Plastic surgery

PART V

AESTHETIC SURGERY

CHAPTER 48  RHINOPLASTY

JEFFREY E. JANIS, JAMIL AHMAD, AND ROD J. ROHRICH

INTRODUCTION

Rhinoplasty is challenging. Over the past 20 years, the trend has shifted from ablative techniques involving reduction or division of the osseocartilaginous framework to techniques that conserve native anatomy. Cartilage sparing suture techniques and augmentation of deficient areas to correct contour deformities and restore structural support are commonly employed.1 The rhinoplasty surgeon must understand the underlying anatomy and have the ability to perform nasofacial analysis to determine the operative plan and the training to execute techniques that manipulate bone, cartilage, and soft tissue. These skills are augmented by an aesthetic eye in order to produce a result that blends harmoniously with the rest of the face.

NASAL ANATOMY

The nose consists of external skin and soft tissue, underlying osseocartilaginous framework, and ligamentous support. Familiarity with the native morphology and potential variations of each structure is essential. Furthermore, the dynamic interplay between these components must be appreciated.

Skin

The nasal skin is not uniform; its thickness, mobility, and sebaceous character vary along the length of the nose.2 The skin of the upper two-thirds is thinner, averaging 1,300 µm versus the lower one-third, which averages 2,400 µm.3 The upper two-thirds is also more mobile and less sebaceous than the skin of the nasal tip. It is important to note that a straight dorsum is actually produced by the underlying convexity in the osseocartilaginous framework combined with the aforementioned variation in dorsal skin thickness.

Skin character also varies between ethnic subpopulations.4-6 Even minor alterations of the underlying framework will be visible through thin skin, whereas thicker skin will tend to obscure the underlying details and require more aggressive manipulation in order to achieve the desired result.

Muscle

While there are several muscles in the nose, two muscles are particularly important in rhinoplasty—the levator labii alaeque nasi and the depressor septi nasi. The levator labii alaeque nasi assists in maintaining the patency of the external nasal valve, while the depressor septi nasi acts to shorten the upper lip and decrease tip projection.

The effects of an overactive depressor septi must be appreciated as part of the preoperative nasofacial analysis and can be recognized by a depressed nasal tip and shortened upper lip upon animation (especially when smiling). In the subgroup of patients in which this muscle significantly alters the nasal appearance, a dissection and transposition of this muscle can be performed.7

Blood Supply

The blood supply to the nose is derived both from branches of the ophthalmic artery and from branches of the facial artery (Figure 48.1). Columellar branches are present in 68.2% of patients.8-10 These branches are transected in the open approach by the transcolumellar incision. This leaves the lateral nasal and dorsal nasal arteries as the remaining blood supply to the tip if the open approach is used. To that end, extended alar resections are avoided, as the lateral nasal artery is found 2 to 3 mm above the alar groove. Furthermore, extensive debulking of the nasal tip is avoided as the subdermal plexus may be injured leading to skin necrosis.

The veins and lymphatics lie in a subcutaneous plane, which is superficial to the musculoaponeurotic layer in which the arteries travel. In the open approach, the dissection is performed in the submusculoaponeurotic plane just above the perichondrium in order to avoid injury to all of these structures. In this way, both bleeding and postoperative edema are minimized.

Osseocartilaginous Framework

The osseocartilaginous nasal framework is comprised of three separate vaults: the bony vault, the upper cartilaginous vault, and the lower cartilaginous vault. The bony vault is made up of the paired nasal bones and the frontal processes of the maxilla, which constitute the upper third to half of the nose. The thickness of the bones varies, with the thickest portion just above the level of the canthus. As a result, osteotomies are rarely indicated above this level.

The upper cartilaginous framework, or midvault, is comprised of the paired upper lateral cartilages (ULCs) and dorsal cartilaginous septum. It begins at the “keystone” area, where the nasal bones overlap the ULCs. Normally, this is the widest part of the dorsum and resembles a “T” shape in cross section (Figures 48.2A and B).

FIGURE 48.1. Blood supply to the nose.

FIGURE 48.2. A. Upper cartilaginous framework. B. Note the “keystone area” where the nasal bones overlap the upper lateral cartilages and the “scroll area” where the lower lateral cartilages overlap the upper lateral cartilages.

The inverted V deformity and/or disruption of the dorsal aesthetic lines may occur if the midvault area is overresected during the dorsal hump reduction. A component dorsal hump reduction is advised to avoid these complications.

The lower cartilaginous framework is composed of the medial, middle, and lateral crura and begins where the lower lateral cartilages (LLCs) overlap the ULCs in what is called the “scroll” area. The tip cartilages are connected to each other, the ULCs, and the septum by fibrous tissue and ligaments (Figure 48.3). Disruption of these ligaments during rhinoplasty can result in diminished tip projection, requiring additional maneuvers to maintain or increase tip support.

Nasal Function

The functions of the nose, specifically respiration, humidification, filtration, temperature regulation, and protection, are regulated by the septum, turbinates, and nasal valves (internal and external).11

The constituents of the septum include the septal cartilage, the perpendicular plate of the ethmoid bone, the nasal crest of the maxilla, and the vomer (Figure 48.4). Laminar airflow is altered by septal deformities and can lead to secondary turbinate hypertrophy.12-15 It is paramount to analyze and address all portions of the septum when attempting to correct septal deformities. Furthermore, it should be noted that the cribriform plate is contiguous with the perpendicular plate of the ethmoid, necessitating care when performing a resection of this structure to avoid potential severe consequences, such as anosmia, cerebrospinal fluid rhinorrhea, or ascending infection/meningitis.

FIGURE 48.3. Ligamentous support of the cartilaginous framework.

FIGURE 48.4. Anatomy of the nasal septum.

The turbinates are mucosa-lined bony extensions of the lateral nasal walls. This mucosa undergoes cyclical expansion and contraction mediated by the autonomic nervous system. The function of the turbinates is to assist in the transport of air during respiration and to condition/humidify inspired and expired air. The inferior turbinate, especially its most anterior portion, has the greatest impact on airway resistance, providing up to two-thirds of the total airway resistance.11 Turbinate pathology is frequently addressed via submucosal resection and/or outfracture techniques.16,17 However, overresection can lead to adverse effects on regulatory and physiologic functions, causing crust formation, bleeding, and nasal cilia dysfunction.

The internal nasal valve is the angle formed by the junction of the nasal septum and the caudal margin of the ULC and is usually 10° to 15° (Figure 48.5). It can be responsible for up to 50% of the total airway resistance and is the narrowest segment of the nasal airway.11 Occasionally, the head (anterior-most portion) of the inferior turbinate can be hypertrophied enough to cause further diminution of the cross-sectional area of this region. A positive Cottle’s sign (lateral traction on the cheek leading to increased airflow) signals collapse of the nasal valves and may indicate the need for spreader grafts to increase the valve angle and stent the airway open.

The external nasal valve is caudal to the internal valve and is the vestibule that serves as the entrance to the nose. This valve may be obstructed by extrinsic factors, such as foreign bodies, or intrinsic factors, such as weak or collapsed LLCs, loss of vestibular skin, or cicatricial narrowing. There are many options to correct these problems, including cartilage grafting (e.g., alar contour grafts,18 alar batten grafts,19 or lateral crural strut grafts20) or flaps (e.g., lower lateral crural turnover flap21), soft-tissue grafting (e.g., mucosal, skin, or composite grafts), lysis of adhesions/synechiae, or scar revision.

FIGURE 48.5. Internal nasal valve.

