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and function, and to predict the long-term outcome, while minimizing the risk of complications.
It is important that the operative plan incorporate the least-invasive intervention and the shortest operative time to achieve an operative result
that satisfies the patient as well as the surgeon. The
increasing use of grafts in the middle nasal vault and
internal and external nasal valve areas has resulted
in a larger percentage of cases carried out through
the external columellar approach in the more open
rhinoplasty fashion.
Experience has shown that it is paramount to
establish a structural foundation for the midnasal
vault, which can prevent later inward contracture of
the upper lateral cartilages.6 Recognizing anatomical variants, such as cephalic malposition of the alar
cartilages,7 which leave inherent weakness in the
alar margins and external nasal valve, has led to the
increased use of alar batten and strut grafts to prevent external nasal valve collapse and inward recurvature of the lateral nasal alar walls.8 Although some
of these grafts can be placed through endonasal
approaches, most of the time it is far easier to place
the structural grafts through an external columellar
approach, suturing them in position and ensuring
that the grafts stay in the proper position.
Understanding tip support and tip dynamics is
critical to a successful outcome in any rhinoplasty
operation. It doesn’t matter whether one uses an external columellar approach or an endonasal approach
when maintaining tip support and projection: both
approaches require reconstruction and support for
tip-support mechanisms that may be interrupted in
the rhinoplasty operation or the approach itself.9 It
is this author’s philosophy that aligning the profile in
a predictable, predetermined fashion is the primary
maneuver that should be accomplished, thus allowing one to appropriately adjust the tip projection to
complement and to be harmonious with pyramid
height. This can often be done endonasally, but it may
be necessary to place an extended tip graft to increase
tip projection substantially, and this is much easier to
perform and suture in place using the external columellar approach. All these points are emphasized in
the discussion of the graduated approach to the various problems one sees in the preoperative condition
of the tip and the lobule. The nature of the midnasal
vault and the length of the nasal bones will also dictate whether an external columellar approach is indicated when otherwise an endonasal approach would
be satisfactory to accomplish the predetermined
goals of nasal tip plasty.
5
Consultation
The evaluation of each individual patient starts
with a conversation in the initial consultation. It is
important first to listen to the patient and to understand what bothers the patient and what the patient
desires as the outcome of the proposed rhinoplasty.
The patient’s concerns and goals may be obvious,
or they may be different from what the surgeon
perceives on initial examination. The consultation
with the patient requires a detailed evaluation of the
patient’s concerns, desires, and history. A history of
significant trauma to the nose or of previous surgery is critical in determining the type of surgery
that will be required and the approach needed to
accomplish the surgical goals. A preoperative nasal
evaluation sheet is very helpful in documenting the
aesthetic and physical evaluation of the nose (Fig-
ures 2-1 and 2-2).
Preoperative Examination
and Analysis
When it involves the lobule, the preoperative analysis is very important in determining the problem with the tip and in planning the appropriate
approach and technical maneuver for aesthetic correction. The surgeon evaluates whether the tip is
bulbous, broad, wide, boxy, bifid, trapezoid, twisted,
asymmetrical, amorphous, infantile, over-projected,
under-projected, under-rotated, or over-rotated.
Evaluation of the tip is based on visual inspection,
palpation, and photographic analysis.1 Palpating the
nose determines the nature, volume, strength, and
resiliency of the lobular cartilages themselves.
In addition, the surgeon can assess the contribution of the anterior septal angle and its fibrous connections to the lobular support, which is critical to
the surgical plan. The thickness of the skin envelope
is also extremely important. It is worth noting that
thin skin shows the defined relief of strong alar cartilages or any postoperative alterations in these cartilages, whereas very thick skin not only may obscure
postoperative anatomical alterations, but also may
otherwise prevent achieving the desired aesthetic
result no matter what technique or approach is used.
