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References
1. Perkins SW, Tardy M, Eugene MD Jr. Open rhinoplasty: External columellar incisional approach to
revision of the lower third of the nose. Facial Plast
Surg Clin N Am 1993;8:79–98.
2. Converse JD. Corrective rhinoplasty. In Converse
JM (ed). Reconstructive Plastic Surgery, 2nd Ed.
Philadelphia, WB Saunders, 1977, pp 1152–1154.
3. Webster RC. Revisional rhinoplasty. Otolaryngol Clin
N Am 1975;8:753.
4. Tardy ME, Cheng EY. Misadventures in nasal tip sur-
gery: Analysis and repair. Otolaryngol Clin N Am 1987;
20:797.
5. Hewell TS, Tardy ME. Nasal tip refinement: Reliable
approaches and sculpture techniques. Facial Plast
Surg 1984;1:87.
6. Dyer WD II. Nasal tip support and its surgical modi-
fication. Facial Plast Surg Clin N Am 2004;12(1):1–13.
7. Rees TD, Krupp S, Wood-Smith D. Secondary rhino-
plasty. Plast Reconstr Surg 1970;46(4):332–340.
8. Kamer FM, Churukian MM, Hanson L. The nasal
bossa: A complication of rhinoplasty. Laryngoscope
1986; 96:303.
9. Kamer FM, McQuown SA. Revision rhinoplasty:
Analysis and treatment. Arch Otolaryngol Head Neck
Surg 1988;114:257.
10. Kern EB: Nasal valve surgery. In Krause CJ, Mangat DS,
Pastorek N (eds). Aesthetic Facial Surgery. Philadelphia,
JB Lippincott, 1991, pp 175–187.
11. Tardy ME. Rhinoplasty: The Art and Science.
Philadelphia, WB Saunders, 1997.
12. Hanasono MM, Kridel RW, Pastorek NJ, et al. Cor-
rection of the soft tissue pollybeak using triamcinolone injection. Arch Facial Plast Surg. 2002;
4(1):26–30.
13. McCollough EG, Mangat D. Systematic approach
to correction of the nasal tip in rhinoplasty. Arch
Otolaryngol Head Neck Surg 1981;107:12.
14. Anderson JR. A reasoned approach to nasal base
surgery. Arch Otolaryngol Head Neck Surg 1984;10:
349.
15. Kridel RWH, Konior RJ, Shumrick K, et al. Advances
in nasal tip surgery: The lateral crural steal. Arch
Otolaryngol Head Neck Surg 1989;115:1206.
16. Lipsett EM. A new approach to surgery of the lower
cartilaginous vault. Arch Otolaryngol 1959;70:42.
17. Kridel RWH, Konior RJ. Dome truncation for management of the overprojected nasal tip. Ann Plast Surg
1990;5:385.
18. Perkins SW, Naderi S. Secondary rhinoplasty.
In Bailey JM, Johnson JE, Newlands SD (eds).
Head and Neck Surgery-Otolaryngology, Fourth
Ed. Philadelphia, Lippincott Williams & Wilkins,
2010.
19. Johnson CM, Toriumi DM. Open Structure Rhinoplasty. Philadelphia, WB Saunders, 1991.
20. Rohrich RJ, Muzaffar AR, Janis JE. Component dorsal
hump reduction: the importance of maintaining
dorsal aesthetic lines in rhinoplasty. Plast Reconstr
Surg 2004;1114(5):1298–1308.
21. Tardy ME, Denneny J, Fritsch MH. The versatile
cartilage autograft in reconstruction of the nose and
face. Laryngoscope 1985;95:523.
22. Godin MS, Waldman SR, Johnson CM. Nasal
augmentation using Gore-Tex: A 10-year experience.
Arch Facial Plast Surg 1999;1:118–121.
23. Peck GC. The onlay graft for nasal tip projection.
Plast Reconstr Surg 1983;71:27–37.
24. Gryskiewicz JM. Dorsal augmentation with
AlloDerm. Sem Plast Surg 2008; 22:90–103.
25. Guyuron B, Poggi JT, Michelow BJ. The subdomal
graft. Plast Reconstr Surg 2004;113(3):1037–1040.
26. Tardy ME, Toriumi DM. Alar retraction: Composite
graft correction. Facial Plast Surg 1989;6:101.
27. Simons RL, Fine IJ. Evaluation of the Goldman tip
in rhinoplasty. In Plastic and Reconstructive Surgery
of the Face and Neck. Proceedings of the Second
International Symposium. Vol I. Orlando, Grune &
Stratton, 1977, pp 38–46.
