close the defect
should be prepared
• Graft places in the defects should be well stabilized
FIGURE 3.11 Spreader graft. • Sutures in spreader flaps should not be tightened too
much towards the keystone, as they may cause an iat-
the “spreader graft” since it expands the width of the internal rogenic inverted V appearance
valve angle [14]. • Spreader grafts should be placed according to the
bone roof rather than the cartilage roof; if there is a
(a) (b)
Dorsum Surgery 31
(c) (d)
(e)
FIGURE 3.12 (a–e) 42-year-old patient: the size of the nose is 7 cm, which emphasizes how severe a reduction should be made. The component hump
excision material (mostly cartilaginous) is seen. Views before and four years after are demonstrated.
region that cannot be covered with an osteotomy, the

spreader graft should reach this region • In the fixing of the grafts/flaps, the knot of the suture
• The thickness of the spreader flaps should also be should always be tied towards the inside
considered, and sutures that are as gentle and absorb- • Grafts and flaps should be combined in difficult
able as possible should be used for their fixation cases (Figure 3.13)
(a) (b)
(c) (d)
(e)
FIGURE 3.13 (a–e) 51-year-old patient: the component hump excision material (mostly bony) is seen. Views before and five years after are presented.
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States, 'while specially asserting the rights of Hungary and
its independence.' Another version of this somewhat oracular
statement runs as follows:—'Hungary, without infringing the
Ausgleich law, will find ways and means of regulating those
affairs which, in virtue of the Pragmatic sanction, are common
to both States, while at the same time protecting her own
interests and giving greater emphasis to her independence.'
Dr. Szell added:—'When the right time comes I shall explain my
views, and eventually submit proposals to the House.
Meanwhile, let us husband our strength and keep our powder
dry.' The self-confident and almost defiant tone of this
forecast, coming from a responsible statesman accustomed to
display such prudence and moderation of language as M. Szell,
has made a profound impression in Austria. It assumes the
breakdown of the Austrian Parliamentary system to be a
certainty, and anticipates the adoption by Hungary of
one-sided measures which, according to M. Szell, will afford
more effective protection to its interests and confirm its
independence. This seems to be interpreted in Vienna as an
indication that the Hungarian Premier has a cut and dry scheme
ready for the revision of the Ausgleich in a direction which
bodes ill for Austria. The gravity of the Ministerial
statement is recognized by journals of such divergent views as
the semi-official 'Fremdenblatt,' the pan-Germanic and
Anti-Semitic 'Deutsche Zeitung,' and the 'Neues Wiener
Tagblatt,' which is the organ of the moderate German element.
The 'Neues Wiener Tagblatt' frankly acknowledges that, in
addition to all her other cares, Austria has now to consider
the crucial question of the form which her relations with
Hungary will assume at no distant date. Commercial severance
and declarations of independence are, it says, being discussed
by the initiated sections of the community in both countries,
as if it were a matter of merely economic concern, instead of
the greatest and most perilous political problem that the
Monarchy has been called upon to solve since the establishment
of the Dual system, which, in spite of its complexity, has
worked well for such a long period. The 'Neues Wiener
Tagblatt,' nevertheless, admits that things have now reached a
stage at which economic severance is no longer impossible." In
a subsequent speech on New Year's Day, M. Szell declared that
it "would be a fatal mistake to sever the ties which had so
long connected the two countries, as the objects for which
they were called into existence still remained and their
fundamental basis was not shaken."
The Vienna journals, on that New Year's Day of 1901, reviewed

the past and surveyed the prospects of the future in gloomy
and pessimistic tones. Heading its article "Progress
Backward," the "Wiener Allgemeine Zeitung" said: "It is true
that Austria has at her disposal a larger and more efficiently
trained army than ever. The natural resources of the country
have been better developed than in the past. The progress of
the century has not been without influence upon ourselves.
But, whereas other nations are more vigorous, greater, and
mightier, we have become weaker, smaller, and less important.
The history of the world during the second half of the past
century has been made at our expense. … In the new partition
of the world no room has been reserved for Austria. The most
important events which will perhaps give the world a new
physiognomy are taking place without Austria's being able to
exercise the slightest influence thereon. We are living upon
our old reputation, but in the long run that capital will
prove insufficient."
AUSTRIA-HUNGARY: A. D. 1900 (December).