Equally important is the presence of columellar distortions, such as a hanging, retracted, angulated, or
twisted medial crura. Evaluation of the base of the
columella at the nasal spine will reveal whether the
tip is over-projected or under-projected in relationship to an overly prominent nasal spine or if there is
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Figure 2-1. Preoperative nasal evaluation sheet (front).
a tension nose related to an overgrowth of the nasal
septum. It is important to determine whether or not
the tip is “hanging” from the nasal septal angle or
is supported on its own by the strength of the alar
cartilages themselves. If the alar cartilages are positioned more cephalad,7 there is less cartilaginous
support to the lateral nasal walls and predictably
retraction, pinching, and inward recurvature will
likely result if no support is added (Figure 2-3).
The alar cartilages may be convex, concave, rolled,
flattened, wide, or narrow. The lateral alar cartilages may be long themselves, creating a dependent
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Figure 2-2. Preoperative nasal evaluation sheet (back).
lobule or under-rotated nose. The medial crura may
be relatively short and the medial crural feet may
not even be supported by the base of the columella
at the anterior nasal spine. In such situations, the tip
may lose significant support when released from the
nasal septum at the septal angle.
Choosing the Appropriate
Surgical Approach
The length of the nasal bones, the prominence of the
nasal hump, and the width or strength of the upper
lateral cartilages are significant in determining the
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ABC
Figure 2-3. Preoperative frontal view and base view of patient with cephalically malpositioned alar cartilages.
amount of surgery required and the approach that
will be necessary to carry out the surgical maneuvers.
If a patient presents with a large, projecting nasal
hump and an overly narrow nasal pyramid and short
nasal bones, there is a high probability of inward contraction and late deformity of the middle nasal vault
if it is not supported at the time of primary surgery6
(Figure 2-4). Evaluating the extent of the deviation
of the nose and to what extent the deviation of the
septum relates to the deviation of the nasal pyramid
and lobule is important in deciding how much septal surgery will be required to correct the crookedness, while maintaining mid-dorsal support. The
septum might be so deviated that a caudal approach
to septoplasty is either impossible or extremely dif-
ficult and a dorsal approach would be more efficacious in correcting the caudal septal deformity. The
external columellar incisional approach affords the
surgeon a more facile way of accomplishing dorsal
septal straightening and supporting it with spreader
grafts. If a great deal of grafting in the nose will be
required to obtain a newly supported functional and
aesthetic result, an external columellar approach
might be required to adequately suture the grafts in
place. In general, the use of the external approach
has increased significantly in primary rhinoplasty
because of the need for additional grafting, not only
to correct the preoperative condition, but also to prevent later aesthetic and functional problems related
to surgical maneuvers performed in the primary
Figure 2-4. Patient with a tall
hump, very narrow and short nasal
bones, and thin skin.
AB
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rhinoplasty.6 The increased use of spreader grafts to
maintain midnasal vault integrity and the increased
use of alar strut grafts placed on the vestibular side of
alar cartilages are two such examples.
10
Photographic Documentation and
Computer Imaging
As part of the initial consultation process, during
which a thorough history is taken and a physical evaluation of the patient is obtained and documented,
a series of standard preoperative photographs are
obtained.11 Photos for computer imaging analysis
are obtained simultaneously so that the surgeon can
show the patient a computerized simulation of the
proposed postoperative result.
Computer imaging is extremely helpful in patient
education and in determining the patient’s expectations. Providing a simulation of the predicted aesthetic results has occasionally resulted in a patient’s
electing not to have surgery because the predicted
results were not as dramatic as the patient hoped
to achieve considering the amount of effort and
expense involved in undergoing the procedure. As
in any cosmetic procedure, in rhinoplasty it is vitally
important that the patient be committed not only
to the extent of the postoperative recovery, but also
to the cost involved. Unrealistic expectations about
the results can leave the patient unhappy, despite an
otherwise satisfactory operative outcome.
Furthermore, because computer imaging enhances communication with the patient about the
expected results and the potential results achievable, the surgeon can learn the patient’s desires
about profile relationships, which may or may not
mirror the surgeon’s preference. Computer imaging
also helps allay any fears the patient may have that
he/she will not “look like myself”once after surgery,
even though the patient strongly desires modification and improvement of the nose’s appearance.
