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98 / Lengthening the Short Nose
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ABC
Figure 7-11. Iatrogenic short nose with over reduction nasal dorsum, loss of tip projection, “polly beak”
deformity and retraction of alar margins causing alar-columellar disproportion.
Although these complications are rare, it is our practice to use costal cartilage as a last resort. If conchal
cartilage is readily available, it offers excellent quality
and quantity of cartilage with a less noticeable scar
and less morbidity than accompany the rib graft.
Due to the patient’s significant loss of tip sup-
port and length, a double-layered tip graft was used.
Although the tip graft provides excellent structure
in the infratip area, the required redraping of the
skin puts tension on lateral crura; therefore, replacing the lateral crura with conchal cartilage is crucial
to the prevention of postoperative contracture and
rotation. In this patient, these measures provided a
good long-term result (Figure 7-13).
Additional iatrogenic causes of a short nose
include aggressive resection of the nasal septum.
This can be seen as deficiencies in the support of the
dorsal septum as well loss of the caudal septum. The
Figure 7-12. Rhinoplasty diagram for correction of iatrogenic short nose. Radix augmented
with septal cartilage graft, absent lateral crural replaced with alar batten grafts, and a
conchal cartilage shield graft providing infratip lobule length.
Figure 7-13. Postoperative views showing
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correction of iatrogenic short nose
deformity with total lobular reconstruction.
Lengthening the Short Nose / 99
A B
concept of the L-strut is important to septal surgery.
The L-strut acts as a “pedestal” on which the tip
or “tripod” is supported and positioned. A caudal
deficiency of the nasal septum will allow the lobule
to rise cephalically, shortening its appearance. The
dorsal septum provides support for projection of
the lobule and can also maintain its rotation. As one
of the main supporting structures of the lobule, the
nasal septum L-strut must be maintained.
Problems with over-resection of the caudal septum are seen in the patient in Figure 7-14, who had
lack of support in the lobule and an over-rotated
appearance. These defects were found to result
from a deficient caudal septum as well as an overshortening of the caudal border of the upper lateral
cartilages. Correction required extensive grafting
to both the septum and the lobule. First, a caudal
septal extension graft was placed and secured to
the remaining quadrangular cartilage (7-15A). This
patient also had an absent portion of her medial
crura that was strengthened with a tip graft secured
to the caudal septal extension graft (7-15B). Also,
lateral crural strut grafts were placed to treat and to
prevent further collapse of the external nasal valve
(7-15C). Figure 7-16 shows the postoperative photos of this patient.
Conclusion
In summary, the short nose appearance can stem
from problems in the upper, middle, and lower third
of the nose. Careful preoperative analysis is required
to identify the deficiencies in each of these areas
prior to surgery. Appropriate structural grafting
using septal or conchal cartilage has been sufficient
to provide long-term support after maneuvers to
lengthen the nose have been performed. Although
rarely used in our practice, costal cartilage grafts can
Figure 7-14. Patient with markedly
over rotated nasal lobule and short nose
deformity caused by over resection of the
caudal septum and over reduction of nasal
dorsum.
A B
100 / Lengthening the Short Nose
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A
Figure 7-15. (A) caudal septal extension graft secured to the quadrangular cartilage extending the length of the
septum and secured to the columellar strut-medial crural complex; (B) double layered tip graft secured to the
caudal septal extension graft/columallar strut-medial crural complex further lengthening the nose; (C) lateral
crural strut grafts placed to provide strength and length to the nasal tip tripod.
ABCD
Candal Septal
Extention
Graft
BC
Absent Medial Crural
Tip Graft
Alar batten graft
Absent Anterior 1/3
E
Figure 7-16. (A,B,C,D) Pre and postoperative oblique and lateral views of a patient with an overly resec ted
caudal septum corrected with a caudal septal extension graft. (E) Illustrative drawing of a caudal septal
extension graft connected to bilateral alar batten grafts and the complete columellar strut-tip shield graft
extended complex.
of Septum
External
Lengthening the Short Nose / 101
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also be appropriate if additional cartilage is required
and the added morbidity is understood. Finally, tip
grafts are excellent in restoring length and projection and can be using in several layers as required
by the patient.