28. McKinney P, Cook JQ. A critical evaluation of 200
rhinoplasties. Ann Plast Surg 1981;7:357.
29. Gunter JP. Tip rhinoplasty: A personal approach.
Facial Plast Surg 1987;4:263.
30. Papel ID. Management of the middle vault. In Papel
ID (ed). Facial Plastic and Reconstructive Surgery
2nd Ed. New York, Thieme, 2002, pp. 407–413.
31. Sheen JH. Aesthetic Rhinoplasty. St. Louis, CV
Mosby, 1978.
32. Byrd HS, Meade RA, Gonyon DL Jr. Using the autospreader flap in primary rhinoplasty. Plast Reconstr
Surg 2007;119(6):1897–1902.
33. Toriumi DM. Structural approach to primary
rhinoplasty. Aesthetic Surg J 2002;22:72–84.
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Short Nose
Henry D. Sandel IV, MD and Stephen W. Perkins, MD
7
Introduction
The short nose can be a challenging problem. It can
present in the primary rhinoplasty patient, especially in those with congenital facial malformations.
More commonly, however, it is a complication seen
in patients who have undergone previous nasal surgery. These patients generally have problems related
to either the failure to correct or to identify a specific
preoperative attribute or the aggressive resection of
certain nasal structures. In either case, the mechanism involved in creating the short nose must be
understood. The reconstruction will mainly focus
on rebuilding of adequate tip-support structures of
the nose.
Facial Analysis
Most patients with a short nose are obvious to the
observer. However, it is important to understand the
normal and abnormal nasofacial relationships and
what defines a true short nose deformity. A decrease
in the length of the nasal dorsum in relation to other
structures of the face defines the short nose. Objective measurements can be found by dividing the
face into vertical thirds. The middle third, measured
from the glabella to the subnasale, should be proportional to the upper and lower third of the face.
Authors have suggested that the height of the nose
as measured from the radix to the subnasion should
be about 47% of the height of the face from menton to radix.
distance from the nasion to the tip-defining points.
1
The short nose also has a decreased
The ideal length of the nose measured from nasion
to the nasal tip has been described by Goode as a
ratio of projection to nasal length of 0.55:1 to 0.6:1.2
Although this holds true for patients with proper
nasal projection, it is a less effective tool for evaluation of the poorly supported, under-projected nose.
Good aesthetic judgment requires use of total facial
proportions when evaluating revision cases.
The length of the nose can also be shortened by
increasing the angle of rotation of the nasal tip. The
ideal nasolabial angle should be between 90 and 115
degrees. This angle is measured from a vertical line
drawn from the subnasion to the upper lip vermillion border and another drawn from the subnasion
tangentially along the columella. Finally, the nasofacial angle should be between 30 and 40 degrees. It
is an acute angle measured from the facial plane, a
line drawn from the nasion to the pogonion, and the
radix to the nasal tip.
In patients with a short nose, findings include
over-rotation of the nasal lobule, under-projection
of the tip, relative over-resection or under-development of the nasal dorsum, exaggerated “double
break,” and retraction of the alae with alar-columellar
disproportion. Revision rhinoplasty patients may
also have findings that don’t fit well into ideal nasofacial relationships. For example, patients with
only a low radix or poor upper-third support may
appear to have a short nasal dorsum but in fact
have normal nasofacial relationships. Nasal tipdefining points may be oriented more superiorly
than expected based on the position of the columella and the nasolabial angle. Also, under-correction
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of tip projection with over-correction of the dorsum may leave a short dorsal appearance with normal angles of tip rotation.
The nose may also be shortened in its superior
aspect through a number of factors. First, a low
radix will give the appearance of a short dorsal nasal
length in relation to the rest of the face. This may
be the result of surgical omission of dorsal hump
reduction or failure to correct the low radix. Second, under-correction of a dorsal bony hump may
shorten the dorsal length. Third, and the most commonly encountered problem of the mid to upper
third, is the over-resection of the bony and cartilaginous dorsum. Overall, sound clinical judgment and
aesthetic sense will lead the surgeon to proper diagnosis of these factors in revision rhinoplasty cases.
Literature Review
Many articles have been written describing individual techniques for correction of the short nose.
These techniques range from camouflaging of the
short nose deficiencies by augmenting the alar cartilages to rebuilding the structural abnormalities to
lengthen the nose. In addition, the function of the
internal and external nasal valves must be protected
to avoid or to treat nasal airway obstruction.