12
Surgical Approach
Non-delivery Approach
Approximately 1%–2% of rhinoplasties in the
author’s practice are performed with a non-delivery
endonasal approach. The inherent nature of the tip,
infratip lobule, and facette area may require minimal to no modification and only minor cephalic
volume reduction. These cases lend themselves to a
retrograde,modified transcartilaginous13 approach
Figure 2-5. Delivery of bipedicled chondrocutaneous
alar cartilage flap.
to trim the cephalic margin of the alar cartilages and
otherwise not disturb and undermine nasal tip skin.
Delivery Approach
Access for the delivery of the alar cartilages involves
bilateral marginal and intercartilaginous incisions2
(Figure 2-5). The intercartilaginous incision at
the limen vestibuli is connected with a high septal
transfixion incision. The septal transfixion incision
is completed posteriorly anterior to the nasal spine,
releasing the medial crural feet from the septum if
deprojection is desired. Otherwise it is not completed posteriorly if the projection is to be maintained or increased. These parallel incisions are used
to deliver bipedicled chondrocutaneous flaps, which
are the alar cartilages with the vestibular skin. The
approach is particularly easy to perform in primary
rhinoplasty in which no undermining has been performed previously over the alar cartilages.
External Columellar
Incisional Approach
The external columellar incisional approach involves
the placement of an incision somewhere across the
base of the nose and the columellar skin, connecting the internal nasal incisions. The author prefers
the inverted “V” columellar incision described by
Rethi14 (Figure 2-6). This incision is placed at the
junction between the lower two-thirds and upper
one-third of the columella and is connected carefully
to the marginal medial crural incisions. The indications for an external columellar incisional approach
in primary rhinoplasty have increased significantly
the past 25 years. Whenever a patient demonstrates
an anatomical problem in the nasal lobule requir-
Figure 2-6. Base drawing of “inverted V” columellar
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incision.
ing significant tip grafting for under-projection, an
overly shortened nose, alar collapse, or an asym-
metrical tip, the author uses the external columellar
approach. Significant over-projection has also been
an indication for the external columellar approach
to maintain structural integrity of the lobule, since
it is being markedly reduced. Soft nasal lobular
cartilages of the infantile type, which lack any real
inherent support, have necessitated an external
columellar approach to add structural grafting. In
approximately 80% to 90% of cases where there is
a hump to be removed, the author places spreader
grafts in the midnasal vault, which stabilizes the
midnasal vault and prevents late inward contraction
and hourglass deformities. With recognition of lat-
eral alar weakness and the possibility of alar collapse
in the postoperative period,8 many more alar strut
grafts10 are placed in primary rhinoplasty, and this is
much more efficaciously performed via an external
columellar incisional approach.
Augmentation of the nasal dorsum with alloplastic materials, such as Gore-Tex®, is better performed
through an external columellar incision, which
separates the incision from the dorsal implant and
prevents late exposure and potential infection.
If a large rib graft augmentation is to be used, an
external columellar incision makes placing the rib
graft much easier, particularly when it is supported
through an L-shaped columellar strut. Finally, it is
sometimes necessary to convert an endonasal rhinoplasty approach to an external columellar open
approach in the middle of the operation if signifi-
Primary Rhinoplasty / 13
cant asymmetries and/or anatomical variances are
encountered and the surgeon is having difficulty
modifying the alar cartilages endonasally.
The Order of the Procedures
Performed in Primary
Endonasal Rhinoplasty
It is important to determine the order of the procedures in any surgical operation. The predicted plan
is important for achieving the entire surgical goal
and for keeping the surgery efficient and operating
time to a minimum. The order of procedures in an
endonasal approach to rhinoplasty is:
1. Access incisions
2. Deliver the alar cartilages
3. Trim cephalic margins of alar cartilages as indicated, removing the dorsal profile component
of the alar cartilages
4. Shorten the caudal septum, if appropriate
5. Perform septoplasty or harvest septal cartilage
for grafting purposes
6. Expose the dorsum and perform profile plasty
7. Place spreader grafts, if indicated (even in the
endonasal approach)
8. Place alar batten or strut grafts, if required
(even through the endonasal approach)
9. Perform single and double-dome suturing as indicated in graduated fashion with final tip modification
10. Place columellar strut and stabilize the medial
crura
11. Perform medial, followed by lateral, osteotomies
12. Place onlay, radix, or “crushed” cartilage grafts
on the nasal dorsum
13. Close intercartilaginous and columellar intranasal incisions
14. Insert alar rim grafts
15. Place infratip lobular soft-tissue tip grafts or
morselized plumping grafts as indicated
16. Narrow alar base
17. Apply dressings
The order of procedures in an external columellar approach is slightly different. Depending on the
need for increasing or decreasing tip projection, it is
imperative to set the nasal dorsum to the appropriate level, then perform the final tip maneuvers with
sutured-on grafts to achieve the appropriate profile
relationship. It is important to place spreader grafts
before the lobuloplasty. It is also noted that a strut
graft is placed directly between the medial crura
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Figure 2-7. Placement of columellar strut graft
through external columellar approach.