Census of Vienna.
See (in this volume)

VIENNA: A. D. 1900.
AUSTRIA-HUNGARY: A. D. 1901.
Parliamentary elections.
Weakening of the Clerical and Anti-Semitic parties.
Gains for the ultra-radical German parties.
Disorderly opening of the Reichsrath.
Speech of the Emperor from the throne.
From the parliamentary elections held in January the Clerical

and Anti-Semitic parties came back to the Reichsrath shorn of
about one-third of their strength, while the various radical
factions, especially those among the Germans, appear to have
made considerable gains. Even in the Tyrol, one of the
strongest of the Clerical leaders, Baron Di Pauli, was
defeated, and in Vienna the Anti-Semitic majority was cut to
less than one-fourth of what it had been three years before.
"The Pan-Germanic group," writes "The Times" correspondent
from Vienna, "which only numbered five in the last Parliament,
now musters 21. It will be remembered that it openly advocates
incorporation with the German Empire, and as a preparatory
measure the wholesale conversion of the German population of
Austria to Protestantism. It has hitherto been to a certain
extent boycotted by the other German parties, being excluded
from their so-called union for mutual defence and joint
action." "But the programme which had thus been boycotted by
the bulk of the German members has been the most successful of
all in the recent general election. The position of its
leading representative, Herr Schönerer, has been so
strengthened that he has been able to impose upon the whole
group the title of Pan-Germanic Union, and to enforce the
acceptance of the principle of 'emancipation from Rome.' The
latter demand caused a certain hesitation on the part of some
of his new followers, who, however, ultimately decided to
adopt it, although not to the full extent of renouncing the
Roman Catholic faith, as Herr Schönerer and his principal
lieutenant, Herr Wolf, themselves had done. At a conference of
the party its programme was declared to be the promotion of
such a federal connexion of the German provinces of Austria
with the German Empire as would furnish a permanent guarantee
for the maintenance of the German nationality in this country.
The party would oppose every Government that resisted the
realization of that object, and it could not participate in
any manifestations of loyalty while such a Government policy
was maintained. At the same time, the party regarded it as
their obvious duty to emancipate themselves from Rome in a
political but not religious sense—that is to say, to free
themselves from the influence of the Roman Curia in affairs of
State.
{46}
"This boycotted party and programme now threatens to win the

voluntary or enforced adherence of the advanced section of the
other German groups which had hitherto declined to commit
themselves to such an extreme policy. The most moderate of all
the German parties, that of the constitutional landed
proprietors, has felt called upon to enter an energetic and
indignant protest against the foregoing Pan-Germanic
programme. While they are convinced supporters of the
Austro-German alliance, they unconditionally reject
aspirations which they hold to be totally inconsistent with
the tried and reliable basis of that agreement, and which
would constitute an undignified sacrifice of the independence
of the Monarchy. They further decline to make their
manifestations of loyalty to the Sovereign dependent upon any
condition; and they strongly condemn the emancipation from
Rome movement as a culpable confusion of the spheres of
religion and politics, and an infringement of the liberty of
conscience which is calculated to sow dissension among the
German nationality in Austria.
"It now remains to be seen to which side the bulk of the

German representatives will rally; to that of the Moderates,
who have re-affirmed their devotion to the Dynasty and the
existing Constitution, or to that of the Pan-Germanic
revolutionaries, who have decided to make their manifestations
of loyalty dependent upon the adoption by the Crown of their
programme.
"The outlook has thus undergone, if anything, a change for the
worse since the last Reichsrath was dissolved. The only
reassuring feature of the situation is that the fall of the
Ministry is not a primary end with any of the parties in the
Reichsrath. Dr. von Körber, who is a politician of great tact
and experience, has avoided friction on all sides."
The opening session of the newly elected Reichsrath was held

on the 31st of January, and the disorderly temper in it was
manifested upon a reference by the President to the death of
Queen Victoria, which called out cries of hostility to England
from both Germans and Czechs.
"In the course of the proceedings some of the members of the

