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78 / Secondary Rhinoplasty with Total Lobular Reconstruction
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AB
Figure 6-14. Intraoperative
photos of harvesting ear conchal
cartilage and the resultant full
piece of auricular cartilage
including the cymba and cavum
conchae.
through the anterior incisional approach. The reason the anterior incision approach is required is
so one can harvest the overlying skin of the cymba
conchal region for vestibular skin replacement in
combination with the cartilage at the marginal incisional location. The incision is made just below the
anterior crus of the anthelical fold, extending in a
curvilinear fashion just underneath the anthelix and
around to the inferior aspect of the conchal bowl.
One plans for the removal of some skin with the
curved portion of the cymba conchae to preserve as
a composite graft.1,2 The skin anteriorly remaining
in the conchal bowl and cymba conchae is now a
skin flap that can be advanced and rotated, closing
the defect.
When reconstructing or augmenting the nasal
dorsum, a variety of autogenous materials can be
used, including septal cartilage, conchal cartilage, or
costal cartilage. Additionally, it is safe to use a material that is soft and pliable and well tolerated by the
dorsal nasal skin. A very well-tolerated alloplastic
material is expanded fibrillated polytetrafluoroethylene (Gore-Tex) sheeting.22 It is slightly porous and
will absorb antibiotic solution if it is soaked prior
to placement. Gore-Tex sheeting has an excellent
safety record, with minimal risk of infection and
hardly any chance of extrusion, because the sheeting
is soft, pliable, and creates no firm pressure on the
overlying skin. Gore-Tex has the advantages that it
is readily available for any patient, does not require
an additional operative site, and avoids the risk of
pneumothorax and increased pain from costal cartilage grafting (Figure 6-15). However, Gore-Tex
sheeting is not appropriate for use in the lobule due
AB
Figure 6-15.
postoperative lateral views of
a patient with an iatrogenic
saddle nose deformity corrected
with a combination of septal
cartilage and Gore-Tex sheeting
augmentation.
Pre- and
Secondary Rhinoplasty with Total Lobular Reconstruction / 79
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to the dynamic nature of the lobule and the closeness to the access incisions.
For total lobular reconstruction, a variety of
grafts are used to correct anatomical distortions.
Tip grafts are typically obtained from septal cartilage, conchal cartilage, nasal fibro-fatty soft tissue,
and even the cephalic margin of the alar cartilages.
Tip grafts are used for:
1. Camouflage
2. Effacement of intradermal bifidity
3. Alar stabilization
4. Infratip lobular definition
5. Lengthening
6. Projection
There are various descriptions of tip grafts, and the
type of tip grafts used are:
1. Infratip lobule shield-type grafts, non-sutured
2. Infratip lobule shield-type grafts, sutured
3. Interdomal grafts
4. Shield grafts that are sutured columellar-lobule
shield grafts, single or double layer
5. Cap grafts
6. Blocking grafts
7. Peck grafts
23
8. Alar facet grafts
9. Soft-tissue overlay grafts
The uses of these grafts in total lobular reconstruction are outlined in what follows.
A sutured columellar lobular shield graft is the
most common graft used, and it provides structural
support to the otherwise weakened alar cartilages,
as well as increased projection and length to the
entire lobule (Figure 6-16). Occasionally, one just
needs to lengthen the infratip lobule area and the
shield graft is shortened and sutured in place in the
infratip lobule or placed in the same location in a
pocket during an endonasal rhinoplasty. In order to
achieve infratip lobule lengthening and projection,
a cap graft is placed on top of the shield graft in the
infra-tip lobular area (Figure 6-17). This is sutured
in place using an external columellar approach.
When using shield grafts to extend the length
of the nose, and particularly when they are used to
increase projection, a blocking graft may be required
to prevent (cephalic) over-rotation of a large tip
extension shield graft and as a filler graft to soften
the transition from the projecting edge of the shield
graft to the supratip region (Figure 6-18).
Less commonly, a graft is sutured directly on top
of the existing dome cartilages to increase projection
Figure 6-16. Intraoperative photo of a sutured-in-
place columellar-lobular shield graft.
Figure 6-17. Intraoperative photo of a cap graft
sutured on top of a shield graft in the infratip lobule
area.