and sutured into position prior to tip refinement
and double-dome tip techniques (Figure 2-7). After
double-dome and single-dome treatments are performed in an external columellar approach, one can
place an alar-spanning suture to further narrow the
supratip lobule (Figure 2-8). Any alar strut grafts
are placed initially after cephalic margin resection,
then they are sutured in place prior to any further
tip modifications. In the event the patient has thin
skin and one is trying to camouflage sharp angles
at the nasal domes or tip grafts in place, soft-tissue
grafts can be sutured in place as the last maneuver
prior to redraping the nasal tip skin and suturing
the columellar incision. The columellar incision is
closed first, and then the marginal incisions after
that.
Tip Support and the Incisional
Approach to the Nose
Although many of the incisions required for access
in the endonasal delivery flap approach to rhinoplasty weaken the support of the nasal lobule and
potentially decrease tip projection15 (Dyer, unpublished manuscript, “Tensegrit”). Restructuring the
nasal lobule with double-dome suture techniques,
suturing the incisions, and providing strut support
to the columella compensate for the loss of support
from the incisions alone.16 It has always been the
author’s philosophy that if the surgeon is required
to interrupt any of the tip-supporting mechanisms1
to accomplish the functional and aesthetic result,
then one must realize the need to reconstruct or
compensate for the loss of support. It is not that the
surgical approach is dictated by whether the supporting mechanisms must be interrupted; rather,
the surgical approach is dictated by what needs to
be accomplished.
Figure 2-8. An alar-spanning suture placed through
the external columellar approach.
Profile Plasty
Before any of the final modifications to the nasal
lobule and domes are made, but after the cephalic
margin of the lower lateral cartilages has been
trimmed appropriately, profile plasty is performed.
Because the alar cartilages contribute to the dorsal
profile, it is important to take care of the cephalic
portion of the alar cartilages before judging the
amount of cartilaginous dorsum that needs to be
reduced. Reduction of the nasal profile needs to be
extremely conservative, based on the desires of the
individual patient, the surgeon’s aesthetic goals, and
the patient’s individuality, ethnicity, and heredity.
The aesthetics are dictated by the surgeon’s concept of the harmonious balance of the overall facial
profile, by the prevailing social concept of beauty,
and by the patient’s own desires. Furthermore, conservative reduction of the nasal profile has proven
to yield stable long-term results in rhinoplasty.
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AB
Figure 2-9. (A) Preoperative lateral view prior to hump reduction. (B) Postoperative lateral view of patient with
iatrogenic saddling of nasal dorsum after hump reduction without the use of spreader grafts. (C) Postoperative
lateral view of a patient with saddle deformity and depressed ULC’s corrected with spreader grafts and onlay ear
cartilage grafts covered with temporalis fascia.
Significant reduction of the midnasal profile or
midnasal vault for an immediate result has proven
to be an over-reduction in the profile alignment 5 to
10 years later, particularly if it is not supported with
spreader grafts (Figure 2-9).
Reduction of the Cartilaginous
Dorsal Pro le
An important criterion in reducing the cartilaginous
profile is to maintain the integrity of the mucoperichondrium. The first maneuver performed prior to
reducing any cartilaginous dorsum is to undermine
the mucoperichondrium from the under surface of
the upper lateral cartilages as they join the septum.