References
1. Farrior EH, Farrior RT. Analysis in rhinoplasty. In
Papel ID and Nachlas N, (eds). Facial Plastic and
Reconstructive Surgery. St.Louis, Mosby, 1992, p. 273.
2. Powell N, Hemphreys B. Considerations and com-
ponents of the aesthetic face. In Smith JD (ed).
Proportions of the Aesthetic Face. New York, ThiemeStratton, 1984, pp. 20–26.
3. Saman N, Baker SR. Lengthening the short nose. Arch
Otolaryngol Head Neck Surg 1998;124:809–813.
4. Becker DG, Pastorek NJ. The radix graft in cosmetic
rhinoplasty. Arch Facial Plast Surg 2001;3:115–119.
5. Guyuron B, Varghai A. Lengthening the nose with a
tongue-and-groove technique. Plast Reconstr Surg
2003;111:1533.
6. Leach J. Interlocking calvarial bone grafts: A solution for the short, depressed nose. Laryngoscope 2000;
110:955–960.
7. Lee Y, Kim J, Lee E. Lengthening of the postoperative
short nose: Combined use of a gull-wing concha
composite graft and a rib costochondral dorsal onlay
graft. Plast Reconstr Surg 2000;105:2190–2199.
8. Beaty MM, Dyer WK 2nd, Shawl MW. The quantification of surgical changes in nasal tip support. Arch
Facial Plast Surg 2002;4:82–91.
9. Verwoerd CD, Verwoerd-Verhoef HL. Rhinosurgery
in children: basic concepts. Facial Plast Surg 2007;
23(4):219–230.
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Index
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A
Alar batten grafts, 8, 28, 38, 41f
for iatrogenic short nose correction, 98f, 100f
for lateral crural support, 87
for lobular reconstruction, 87
for nasal alar base maintenance, 27, 27f
placement and suturing of, 27, 28f
revision of, 68f
Alar cartilage
cephalically-malpositioned, 8, 9, 11f, 20, 22, 27, 66f
cephalic margin of, in profile-plasty, 49
loss of cephalic support for, 91
in nose-lengthening procedures, 91
over-resection of, 80
preoperative evaluation of, 9–10, 11f
Alar cartilage flaps, bipedicled chondrocutaneous, 12, 12f
Alar collapse, correction or prevention of
with primary rhinoplasty, 27, 27f
with revision rhinoplasty, 80–82f, 82f
Alar-columellar disproportion, revision of, 73, 74f
Alar grafts. See also Alar batten grafts; Alar strut grafts
for bossae treatment, 75, 76f
Alar point-to-nasal tip line, 3–4
Alar point-to-nasion line, 3–4
Alar recurvature, correction or prevention of
with primary rhinoplasty, 27
with revision rhinoplasty, 80–82f, 81f, 82f
Alar retraction, correction of
with primary rhinoplasty, 28, 29f
with revision rhinoplasty, 82, 82f
Alar rim grafts
for alar base maintenance, 27
placement of, 29f
in primary rhinoplasty, 28, 29f
in tip rhinoplasty, 38, 42f
Alar-spanning sutures, 14, 14f, 17, 19, 21f
Alar strut grafts, 34
for alar collapse and recurvature prevention,
80, 81f
for bulbous tip narrowing, 19, 20f
in endonasal rhinoplasty, 38
in external columellar approach, 14
for lobular reconstruction, 87
as medial crural support, 87
for nasal alar base maintenance, 27
placement and suturing of, 28
in primary rhinoplasty, 27–28
in revision rhinoplasty, 66f
for scar contracture prevention, 43
in tip rhinoplasty, 36, 38, 40f
on vestibular side of alar cartilage, 11–12
Anatomy, nasal, 3–4
base analysis, 4
frontal analysis, 3
intranasal, 2
keystone area of, 1
profile analysis, 3–4, 4f
skin, 3
Anderson’s tripod theory, 2, 33
Aquaplast® nasal splints, 61–62
Auto spreader grafts, 15, 52, 85–86, 86f