PREOPERATIVE ASSESSMENT

The Initial Consultation

The patient’s concerns and levels of expectation must be assessed prior to any operative intervention. “Danger signs” have been described that may indicate that the patient has underlying psychological issues (Figure 48.6).22-24 Patients that fit these criteria are approached with caution, as surgical intervention may not be in either the patient’s or the surgeon’s best interest.

Patients are appropriate surgical candidates if their concern is proportionate to the degree of their deformity (green area; Figure 48.7). However, there are some patients with a degree of concern that is disproportionate to their deformity (red area). These patients frequently have unrealistic expectations that cannot be met regardless of the aesthetic improvement. It is best to avoid operating on these patients. Furthermore, regardless of the degree of deformity, if the skill level and expertise required to perform the rhinoplasty exceeds one’s ability, that patient should be referred to another surgeon who possesses the required proficiency.

Computer imaging has proven to be a useful tool to provide the patient with a visual understanding of the anticipated outcome, although the images are not meant to guarantee surgical results.25,26These images, combined with standardized anterior, oblique, lateral, and basal photographs, serve as helpful adjuncts in the planning of the operation.

Nasofacial Analysis

Accurate, systematic, and thorough nasofacial analysis is performed to determine the subsequent operative plan. The nose must be examined not only in isolation but also in the context of the whole face so that the procedure preserves the overall facial balance and harmony. It is also necessary to evaluate the patient preoperatively for any natural facial asymmetries so that the patient gains a better understanding of exactly what was present before any operative intervention.

FIGURE 48.6. “Danger signs” that may indicate the patient has underlying psychological issues.

FIGURE 48.7. “GorneyGram” comparing patient concern with the actual degree of deformity.

The skin type, thickness, and texture are evaluated. As mentioned, thicker, more sebaceous skin will require more aggressive modification of the underlying osseocartilaginous framework as changes tend to be camouflaged. Thinner skin will tend to show even minor changes.

The nasofacial analysis then proceeds in a systematic, methodical fashion (Table 48.1).1 Below are some of the routine relationships and proportions that are used when analyzing the rhinoplasty patient. While derived from Caucasian females, they can be modified depending on the ethnicity and gender of the patient.4-6,27,28 It is important to remember that these proportions are only general guidelines. Each nose is individualized to the patient in order to achieve optimal nasofacial balance and harmony.

1.  The face is divided into thirds using horizontal lines tangent to the hairline, brow (at the level of the supraorbital notch), nasal base, and chin (menton). The upper third (between the hairline and the brow) is the most variable, as it depends on the hairline and hairstyle, and therefore is the least important. The middle third lies between the brow and the nasal base. The lower third of the face can be subdivided into thirds by visualizing a horizontal line between the oral commissures (stomion). The upper third of this subdivision lies between the nasal base and the oral commissures and the lower two-thirds between the commissures and the menton (Figure 48.8). Deviation from these proportions may signal an underlying craniofacial anomaly, such as vertical maxillary excess or maxillary hypoplasia, that may need to be addressed prior to rhinoplasty (Chapter 25).

2.  The nasal length (radix-to-tip, or R-T) should be equivalent to the stomion-to-menton distance (S-M) (Figure 48.9).

3.  The lip–chin relationship is assessed by dropping a vertical line from a point one-half the ideal nasal length tangent to the vermillion of the upper lip. The lower lip should lie approximately 2 mm behind this line. The ideal chin position varies with gender, with the chin lying slightly posterior to the lower lip in women, but equal to the lower lip in men. Orthodontics, a chin implant, or orthognathic surgery may be necessary to improve overall facial harmony if there is a discrepancy in these relationships (Figure 48.10).

4.  The nose itself is addressed from the anteroposterior view. A vertical line is drawn from the midglabellar area to the menton, bisecting the nasal ridge, upper lip, Cupid’s bow, and central incisors (if the patient has normal occlusion). Any nasal deviation from this line is likely to require septal surgery (Figure 48.11).

5.  The curvilinear dorsal aesthetic lines are traced from their origin at the supraorbital ridges toward their convergence at the level of the medial canthal ligaments. From here, they flare slightly at the keystone area and then track down to the tip-defining points, slightly diverging from each other along the dorsum during their course. The ideal width of the dorsal aesthetic lines should be approximately equivalent to the width between the tip-defining points or the interphiltral distance (Figure 48.12).

6.  The normal alar base width is equivalent to the intercanthal distance, or the transverse dimension from the medial to lateral canthus. If the alar base width is greater than the intercanthal distance, the underlying etiology is examined. If the discrepancy is the result of a narrow intercanthal distance, it is better to maintain a slightly wider alar base. If there is true increased interalar width, a nostril sill resection may be indicated. If the increase in width is secondary to alar flaring (greater than 2 to 3 mm outside the alar base), an alar base resection should be considered. The bony base should equal approximately 80% of the alar base width (Figures 48.13A and B). If the bony base is greater than 80% of the alar base width, osteotomies may be required. Over-narrowing the dorsum should be avoided in males as this can lead to an “over-feminized” look.

FIGURE 48.8. The face is divided into thirds, using horizontal lines tangent to the hairline, brow, nasal base, and chin.

7.  The alar rims are examined for symmetry. They should normally flare slightly outward in an inferolateral direction (Figure 48.14).

8.  The tip is assessed by drawing two equilateral triangles with their bases opposed (Figure 48.15). The supratip break, tip-defining points, and columellar-lobular angle serve as landmarks. If these triangles are asymmetric, the patient will likely require tip modification.

9.  The final assessment on frontal view is of the outline of the alar rims and the columella. Normally, this outline should resemble a seagull in gentle flight. If the angles are too steep, the patient likely has an increased infratip lobular height. Conversely, if the angle/curve is too flattened, it is likely the patient has decreased columellar show, which may require columellar and/or alar rim modification (Figure 48.16).

FIGURE 48.9. The ideal nasal length is equivalent to the stomion- to-menton distance. A, ala; M, menton; R, radix; S, stoma; T, tip.

FIGURE 48.10. The ideal lower lip position is 2 mm behind a vertical line dropped from a point half the ideal nasal length along the natural horizontal facial plane.

10.  The basal view of the nose is examined focusing on the outline of the nasal base and the nostrils themselves. The outline of the nasal base should describe an equilateral triangle with a lobule-to-nostril ratio of 1:2 (Figure 48.17). The nostril itself should have a teardrop geometry, with the long axis oriented in a slight medial direction (from base to apex).

FIGURE 48.11. Symmetry is determined by drawing a vertical line from the midglabellar area to the menton.

FIGURE 48.12. The curvilinear dorsal aesthetic lines extend from the supraorbital ridges to the tip-defining points.

FIGURE 48.13. A. The normal alar base width equals the intercanthal distance, or the width of one eye. B. The bony base should be approximately 80% of the alar base width.

11.  Attention is turned to the lateral view, beginning with analysis of the nasofrontal angle. This angle connects the brow and nasal dorsum through a soft concave curve. The apex of this angle (radix) should lie between the supratarsal fold and the upper lid lashes, with the eyes in primary gaze. The nasofrontal angle can vary between 128° and 140°, but is ideally approximately 134° in females and 130° in males.

12.  It is important to note that the perceived nasal length and tip projection can be altered by the position of the nasofrontal angle. For instance, the nose appears longer if the nasofrontal angle is positioned more anteriorly and superiorly than normal. In this instance, the nasofacial angle (as defined by the junction of the nasal dorsum with the vertical facial plane) is decreased and the tip projection will appear diminished (yellow line). Conversely, the nose can appear shorter if the nasofrontal angle is positioned too posteriorly and/or inferiorly. In this case, the tip may also appear more projecting (red line; Figure 48.18). Ideally, the nasofacial angle should measure 32° to 37°.