Saman and Baker discussed five techniques for
lengthening the short nose:3 the techniques discussed
included the flying buttress graft, caudal septal struts,
tip grafts, radix grafts, and interposition grafts. The
flying buttress graft, described by Dyer in 1996, uses
spreader grafts placed along the dorsal septum that
are allowed to extend caudally beyond the anterior
septal angle. This caudal extension is then secured to
a columellar strut graft at a length appropriate for
the new nasal length. This technique significantly derotates the tip by elongating the tip-defining point.3
The process of pushing the alar cartilages caudally
can also be accomplished by using caudal septal strut
grafts, placed caudal to the septum and secured to
the medial crura of the lower lateral cartilages. The
function is similar to that of the flying buttress graft
in that the lobule is also caudally displaced.
The third method of achieving lengthening of
the nose is the use of tip grafts. Although there are
many types of tip grafts, their placement is critical
to their role. Shield grafts are placed caudal to the
lobule in the infratip area. These grafts can augment
the infratip lobule, providing length to the mildly
to moderately shortened nose. Other grafts, such as
the interposition graft, are placed between the upper
and lower lateral cartilages to push the tip caudally.
This technique is suggested for use in patients with
retracted ala in order to give length to the lateral
aspect of the nose as well as the tip.3 Finally, the
radix graft can correct the short nose that is deficient
in the cephalic third. The radix graft will move the
nasofrontal angle cephalically and give the appearance of a longer nose without movement of the tip.
The radix graft was discussed in detail by Becker
and Pastorek in 2001.4 Their article emphasizes the
importance of proper preoperative facial analysis
determining where the naso-frontal angle begins.
The radix should begin at a point parallel with the
superior palpebral fissure of the upper eyelid. This
effectively “shortens” the nose as nasal length is
measured from the radix to the tip-columellar line.
The authors describe how a short nose appearance
is commonly identified in the revision rhinoplasty
patient who has had an overzealous dorsal hump
removal thereby artificially lowering the radix and
how it can also be found in the primary rhinoplasty
patient with a deep or low nasofrontal angle. This
effectively “shortens” the nose as nasal length is
measured from the radix to the tip-columellar line.
A tongue-and-groove technique was described
by Guyuron and Varghai in 2002.5 They employ
the use of bilateral spreader grafts along the dorsal
septum that are allowed to extend caudally past the
anterior septal angle. These grafts are then secured
to a caudal septal extension graft at a length that
is appropriate for the patient. The authors suggest
that this technique is superior to other techniques
for several reasons. First, the spreader grafts are
used to secure the septal extension graft in its position. This will help avoid displacement of the graft
to either side of the septum. Also, as the spreader
grafts are secured to the septal extension graft, there
is additional support along the caudal length of the
septum, as opposed to a loose columellar strut graft
that can be 1–2 mm away from the septal cartilage.
For those patients with a severe nasal deformity
and almost complete loss of the bony and cartilaginous support of the nose, interlocking calvarial bone
grafts can be an option, as described by Leach in
2000.6 These patients often have complete collapse
of the nose, giving a short, under-projected, and
over-rotated appearance. Leach studied 20 patients
who underwent external rhinoplasty approaches
for the placement of two calvarial bone grafts. The
grafts were fitted together in a tongue-and-groove
fashion to a caudal cartilaginous strut and secured
to the existing frontal bone or nasal bone if present.
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There is moderate tension in the nasal tip secondary to contraction forces, which are stabilized by the
use of strong bone grafts. This necessitates the use
of soft-tissue tip grafts to soften the caudal aspect
of the bone grafts and to buffer the skin against erosion. Although Leach admitted to some problems of
bone extrusion or graft exposure due to either the
patient’s underlying medical condition, social factors such as smoking or lack of internal nasal lining,
the main structure of the dorsum held up well. This
technique also incurs much less risk of the warping
seen in costal cartilage grafting. The authors opinion is that reconstructing the nose with bone grafts
is unnatural, too hard, and inflexible.