Extreme Czech fraction warned the Prime Minister in
threatening terms against introducing a single word hostile to
the Czech nation in the coming Speech from the Throne. They
also announced their intention of squaring accounts with him
so soon as the Speech from the Throne should be delivered. The
whole sitting did not last an hour, but … what happened
suffices to show that not only the Pan-Germanic Union, but
also the Extreme section of the German People's party and a
couple of Radical Czechs, are ready at a moment's notice to
transform the Reichsrath into a bear garden."
On the 4th of February the two Houses of the Reichsrath were

assembled at the Palace and addressed by the Emperor, in a
speech from the throne of which the following is a partial
report: "His Majesty referred to various features of
legislation, including the Budget, the revision of the Customs
tariff, the promotion of trade, industry, and navigation, the
protection of the working classes and the regulation of the
hours of labour, the Government railway projects and the
Bosnian lines, and Bills for the regulation of emigration, the
construction of dwellings for the lower classes, the
repression of drunkenness, the development of the University
system and other educational reforms, and a revision of the
Press laws—in fact a whole inventory of the important
legislative arrears consequent upon the breakdown of
Parliament.
"The following passage occurs in the further course of the

speech: 'The Constitution which I bestowed upon my dominions
in the exercise of my free will ought to be an adequate
guarantee for the development of my people. The finances of
the State have been put in order in exemplary fashion and its
credit has been raised to a high level. The freedom of the
subject reposes upon a firm foundation, and thanks to the
scholastic organization and the extraordinary increase of
educational establishments general culture has reached a
gratifying standard, which has more especially contributed to
the efficiency and intelligence of my army. The Provincial
Diets have been able to do much within the limits of their
jurisdiction. The beneficial influence of the constitutional
system has penetrated as far as the communal administrations.
I am thus justified in saying that the fundamental laws of the
State are a precious possession of my loyal people.
Notwithstanding the autonomy enjoyed by certain kingdoms and
provinces, they constitute for foreigners the symbol of the
strength and unity of the State. I was, therefore, all the
more grieved that the last sessions of the Legislature should
have had no result, even if I am prepared to acknowledge that
such business as affected the position of the Monarchy was
satisfactorily transacted by all parties.'
"The Emperor then expressed his regret that other matters of

equal importance affecting the interests of Austria had not
been disposed of. His Majesty made an appeal to the
representatives of the Reichsrath to devote their efforts to
the necessary and urgent work awaiting them, and assured them
that they might count upon the Government. All attempts at the
moral and material development of the Empire were, he said,
stultified by the nationality strife. Experience had shown
that the efforts of the Government to bring about a settlement
of the principal questions involved therein had led to no
result and that it was preferable to deal with the matter in
the Legislature. The Government regarded a generally
satisfactory solution of the pending language question as
being both an act of justice and a necessity of State.
Trusting in the good will manifested by all parties, the
Ministry would do its utmost to promote a settlement which
would relieve the country of its greatest evil. At the same
time, the Cabinet was under the obligation of maintaining
intact the unity of language in certain departments of the
Administration, in which it constituted an old and well-tested
institution. Success must never again be sought through
paralysing the popular representation. The hindrance of
Parliamentary work could only postpone or render quite
impossible the realization of such aspirations as most deeply
affected the public mind. The Sovereign then referred to the
damage done to the interests of the Empire by the obstacles
placed in the way of the regular working of the Constitution,
and pointed to the indispensable necessity of the vigorous
co-operation of Parliament in the approaching settlement of
the commercial relations between the two halves of the
Monarchy. The speech concluded with a warmly-worded appeal to
the representatives to establish a peace which would
correspond to the requirements of the time and to defend as
their fathers had defended 'this venerable State which accords
equal protection to all its peoples.'"
{47}
AUSTRIA-HUNGARY: A. D. 1901 (March).