13.  While still analyzing the lateral view, tip projection is addressed. This can be done in two ways. The first is to draw a horizontal line from the alar-cheek junction to the tip of the nose. The distance between these points should equal two things: (1) the alar base width, and (2) 0.67 × R-T (radix-to-tip) (Figures 48.19A and B). The second way to assess tip projection is to examine how much of the tip lies anterior to a vertical line tangent to the most projecting part of the upper lip vermillion. If 50% to 60% of the tip lies anterior to this line, projection is considered normal. If the tip projection is outside of these proportions, it likely will require tip modification (Figure 48.20).

FIGURE 48.14. The alar rims should flare outward inferolaterally.

14.  The dorsum is analyzed by drawing a line from the radix to the tip-defining points. In women, the ideal aesthetic nasal dorsum should lie approximately 2 mm behind and parallel to this line, but in men, it should approach this line to avoid feminizing the nose (Figure 48.21).

15.  The degree of supratip break is also evaluated on the lateral view. This break helps to define the nose and separate the tip from the dorsum. A slight supratip break is preferred in women but not in men.

16.  The degree of tip rotation is assessed by evaluating the nasolabial angle, which is the angle formed between a line coursing through the most anterior and posterior edges of the nostril and a plumb line dropped perpendicular to the natural horizontal facial plane (Figure 48.22). This angle is usually 95° to 100° in women and between 90° and 95° in men.

17.  The nasolabial angle is often confused with the columellar-lobular angle, which is formed at the junction of the columella with the infratip lobule (Figure 48.23). This angle is normally 30° to 45°. A prominent caudal septum can cause increased fullness in this area, which can give the illusion of increased rotation, despite a normal nasolabial angle.

FIGURE 48.15. Tip assessment is performed by analyzing two equilateral triangles with opposing bases.

FIGURE 48.16. The outline of the alar rims and columella should resemble a “seagull in gentle flight.”

FIGURE 48.17. The outline of the nasal base should resemble an equilateral triangle with a lobule-to-nostril ratio of 1:2.

18. The alar-columellar relationship is assessed by drawing a line through the long axis of the nostril and a second, perpendicular line drawn from the alar rim to the columellar rim that bisects this axis. If the alar-columellar relationship is normal, the distance from the alar rim (“point A”) to the long axis line (“point B”) should equal the distance between the long axis line and the columellar rim (“point C”) (AB = BC ≈ 2 mm) (Figure 48.24). If abnormal, the deformity can be stratified into six classes.29 Classes I to III describe increased columellar show, while classes IV to VI demonstrate decreased columellar show. The treatment of the discrepancy varies by class.

FIGURE 48.18. Perceived nasal length and tip projection can be altered by the position of the nasofrontal angle. A posteriorly and inferiorly positioned nasofrontal angle can make the nose appear shorter with increased tip projection (red). An anteriorly and superiorly positioned nasofrontal angle can make the nose appear longer with diminished tip projection (yellow).

FIGURE 48.19. A. Tip projection should equal alar base width. B. Tip projection should also equal 0.67 × R-T (radix-to-tip).

FIGURE 48.20. About 50% to 60% of the tip should lie anterior to a vertical line tangent to the most projecting part of the upper lip vermillion.

FIGURE 48.21. The dorsum is analyzed by drawing a line from the radix to the tip-defining points.

FIGURE 48.22. The nasolabial angle is usually 95° to 100° in females and 90° to 95° in males.

The final critical part of the preoperative analysis is the intranasal exam, which is performed with a nasal speculum, headlight, and vasoconstriction. Deformities or abnormalities of the septum, turbinates, and internal nasal valve are evaluated. If turbinate hypertrophy is identified, the underlying etiology should be investigated and a detailed history taken, as the enlargement may be either congenital or acquired. If acquired, it may be the result of autonomic, environmental, medical, or anatomic factors (Table 48.2).

FIGURE 48.23. The columellar-labial angle is normally 30° to 45°.

FIGURE 48.24. The alar-columellar relationship is assessed by drawing two perpendicular lines—one through the long axis of the nostril (B) and the other from the alar rim to the columellar rim (AC).

OPERATIVE TECHNIQUE

Type of Approach

There are two schools of modern rhinoplasty—those who prefer the open approach and those who prefer the closed one.30-36 While both approaches have their advantages and disadvantages, it is important to be familiar with both (Tables 48.3 and 48.4). The experienced surgeon will tailor the approach to the patient’s anatomic deformity. Regardless of the approach, however, the modifications made to the underlying framework are more important than which incision is used.

Many experienced surgeons prefer the open approach because it provides better exposure of the nasal framework resulting in an accurate diagnosis of all the potential causes of either the nasal airway obstruction or the etiology of the cosmetic deformity. Furthermore, precise manipulation of the various structures can be performed and the dynamic interplay between these structures appreciated, leading to reproducible results. The open approach is particularly advantageous in the following circumstances: (1) posttraumatic deformities, where complete release of all intrinsic and extrinsic deforming forces is necessary, (2) revisional surgery, and (3) when complex tip modifications are necessary.

The endonasal approach lends itself well to patients who have an isolated dorsal hump deformity or where there is minimal change needed to modify the tip structure. In these instances, a marginal incision is useful. In cases requiring minor tip refinement, an intercartilaginous incision allows for adequate cartilage delivery and exposure. A hemitransfixion or transfixion incision is used if the caudal septum requires repositioning.

Anesthesia/Preoperative Preparation

Rhinoplasty can be performed with either local anesthesia with IV sedation or general anesthesia. After induction, the nasal vestibules are prepared by clipping the nasal vibrissae and swabbing the entire nostril with Betadine solution. Before injecting local anesthetic, the incision is marked (transcolumellar stair-step, if using an open approach) so as not to distort the anatomy. Approximately 10 mL of 1% Lidocaine with 1:100,000 epinephrine is injected into the intranasal mucosa, along the septum, and into soft-tissue envelope. Additional local anesthetic is used on the inferior turbinates when an inferior turbinoplasty is anticipated.

After injection, cottonoid pledgets soaked with a local vasoconstrictor solution are inserted to shrink the nasal mucosa, facilitate exposure, and minimize blood loss. Oxymetazoline or 4% cocaine may be used to provide vasoconstriction; however, cocaine has the risk of myocardial infarction (Chapter 12).37,38 A throat pack is carefully placed in the posterior oropharynx to prevent aspiration or swallowing of blood. The patient is prepped and draped for surgery.

FIGURE 48.25. Intercartilaginous and marginal incisions for cartilage delivery during endonasal rhinoplasty.

Incision—Endonasal Approach

There are two basic endonasal techniques, nondelivery and delivery. The nondelivery approach is performed using either a cartilage-splitting (transcartilaginous) incision or an eversion (retrograde) incision. The transcartilaginous incision is made by incising several millimeters cephalad to the caudal margin of the lateral crura. This preserves a rim strip to support the ala. Exposure is facilitated by double hook retraction combined with digital alar eversion. The cephalic portion of the cartilage is then exposed for resection by dissecting the vestibular skin off it. In the eversion approach, rather than going through the cartilage, the vestibular incision is made at the cephalic-most margin of the LLC. The cephalic portion of the cartilage is exposed and resected. The theoretical advantage to this incision is that it maintains the caudal alar margins and prevents potential scar contracture deformities in this area.