B
Base analysis, 4
Birth trauma, as nasal fracture cause, 57
Blanket grafts, 17, 36
Bleeding disorders, 5
Blocking grafts
cephalic, 17f
in lobule deficiency correction, 92
placement between domes, 92
in primary rhinoplasty, 17
in revision rhinoplasty, 79, 79f
in tip rhinoplasty, 36–37, 37f
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Body dysmorphic disorder, 4
Boise elevators, 61, 62f
Bone grafts, for short nose lengthening, 90–91
Bones, nasal. See also Fractures, nasal
anatomy of, 1
external columellar rhinoplasty approach to, 8
length of, 10–11, 11f
relationship to nasal profile, 47
revision surgery of, 75
short, 5
Bossae, 75, 75f
Brow-tip aesthetic lines, 3
C
Calvarial bone grafts, interlocking, 90–91
Camouflage grafts, 54–55
infratip lobular, 19–20, 22f
Cap grafts
in combination with shield grafts, 79, 79f, 92,
93, 93f
in infratip lobule lengthening, 92
in primary rhinoplasty, 17
in revision rhinoplasty, 79, 79f, 92, 93, 93f
in tip rhinoplasty, 36, 37f
Caudal septal extension grafts, 99, 100f
Caudal septal struts, 90
Cephalic margin trim, in tip rhinoplasty, 35, 36
Children, nasal bone fractures in, 57, 60–61, 63
Chin augmentation, 46–47
Chin implants, 34
Chin projection, ideal, 46, 46f
Columella, hanging, 73
Composite grafts, 27
Computer imaging analysis, 5–6. See also Photographic
documentation
implication for physician-patient relationship, 49
legal risks of, 48–49
of primary rhinoplasty patients, 12
of profile-plasty patients, 47–49, 47f, 48f
of tip rhinoplasty patients, 34
Conchal cartilage grafts
alar replacement, 97–98, 98f
harvesting of, 77–78, 78f
onlay dorsal, 97f
tip, 93, 94f, 95
Consultations, preoperative, 4–6
computer image analysis in, 5–6
conclusion of, 6
digital photographic analysis in, 5–6
physical examination in, 5
Crushed cartilage grafts, 28, 54–55
Cymba conchae composite grafts, 29
bilateral, 82, 82f
D
DARTT (dynamic adjustable rotation tip-tensioning
technique), 93–95, 94f, 95f, 96f
Depressor septi nasi muscle
function of, 1
preoperative examination of, 5
Dome division, 17, 18f, 23, 24, 37
Dome-narrowing techniques, individual, 17, 18f
Dorsal hump, reduction or removal of
with external columellar approach, 13
with osteotomy, 15
over-reduction, 53, 90, 91
pre- and postoperative photographs of, 15f
in profile-plasty, 50–52, 50f
revision surgery following, 69f
Dorsal profile
analysis of, 4
bony, reduction of, 15
cartilaginous, reduction of, 15
preoperative evaluation of, 45–47, 46f
Dorsal projection, ideal, 45
Dorsal prominence, 45
Dorsum, nasal. See also Dorsal hump; Dorsal
profile
augmentation of, 15–16, 16f
excessive, 54
with external columellar approach, 13
with revision rhinoplasty, 93–95, 94f, 96f
bony, over-reduction of, 54, 90
cartilaginous
over-reduction of, 54, 90
under-reduction of, 53
deficiency of, 94, 94f, 95f
in external columellar approach, 13
frontal analysis of, 3
iatrogenic saddling of, 15f
over-reduction of
of cartilaginous dorsum, 54, 90
as “pollybeak” deformity cause, 86
“Double break,” exaggerated, 89, 92
Double-dome suturing technique
for narrowing of boxy nasal tips, 19–20, 22f
in trapezoid nasal tip, 23f
Double-dome tip-sculpting technique, 17
Double infratip shield grafts, 96f
Dressings, postoperative nasal
for primary rhinoplasty patients, 29–30, 30f