Continued turbulence of the factions
in the Austrian Reichsrath.
Outspoken aim of the Pan-Germans.
At this writing (late in March), the disgraceful and

destructive conflict of reckless factions is still raging in
the Austrian Reichsrath, and the parties have come to blows
several times. The hope of the German extremists for a
dissolution of the Empire seems to be more and more openly
avowed. On one occasion, "a Czech member, Dr. Sieleny, having
accused the Pan-Germans of wistfully glancing across the
frontier, Herr Stein, a member of the Pan-Germanic group,
replied, 'We do not glance, we gaze.' Being reproached with
looking towards Germany with an ulterior motive, the same
gentleman answered, 'You Czechs want to go to Russia, and we
Germans want to go to Germany.' Again, on being told that he
would like to become a Prussian, he exclaimed, 'I declare
openly that we want to go to the German Empire.' Finally, in
reply to another remark, Herr Stein observed that everybody in
the country who was an Austrian patriot was stupid."
----------AUSTRIA-HUNGARY: End--------
AUTONOMY, Constitutional:
Granted by Spain to Cuba and Porto Rico.

CUBA: A. D. 1897 (NOVEMBER);
and 1897-1898 (NOVEMBER-FEBRUARY).
AYUNTAMIENTOS.
Town councillors in Spain and in the Spanish American states.

CUBA: A. D. 1901 (JANUARY).
B.
BABYLON: Exploration of the ruins of the city.

ARCHÆOLOGICAL RESEARCH:
BABYLONIA: GERMAN EXPLORATION.
BABYLON: Railway to the ruins.

TURKEY: A. D. 1899 (NOVEMBER).
BABYLONIA: Archæological Exploration in.

ARCHÆOLOGICAL RESEARCH: BABYLONIA: AMERICAN
EXPLORATION.
BACHI,
BASHEE ISLANDS, The American acquisition of.

UNITED STATES OF AMERICA: A. D. 1898 (JULY-DECEMBER).
BACTERIAL SCIENCE, Recent.

SCIENCE, RECENT: MEDICAL AND SURGICAL.
BADENI, Count: Austrian ministry.

AUSTRIA-HUNGARY: A. D. 1895-1896.
BADEN-POWELL, General R. S. S.: Defense of Mafeking.

SOUTH AFRICA (THE FIELD OF WAR):
A. D. 1899 (OCTOBER-NOVEMBER); and 1900 (MARCH-MAY).
BAGDAD, Railways to.

TURKEY: A. D. 1899 (NOVEMBER); and JEWS: A. D. 1899.
BAJAUR.

INDIA: A.D. 1895 (MARCH-SEPTEMBER).
BALFOUR, Arthur J.:

First Lord of the Treasury in the British Cabinet.

ENGLAND: A. D. 1894-1895; and 1900 (NOVEMBER-DECEMBER).
BALFOUR, Arthur J.:

Tribute to Queen Victoria.

ENGLAND: A. D. 1901 (JANUARY).
BALKAN AND DANUBIAN STATES, The.
"The States of the Balkan Peninsula, ever since the practical

disruption of European Turkey after the war of 1877-78, have
been in a condition of chronic restlessness. Those who desire
the repose of Europe have hoped against hope that the new
communities which were founded or extended on the ruins of the
Ottoman dominion in Europe would be able and willing to keep
the peace among themselves and to combine in resisting the
intrusion of foreign influences. These expectations have been
too frequently disappointed. The lawlessness of Bulgaria and
the unsettled state of Servia, more especially, continue to
constitute a periodical cause of anxiety to the diplomacy of
Europe. The recent murder at Bukharest of Professor
Mihaileano, a Macedonian by birth and a Rumanian by
extraction, appears to be a shocking example of the teaching
of a school of political conspirators who have their centre of
operations at Sofia. These persons had already combined to
blackmail and terrorise the leading Rumanian residents in the
capital of Bulgaria, where the most abominable outrages are
stated to have been committed with impunity. Apparently, they
have now carried the war, with surprising audacity, into the
Rumanian capital itself. Two persons marked out for vengeance
by the terrorists of Sofia had previously been murdered in
Bukharest, according to our Vienna Correspondent, but these
were Bulgarians by birth. It is a further step in this
mischievous propaganda that a Rumanian subject, the occupant
of an official position at the seat of the Rumanian
government, should be done to death by emissaries from the
secret society at Sofia. His crime was that, born of Rumanian
parents in Macedonia, he had the boldness to controvert in the
Press the claims of the Bulgarians to obtain the upper hand in
a Turkish province, where Greeks, Turks, Bulgarians,
Albanians, and Serbs are inextricably mixed up. Professor
Mihaileano had probably very good reasons for coming to the
conclusion that, whatever may be the evils of Ottoman rule,
they are less than those which would follow a free fight in
the Balkans, ending, it may be, in the ascendency of Bulgarian
ruffianism.
"It is for this offence that M. Mihaileano suffered the