The delivery approach is used in cases where moderately complex tip modifications are necessary. This is especially true in cases where there is significant tip bifidity. The cartilaginous margins are delineated with double hook retraction in the ala and digital counterpressure, and a #15 blade scalpel is used to create an intercartilaginous incision starting just above the cephalic margin of the lateral crus. Subsequently, a marginal incision is created along the caudal margin of the LLC, from lateral crus to medial crus, ending at the columellar-lobular junction (Figure 48.25). The soft tissue is then dissected off of the cartilage in a plane just above the perichondrium, including over the dorsal cartilaginous septum. The same procedure is repeated on the contralateral side, and the two incisions are connected in the midline over the anterior septal angle, ending in a hemitransfixion incision. This can be extended to a full transfixion incision, if indicated. The LLC is then dissected free from the surrounding tissues and delivered outside the incision. The incisions may be extended and the soft tissue undermined more aggressively if there is difficulty delivering the cartilages. Modifications are made once the cartilages and domes are delivered.

Incision—Open Approach

A transcolumellar stair-step incision across the narrowest portion of the columella is generally preferred. The advantages of the stair-step incision include the provision of landmarks for accurate closure, the prevention of linear scar contracture, and a camouflaged scar.

Infracartilaginous extensions are then performed bilaterally, beginning from lateral to medial along the caudal border of the LLC. These incisions meet the transcolumellar incision to complete the approach. Exposure during this dissection is facilitated by double hook alar eversion and digital counterpressure.

It is important that the surgeon not be in a rush during this portion of the procedure, as most mistakes are made trying to obtain exposure. Furthermore, the incisions should be kept superficial and the caudal border of the LLC should be identified prior to cutting to prevent injury to the underlying cartilages. Injuries to the domes are not uncommon and are difficult to repair.

Skin Envelope Dissection

Extreme care is taken during the exposure of the nasal framework so as not to injure the cartilages. The dissection should be carried out immediately on the surface of the tip cartilage. If performed properly, there should be no residual soft tissue remaining on the LLCs. This dissection is continued superiorly to expose the cartilaginous dorsum and ULCs until the bony pyramid is encountered. At this point, a limited subperiosteal dissection is performed over the area of the bony dorsal hump that needs to be addressed. Care is taken to avoid disruption of all of the periosteal attachments to the nasal bones, as this can destabilize the area and lead to prolonged wound healing and potential nasal bone malposition. Care is also taken to assure that the ULCs are not detached from the nasal bones by accidental dissection under the nasal bones.

Nasal Dorsum

The nasal dorsum can be reduced as a composite or a component dorsal hump reduction can be performed.Component dorsal hump reduction has the advantage of incremental control and greater precision.39 It is performed using five essential steps:

(1)  Separation of the ULC from the septum:

The component dorsal hump reduction technique begins with the creation of bilateral superior submucoperichondrial tunnels in order to minimize mucosal trauma, resulting in potential internal nasal valve stenosis or vestibular webbing. This is done by elevating the mucoperichondrium of the dorsal septum in a caudocephalad direction with a Cottle elevator until the nasal bones are reached. The transverse processes of the ULCs are then sharply separated from the septum using a #15 blade scalpel (without damaging the mucosa).

(2)  Incremental reduction of the septum proper:

The cartilaginous dorsal septum is separated into three components—the septum centrally and the transverse portions of the ULC laterally. The cartilaginous dorsum is then reduced in an incremental fashion by resecting the dorsal hump deformity with either a sharp scalpel or scissors in serial fashion. In some cases, the resected dorsal septum can be used as a columellar strut graft.40 Reduction of the cartilaginous dorsum is performed under direct vision. Care is taken to avoid damage to the adjacent ULCs. In rare cases, the ULCs may require resection, although this is not routine in our practice. If required, it must be performed cautiously, as overresection of the ULCs will cause internal nasal valve collapse and long-term dorsal irregularity. Maintaining the transverse portions of the ULC also preserves the dorsal aesthetic lines. If the septum and ULCs were taken down en bloc (not in component fashion), a rounded dorsum would result. Furthermore, an inverted V deformity could result if the ULCs were resected to a greater extent than the septum.

(3)  Incremental dorsal bony reduction:

Large humps (generally >5 mm) are reduced by either a power burr with a dorsal skin protector or a guarded 8-mm osteotome. Smaller humps can be addressed with a sharp rasp (e.g., a down-biting diamond rasp). The rasping is done in a controlled, methodical fashion, proceeding along the left and right dorsal aesthetic lines, and then centrally using the nondominant thumb and index finger for maximal control. It is important to maintain a slightly oblique bias when rasping in order to prevent mechanical avulsion of the ULCs from the nasal bones.

(4)  Verification by palpation:

The three-point dorsal palpation test, performed with a saline-moistened dominant index fingertip, is used to gently palpate the left and right dorsal aesthetic lines, as well as centrally, in order to ascertain if there are any residual dorsal irregularities or contour depressions. This maneuver is performed repeatedly throughout this process (after redraping the skin envelope).

(5)  Final modifications, if indicated (spreader grafts, suturing techniques, osteotomies).

Septal Reconstruction/Cartilage Graft Harvest

The septum is harvested if there is a septal deformity or if cartilage is needed for grafting. Septal cartilage is ideal for graft material because of its minimal donor site morbidity and close geographic proximity to the operating field.

A Killian or hemitransfixion incision is generally used when employing the endonasal approach. A complete transfixion incision can lead to decreased tip projection, especially if dissection is carried down over the anterior nasal spine.

In the open approach, the anterior septal angle is exposed by separating the middle crura and incising the interdomal suspensory ligament. The septal mucoperichondrium is incised with a #15 blade scalpel exposing the distinctive bluish-gray underlying cartilage. A Cottle elevator is then used to carry the dissection in a submucoperichondrial plane posteriorly to the perpendicular plate of the ethmoid down to the nasal floor and across the face of the septum. This submucoperichondrial dissection should proceed almost effortlessly if performed in the correct plane. Dissection in the correct plane is also almost bloodless. The dissection should proceed with caution, however, at the junction of the cartilaginous and bony septum, as the overlying mucoperichondrium is more adherent, and mucosal perforation is more likely. The identical dissection is performed on the contralateral side, and the entire septum is examined using a Vienna speculum in order to identify deformities and to help achieve exposure for the septal harvest.

When resecting septal cartilage, it is important to maintain the stability of the cartilaginous framework by preserving an L-strut with 10 mm of dorsal septum and 10 mm of caudal septum.The harvested cartilage should be preserved in saline to prevent desiccation. Residual deviations in the ethmoid or vomer are resected and any mucosal perforations are repaired.

Correction of the Deviated Nose

Septal deviation may manifest itself as external deviation of the nose. The deviated nose is classified into three basic types: caudal septal deviations, concave dorsal deformities, and concave/convex dorsal deformities (Table 48.5).41

Correction of the deviated nose is based on the following principles:

1.  The open approach to expose all deviated structures

2.  Release of all mucoperichondrial attachments to the septum, especially the deviated part

3.  Straightening of the entire septum while maintaining a 10 mm caudal and dorsal L-strut

4.  Restoration of long-term support with buttressing caudal septal batten or dorsal spreader grafts

5.  Outfracture or submucous resection of hypertrophied anteroinferior turbinates, if necessary, for correction of the deviated septum

6.  Precisely planned and executed external percutaneous osteotomies

Inferior Turbinoplasty

An inferior turbinoplasty is performed in those patients with inferior turbinate hypertrophy causing symptomatic nasal airway obstruction.11,16,17 In most cases, outfracture of the inferior turbinate is adequate. With more significant inferior turbinate hypertrophy, submucous morselization of the turbinate bone and submucous resection of the anterior one-third to one-half of the inferior turbinate may be required. Submucous resection technique begins with the development of medial mucoperiosteal flaps, which exposes the conchal bone. The anterior portion of the conchal bone is resected, while the posterior portion is preserved to avoid bleeding complications. The flaps are replaced after this resection without the need for suture repair.

