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38 / Tip Rhinoplasty
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de-projection by disrupting the attachment of the
medial crural footplate to the caudal septum; once
appropriate de-projection is achieved via the complete transfixion incision, the medial crural footplate is reconstituted to the caudal septum with
3-0 chromic gut suture. If further de-projection is
required, the individual dome sutures are placed;
then, the entire dome is truncated or excised with
a #15 blade. Following this maneuver, the entire
dome is reconstituted with the transdomal suture. A
soft-tissue onlay graft or morselized cartilage graft is
then used to camouflage the tip.
Techniques to Increase Tip Rotation
A graduated approach is used to provide rotation
of the tip.6 Evaluation of the anterior septal angle is
performed first. If this is not deficient, then one may
excise the anterior septal angle with its corresponding vestibular skin to provide upward rotation of
the nasal tip. Another method of providing modest
upward rotation of the nasal tip as well as tip support is placement of the columellar strut. The columellar strut is routinely used to provide tip support
and to restructure the medial crural component of
the nasal tip tripod. The strut is positioned between
the medial crura and extends from the anterior
nasal spine to the junction of the medial crura with
the intermediate crura. In order to avoid an unnatural flattening of the columella-lobular double break,
one should avoid suturing the normally divergent
intermediate crural caudal margins.
If more rotation is needed, a lateral crural flap
is performed. First, the underlying vestibular skin is
mobilized from the lateral crus. Then, the lateral crus
is vertically divided approximately 10 mm lateral to
the dome. The nasal tip is repositioned to achieve
the necessary upward rotation and the overlapping
margins of the lateral crus are then secured with two
transcartilaginous horizontal mattress sutures using
5-0 polydiaxanone (Figure 3-4).
Techniques to Decrease Rotation
If the nasal tip requires de-rotation, the posterior caudal septal angle can be excised. Otherwise,
extended spreader grafts used as cantilevers will
push the entire lobular complex more caudally, thus
providing decreased rotation. Prior to placement of
the extended spreader grafts, mucoperichondrial
flaps are elevated between the junction of the nasal
septum and upper lateral cartilage, thus creating a
pocket within which the spreader grafts are placed.
The extended spreader grafts are then sutured to the
upper lateral cartilage and septum in a horizontal
mattress fashion with 5-0 polydiaxanone.
Special Considerations
Cephalic Malposition of the Lower
Lateral Cartilage
Cephalic malposition of the lower lateral cartilage
may predispose the patient to inward collapse or
recurvature as a late consequence of surgery. To
avoid this, alar strut grafts are placed. The alar strut
graft is placed in a pocket between the lateral crura
and the vestibular skin; it extends from the piriform aperture laterally to at least two-thirds of the
length of the lateral crura. Although this graft may
be placed via an endonasal rhinoplasty, an external
rhinoplasty affords the surgeon the opportunity to
develop the pocket from the cephalic margin of the
lower lateral crus, thus making it easier. The graft is
sutured directly to the lateral crus with 5-0 Monocryl™; then the vestibular skin is repositioned with
5-0 Dexon™ (Figure 3-5).
External Valve Collapse
In a patient who demonstrates external valve collapse, an alar batten graft is sutured as an onlay
to the weak lateral crura; a curved portion of the
cymba conchae is an ideal source for this graft. The
graft is secured into position with non-absorbable
suture in a mattress fashion through the graft, lateral
crura, and vestibular skin (Figure 3-6).
Alar Rim Graft
Whereas significant alar retraction may require an
auricular composite graft, mild alar retraction is
effectively treated with an alar rim graft.7 This is
placed at the end of the procedure through a small
incision made slightly caudal to the caudal margin
of the lower lateral cartilage. Then, a 2 mm pocket
is created along the rim of the nostril and a linear
piece of cartilage is placed in the pocket, thus adding
strength to the slightly weakened or retracted alar
rim (Figure 3-7).
If alar retraction is significant, then a composite
graft from the anterior surface of the cymba conchae is required and sutured to the edges of the marginal incision.
AB C
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Lateral crural flap
Tip Rhinoplasty / 39
D
Septal Cartilage
5-0 PDS
Lateral Crural Flap
Strut
E
Figure 3-4. (A), B) Lateral crural flap technique. After the lateral crus is separated from the vestibular skin, it
is vertically divided approximately 10 mm from the dome. Then, the tip is rotated upward to the proper position;
the overlapping segments of the lateral crura are then sutured in a mattress fashion with 5-0 polydiaxanone.