Telfa, 41, 43f
Dynamic adjustable rotation tip-tensioning technique
(DARTT), 93–95, 94f, 95f, 96f
E
Ear cartilage composite grafts, 80
Edema, nasal fracture-related, 59, 64
Endonasal approach, 7
conversion to external columellar approach, 13
incisional approach to the dorsum in, 49
nasal tip support in, 14
order of procedures in, 13, 14f
to postoperative contour deformities, 87
Index / 105
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for short-nose lengthening, 91
spreader graft use in, 16, 16f
Epistaxis
nasal fracture-related, 59, 63
postoperative, 41, 43
External columellar incisional approach, 12–13
advantages of, 7–8
approach to the dorsum in, 49
to bifid nasal tip correction, 20
dorsal septal straightening in, 11–12
increased use of, 7–8, 11–12
indications for, 12–13
with inverted “v” incisions, 12–13, 13f
for medial crura asymmetry correction, 24–25
to nasal tip under-projection, 24
order of procedures in, 13–14, 14f
for postoperative contour deformities, 87
for short nose lengthening, 92–93, 93f, 94f, 95, 95f,
97f
spreader graft use in, 16, 16f
for total lobular reconstruction, 65
External nasal valve
anatomy of, 2, 33
collapse of, 33
alar batten grafts for, 38, 41f
in tip rhinoplasty, 33
External nasal vault, preoperative examination of, 5
F
Face
chimeric, 2
divisions of, 2, 2f, 89
Facial analysis, 2–3, 2f, 3f
of primary rhinoplasty patients, 8–10, 11f
of profile-plasty patients, 45–47, 46f
of short-nosed patients, 89–90
of tip rhinoplasty patients, 33
Flying buttress grafts, 90
Fractures, nasal, 57–64
diagnosis of, 59–61, 60f
incidence of, 57–58
injury mechanism of, 58–59
treatment techniques for, 61–64
anesthesia, 61
closed reduction, 61–62, 62f
immediate septorhinoplasty, 62
for pediatric fractures, 63
for septal fractures, 62, 63–64, 63f
Frankfort horizontal line, 4, 4f, 45, 46, 46f
Frontal analysis, 3
Frontal bone, anatomy of, 1
G
Gingko biloba, 5
Gore-Tex
®
advantages of, 78
contraindication for use in lobule, 78–79
layered onlay grafts, 96f
for nasal dorsum augmentation, 13, 16, 16f
premaxillary grafts, 95, 97f
rib grafts versus, 16
Graduated approach, to rhinoplasty, 17
Grafts. See also specific types of grafts
in revision rhinoplasty, 77–80
Gull-wing conchal compromise grafts, 91
Gunter alar-spanning grafts, 84
H
Hematoma, septal
childhood nasal trauma-related, 57–58
nasal fracture-related, 60–61, 83
postoperative, 43
Hemorrhage, medication-related, 5
Herbal medications, as bruising and/or bleeding risk
factor, 5
“Hourglass deformity,” 51, 53, 69
iatrogenic, 85–86, 85f
Hypertension, 5
I
Infratip lobular grafts, 17, 36
Interdomal grafts, 80, 83, 83f, 84
Interdomal ligament, 33
Intermediate crura, divergent, in trapezoid nasal tip,
20, 22
Internal nasal valves
anatomy of, 1
collapse of, 60
normal angle of, 5
preoperative evaluation of, 5
Interposition grafts, 90
L
Lateral cartilages
lower
anatomy of, 2
cephalic malpositioning of, 36, 38, 40f, 45
cephalic margin trimming of, 17
iatrogenic loss of, 71
orientation of, 34
over-resection of, 75
upper
articulation of, 1
in “hourglass” deformity, 51, 53, 85–86, 85f, 86f
medial or lateral collapse of, 84
preoperative evaluation of, 10–11
subluxation of avulsion of, 60, 60f, 85
Lateral crura
cephalic trim of, 84
recurvature of, 80, 81f
shortening of, 71, 71f
Lateral crural complex, 2