penalty of death by the decree of a secret tribunal, and at
the hands of assassins sent out to do their deadly work by
political intriguers who sit in safety at Sofia. The most
serious aspect of the matter, however, is the careless and
almost contemptuous attitude of the Bulgarian Government. The
reign of terror at Sofia and the too successful attempts to
extend it to Rumania have provoked remonstrances not only from
the government at Bukharest, but from some of the Great
Powers, including Austria-Hungary, Germany, and Italy. … There
is only too much reason to fear, even now, that both the
Bulgarian Government and the ruler of the Principality are
afraid to break with the terrorists of Sofia.
{48}
Political assassination is unfortunately among the traditions
of the Bulgarian State, but it has never been practised with
such frequency and impunity as under the rule of Prince
Ferdinand. … His own conduct as a ruler, coupled with the
lamentable decline of the spirit of Bulgarian independence,
which seemed to be vigorous and unflinching before the
kidnapping of Prince Alexander, has steadily lowered his
position. The Bulgarian agitation—to a large extent a sham
one—for the 'redemption,' as it is called, of Macedonia is a
safety-valve that relieves Prince Ferdinand and those who
surround him from much unpleasant criticism. …
"The situation in the Balkans is in many respects disquieting.

The Bulgarian agitation for the absorption of Macedonia is not
discouraged in high quarters. The hostility of the Sofia
conspirators to the Koutzo-Wallachs, the Rumanians of
Macedonia, is due to the fact that the latter, being a small
minority of the population, are ready to take their chance of
equal treatment under Turkish rule, subject to the supervision
of Europe, rather than to be swallowed up in an enlarged
Bulgaria, dominated by the passions that now prevail in the
Principality and that have been cultivated for obvious
reasons. Russia, it is believed, has no wish to see Bulgarian
aspirations realized, and would much rather keep the
Principality in a state of expectant dependence. Servia and
Greece would be as much embarrassed as Rumania by the success
of the Bulgarian propaganda, and Austria-Hungary would regard
it as a grave menace. Of course the Turkish government could
not be expected to acquiesce in what would, in fact, be its
knell of doom. … In Greece, the insubordination in certain
sections of the army is a symptom not very alarming in itself,
but unpleasantly significant of latent discontent. In Turkey,
of course, the recrudescence of the fanaticism which
periodically breaks out in the massacres of the Armenians
cannot be overlooked. A more unfortunate time could not be
chosen for endeavouring to reopen the Eastern question by
pressing forward the Bulgarian claim to Macedonia. Nor could a
more unfortunate method be adopted of presenting that claim than
that of the terrorists who appear to be sheltered or screened
at Sofia."
London Times, August 23, 1900.
See, also (in this volume),

TURKEY: A. D. 1899-1901.
BALKAN AND DANUBIAN STATES:

Bulgaria.
On the 15th of July, 1895, M. Stambouloff, lately the powerful

chief minister in the Bulgarian government, but now overthrown
and out of favor, was attacked by four assassins, in the
streets of Sofia, and received wounds from which he died three
days afterwards.
The increasing influence of Russia in Bulgaria was manifested

unmistakably on the 14th of February, 1896, when Prince Boris,
the infant son and heir of the reigning Prince Ferdinand, was
solemnly baptised into the Orthodox Greek Church, the Tzar of
Russia, represented by proxy at the ceremony, acting as
sponsor. This is understood to have been done in opposition to
the most earnest remonstrances of the mother of the child, who is
an ardent Roman Catholic, the father being nominally the same.
BALKAN AND DANUBIAN STATES: Montenegro:

Recent changes.
"The accession of territory obtained under the Berlin Treaty

has already begun to alter the character of the country. The
area of the Principality has been almost doubled, and fertile
valleys, tracts of rich woodland and a strip of sea-coast have
been added to the realm of Prince Nikolas. Montenegro is now
something more than the rocky eyrie of a warlike clan, and the
problem of its commercial development constantly occupies the
mind of its ruler. The state of transition is reflected in the
aspect of the capital. A tiny hamlet in 1878, Tzetinye now
bears witness to the growth of civilisation and to the
beneficent influence of a paternal despotism. … Nikolas I.,
'Prince and Gospodar of free Tzrnagora and the Berda,' is the
most picturesque and remarkable figure in the South Slavonic
world. Descended from a long line of heroes, the heir of the
Vladikas, he has, like them, distinguished himself in many a
hard-fought conflict with the hereditary foe. In the field of
poetry he has also won his triumphs; like his father Mirko,
'the Sword of Montenegro,' he has written lyric odes and
ballads; like his ancestor, the Vladika Petar II., he has
composed historical dramas, and his poems and plays hold a
recognised place in contemporary Slavonic literature. The
inheritor of a splendid tradition, a warrior and a bard,
gifted by nature with a fine physique and a commanding
presence, he forms the impersonation and embodiment of all
that appeals most to the imagination of a romantic and
impressionable race, to its martial instinct, its poetic
temperament, and its strange—and to us
incomprehensible—yearning after long-vanished glories. … Any
attempt to describe Prince Nikolas' work as an administrator
and a reformer would lead me too far. The codification of the
law, which was begun by his ancestors, Danilo I. and Petar I.,
has been almost completed under his supervision. … The
suppression of the vendetta is one of the greatest of the
Prince's achievements. … Crime is now rare in the
Principality, except in the frontier districts, where acts of
homicide are regarded as justifiable, and indeed laudable, if
perpetrated in payment of old scores, or if the victim is an
Albanian from over the border. Primary education has been made
universal, schools have arisen in every village, and lecturers
have been appointed to explain to the peasants the advantages
of learning. Communications are being opened up, and the
Principality, which a few years since possessed nothing but
mule-tracks, can now boast of 138 miles of excellent
carriage-road, better engineered and maintained than any I
have seen in the Peninsula. The construction of roads is
viewed with some apprehension by the more conservative
Montenegrins, who fear that their mountain stronghold may lose
its inaccessible character. But the Prince is determined to
keep abreast of the march of civilisation. Nine post-offices
and thirteen telegraph stations have been established. The
latter, which are much used by the people, will play an
important part in the next mobilization of the Montenegrin
army. Hitherto the forces of the Principality have been called
together by stentorian couriers who shouted from the tops of
the mountains. A great reform, however, still remains to be
attempted—the conversion of a clan of warriors into an
industrial nation. The change has been rendered inevitable by
the enlargement of the bounds of the Principality, and its
necessity is fully recognised by the Prince.
{49}
Once the future of the country is assured, his order will be
'à bas les armes.' He is aware that such an edict would be
intensely unpopular, but he will not flinch when the time for
issuing it arrives. Every Montenegrin has been taught from his
cradle to regard warfare as his sole vocation in life, and to
despise industrial pursuits. The tradition of five hundred
years has remained unbroken, but the Prince will not hesitate
to destroy it. So enormous is his influence over the people,
that he feels confident in his ability to carry out this
sweeping reform."
J. D. Bourchier,
Montenegro and her Prince
(Fortnightly Review, December, 1898).
BALKAN AND DANUBIAN STATES: Montenegro:

New title of the Prince.
On the 19th of December, 1900, at Tzetinye, or Cettigne, "the