(C) A patient who would benefit from increased rotation. (D) Proper rotation is the postoperative result. (E) The
maneuvers performed during rhinoplasty, including lateral crural flap for increased rotation.
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A
B
CDE
5-0 Clear Prolene
5-0 Dexon
Spreader grafts
Bilateral alar struts
Alar Batten Strut
Alar spanning suture
Single and double
dome sutures
F
.
Columellar strut
Figure 3-5. Alar strut grafts are used to address the consequences of
cephalically malpositioned lateral crura of the lower lateral cartilage, as shown.
(A) A pocket is created between the lateral crus and vestibular skin. (B, C)
The alar strut graft is then placed in the pocket and sutured into position in a
mattress fashion. (D) Preoperative base view demonstrating cephalic malposition
of the lower lateral cartilage. (E) Postoperative base view demonstrating the
benefit of alar strut placement. (F) The maneuvers performed in the rhinoplasty
including bilateral alar struts. (G) Schematic drawing of alar strut placement.
G
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AB
Figure 3-6.
nasal valve. (B) Collapse repaired with
bilateral alar battens. (C) Drawing of
placement of alar batten.
(A) Preoperative collapsed
Postoperative Care
The postoperative dressing is applied as follows:
tan 0.5 in Micropore™ tape (3M™, USA) is used
for taping the nose and the tape around the lobule is pinched slightly to maintain hemostasis in
and around the lobule and supratip area. The small
brown nasal splint (Integra, USA) is used to provide
stabilization of the nasal pyramid and to maintain
the medial position of the nasal bones, if needed;
the splint is trimmed to size and bent manually to
accommodate the nasal bony pyramid (Figure 3-8).
A small ball of Surgicel® (Johnson & Johnson, USA)
is placed under each dome to re-approximate the
elevated vestibular skin and prevent small hematomas in this area. A short Telfa (Kendall, USA) dressing is placed at the aperture to collect expected nasal
drainage. No packing is placed.
C
Cold compresses are placed over the eyes and
dorsum of the nose for the first 36 hours. The
patient is seen on the first postoperative day and
the Telfa dressing is removed. Postoperative instructions include no heavy lifting, bending, straining,
or nose blowing. The patient is to avoid hot, spicy
foods for the first week after surgery because they
can initiate vasodilatation and epistaxis. The patient
is instructed to elevate the head of the bed to minimize not only postoperative edema but also the
risk of epistaxis. The patient is to clean the nasal
aperture with a cotton-tipped applicator soaked
in hydrogen peroxide followed by the application
of a petroleum-based product four times a day. If
an external rhinoplasty was performed, the patient
is instructed to cleanse the nylon sutures on the
columella with a cotton-tipped applicator soaked
in hydrogen peroxide followed by the application
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A
B
Hump removal
Spreader grafts
3.0 chromic
Spine resection
Crushed cartilage
onlay graft
Single and double
dome sutures
Bilateral rim graft
C
Figure 3-7. (A) Preoperative patient showing weakness of the alar rim. (B, C) After placement of bilateral
alar rim grafts to address the weakness of the alar rims, there is marked improvement seen in the postoperative
photograph.
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AB
Figure 3-8. Tan, 0.5 inch Micropore™ tape (3M™,
USA) is used for postoperative taping of the nose. The
tape around the lobule is pinched slightly to maintain
hemostasis in and around the lobule and supratip area
(A). The small brown nasal splint (Integra, USA) is
used to provide stabilization of the nasal pyramid and
to maintain the medial position of the nasal bones, if
needed; the splint is trimmed to size and bent manually
to accommodate the nasal bony pyramid (B, C). A
small ball of Surgicel® (Johnson & Johnson, USA) is
placed under each dome to re-approximate the elevated
vestibular skin and to prevent small hematomas in this
area. A short Telfa (Kendall, USA) dressing is placed at
the aperture to collect expected nasal drainage.
C
of a petroleum-based product four times a day. On
the fourth postoperative day, the columellar sutures
are removed. One week after surgery, the patient is
evaluated in the office, the dorsal splint is removed,
the nasal passageways are suctioned, and the patient
is provided with a copy of the preoperative photographs to reinforce the changes acquired through
rhinoplasty.