Cephalic Trim

Indications for a cephalic trim of the LLCs include the need for tip rotation, medialization of the tip-defining points, and/or the tip requiring better refinement and definition as in the case of the boxy or bulbous tip.42-44 A caliper is used to measure a 6 mm rim strip of the caudal margin of the LLC that is to be preserved. Subsequently, the cephalic portion of the middle and lateral crura is resected and preserved for possible use as a graft later in the case.

Lower Lateral Crural Turnover Flap

A lower lateral crural turnover flap is a useful technique to address paradomal fullness while providing additional support to the LLCs (Figure 48.26).21 It is beneficial for deformities, weakness, and collapse of the lower lateral crura and can also be used to improve lower lateral crural strength during tip reshaping.

Spreader Grafts and Autospreader Flaps

Spreader grafts are extraordinarily versatile and can be used to help stent open the internal valve, to stabilize the septum, and to preserve or enhance the dorsal aesthetic lines (Figure 48.27).45,46 These grafts, usually obtained from septal cartilage, are fashioned to measure approximately 25 to 30 mm by 3 mm. They can also be made longer and placed in such a way as to project past the anterior septal angle, effectively lengthening the nose. They can also be positioned more anteriorly (i.e., visible) along the septum in order to recreate stronger dorsal aesthetic lines or can be positioned lower (i.e., invisible) for septal support or internal valve stenting. The grafts are secured with 5-0 PDS in a horizontal mattress fashion.

FIGURE 48.26. Lower lateral crural turnover flap.

Autospreader flaps are an alternative when there is ULC excess after reduction of the dorsal septum.47 The transverse portion of the ULCs is rotated medially to function as a local spreader flap while reducing the profile of the dorsum and preserving the dorsal aesthetic lines. This surgical technique adjusts the height of the ULCs in a precise and safe manner while preserving the function of the internal valve.

Tip Refinement

Successful tip refinement and projection depends on (1) proper preoperative analysis of the deformity; (2) a fundamental understanding of the intricate and dynamic relationships between tip-supporting structures that contribute to nasal tip shape and projection; and (3) execution of the operative plan using controlled, nondestructive, and predictable surgical techniques.

Altering Tip Projection. Tip projection is affected by48:

1.  Length, width, and strength of the LLCs

2.  Length and stability of the medial crura

3.  Suspensory ligament that spans the crura over the anterior septal angle

FIGURE 48.27. Spreader grafts can be used to stent open the internal nasal valve, stabilize the septum, or preserve or enhance the dorsal aesthetic lines.

4.  Fibrous connections between ULCs and LLCs

5.  Abutment with the pyriform aperture

6.  Anterior septal angle

7.  Skin and soft-tissue thickness and availability

Alteration of any of these anatomic structures can result in incremental changes in tip projection. An algorithmic approach to tip refinement includes the use of cephalic trim, nasal tip suture techniques, and cartilage grafting (Figure 48.28).

Nasal Tip Sutures. Nasal tip suture techniques can reliably produce an increase of 1 to 2 mm of tip projection.42-44,48-53 The choice of suture material is surgeon dependent, though the underlying premise is to select a material that will hold the cartilage in its altered position long enough to allow for the natural fibrotic reaction to solidify the result.

There are four general types of techniques used to alter projection:

•  Medial crural

•  Medial crural-septal

•  Interdomal

•  Transdomal (intradomal)

Medial crural sutures can be used to unify the medial crura of the LLCs and to rectify flaring of the medial/middle crura, thereby effecting a limited increase in projection (Figure 48.29). They are also frequently used to help stabilize a columellar strut. Medial crural-septal sutures alter both projection and rotation by anchoring the medial crura to the caudal septum.

Interdomal sutures can increase both tip refinement and tip projection. They serve to narrow the interdomal distance by approximating the medial/middle crura. Sutures are placed in mattress fashion and can be tightened to a variable degree in order to achieve the desired result (Figure 48.30).

Transdomal (or intradomal) sutures can also affect both tip refinement and projection. These mattress-type sutures are placed across the dome of the middle crura after hydrodissection of the underlying mucoperichondrium from the cartilage in order to help prevent inadvertent intranasal exposure of the suture (Figure 48.31). Knots are left on the medial aspect of the dome and one end may be left long on each side, which can be used to tie the transdomal sutures together (i.e., an interdomal suture) in order to narrow the tip-defining points. It is important, however, to avoid over-tightening of this suture, which will result in an unnaturally sharp tip-defining point. They may also be placed asymmetrically in order to correct anatomic differences that may exist from side to side.

Columellar Strut Graft. The placement of a columellar strut is the second step in the algorithm for tip refinement and projection.48 Usually fashioned from septal cartilage, the strut can be placed in a “fixed” or a “floating” fashion, depending on whether or not it is secured to the anterior maxilla. Columellar struts can control columellar profile as well as support tip projection. A pocket is dissected between the medial crura and the strut is inserted. Its final position is set by gently retracting the medial crura anteriorly by a double hook and gauging the desired amount of tip projection. This configuration is temporarily stabilized with a transversely placed 25G needle and then sutured into position by medial crural sutures (described previously). Additional medial crural sutures can then be placed, if necessary, to control medial crural flaring.

FIGURE 48.28. Algorithmic approach to tip refinement.

FIGURE 48.29. Medial crural sutures can unify the medial crura and help stabilize the columellar strut. Medial crural-septal sutures anchor the medial crura to the caudal septum and can alter both projection and rotation.

Nasal Tip Grafts. Nasal tip grafts are the final step in the algorithm if more tip projection or definition is desired after the preceding maneuvers.48 These grafts may take several forms, but have a tendency to become visible in the long term regardless of the specific type used. Tip grafts are reserved for the patient in whom the prior, more predictable, methods do not result in satisfactory tip refinement and projection. There are three general types of tip grafts:

•  Onlay tip grafts

•  Infratip lobular graft

•  Combination tip graft

The onlay tip graft is usually placed over the dome of the middle crura and can be fashioned from any type of cartilage54,55; the cartilage obtained from the cephalic trim harvest (if performed) works exceptionally well (Figure 48.32).56

The infratip lobular graft is a shield-shaped graft used to increase infratip lobular definition and projection.57,58 It is positioned with its superior margin overlying the dome/tip-defining points and extends inferiorly a variable distance (usually 10 to 12 mm). It is fashioned with rounded graft edges in order to avoid a visible and palpable step-off (Figure 48.33).

FIGURE 48.30. Interdomal sutures approximate the medial/middle crura and can affect both tip refinement and projection.

FIGURE 48.31. Transdomal sutures are mattress-type sutures placed across the dome of the middle crura and can also affect tip refinement and projection. In addition, transdomal sutures with the ends left long can be tied together in an interdomal fashion.

The combination tip graft is generally used in difficult primary rhinoplasties, thick-skinned patients, and secondary rhinoplasties with inadequate tip projection. It is essentially a combination of the above-mentioned onlay tip graft and infratip lobular graft. Superiorly, it is anchored to the ULCs and inferiorly it is secured to the caudal margin of the medial crura (Figure 48.34).