President of the Council of State, in the presence of the
other Ministers and dignitaries and of the members of the
Diplomatic Corps, presented an address to the Prince of
Montenegro praying him, in token of the gratitude of the
Montenegrin people for the benefits which he had conferred on
them during his 40 years' reign, to take the title of Royal
Highness. The Prince acceded to the request, and, replying to
the President, thanked all the European rulers who on this
occasion had given him a fresh proof of their friendship by
their recognition of his new title. After the ceremony a Te
Deum was celebrated in the Cathedral, and the Prince
subsequently reviewed the troops, receiving a great welcome
from the people."
Telegram,
Reuter's Agency.
BALKAN AND DANUBIAN STATES:

Servia.
In January, 1894, the young king, Alexander, called his

father, the ex-king, Milan (abdicated in 1889—see, in volume
1. BALKAN AND DANUBIAN STATES: A. D. 1879-1889), to Belgrade
to give him help against his Radical ministers, who had been
taking, the latter thought, too much into their own hands. The
first result was a change of ministry, soon followed by a
decision from the synod of Servian bishops annulling the
divorce of ex-King Milan and Queen Natalie; by a public
announcement of their reconciliation, and by an ukase from
King Alexander, cancelling all laws and resolutions which
touched his parents and restoring to them their rights and
privileges as members of the royal house. This, again, was
followed, on the 21st of May, by a royal proclamation which
abolished the constitution of December, 1888, and restored the
old constitution of 1869. This was a tremendous step backward, to
a state of things in which almost no protection against
arbitrary kingship could be found.
For some years the ex-king exercised considerable influence

over his son, and was again an uncertain and much distrusted
factor in the troubled politics of southeastern Europe. In
1898 the son appointed him commander-in-chief of the Servian
army, and he is said to have ably and energetically improved
its efficiency during the brief period of his command. A
breach between father and son was brought about before long,
however, by the determination of the latter to marry a lady,
Madame Draga Maschin, considerably older than himself, who had
been lady-in-waiting to his mother; while the father was
arranging a political marriage for him with a German princess.
The young king married his chosen bride in August, 1900, and
guarded his frontier with troops to bar the return of his
father, then sojourning at a German watering place, to the
kingdom. It was a final exile for the ex-king. He visited
Paris for a time; then went to Vienna, and there, on the 11th
of February, 1901, he died, at the age of 47.
BALLOONS, Declaration against explosives from.

PEACE CONFERENCE.
BALTIC and NORTH SEA CANALS.

GERMANY: A. D. 1895 (JUNE); and 1900 (JUNE).
BANK OF FRANCE: Renewal of privileges.

MONETARY QUESTIONS: A. D. 1897.
BANKING: Its effect on the Nineteenth Century.

NINETEENTH CENTURY: THE TREND.
BANKRUPTCY LAW, National.

UNITED STATES OF AMERICA: A. D. 1898 (JULY 1).
BARBADOS: Condition and relief measures.

WEST INDIES, THE BRITISH: A. D. 1897.
BARCELONA: A. D. 1895.
Student riots.

SPAIN: A. D. 1895-1896.
BAROTSILAND:
British Protectorate proclaimed.

SOUTH AFRICA (RHODESIA): A. D. 1900 (SEPTEMBER).
BARRAGE WORKS, Nile.

EGYPT: A. D. 1898-1901.
BARRIOS, President: Assassination.

CENTRAL AMERICA (GUATEMALA): A. D. 1897-1898.
BARTON, Miss Clara, and the Red Cross Society.

Relief work in Armenia and Cuba.

ARMENIA: A. D. 1896 (JANUARY-MARCH);
and CUBA: A. D. 1896-1897.
BASHEE,
BACHI ISLANDS, The American acquisition of.

UNITED STATES OF AMERICA: A. D. 1898 (JULY-DECEMBER).
BECHUANALAND, British:
Annexation to Cape Colony.

AFRICA: A. D. 1895 (CAPE COLONY).
BECHUANALAND, British:
Partial conveyance to the British South Africa Company.