Lateral crural flap overlay technique, 71, 71f
Lateral crural flaps, 17, 25, 27
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Lateral crural flap technique, 38, 39f
Lateral crural grafts, 27
Lateral crural steal maneuver, 24, 37, 86
Levator labii superioris muscle, function of, 1
Lip-chin complex, 2–3
Lipsett maneuver, 17, 23, 24, 25, 26f, 72, 72f
Lobule, nasal
infratip
in bifid nasal tip, 20
in boxy nasal tip, 19–20, 22f
camouflage grafts for, 19–20, 22f
in infantile nasal tip, 23, 23f
tip grafting of, 22, 22f
preoperative analysis of, 8
reconstruction of
in endonasal rhinoplasty, 14
total reconstruction, 65, 67–69, 70, 97–99, 98f, 99f
rotation of
over-rotation, 27, 70
preoperative evaluation for, 47
under-rotation, 25, 27
in short nose deficiency, 91–92
L-strut grafts, 13, 98–99
M
Malar prominence, 3
Malar recession, 3
Mandible, hyperplasia or hypoplasia of, 3
Maxilla
anatomy of, 1
hyperplasia of, 3
hypoplasia of, 3
Medial crura
asymmetric, 24–25, 26f
concavity curvature of, 85
iatrogenic loss of, 71
short, 10
Medications, as bruising and/or bleeding risk factor, 5
Mentum, hypoplastic, 46f
Micropore
™
tape, 41, 43f
Middle nasal vault
collapse of, 5
external columellar rhinoplasty approach to, 8
lack of structural support for, 51, 53
maintenance of, 84
narrowing of
as “hourglass” deformity, 51, 53, 85–86, 85f
iatrogenic, 84
over-reduction of, 15
post-rhinoplasty irregularities of, 68, 69f
in profile-plasty, 49–50
revision surgery on, 65
indications for, 69
spreader graft support for, 51–52, 51f, 52f
structural foundation for, 8
Mucoperichondrium
integrity of, 15
in profile-plasty, 49–50
Mucoperiosteum, in osteotomies, 17
Muscles, of the nose, anatomy of, 1
N
Nasal-chin relationship, 34
Nasal deformities, posttraumatic, 63–64
Nasal hump. See also Dorsal hump
prominence of, 10–11, 11f
Nasal orbital ethmoid (NOE) complex fractures, 59, 59f
Nasal profile. See also Dorsal profile
patients’ concerns about, 45–46
Nasal pyramid
preoperative evaluation of, 11
revision rhinoplasty of, 65
indications for, 69
timing of, 68
Nasal septum. See Septum, nasal
Nasal surgery, as nasal septal injury cause, 95
Nasal tip. See also Tip grafts
alar cartilage support for, 9, 11f
anatomy of, 2
asymmetrical or twisted, 24–25, 26f
bifid, 19–20, 22f, 36, 94, 95f
bossae on, 75, 75f
boxy, 19–20, 22f, 36
broad, 36
dome division narrowing of, 17, 18f
sutured double-dome narrowing of, 17, 19, 19f
bulbous, 36
alar strut grafts for, 19, 20f
cephalic alar malpositioning associated with, 19
revision surgery on, 70–71
de-projection of, 37–38
“hanging,” 9
overly-narrow, postsurgical, 82–84, 83f, 84f
over-rotated, 27, 86
preoperative analysis of, 8
revision surgery on, 68
on bulbous tip, 70–71
on nasal tip support structures, 67, 87
rotation of
evaluation of, 4
over-rotation, 94, 94f
support structures of, 9, 11f, 33, 67
in endonasal rhinoplasty, 14
major, 2, 33
minor, 2, 33
revision reconstruction of, 67, 87
trapezoid, surgical narrowing of, 20, 22, 22f, 23f
under-rotated, 25, 27
wide, 36
revision surgery on, 70–71
Nasal tip projection
adequate, 3
computer imaging of, 48
control of, 37–38
in endonasal rhinoplasty, 8
in external columellar rhinoplasty, 8
Index / 107
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ideal, 46
over-projection