A thorough understanding of the anatomic basis of tip support is also required when trying to decrease nasal tip projection. For instance, in the open approach where the skin envelope has been undermined and the fibroelastic and ligamentous attachments have been disrupted, the primary means of decreasing tip projection lies in alteration of the length and strength of the LLCs. Several techniques, such as transection, setback, and resuturing of the medial or lateral crura, may be used to obtain the desired result. However, regardless of the technique used, it is important to recognize that if the tip projection is significantly decreased, alar flaring or columellar bowing may result. This, then, would require concomitant correction.

FIGURE 48.32. The onlay tip graft is usually placed over the dome of the middle crura.

FIGURE 48.33. The infratip lobular graft overlies the dome and extends inferiorly a variable distance.

Altering Tip Rotation. In order to alter tip rotation, the existing extrinsic forces stabilizing the tip at its current position must be released. The first step is usually to perform a cephalic trim, which separates the connection between ULCs and LLCs. Another technique is to resect a variable amount of the caudal septum. This releases tension on the nasal tip and allows for more cephalad rotation by transecting the fibrous attachments of the medial crura and the caudal septum. This maneuver can also affect tip projection. After the desired amount of tip rotation has been achieved, its position is maintained with suture techniques (medial crural-septal sutures) and/or a columellar strut or septal extension graft.

It may be necessary to perform a limited resection of nasal mucosa and membranous septum in order to maintain proper nasal balance and harmony when altering the amount of tip rotation.

FIGURE 48.34. The combination tip graft combines the onlay tip graft and the infratip lobular graft.

Osteotomies

Several techniques exist in order to perform osteotomies, including medial, lateral, transverse, and a combination of the above. These can be performed via an external or internal approach.

Osteotomies are generally performed for the following reasons:

•  To narrow the lateral walls of the nose

•  To close an open roof deformity (after dorsal hump reduction)

•  To create symmetry by allowing for straightening of the nasal bony framework

Contraindications include patients with short nasal bones, elderly patients with thin, fragile nasal bones, and patients with heavy eyeglasses.59-66

Lateral osteotomies may be performed as “low-to-high,” “low-to-low,” or a “double level” (Figure 48.35). Furthermore, they may be combined with medial, transverse, or greenstick fractures of the upper bony segment. Regardless of the technique used, however, it is paramount to preserve Webster’s triangle. This bony triangular area of the caudal aspect of the maxillary frontal process is necessary for a patent airway. Preservation of this triangle prevents functional nasal airway obstruction (Figure 48.36).

A step-off deformity is prevented by maintaining a smooth fracture line low along the bony vault. The cephalic margin of the osteotomy should not be higher than the medial canthal ligament, as the thick nasal bones above this area increase the technical difficulty, and it is possible to cause iatrogenic injury to the lacrimal system with resultant epiphora.

A “low-to-high” osteotomy begins low at the pyriform aperture and ends “high” medially on the dorsum and is generally used to correct a small open roof deformity or to mobilize a moderately wide nasal base. The nasal bones are then medialized by a gentle greenstick fracture along predictable fracture patterns obtained based on nasal bone thickness.59-61 Thicker nasal bones may require a separate superior oblique osteotomy in order to mobilize them enough to be greensticked.

A “low-to-low” osteotomy starts low along the pyriform aperture and continues low along the base of the bony vault to end up in a lateral position along the dorsum near the intercanthal line. It is generally considered a more powerful technique in that it results in more significant medialization of the nasal bones and therefore is classically used when there is a large open roof deformity or if a wide bony base requires correction. This type of osteotomy technique is frequently accompanied by a medial osteotomy in order to better mobilize the nasal bones to achieve the desired result.

Medial osteotomies are used to facilitate medial positioning of the nasal bones and are generally indicated in patients with thick nasal bones or a wide bony base in order to achieve a more predictable fracture pattern. Although medial osteotomies are frequently used in combination with lateral osteotomies, it is not necessary to use both in all cases. If both techniques are performed, however, the medial osteotomy is performed first as this makes it technically easier to perform the subsequent lateral osteotomy. The cant of the medial osteotomy can be oriented in a medial oblique, paramedian, or transverse direction. Regardless of the cant, the cephalic end of the osteotomy still should not cross the intercanthal line for the reasons previously discussed. It is also important to avoid placing the medial osteotomy too far medially as this can cause a “rocker deformity,” where a widened upper dorsum results from the fractured nasal bone “kicking out.” This can be avoided by following a superior oblique angle (Figures 48.37A and B).

FIGURE 48.35. The various types of lateral osteotomies.

A “double-level” lateral osteotomy is indicated in cases where there is an excessive lateral wall convexity that is too great to be corrected with a standard single-level lateral osteotomy or when significant lateral nasal wall asymmetries exist. The more medial of the two lateral osteotomies is first created along the nasomaxillary suture line. The more lateral of the two is then created in standard low-to-low fashion (Figure 48.38).

Potential complications that can occur with osteotomies (of any type) are listed in Table 48.6.

Closure

At the conclusion of the procedure, after meticulous hemostasis has been obtained, the skin envelope is redraped. The transcolumellar incision is closed in simple interrupted fashion using 6-0 nylon suture, assuring precise reapproximation of the incision. The infracartilaginous incisions are reapproximated using 5-0 chromic gut sutures. Special care is taken to prevent overbiting with the suture, especially in the soft triangle area, as contour irregularities and notching may result.

FIGURE 48.36. Preservation of Webster triangle is paramount when performing lateral osteotomies to prevent internal nasal valve collapse.

The throat pack is removed and the oropharynx and stomach are carefully suctioned of any blood, which may result in postoperative nausea and vomiting. Antibiotic ointment–coated intranasal Doyle splints are placed if septal work has been performed, which are secured with a transseptal 3-0 nylon suture. The nasal dorsum is then carefully taped and a malleable Denver splint is applied over the dorsum. Finally, a drip pad is fashioned from a 2 × 2 gauze and secured under the nose with ½ inch paper tape.

POSTOPERATIVE MANAGEMENT

All preoperative and postoperative instructions are reviewed verbally and in writing prior to as well as on the day of surgery. The following are prescribed routinely:

1.  Medrol Dosepak for 7 days (to minimize postoperative edema)

2.  Hydrocodone/acetaminophen 5/500 for postoperative pain every 4 to 6 hours as needed

FIGURE 48.37. A. The course of a superior oblique medial osteotomy. B. “Rocker deformity” caused by placing the medial osteotomy too far medially.

FIGURE 48.38. The double-level osteotomy. The medial-most one is made first.

3.  Normal nasal saline for postoperative nasal congestion

4.  Antibacterial ointment to incisions three times daily

During the first 48 to 72 hours, the patient is instructed to keep the head of bed elevated at 45° and use a chilled gel eye mask (Swiss Eye Therapy) to help minimize postoperative swelling. The drip pad under the nose is changed as necessary until the drainage stops. Any manipulation of the nose, including rubbing, blotting, or blowing, is discouraged for the first 3 weeks postoperatively. Sneezing should be done through the mouth during this time. It is imperative to keep the nasal splint dry in order to prevent premature discontinuation of the splint. The hair should be washed with assistance in the sink.

Our preference is to keep our patients on a liquid diet on the day of surgery and then advance them to a soft regular diet the following day. Any foods that require excessive lip movements, such as eating apples or corn on the cob, should be avoided for 2 weeks after surgery.

During the first 2 weeks, nasal congestion is treated with the use of normal saline nasal spray. The patient is encouraged to breathe through the mouth if there is difficulty with air passage through the intranasal splints. Extreme congestion should be treated with office suctioning.