In contrast, Lee et al. described the use of a combined gull-wing conchal composite graft and a rib
costochondral dorsal onlay graft for the correction
of the moderately to severely shortened nose.7 This
technique attempts to correct each soft-tissue and
structural layer of the nose independently. The
authors performed the reconstruction using an
endonasal rhinoplasty technique to avoid tension
across a columellar suture line as well as to reduce
patient fears of an additional scar. The procedure
was performed on 6 females over a 10-year period
with an average follow-up of 8.7 months. Specific
technical points included the wide dissection and
undermining of the nasal soft-tissue envelope, composite grafts to supplement the inner mucosal lining and cartilaginous support, and a strong dorsal
strut graft to reinforce the framework. The only
reported complications included transient epidermal sloughing of the gull-wing graft. Disadvantages
of this approach are the use of multiple donor sites,
technical difficulty with the endonasal approach,
and the potential for loss of the composite grafts.
The authors opinion is that a well designed rib or
costal cartilage graft(s) are more natural and can
be more easily and safely performed through the
external columellar or “open” appreoach. Rib graft
reconstruction of the total nasal framework is the
preferred and state of the art technique for lengthening these severely shortened noses.
The Short Nose
Although there are many different techniques for
lengthening the short nose, they each have in common the addition of support and structure. Many
cases involve patients with old deformities where
the skin has shrink-wrapped onto the existing structure. If the skin/soft-tissue envelope is placed over a
lengthened nose with no support, it will cause collapse. Therefore, in addition to paying close attention to the tip appearance, the surgeon must also
address supporting elements.
Once the proper support is in place, other grafts
are placed to define the aesthetic points of the nose.
Not only should length be a primary concern, but
also projection, rotation, and the alar-columella
relationship should be evaluated. Changing a deficiency in any one of these can directly affect another.
Understanding the relationships among these concerns is crucial to the surgeon performing rhinoplasty for the short nose.
After the appropriate nasal facial analysis is performed, the mechanism that is creating the short
nose deformity should be identified. Deficiencies
can arise in the upper third, middle third, lobule,
and nasal septum. Upper-third problems are related
to deep nasofrontal angles as well as short nasal
bones. If upper-third problems are seen in the revision rhinoplasty patient, overzealous bony hump
reduction is the most common etiology. Furthermore, in these patients the deficiency may extend
onto the middle vault, producing airway obstruction and internal nasal valve collapse. Patients
with congenital abnormalities may have underdevelopment of the nasal dorsum or poor development of the midface or maxillary structures.
A middle-third deficiency in the revision rhinoplasty patient is also likely to be related to overzealous dorsal reduction. A saddle nose deformity can
have an isolated middle-third deficiency with loss
of support from the nasal septum. Sometimes it can
be difficult to distinguish between the two unless a
thorough history and physical exam are performed.
The lobule is the site for much of the structural
loss resulting in the short nose. In patients who have
had prior surgery, overzealous resection of the tip
cartilages can be a major concern. Also, in patients
with a deficient nasal septum, the tip can lose projection and rotate upward, even without loss of the
lower lateral cartilages. A variety of tip grafts can be
used to correct specific deficiencies outside of the
loss of its support pedestal. Tip grafts are employed
to stabilize the alar cartilages, camouflage irregularities, add length to the tip or infratip lobule, and
assist in the de-rotation of the nose. In patients with
loss of cephalic support of the alar cartilages, grafts
can support the external nasal valve and assist in
pushing the tip caudally. These can be secured to the
remaining lateral crural cartilage using absorbable
suture through the vestibular skin. They are placed
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AB
Figure 7-1. Hereditary short nose
lengthened by placement of an
infratip lobule septal cartilage graft.
laterally into a pocket created to support the graft
just outside of the piriform aperature.
Tip grafts add length and aid in the contouring of the lobule. This is especially important in
patients with exaggerated double breaks or deficits
in the infratip lobule. Tip grafst are generally placed
so that they add projection to the nose as well as give
more fullness to the infratip area. Specific grafting
techniques, such as cap grafting, can be powerful
tools in lengthening the infratip lobule. If the lobule is poorly supported or deficient, reinforcement
through strut grafting in the columella and on the
alar cartilages may be necessary. Once the support
is in place, cap grafts are placed. Cap grafts can also
be used to provide additional length on top of shield
grafts and in addition to other types of tip grafting.
They also allow the surgeon to contour the tipdefining points in a precise manner.
For patients with pinched tips or narrow lobules, a blocking graft can be used. Blocking grafts
are placed between the domes prior to double-dome
suturing. Blocking grafts allow width to be placed
between the dome-defining points. They can also
serve as a base for cap or shield grafting in the lobule. These grafts are secured with 6-0 PDS suture.