double-dome endonasal delivery flap approach
to, 24, 25f
external columellar incisional approach to, 13
preoperative evaluation of, 8–9
revision rhinoplasty of, 72, 72f
preoperative evaluation of, 8–9
in primary rhinoplasty, 3–4, 8
under-correction of, with dorsum overcorrection,
89–90
under-projection, 3
correction of, 86, 87f
dome division of, 24
external columellar incisional approach to, 12–13,
24, 24f
iatrogenic, 86, 87f
lateral crural steal technique for, 24
nasal length in, 89
preoperative evaluation of, 8–9
Nasal valves
anatomy of, 84
iatrogenic collapse of, 84
Nasal vaults, bony. See also External nasal vault
anatomy of, 1
in profile-plasty, 45–55
Nasion-to-nasal tip line, 3–4
Nasofacial angle, ideal, 89
Nasofrontal angle, 3, 4f, 34
augmentation of, 47
computer imaging of, 48
deep, 94, 94f
ideal, 45
short nose-associated, 92
Nasolabial angle, 34
deep, 95, 96f
ideal, 89
preoperative evaluation of, 47
short nose-associated, 92
National Trauma Data Bank, 57
Nose. See also Short nose
anatomy of, 1–2
ideal height and length of, 89
triangular form of, 34
wide, computer-imaged narrowing of, 48f
Nostrils, overly wide of flared, 73, 74f
O
Onlay grafts
for “hourglass” deformity camouflage, 85
layered Gore-Tex
®
, 96f
for medial crura concavity curvature correction, 85
for open-roof deformity treatment, 75
septal cartilage, 27, 93, 93f, 94f
Osteotomy
after dorsal hump reduction/removal, 52–53, 53f
for dorsal hump reduction/removal, 50
instrumentation for, 52, 53f
lateral, 52–53, 75
medial, 51, 52, 53, 75
in patients with short nasal bones, 5
transverse root, 53, 75
as upper lateral cartilage weakening cause, 84
P
Packing, nasal, in nasal fracture repair, 61
Palpation, of the nose, 8
of the nasal tip, 34
Pars alaris muscle, function of, 1
Pars transverse muscle, function of, 1
Patient expectations, 4
about need for revision surgery, 67–68
based on computer images, 6
of primary rhinoplasty patients, 12
unrealistic, 48–49
Patient history, 4–5
Peck grafts, 17, 36, 79–80
Photographic documentation, 5–6
of primary rhinoplasty patients, 12
of tip rhinoplasty patients, 34
Physical examination, preoperative, 5
Piriform aperture recession, 3
“Pollybeak deformity,” 53, 69, 75
cartilaginous, 73
correction of, 73, 73f, 76f
iatrogenic, 86
soft-tissue, 73
Preoperative evaluation, 4–6, 8–10, 9–10f
Preoperative evaluation sheets, 9–10f
Primary rhinoplasty, 7–31
adverse effects of, 65
revision rates of, 30, 67
surgical approach in, 12–29
alar batten grafts, 27, 27f, 28f
for alar cartilage cephalic malpositioning
correction, 27
for alar recurvature and collapse prevention, 27
for alar retraction correction, 28, 29f
alar strut grafts, 27–28
to amorphous nasal tip, 22–23
for asymmetry or crural length disparity
correction, 24–25, 26f
for boxy nasal tip narrowing, 19–20, 22f
for broad or wide nasal tip narrowing, 17, 18f, 19
for bulbous nasal tip narrowing, 19, 20f
for cartilaginous dorsal profile reduction, 15
choice of, 7–8, 10–12
delivery approach, 12, 12f
factors affecting results of, 65
individualized approach in, 7
to infantile nasal tip, 22–23, 23f
lobular cartilage strengthening procedures, 22–23,
23f
for lobule rotation, 25, 27
for nasal tip over-projection decrease, 24, 25f
for nasal tip projection increase, 24, 24f
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