The sutures and nasal splints are removed at the initial visit on postoperative days 5 to 7. The nose (especially the tip) may appear swollen and turned up and the tip may feel numb, but the patient is reassured that both are expected and will resolve over several months. Normal sensation usually returns within 3 to 6 months. The patient is instructed to avoid letting anything, including eyeglasses, rest on the nose for at least 4 weeks. During this time, glasses are taped to the forehead. Contact lenses may be worn as soon as the swelling has diminished enough to allow easy insertion (usually less than 5 to 7 days postoperatively).

The patient’s activity is restricted for 3 weeks postoperatively. Any contact sports or activities that may cause direct trauma to the nose are prohibited for at least 4 to 6 weeks after surgery. Although some noses look excellent within 6 to 8 weeks, some may have persistent edema for up to 1 year. After 3 to 4 weeks, however, the swelling will generally not be obvious to anyone but the patient.

After the first postoperative visit, the patient returns for follow-up at 3 and 8 weeks after the operation and then at 3, 6, and 12 months postoperatively.

REVISION RHINOPLASTY

Revision rhinoplasty offers a unique set of challenges. Cicatricial tissue, altered or compromised vascularity, and distorted anatomy can be major factors that alter the planning and execution. The septal cartilage may have already been harvested, which creates the need for remote cartilage harvest from locations such as the ear or rib.

In a 2009 survey of board-certified plastic surgeons and otolaryngologists, the majority reported revision rhinoplasty was required in less than 10% of patients.36 The underlying etiology that drives the need for reoperation usually includes one or a combination of the following:

1.  Displaced anatomic structures

2.  Undercorrection from an overconservative primary procedure

3.  Overresection/overcorrection from overzealous surgery

In the lower third of the nose, the most frequent reasons for reoperation include further tip refinement or correction of tip asymmetries. In the middle third, a parrot beak or narrow mid vault deformity is responsible for most revisions. In the upper third, it is excessive dorsal reduction or dorsal irregularities that require revision.

From a functional point of view, persistent nasal airway obstruction from excessive narrowing of the internal valve was previously the most common reason for secondary rhinoplasty. Once we adopted the component dorsum reduction technique with preservation of the ULCs and placed spreader grafts when necessary, our incidence of internal valve obstruction decreased.

The open approach is preferred when performing revision rhinoplasty as it affords superior exposure of the underlying nasal framework, permits accurate anatomic diagnosis, and facilitates complete correction.36

References

1.  Rohrich RJ, Ahmad J. Rhinoplasty. Plast Reconstr Surg. 2011;128:49e-73e.

2.  Ha RY, Nojima K, Adams WP Jr, et al. Analysis of facial skin thickness: defining the relative thickness index. Plast Reconstr Surg. 2005;115: 1769-1773.

3.  Gonzalez-Ulloa M, Castillo A, Stevens E, et al. Preliminary study of the total restoration of the facial skin. Plast Reconstr Surg. 1954;13:151-161.

4.  Rohrich RJ, Bolden K. Ethnic rhinoplasty. Clin Plast Surg. 2010;37: 353-370.

5.  Rohrich RJ, Muzaffar AR. Rhinoplasty in the African-American patient. Plast Reconstr Surg. 2003;111:1322-1339.

6.  Rohrich RJ, Ghavami A. Rhinoplasty for Middle Eastern noses. Plast Reconstr Surg. 2009;123:1343-1354.

7.  Rohrich RJ, Huynh B, Muzaffar AR, et al. Importance of the depressor septi muscle in rhinoplasty: anatomic study and clinical application. Plast Reconstr Surg. 2000;105:376-383.

8.  Rohrich RJ, Gunter JP, Friedman RM. Nasal tip blood supply: an anatomic study validating the safety of the transcolumellar incision in rhinoplasty. Plast Reconstr Surg. 1995;95:795-799.

9.  Adams WP Jr, Rohrich RJ, Hollier LH, Minoli J, Thornton LK, Gyimesi I. Anatomic basis and clinical implications for nasal tip support in open versus closed rhinoplasty. Plast Reconstr Surg. 1999;103:255-261.

10.  Rohrich RJ, Muzaffar AR, Gunter JP. Nasal tip blood supply: confirming the safety of the transcolumellar incision in rhinoplasty. Plast Reconstr Surg. 2000;106:1640-1641.

11.  Howard BK, Rohrich RJ. Understanding the nasal airway: principles and practice. Plast Reconstr Surg. 2002;109:1128-1146.

12.  Gunter JP, Rohrich RJ. Management of the deviated nose. The importance of septal reconstruction. Clin Plast Surg. 1988;15:43-55.

13.  Guyuron B, Uzzo CD, Scull H. A practical classification of septonasal deviation and an effective guide to septal surgery. Plast Reconstr Surg. 1999;104:2202-2209.

14.  Guyuron B, Behmand RA. Caudal nasal deviation. Plast Reconstr Surg. 2003;111:2449-2457.

15.  Mowlavi A, Masouem S, Kalkanis J, Guyuron B. Septal cartilage defined: implications for nasal dynamics and rhinoplasty. Plast Reconstr Surg. 2006;117:2171-2174.

16.  Rohrich RJ, Krueger JK, Adams WP Jr, et al. Rationale for submucous resection of hypertrophied inferior turbinates in rhinoplasty: an evolution. Plast Reconstr Surg. 2001;108:536-544.

17.  Pollock RA, Rohrich RJ. Inferior turbinate surgery: an adjunct to successful treatment of nasal obstruction in 408 patients. Plast Reconstr Surg. 1984;74:227-236.

18.  Rohrich RJ, Raniere J Jr, Ha RY. The alar contour graft: correction and prevention of alar rim deformities in rhinoplasty. Plast Reconstr Surg. 2002;109:2495-2505.

19.  Toriumi DM, Josen J, Weinberger M, Tardy ME Jr. Use of alar batten grafts for correction of nasal valve collapse. Arch Otolaryngol Head Neck Surg. 1997;123:802-808.

20.  Gunter JP, Friedman RM. Lateral crural strut graft: technique and clinical applications in rhinoplasty. Plast Reconstr Surg. 1997;99:943-952.

21.  Janis JE, Trussler A, Ghavami A, Marin V, Rohrich RJ, Gunter JP. Lower lateral crural turnover flap in open rhinoplasty. Plast Reconstr Surg. 2009;123:1830-1841.

22.  Gunter JP. Rhinoplasty. In: Courtiss EH, ed. Male Aesthetic Surgery. 2nd ed. St. Louis, MO: Mosby; 1991.

23.  Gorney M. Patient selection in rhinoplasty: Practical guidelines. In: Daniel RK, ed. Aesthetic Plastic Surgery: Rhinoplasty. Boston, MA: Little Brown; 1993.

24.  Gorney M, Martello J. Patient selection criteria. Clin Plast Surg. 1999;26: 37-40, vi.

25.  Rohrich RJ, Janis JE, Kenkel JM. Male rhinoplasty. Plast Reconstr Surg. 2003;112:1071-1085.

26.  Stal SM, Klebuc M. Chapter 6: advances in computer imaging for rhinoplasty. In: Gunter JP, Rohrich RJ, Adams WP Jr, eds. Dallas Rhinoplasty. Nasal Surgery by the Masters. 2nd ed. St. Louis, MO: Quality Medical Publishing; 2007:81-104.