Complications
Immediate complications of rhinoplasty include
epistaxis and septal hematoma. In the event of
epistaxis, the patient is instructed to use oxymetazoline nasal spray to minimize the epistaxis. Indeed, if
the epistaxis persists despite conservative measures,
the patient will need to be seen by the surgeon; the
patient is evaluated for hypertension and light nasal
packing is used to control the hemorrhage and to
minimize trauma to the freshly operated nose. If
septal hematoma is identified, then incision, drainage, and subsequent splinting with silicone septal
splints may be required. Of note, mattress suturing of the septal flaps with 4-0 plain gut on a short
Keith needle has significantly reduced the incidence
of postoperative septal hematoma and obviated the
need for aggressive nasal packing.
Late complications include scar contracture,
which can shrink the skin envelope over the modified tip structure and result in a pinched appearance
of the nasal tip. This can be avoided by refinement
techniques and the use of alar strut grafts. For example, the thin-skinned patient undergoing rhinoplasty
benefits from camouflaging of the nasal tip with a
soft-tissue graft overlaying the tip-lobular complex.
If the lower lateral cartilages are in the cephalic position and/or there is inherent weakness to the lateral
crura, then placement of alar strut grafts may prevent the inward curvature of the alar sidewalls.
Supratip fullness can be treated with intralesional steroids. Intralesional steroids are helpful in
selected cases of thick skin or revision cases where
robust scar tissue is found in the supratip region.
Intralesional steroids are started 2 weeks postoperatively and repeated once, or at most twice, in the first
3-month postoperative period. Subdermal injection
(0.1–0.2 ml) of triamcinolone acetonide (10 mg/
ml) is used.
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Acknowledgments
The authors acknowledge Nancy A. Rothrock
for her assistance in the preparation of the digital
images used in this article.
References
1. Dyer WK. Nasal tip support and its surgical modification. Facial Plast Surg Clin N Am 2004;12:1–13.
2. Tardy ME Jr, Dayan S, Heck D. Preoperative
rhinoplasty: evaluation and analysis. Otolaryngol Clin
Am 2002;35:1–27.
3. Perkins SW. The evolution of the combined use of
endonasal and external columellar approaches to
rhinoplasty. Facial Plast Surg Clin N Am 2004;12:
35–50.
4. Perkins SW, Tardy ME Jr. External columellar
incisional approach to revision of the lower
third of the nose. Facial Plast Surg Clin N Am
1993;1:79–94.
5. Peck GC. The onlay graft for nasal tip projection. Plast
Reconstr Surg 1983;71:27–37.
6. Konior RJ. The droopy nasal tip. Facial Plast Surg Clin
N Am 2006;14:291–299.
7. Toriumi DM. New concepts in nasal contouring. Arch
Facial Plast Surg 2006;8:156–185.
Profile-plasty: The
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Bony and Cartilaginous
Nasal Vault
Stephen W. Perkins, MD and Henry D. Sandel, IV, MD
4
Surgical management of the nasal pyramid in cosmetic rhinoplasty often results in the most dramatic
aesthetic improvement, particularly in the profile.
Every patient has his/her own ideas about what type
of nasal appearance they desire. The most common
reason patients seek rhinoplasty is for a reduction
in the overall size of the nose and the desire for
hump removal. The second most common reason
patients seek rhinoplasty is related to the cosmetic
appearance of the nasal tip, followed by the need for
improvement in overall airway competence. Management and treatment of the bony and cartilaginous nasal vault directly involves two of these three
reasons.
Management of the bony and cartilaginous nasal
vault requires the surgeon to have a good understanding of the ideal nasal profile. Certain parameters have been identified with respect to dorsal
projection in relationship to the remainder of the
1
face:
1. The dorsal projection should be approximately
30 degrees from the vertical plane of the face
when the patient’s head is in the Frankfort
horizontal line.
2. The nasal frontal angle should be sufficiently
distinct yet not overly deep, and it should lie at
the same level as the superior palpebral crease.
3. There should be a suggestion of a dorsal
prominence at the rhinion in relationship to the
upper nasal dorsum.
4. There should be supralobular definition with
slight supratip depression.
5. The tip should be the leading point of the profile.
The dorsal profile is properly identified in the
true lateral view with the Frankfort horizontal
line being parallel to the ground (the line
connecting the infraorbital rim and the superior
aspect of the tragus constitutes the Frankfort
horizontal plane. Another excellent view for
determining proper dorsal profile alignment is
the three-quarter view, with the tip of the nose
just touching the lateral malar prominence. This
gives a gentle curvilinear line from the eyebrow
to the tip-defining point without interruption
(Figure 4-1).