The upper lateral cartilages are then sharply separated from the dorsal septum as a separate maneuver
rather than an en bloc resection. The cartilaginous
septal profile is then reduced independent of the
upper lateral cartilages. Separating the upper lateral
cartilages from the septum and making the pocket
for spreader graft placement has been helpful to
maintain the width integrity of the midnasal vault
and the internal nasal valve. By preserving the upper
lateral cartilages prior to any lowering or trimming,
the cephalic redundant portion of the upper lateral
cartilages may be used as “auto spreaders”
between the upper lateral cartilage and the septum.
By placing spreader grafts or auto spreader grafts,
it is possible to stabilize the midnasal vault and to
17
placed
prevent inward contracture of one or both upper
lateral cartilages for long-term healing.
Reduction of Bony Dorsal Pro le
After reducing the cartilaginous profile, but prior
to placing spreader grafts, one normally uses sharp
osteotome reduction of the bony hump. Occasionally, rasping is all that is required, but a sharp reduction using the Cinelli osteotome with blunt tip guards
on either side is very effective and safe for reducing
the bony hump. Rasping is used most commonly
to smooth out rough edges on the nasal bones after
they have been sharply reduced with the osteotome.
In the past several years, the frequent use of radix
grafts has allowed an overall lesser reduction of the
bony and cartilaginous profile, still maintaining
balance and improving the overall aesthetic profile
result.18 Less reduction of the cartilaginous profile,
while achieving a more desirable nasal profile angle,
leads to a more functional and improved long-term
cosmetic result.
Dorsal Augmentation
Improving the dorsal profile less frequently
involves dorsal augmentation for relative and true
C
Radix Grafts
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Figure 2-10. Gore-Tex® sheeting for dorsal
augmentation.
curvature of one upper lateral cart ilage. Etiolog ies
include posttraumatic deformity, iatrogenic
injury from previous surgery, or developmental
abnormality.
2. Bilateral inward curvature of upper lateral
cartilages with “hourglass” appearance; most
commonly iatrogenic, but can be natural.
3. Extremely narrow pyramid with a tall dorsal
hump, thin skin, and short nasal bones.
4. Prophylaxis of delayed contracture deformity
of the upper lateral cartilage–nasal bone junction.
5. Use of bilateral spreader grafts as a cantilever to
lengthen an overly rotated lobule.
saddle-nose deformities. Use of implants for dorsal
augmentation has enhanced the overall aesthetic
results of rhinoplasty. In most cases, the use of autogenous rib cartilage can be avoided as a primary graft.
Septal cartilage is the first choice in most patients.
The author’s materials of choice for dorsal augmentation for saddle-nose deformities are: (1) septal
cartilage graft, (2) conchal cartilage, with or without
temporalis fascia overlay graft, (3) Gore-Tex sheeting (1 mm or 2 mm, which can be layered), or (4)
costal cartilage, more rarely. It is always good surgical practice to avoid the use of alloplastic materials in
the nose if at all possible; however, implant material
like Gore-Tex® (polytetrafluoroethylene) as a dorsal augmentation material has proven to be safe and
effective in minimizing the morbidity of extended
operations to obtain further grafting materials19
(Figure 2-10). Gore-Tex® may be preferable to rib
graft when a small layer is all that is required to finetune the augmentation overlying previously placed
septal and/or conchal cartilage grafts. Gore-Tex®
has the added benefit of allowing a smooth transition from grafted areas to non-grafted areas.
Although placement of spreader grafts can be
performed endonasally, and, in some cases with
minimal cartilaginous reduction, an isolated submucoperichondrial pocket is constructed and the
graft is easily placed and stabilized endonasally, it
is much more common that an external columellar approach is so that the spreader grafts may be
sutured in position under direct vision both caudally and cephalically (Figure 2-11).
Osteotomies
The author’s preferred technique for osteotomies
involves completing medial osteotomy with or
without hump removal using a 6 mm curved
Spreader Grafts
As noted previously, the use of spreader grafts has
become extremely common in primary rhinoplasty,
particularly for dorsal profile reduction. Over 80%
to 90% of patients with significant bony and cartilaginous humps will require spreader grafts to
maintain stability to the midnasal vault. In addition,
patients with a crooked nose or curved dorsal frontal profile benefit from unilateral spreader grafts to
camouflage and correct the visible curvature.