AFRICA: A. D. 1895 (BECHUANALAND).
BEEF INVESTIGATION, The American Army.

UNITED STATES OF AMERICA: A. D. 1898-1899.
BEET SUGAR.

GERMANY: A. D. 1896 (MAY);
and SUGAR BOUNTIES.
BEHRING SEA.

BERING SEA.
BÊL, Temple of:

Exploration of its ruins at Nippur.
ARCHÆOLOGICAL RESEARCH: BABYLONIA: AMERICAN
EXPLORATION.
BELGIAN ANTARCTIC EXPEDITION.

POLAR EXPLORATION, 1897-1899.
{50}
BELGIUM: A. D. 1894-1895.
The first election under the new constitution.
Victory of the Catholics and surprising Socialist gains.
Elsewhere in this work the full text of the Belgian

constitution as it was revised in 1893;
See in volume 1
CONSTITUTION OF BELGIUM).
The peculiar features of the new constitution, especially in

its provision of a system of cumulative or plural voting, are
described.
See in volume 3
NETHERLANDS (BELGIUM): A. D. 1892-1893)
The singularity of the experiment thus introduced caused the

elections that were held in Belgium in 1894 and 1895 to be
watched with an interest widely felt. Elections for the
Chamber of Representatives and the Senate occurred on the same
day, October 14, 1894. Previously the Belgian suffrage had
been limited to about 130,000 electors. Under the new
constitution the electors numbered no less than 1,370,000, and
the working of the plural system gave them 2, 111,000 votes.

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Rhinoplasty in Practice An Algorithmic

Approach to Modern Surgical

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Videos are available on the Companion Website: www.routledge.com/cw/tas

1.4 Functional Evaluation

second observation provides numerous advantages; the patient

Name and Surname:

2. How often do you visit a hairdresser?

Although many incisions have been presented in the litera-

• The incision can be repaired by primary suturing

Therefore, before choosing the open technique, the irrevers-

2.2 Stages of the Closed Atraumatic Technique

2.2.1 Local Injection

FIGURE 2.4 Divisions of trigeminal nerve.

Due to the septum’s rich blood supply, tachycardia and

Fundamental Closed Atraumatic Rhinoplasty Incisions

1. Inferior intracartilaginous incision

FIGURE 2.7 Classic rhinoplasty incisions.

FIGURE 2.9 The framework of the nose.

Classic Rhinoplasty Incisions (Figure 2.7)

2.2.3 Dissection Plane

FIGURE 2.13 The bloodless surgical plane created by the subperichon-

plane is the most bloodless surgical plane that can be achieved

FIGURE 2.15 The DUAL dissection plane described by the author is

2.2.3.1 Room Concept

(b) • For the submembranous dissection plane:

• For subSMAS dissection plane:

FIGURE 2.16 The transition zone described by the author is schema-

The upper room is separated from the middle room by the

FIGURE 2.29 SubSMAS dissection meets with the subperiosteal dis-

bones, the dissection switches itself under the periosteum of

FIGURE 2.28 In this histological study of the author, it is clearly

Important Note: When dissecting the dorsum completely in

• With respect to the thickness of the nasal bones, they

2.2.6 Reconstruction 2.2.7 Structure

FIGURE 2.37a Exposure of the lower lateral cartilages, while com-

FIGURE 2.35 As a result of component excision from cartilage dor-

2.2.8 Redraping and Closure

FIGURE 2.39 (a, b) In a patient who underwent rhinoplasty with

FIGURE 2.42 (Continued)

TABLE 2.2 Rhinoplasty Society), ISAPS (International Society of

FIGURE 3.1 The correction of a severely crooked nose with asymmet-

closed with the lower concha lateralization, the tear drainage

The Following Should Be Done in These Cases

1. The eye should immediately be covered with a strip

If the nasolacrimal duct is damaged, or if there was already

3.1.1.3 Airway Problems

If power instruments are not available, TAŞ3® can be used

FIGURE 3.6 (a) The historical categorization of dorsum surgery.

and proposed closed roof techniques, popularizing the push

3.4.1.2 Composite Hump Removal