27.  Galdino GM, DaSilva And D, Gunter JP. Digital photography for rhinoplasty. Plast Reconstr Surg. 2002;109:1421-1434.

28.  Gunter JP, Hackney FL. Chapter 7: clinical assessment and facial analysis. In: Gunter JP, Rohrich RJ, Adams WP Jr, eds. Dallas Rhinoplasty. Nasal Surgery by the Masters. 2nd ed. St. Louis, MO: Quality Medical Publishing; 2007:105-123.

29.  Gunter JP, Rohrich RJ, Friedman RM. Classification and correction of alar-columellar discrepancies in rhinoplasty. Plast Reconstr Surg. 1996;97:643-648.

30.  Gunter JP, Rohrich RJ. External approach for secondary rhinoplasty. Plast Reconstr Surg. 1987;80:161-174.

31.  Gruber RP. Open rhinoplasty. Clin Plast Surg. 1988;15:95-114.

32.  Friedman GD, Gruber RP. A fresh look at the open rhinoplasty technique. Plast Reconstr Surg. 1988;82:973-982.

33.  Gunter JP. The merits of the open approach in rhinoplasty. Plast Reconstr Surg. 1997;99:863-867.

34.  Constantian MB. Differing characteristics in 100 consecutive secondary rhinoplasty patients following closed versus open surgical approaches. Plast Reconstr Surg. 2002;109:2097-2111.

35.  Tebbetts JB. Open and closed rhinoplasty (minus the “versus”): analyzing processes. Aesthet Surg J. 2006;26:456-459.

36.  Warner J, Gutowski K, Shama L, Marcus B. National interdisciplinary rhinoplasty survey. Aesthet Surg J. 2009;29:295-301.

37.  Chiu YC, Brecht K, DasGupta DS, Mhoon E. Myocardial infarction with topical cocaine anesthesia for nasal surgery. Arch Otolaryngol Head Neck Surg. 1986;112:988-990.

38.  Tarver CP, Noorily AD, Sakai CS. A comparison of cocaine vs. lidocaine with oxymetazoline for use in nasal procedures. Otolaryngol Head Neck Surg. 1993;109:653-659.

39.  Rohrich RJ, Muzaffar AR, Janis JE. Component dorsal hump reduction: the importance of maintaining dorsal aesthetic lines in rhinoplasty. Plast Reconstr Surg. 2004;114:1298-1308.

40.  Rohrich RJ, Liu JH. The dorsal columellar strut: innovative use of dorsal hump removal for a columellar strut. Aesthet Surg J. 2010;30:30-35.

41.  Rohrich RJ, Gunter JP, Deuber MA, Adams WP Jr. The deviated nose: optimizing results using a simplified classification and algorithmic approach. Plast Reconstr Surg. 2002;110:1509-1523.

42.  Rohrich RJ, Adams WP Jr. The boxy nasal tip: classification and management based on alar cartilage suturing techniques. Plast Reconstr Surg. 2001;107:1849-1863.

43.  Tebbetts JB. Shaping and positioning the nasal tip without structural disruption: a new, systematic approach. Plast Reconstr Surg. 1994;94:61-77.

44.  Gruber RP, Friedman GD. Suture algorithm for the broad or bulbous nasal tip. Plast Reconstr Surg. 2002;110:1752-1764.

45.  Sheen JH. Spreader grafts: a method of reconstructing the roof of the middle nasal vault following rhinoplasty. Plast Reconstr Surg. 1984;73:230-239.

46.  Rohrich RJ, Hollier LH. Use of spreader grafts in the external approach to rhinoplasty. Clin Plast Surg. 1996;23:255-262.

47.  Byrd HS, Meade RA, Gonyon DL. Using the auto-spreader flaps in primary rhinoplasty. Plast Reconstr Surg. 2007;119:1897-1902.

48.  Ghavami A, Janis JE, Acikel C, Rohrich RJ. Tip shaping in primary rhinoplasty: an algorithmic approach. Plast Reconstr Surg. 2008;122:1229-1241.

49.  Rohrich RJ, Griffin JR. Correction of intrinsic nasal tip asymmetries in primary rhinoplasty. Plast Reconstr Surg. 2003;112:1699-1712.

50.  Toriumi DM. New concepts in nasal tip contouring. Arch Facial Plast Surg. 2006;8:156-185.

51.  Gruber RP, Weintraub J, Pomerantz J. Suture techniques for the nasal tip. Aesthet Surg J. 2008;28:92-100.

52.  Behmand RA, Ghavami A, Guyuron B. Nasal tip sutures part I: the evolution. Plast Reconstr Surg. 2003;112:1125-1129.

53.  Guyuron B, Behmand RA. Nasal tip sutures part II: the interplays. Plast Reconstr Surg. 2003;112:1130-1145.

54.  Peck GC. The onlay graft for nasal tip projection. Plast Reconstr Surg. 1983;71:27-39.

55.  Peck GC Jr, Michelson L, Segal J, Peck GC Sr. An 18-year experience with the umbrella graft in rhinoplasty. Plast Reconstr Surg. 1998;102:2158-2165.

56.  Sheen JH. Achieving more nasal tip projection by the use of a small autogenous vomer or septal cartilage graft. A preliminary report. Plast Reconstr Surg. 1975;56:35-40.

57.  Sheen JH. Tip graft: a 20-year retrospective. Plast Reconstr Surg. 1993;91:48-63.

58.  Rohrich RJ, Deuber MA. Nasal tip refinement in primary rhinoplasty: the cephalic trim cap graft. Aesthet Surg J. 2002;22:39-45.

59.  Rohrich RJ, Janis JE, Krueger JK, Adams WP Jr. Chapter 16: percutaneous lateral nasal osteotomies. In: Gunter JP, Rohrich RJ, Adams WP Jr, eds. Dallas Rhinoplasty. Nasal Surgery by the Masters. 2nd ed. St. Louis, MO: Quality Medical Publishing; 2007:269-286.

60.  Sullivan PK, Freeman MB, Harshbarger RJ, Oneal RM, Landecker A. Chapter 15: nasal osteotomies. In: Gunter JP, Rohrich RJ, Adams WP Jr, eds. Dallas Rhinoplasty. Nasal Surgery by the Masters. 2nd ed. St. Louis, MO: Quality Medical Publishing; 2007:245-267.

61.  Harshbarger RJ, Sullivan PK. Lateral nasal osteotomies: implications of bony thickness on fracture patterns. Ann Plast Surg. 1999;42:365-370; discussion 370-371.

62.  Rohrich RJ, Minoli JJ, Adams WP, Hollier LH. The lateral nasal osteotomy in rhinoplasty: an anatomic endoscopic comparison of the external versus the internal approach. Plast Reconstr Surg. 1997;99:1309-1312.

63.  Rohrich RJ, Krueger JK, Adams WP Jr, Hollier LH Jr. Achieving consistency in the lateral nasal osteotomy during rhinoplasty: an external perforated technique. Plast Reconstr Surg. 2001;108:2122-2130.

64.  Rohrich RJ, Janis JE, Adams WP, Krueger JK. An update on the lateral nasal osteotomy in rhinoplasty: an anatomic endoscopic comparison of the external versus internal approach. Plast Reconstr Surg. 2003;111:2461-2462.

65.  Rohrich RJ, Janis JE. Osteotomies in rhinoplasty: an updated technique. Aesthet Surg J. 2003;23:56-58.

66.  Goldfarb M, Gallups JM, Gerwin JM. Perforating osteotomies in rhinoplasty. Arch Otolaryngol Head Neck Surg. 1993;119:624-627.



If you find an error or have any questions, please email us at admin@doctorlib.info. Thank you!