Figure 6-18. Blocking graft to prevent rotation and
to act as a “filler” in the supratip area.
80 / Secondary Rhinoplasty with Total Lobular Reconstruction
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the lobular cartilage, the result may be a visible collapse of the lateral nasal ala, with or without external valvular collapse and airway compromise. It may
also be due directly to over-resection of the cephalic
margin of the alar cartilage, leaving no resistance to
late valvular collapse (Figure 6-20). Many cases of
alar collapse and a pinched ala appearance occur
due to complete resection of the lateral crus of the
alar cartilage in the primary surgery. Two grafts are
used to correct or to prevent lateral crural recurvature and alar collapse: (1) alar batten grafts and (2)
alar strut grafts. Treatment of alar retraction, either
Figure 6-19. Intraoperative view of a reconstructed
lobule with multiple structural grafts overlayed with a
soft-tissue blanket.
without lengthening the entire nose, as does a shield
graft. This graft, first described by Peck, is known
as a Peck graft.23 Frequently, when using multiple
grafts in the nasal tip, especially in thin-skinned
patients, a soft-tissue overlay graft is sutured as a
blanket, camouflaging the edges and giving a layer
of fibrosis to prevent bossae from forming postoperatively (Figure 6-19). When the skin begins to
shrink wrap, it is nice to have soft-tissue camouflage
between the thin skin and the edges of the shield
grafts. If there is not sufficient fibro-fatty soft tissue
available from the patient’s nose, temporalis fascia
or acellular dermal graft is used. AlloDerm sutured
directly over the lobular complex just prior to closing the external columellar incision finishes the lobular reconstruction.
A less commonly used graft, but one used to
maintain interdomal width in double-dome suturing techniques, is called an interdomal graft.25 This
graft is placed between the domes, not projecting
cephalically or caudally. It is used merely as a spacer
to maintain a double light-reflective highlight at
the lobule. The graft can be placed endonasally or
through an external columellar approach.
24
Alar Collapse and Retraction
Alar Collapse or Recurvature of the
Lateral Crus
Even in properly performed primary rhinoplasty,
when cephalic margin trim procedures are performed to correct a wide or bulbous nasal tip, the
lateral alar cartilages are inherently weakened. If
there is preexisting weakness in the lateral crus of
mild or significant, is discussed in the next section.
Grafts used to correct mild to moderate retraction
of the alar margin are (1) rim grafts and (2) ear cartilage composite grafts.
weakness in the lateral alar cartilages, particularly
in combination with a firm, convex dome and
cephalic margins, it is incumbent upon the surgeon
to place alar strut grafts to prevent recurvature
and alar collapse. Alar strut grafts are structural
grafts placed between the lateral crus and the
vestibular skin, extending from the piriform
aperture to near the dome19 (Figure 6-21). These
grafts can be placed endonasally but are more frequently and much more easily placed through the
external columellar approach from the cephalic
direction. They are sutured directly to the alar cartilage with a 5-0 Monocryl suture. The vestibular
skin is then reapproximated to the alar strut and
alar cartilage with 2 or 3 mattressing 5-0 Dexon
sutures.
when one recognizes alar collapse and significant
alar recurvature, it may be difficult to place an alar
strut graft if the vestibular skin has been previously
elevated. Alar batten grafts are also very efficacious in
cosmetically correcting this problem as well as giving
some structural support. They are more commonly
used for alar contour restoration and secondarily
improve the airway by preventing further alar collapse. Alar batten grafts obtained from the cymba
or cavum conchae have a preexisting natural curvature or convexity, so that when they are placed on
the superficial surface of the alar cartilage, they hold
the alar cartilage, preventing it from collapsing and
recurving.19 Alar grafts are placed with mattressing,
transvestibular skin 5-0 Dexon sutures (Figure 6-22).
These grafts can be placed endonasally or through an
open or external columellar approach.
If, in the preoperative examination, one notes
However, in secondary or revision rhinoplasty,
Secondary Rhinoplasty with Total Lobular Reconstruction / 81
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Figure 6-20.
frontal and basal views of a patient with
alar collapse and retraction corrected by
alar batten grafts.