Consultation
As with any facial plastic surgical procedure, the
initial consultation with the patient is of utmost
importance for developing a rapport and for understanding the patient’s goals for the proposed rhinoplasty. It is very common for patients to bring in
photographs of themselves in different situations to
show you what they do and do not like about their
nose. It is also common for patients to bring in pictures of other people, such as models or actresses,
to point out how they would like their nose to look.
One of the most common concerns for patients
seeking rhinoplasty is the nasal profile, particularly
46 / Profi le-plasty: The Bony and Cartilaginous Nasal Vault
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A
B
Figure 4-1. (A) Patient in
lateral profile view demonstrating
Frankfort horizontal line. (B) Threequarter view showing brow-dorsal
nasal aesthetic line.
if the profile is too prominent and the nose has either
a large hump or a hooked appearance. Patients will
frequently comment that they “hate” their profile
and that they try to avoid seeing themselves in a
side view. Therefore, initial evaluation of the patient
starts in front of a three-way mirror. The patient
and surgeon view the patient in the mirror in frontal, three-quarter, and lateral views. The surgeon can
guide the patient through assessment of the entire
nasal profile and the profile of the patient’s face.
The first and most important determination
of proper profile alignment is the nasal tip projection. The ideal nasal tip projection from the base
of the nose to the tip-defining point is equal to the
distance from the base of the nose to the upper lip
vermilion.2 Of course, distances vary depending
on the patient’s lip anatomy, but this formulation
is a useful guide for determining tip projection.
Overall tip projection and dorsal nasal height are
directly and adversely affected by the projection of
the pogonion (chin), which includes the soft tissue and bony chin. Chin projection should at least
approach a vertical line dropped from the lower lip
vermilion perpendicular to the Frankfort horizontal
line (Figure 4-2). If the forehead slopes posteriorly
and the chin recedes, the prominence of the nose is
much more dramatic. Often, patients are unaware
of this contribution to the prominence of the nasal
profile. Through education, evaluation, and imaging, patients gain an appreciation of how chin aug-
AB
Figure 4-2. Lateral views of a
patient with ideal projection of chin
and a view of a hypoplastic mentum
(
vertical line
).
Profi le-plasty: The Bony and Cartilaginous Nasal Vault / 47
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mentation reduces the perceived nasal projection
and helps the face achieve a harmonious balance.
Thus, efforts to improve the entire facial profile will
enhance the rhinoplasty result and will allow the
surgeon to reduce the nasal structures to a lesser
degree, maintaining structure, form, and function
in a better fashion, yet achieving a more ideal result.
The rotation of the lobule and the nasolabial
angle are also quite important to evaluate because
they determine the profile in reference to the upper
lip. Visualization of the nasolabial angle and palpation of the nasal lobule enable the surgeon to determine the kind of tip support that will be required
to maintain the tip as the leading point of the profile after nasal dorsal reduction. In some patients,
the profile is led by the septal angle, with weak tipsupport mechanisms of the lobule. Lowering the
septal angle to achieve a more desired profile can
leave the tip with little or no support and requires
certain maneuvers to maintain projection.
The length of the nasal bones and their contributions to the dorsal hump and overly large profile
are important to determine. This information influences the procedures required to achieve a longterm satisfactory result and may in fact dictate the
approach to the rhinoplasty itself. The nasal bone
parameters, in combination with the height of the
cartilaginous profile and the narrowness of the
pyramid, will determine whether spreader grafts are
required to maintain proper nasal vault width over
time.
Finally, in examining the dorsal nasal profile, it
is increasingly common to evaluate whether augmentation of the nasal frontal angle will reduce
the need for dorsal profile bony and cartilaginous
hump reduction. By augmenting a deep nasal frontal angle, one can achieve harmonious balance in
the profile without as great a reduction as would
otherwise be required. This is particularly evident in
the three-quarter view, as well as the lateral view of
the dorsal profile.
Computer Imaging
During the consultation and after history-taking
about any injuries and/or functional limitations,
the patient’s expectations for the new and improved
profile are assessed. This is also done in front of the
three-way mirror. However, the best communicative
strategy and an important aspect of the completion
of the consultative process is to perform computerassisted imaging, which will actually demonstrate
the changes in the profile for the patient to see
and agree upon. Computer (digital) imaging is an
extremely valuable tool in preoperative assessment,
as well as planning and prediction of the final rhinoplasty result. It is also one of the most valuable
tools for allaying patients’ fears about what their
nose will actually look like once altered. Nothing is
more effective than seeing a properly altered computer image side-by-side with preoperative views
(Figure 4-3). This is far superior to line drawings
Figure 4-3. Lateral view of a computer-imaged profile reduction.
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