The indications for spreader grafts are:
1. Unilateral asymmetry and deviation of the
middle nasal vault with infrastructure or inward
20
Figure 2-11. Bilateral spreader grafts in place,
stabilizing the midnasal vault.
Primary Rhinoplasty / 17
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osteotome transmucosally (internally) through the
nasal vault.
When the medial osteotomies are complete,
a #15 blade is used to make an incision just superior to the anterior end of the inferior turbinate,
superior to the piriform aperture. Subperiosteal
elevation of the mucoperiosteum forms a “tunnel”
for the guarded Nievert osteotome on the medial
surface of the nasal process of the maxilla and nasal
bone. This is a submucosal periosteal elevation on
the internal aspect, not the lateral aspect, of the
nasal bone. When it is completed, a guarded Nievert
osteotome is used with the guard oriented internally
and the outward, sharp, pointed edge beveled off at
a 45-degree angle.
Tip Grafts
Tip grafts are septal or conchal cartilage, nasal fibrofatty soft tissue, and, occasionally, alar cartilage
cephalic margin. Tip grafts are used for camouflage,
effacement of interdomal bifidity, alar stabilization,
infratip lobular definition, lengthening, and projection. The types of tip grafting the author uses are
(1) single- and double-dome shield grafts, (2) cap
grafts, (3) blocking grafts, (4) blanket or soft-tissue
onlay grafts, (5) infratip lobule grafts, and (6) Peck
grafts.21 A Peck graft is a graft placed on top of the
nasal dome, giving more height and definition.22 A
cap graft is placed in the infratip lobular area, often
on top of a shield graft, giving more infratip lobular length. A blocking graft, which is often used to
prevent cephalic rotation of a shield graft and to fill
in supratip dead space, can also double as an alarspanning graft (Figure 2-12).
Specific Tip-Sculpting Techniques
Graduated Approach
Using primarily the endonasal delivery flap approach, but also when using the external columellar approach, it is the author’s practice to modify
and sculpt the nasal tip and lobule in a graduated
fashion. The graduated approach to rhinoplasty23
involves: (1) trimming the cephalic margin of
the lower lateral cartilage, (2) individual domenarrowing techniques, (3) double-dome unit suturing procedure,16 (4) lateral crural flap,24 (5) dome
division, (6) Lipsett maneuver,25 and (7) alarspanning suture.
Single- and DoubleDome Tip Sculpting
The individual treatment of a dome to narrow and
gain definition involves (1) a slight pinch of the
dome with the Griffith’s Brown forcep, (2) beveling the cephalic edge of the single-dome unit, (3)
suturing the single dome together with a 5-0 Dexon
mattress suture (Figure 2-13), (4) incising or scoring the single-dome unit for definition, (5) complete
dome division for narrowing and rotation (Figure
2-14), or (6) dome truncation for de-projection.
Before the 5-0 Dexon suture is placed for individual
dome narrowing, the vestibular skin on the undersurface of the alar domes is dissected free from the
cartilage so that no vestibular mucosa or epithelium
is caught within the single-dome or double-dome
mattress suture, which allows better scarification
and maintenance of the new, narrow, single dome.2
The double-dome tip-sculpting technique allows
the domes to be treated individually, which might
be different for each dome or crus, before they are
then reconstituted into a single tip–lobular complex.
26
Figure 2-12. Tip grafts: Tip columellar shield graft
with a cephalic blocking graft.
Operative Effects or Results that
are Achieved by Sutured Double-
Dome Tip Surgery
De nition and Narrowing of the
Bulbous, Broad, or Amorphous Tip
Broad or Wide Tip
To achieve definition and narrow a broad or wide
tip, the endonasal delivery flap approach is used
and each dome is narrowed with a single 5-0 Dexon
suture and the double-dome unit is reconstituted
with a 5-0 clear Prolene transdomal mattress suture
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