Pre- and postoperative
A
C
B
D
Figure 6-21. Intraoperative view and
drawing of alar strut grafts placed between
the lateral crura and the vestibular skin.
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is divided and not reconstituted, upward retraction
of the alar margin can occur over time.
notching and retraction is to use inter-position
composite grafts from the cymba conchae of the
auricle
is inserted into the marginal incision made along
the caudal margin of the lateral crus to get the point
of maximum alar notching. The composite graft
acts to push down the retracted alar margin, replacing vestibular skin deficit and creating a more aes-
Figure 6-22. Intraoperative view of alar batten graft
sutured in place on top of an over-resected lateral
crus.
thetic alar rim appearance. The graft is sutured into
position with simple 5-0 plain catgut sutures placed
around the margin. The graft is universally viable, as
it is small and receives a good blood supply. How-
Alar Retraction
Abnormal and unsightly retraction of the alar rim
or notching results from either over-resection of the
lateral crus, interruption of the alar cartilage lateral
ever, composite grafts do not correct the underlying cartilage defect that was responsible for the alar
retraction. Reconstruction of the lateral crus or support of the lateral crus is required, often with the use
of an alar batten graft simultaneously.
to the domes, or late contracture that overpowers
inherently weak lateral crura. The anatomical basis
for retraction of the alar margin includes buckling
of the lateral alar crus, over-resection of the cephalic
margin of the lateral crus, lateral division of the alar
cartilage (called a rim strip), and/or total removal of
the lateral crus.
Resection of the excessive cephalic margin of
the lateral crus creates a variable tissue void. The
point of relative instability at the alar rim will move
toward the point of relative stability of the upper lateral cartilage at the middle third of the nose.26 Any
time the lateral crus is weakened or the lateral crus
Overly Narrow Nasal Tip
(Unitip Deformity)
If the domes of the lateral cartilage have been overnarrowed and placed too close together with an
interdomal suture, the normal bidomal configuration of the domes is replaced by a unitip deformity (Figure 6-24). This deformity is most frequently
seen after maneuvers that pinch the domes together,
particularly in patients with thin skin. An interdomal suture itself does not create this deformity
unless the domes are inherently weakened or the
A very effective method for correcting alar
26
(Figure 6-23). A fusiform composite graft
A B
Figure 6-23. Pre- and
postoperative oblique views of
a patient with alar retraction
corrected with bilateral cymba
conchae composite grafts.
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A
D
Figure 6-24. Pre- and postoperative frontal and basal views of a patient with
unitip deformity corrected by placement of an interdomal graft giving the tip a
more pleasing width and double light reflection.
B
E
suture is over-tightened.1 Vertical dome division
with suturing of the medial crural segments to the
lower lateral cartilages can create this deformity if
the normal divergence of the dome from the inter-
mediate crura is not maintained.27 Another cause
of the over-narrowed tip can be overlapping of lat-
eral crus divided from the medial crus so that they
become the leading point of the nasal lobule, almost
in a “bow of the boat” appearance.
C
F
Prevention of the unitip deformity requires preservation of the normal orientation of the domal
structures without excessive narrowing of the interdomal distance. An interdomal graft can be placed
prior to the transdomal suture to maintain this normal interdomal distance25 (Figure 6-25). An interdomal suture can also be placed to allow normal
divergence of the caudal margin of the domes compared to the cephalic margin. In addition, making
AB
Figure 6-25. Intraoperative photo of an interdomal graft sutured into place between the domes.
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A
B
Figure 6-26. Pre- and
postoperative frontal views of a
patient with an overly narrowed
tip due to lateral crura overlaying
medial crura, corrected by
trimming the lateral crura and
placing a tip buttress graft.
sure that the medial crura are the leading point of
the nasal tip is always imperative in reference to the
leading edge of the lateral crus.
Correction of the pinched or unitip deformity
requires recreation of the bidomal tip shape. This
can be accomplished by separating the domal structures and using a shield-shaped tip graft sutured to
the caudal margin of the medial crura to hold the
domes in a lateralized position, almost as though
one has formed a buttress graft28 (Figure 6-26).