Case Studies
Hereditary Short Nose
The heriditary short nose can present in many
different ways. Many patients have syndromic
anomalies that caused poor midfacial and nasal
development. Others simply have isolated findings
that can be found throughout their family. Patients
with syndromic anomalies have multiple findings
that are beyond the scope of this chapter and are not
discussed. We focus on the isolated deformity and
present our techniques for correction.
The patient in Figure 7-1 has a hereditary short
nose that exhibits several problems. Analysis of the
upper and middle third reveals she has a relatively
deep nasofrontal angle that is exacerbated by a slight
dorsal bony and cartilaginous hump. This gives
the nose the appearance of being short due to the
disconnected line drawn from the forehead. There
should be a smooth transition of the line drawn from
the forehead to the nasal tip. The lower third of the
nose, or nasal tip, also shows several abnormalities.
Analysis of the nasolabial angle shows the tip is a little over-rotated. There is a deficiency of the infratip
lobule and and poor tip definition over all. The double break in the infratip area is poorly defined. Also,
the supratip break is almost nonexistent.
The patient underwent an external columellar
approach rhinoplasty. (Generally, we use a high septal transfixion incision to gain acess to the nasal septum for graft harvest. Unlike a complete transfixion
incision, this incision protects the tip from forces
that can result in deprojection.) The upper third of
the nose was corrected with dorsal bony and cartilaginous hump reduction. The low radix was corrected with a morselized radix graft fashioned from
septal cartilage. The main focus was then placed on
the tip, where cephalic trim of the lower lateral cartilages as well as single- and double-dome suturing
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Figure 7-2. Intraoperative placement
of a shield graft to lengthen nose.
A
were performed for definition. Length was achieved
through the use of a thick shield graft (Figure 7-2).
At the same time, this graft also gained more definition of the infratip lobule.
The next patient had a similar hereditary short
nose but with different findings (Figure 7-3). The
upper and middle thirds of the nose were deficient.
This deficiency created the illusion of a short dorsum, again secondary to the low “takeoff ” point
from the forehead. The over-rotation of the tip
added to this problem.
The patient underwent an external columellar approach with access to the septum through a
complete transfixion incision. An identified over-
B
projection and over-rotation of the tip can be helped
if the tip is allowed to settle across the anterior septal angle. The dorsum was augmented with a septal
cartilage dorsal onlay graft that extended up onto
the nasion. Refinement of the tip was accomplished
through cephalic trim of the lower lateral cartilages,
single- and double-dome mattress sutures, and
finally a conchal cartilage tip graft to add additional
length to the infratip (Figure 7-4).
Another excellent technique for strengthening
the dorsal and caudal septum as well as positioning of the nasolabial angle is called the DARTT
technique. Described in 1997 by Dyer and Yune,
dynamic adjustable rotation tip-tensioning
Figure 7-3. Hereditary short
nose with upper and middle third
deficiencies corrected by septal
cartilage dorsal onlay graft and
double layered tip/shield grafts.
AB
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Septal Cartilage Onlay Graft
Conchal Cartilage
Tip Graft
Figure 7-4. Rhinoplasty diagram with dorsal graft and a double layered conchal cartilage tip graft to increase
nasal length.
technique (DARTT) has proven to provide strength
to the nasal tip in secondary rhinoplasty.8 A columellar strut graft is sutured to the medial crura as
the base for the tip support, which is then secured
to septocolumellar interposition grafts. The tip is
then extended with a double hook placed beneath
the domes. The tip can then be precisely placed into
the correct projection and rotation by securing the
tip unit to the septum. An increase of tip support by
70% has been documented.
Figure 7-5 shows a patient with a deficiency of
the dorsum, low radix, and over-rotation of the tip.
He is a good candidate for the DARTT technique
with extended spreader grafts used to “push” the
nasal lobule caudally via the columellar-medial
crural strut to connect addressing the deficiency
of the dorsal height and overly short caudal septum. The radix is low, creating a deep nasofrontal
angle. There is a defiency of the dorsum extending
down onto the tip with upward rotation, and alarcolumellar disproportion. On frontal view, the nose
appears narrow in the upper two-thirds with a bifid
tip causing separation of the tip-defining points
(Figure 7-6).
AB
Figure 7-5. Patient with an
overly low dorsum, low radix, and
over-rotated tip, and retracted
columella giving the appearance
of a small, short nose.
Figure 7-6. Frontal view with a poorly
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defined upper two-thirds, retracted
columella, too much nostril show and
a long upper lip. Very short nose in
reference to the other thirds of the face.