Use of tip grafts in this manner in thin-skinned
patients is difficult to camouflage and an overlay
soft-tissue graft may be required. Cymba conchae
graft is ideal for these tip grafts because the cartilage
is soft and pliable.
A variant of the interdomal graft was described
by Gunter,29 who used septal cartilage struts placed
between the cephalic margins of the alar cartilage
behind the domes. The structure lateralizes the
position of the cephalic margin of the lateral crus,
maintaining the interdomal width. Placing either
the shield graft, acting as a buttress, or the Gunter
alar-spanning graft requires an external columellar open approach in order to suture the grafts into
proper position. An interdomal graft can be placed
either endonasally or through the open approach.
Middle Nasal Vault Narrowing
and Valve Collapse
Collapse of the middle third of the nose and nasal
valve is usually due to inferior or medial collapse of
the upper lateral cartilages. This usually occurs after
support of the upper lateral cartilages is surgically
compromised. The upper lateral cartilage is supported by its attachments to the anterior or dorsal
border of the nasal septum, recurvature or scroll
with the cephalic margin of the lateral crus, the
nasal bone, and the piriform aperture.30 Nasal hump
removal with division of the upper lateral cartilages
from the septum will weaken one support structure.
Cephalic trim of the lateral crus will weaken another
support attachment. Osteotomies within, or displacement of, the nasal bones will weaken a third
support attachment. In most rhinoplasties, at least
two of the support attachments to the upper lateral
cartilages are weakened, which is why pinching of
the middle third of the nose and valve collapse are
so prevalent in rhinoplasty.
1
The nasal valve is comprised of the caudal mar-
gin of the upper lateral cartilage and the nasal sep-
10
If the upper lateral cartilage is freed from
tum.
the septum and the lateral crus, it tends to collapse
inferomedially. This can be seen at the time of surgery. In many cases, the upper lateral cartilages that
have fallen inferomedially are collapsed against the
septum. To prevent valve collapse and pinching
of the middle third of the nose, the surgeon can
re-suspend the caudal-most aspect or anterior dorsal border of the upper lateral cartilage to the anterior dorsal septum. However, two much more stable
and predictive methods for maintaining the middle
nasal vault with and the patent internal nasal valve
are either placement of autogenous septal cartilage
spreader grafts or the creation of auto spreader
19,31
grafts.
Figure 6-27. Pre- and
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postoperative frontal views of
a patient with an iatrogenic
hourglass deformity corrected
with the placement of spreader
grafts.
Secondary Rhinoplasty with Total Lobular Reconstruction / 85
AB
Midnasal Narrowing or
Hourglass Deformity
If this deformity is due to subluxation or avulsion of
the upper lateral cartilage from its attachment to the
nasal bone, an onlay cartilage graft can be used to
camouflage the deformity. The graft can be inserted
into a precise pocket made through an intracartilag-
inous incision. Narrowing in the middle third of the
nose from inferomedial collapse of the upper lateral
cartilages is usually due to dividing the upper lateral
cartilage from the nasal septum (Figure 6-27). This
deformity can be prevented by using autogenous
cartilage spreader grafts placed between the medial
crura and the upper lateral cartilages (Figure 6-28).
This may be required in secondary rhinoplasty
when, in fact, the alar cartilages are not dehiscent
or avulsed from their attachments to the nasal
bone. Placement of the spreader grafts may assist
in improving the internal nasal valve as well, but it
is most commonly used to improve the dorsal
contour from the frontal and three-quarter view.
19
True concavity curvatures of the medial crura,
despite the placement of spreader grafts, are corrected with the placement of lightly morselized
onlay grafts prior to redraping the nasal skin.
When one has separated the upper lateral cartilages from the septum prior to lowering the dorsal
septal profile, there may be redundancy of upper
lateral cartilage that could be trimmed to match
Figure 6-28. Diagram and
intraoperative photo of spreader
grafts.
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Figure 6-29. Intraoperative photo
of the use and creation of upper
lateral cartilage spreader grafts,
known as auto spreader grafts.
the new lowered profile. However, if one preserves
the medial dorsal height of each upper lateral cartilage by incising through the cartilage, but not the
underlying mucoperichondrium, the upper lateral
cartilage can then medially be turned inward and
sutured directly to the septum, acting as an auto
spreader graft, also known as an upper lateral cartilage spreader flap
32
(Figure 6-29).
A more commonly used technique is to place
strips of septal cartilage along the superior dorsal
border of the quadrangular cartilage between the
collapsing upper lateral cartilage bilaterally. The
strips are sutured directly in place on both sides and
are called spreader grafts.
19
Spreader grafts can be sutured in place through
an endonasal approach, but they are much more
easily placed and sutured, particularly cephalically,
through an open or external columellar approach.
The strut requires elevating the mucoperichondrial pocket. It is always preferable in hump reduction to leave the mucoperichondrium intact prior
to any cartilage reduction. Suturing spreader grafts
into position effectively widens the middle third of
the nose while also elevating and lateralizing the
caudal margin of the upper lateral cartilage. The
repositioning of the caudal margin of the upper
lateral cartilage may actually be a major reason why
spreader grafts can improve nasal valve function.
Unfortunately, other factors, such as scarring, weakening of the tissues, and septal deformities, may prevent complete correction of the nasal valve problem.
Inadequate Tip Projection
As mentioned previous, inadequate tip projection
can be found in association with over-reduction of
the nasal dorsum, creating a pollybeak deformity.
The postoperative loss of tip projection is usually
due to compromise of the major support structures
of the nasal lobule without adequate compensatory maneuvers (i.e., struts, grafts, or other suturing techniques). If the tip projection is appropriate
with the nasal profile, but the nasal profile has been
over-reduced, the whole nose appears too small for
the individual’s face. This requires entire rebuilding
of the nasal lobule and augmentation of the nasal
dorsum simultaneously.
Tip projection can be increased by using sutured-
33
in-place columellar struts
and tip grafts19 (Figure
6-30) or surgical maneuvers that recreate the lateral
crura medially.17 This can be done either by lateral
crural steal maneuvers, maintaining the continuity
of the medial crus and the lateral crus, or by dividing the lower lateral cartilages lateral to the dome
and recruiting the lateral crus to a more projected
medial crural segment.
The Over-Rotated Nasal Tip
or Short Nose
The many causes of short nose or over-rotated nasal
lobule are described in detail in Chapter 7, “Lengthening the Short Nose.”
Summary
The key to a successful secondary or revision rhinoplastic procedure, particularly when it comes to
reconstructing the lobule, is to recognize the contributions of the skin envelope, scar tissue plane, and
distortions of the lobular cartilage, because they all
play a significant part in the resulting aesthetic and
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Figure 6-30.
postoperative lateral views of patient
with loss of tip projection corrected
by a columellar strut and an extended
tip graft.
Drawing and pre- and
functional deformity. Endonasal approaches to correct contour deformities with precise pocket grafting may treat a small number of minor deformities,
but these techniques do not correct the underlying
structural deficits, which often lead to airway compromise. It is extremely important to adequately
diagnose, by direct visualization, what was done by
the previous surgeon and what the forces in healing
and contracture have caused to further the aesthetic
and functional deformities. One can most efficaciously deal with this through an external columellar incisional approach. This allows one to elevate
the dorsal lobular skin envelope under direct vision,
often tediously dissecting through the adherent
scar tissue. It is often nearly impossible to separate
the scarred skin envelope from the alar cartilages in a
traditional delivery flap approach done endonasally.
By carefully preserving the dermal complex and
elevating the dorsal nasal skin, one now has an
accurate view of the condition of the alar cartilages
or the lack thereof. Releasing the scar tissue and reorienting the cartilages is often a major step toward
improving the overall appearance. However, it is
most often necessary to reconstitute the tip-support
structures and to rebuild the lobular tripod.14
Providing medial crural support through alar
strut grafts and lateral crural support by either alar
batten grafts or, commonly, alar strut grafts, and
adding some form of shield graft create a newly
formed lobule that resists contracture and the
resulting deformed appearance or functional collapse. The ability to take a nasal lobule apart and to
rebuild it with predictable graft techniques allows
one to tackle the most challenging revision rhinoplasty cases one encounters. Surgeons have the tools
to perform these maneuvers and to achieve consistently happy patients and while markedly improving
the nasal appearance in most cases.
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