Lengthening the Short Nose / 95
AB
Again, we used an external columellar approach
in order access the tip and dorsum for grafting and
suturing. The dorsum was corrected with an onlay
sandwich graft using both septal cartilage and GoreTex. This provided a good “takeoff” point of the
nose, raising the nasion.
Extended spreader grafts were placed to add
width to the middle vault and were sutured in
place with 5-0 Monocryl. The tip was refined with
a cephalic trim of the lower lateral cartilages as well
as single- and double-dome mattress sutures. An
alar-spanning suture allowed the convex surface
of the lateral crura to be brought inward, further
narrowing the tip. Additional length was added
using an infratip shield graft. Support of the tip
and augmentation of the columella were accomplished with the columellar strut graft and a
plumping graft at the apex of the nasolabial angle
(Figure 7-7).
Predevelopmental/Posttraumatic
Short Nose
Some have undergone surgery or experienced
trauma to the nose in childhood. The cartilaginous
septum is known to be an important growth center
for the nose. Frequently, if children sustain an injury
to the nasal septum that causes cartilage damage or
destruction, the overall development of the nose is
changed.9 Underdevelopment can also be caused
by iatrogenic injury secondary to nasal surgery or
nasal septal surgery in childhood. The patient in
Figure 7–8 had sustained significant trauma to the
nose and septum as a child, resulting in underdevel-
opment of the nasal dorsum. The patient had relatively normal development of the lower third of the
nose and under development of middle third of the
nose. The result was a short nose appearance, with
an over-rotated and under-projected tip. The patient
also had a deficiency in the normal columellar show,
giving her a deep nasolabial angle. This deficient
base to the nasal tip and columella was augmented
by a Goretex premaxillary graft.
She underwent an external columellar approach
rhinoplasty (Figure 7-9). The dorsum was augmented with temporalis fascia wrapped around
conchal cartilage grafts. The augmentation extended
distally to just beyond the anterior septal angle in
order to assist in de-rotation of the nasal tip as well
as in preventing additional upward rotation. Her
nasal tip was refined by performing a cephalic trim
of the lower lateral cartilages in addition to singledome mattress sutures. Additional length was
gained by using a shield graft at the infratip lobule.
As a result, the patient obtained excellent lengthening and projection of the nose (Figure 7-10). The
plumping graft appropriately filled in the nasolabial
angle and the nasal tip was returned to a more normal rotation.
Iatrogenic Short Nose
One of the most common causes of the short nose is
seen in patients who have undergone previous rhinoplasty. Problems can be caused by aggressive resection of the bony and cartilaginous dorsum in the
upper two-thirds of the nose and by over-resection of
cartilage and loss of support in the lower third. The
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A
Dorsal Onlay Sandwich
5-0 Monocryl
Goretex
5-0 Clear Prolene
5-0 Dexon
Tip Graft
Plumping Graft
Strut
B
Figure 7-7. (A) rhinoplasty diagram showing dorsal augmentation with septal cartilage and Gore Tex layered
onlay graft, a double infratip shield graft and bilateral extended spreader grafts connected to columellar strut,
to increase nasal length derotating the entire lobule. (B) Interoperative photo of extended spreader graft pushing
columellar strut-lobular complex caudally.
Figure 7-8. Post traumatic short nose
with underdeveloped nasal dorsum,
retracted columella, over rotated tip, mid
AB
facial weakness and acute nasolabial
angle and underdeveloped nasal base.
Temporalis fascia
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graft wrapped
around conchal
cartilage graft.
Around Conchal
Cartilage Graft
5-0 Monocryl
Tip Graft
Goretex
Premaxillary Graft
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Figure 7-9. Rhinoplasty diagram showing temporalis fascia wrapped around conchal cartilage onlay dorsal
graft augmentation and shield graft at the infratip lobule to increase length and derotation of the nose. GoreTex
premaxillary graft placed to provide basal projection to the nasal base.
patient in Figure 7-11 was found to have had overresection of the caudal septum and over-resection of
the alar cartilages, with loss of tip projection.
The patient required total reconstruction of the
lobule using alar replacement conchal cartilage grafts
(Figure 7-12). Some surgeons suggest the use of
costal cartilage in patients like this. Costal cartilage
has the main advantage of being an excellent source
of hyaline cartilage in large quantities. Its disadvantages include the addition of a scar to the anterior
lower chest, a small possibility of ruptured parietal pleura, and the tendency for cartilage warping.
Figure 7-10. Postoperative
views showing correction of post
traumatic short nose deformity.
AB
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