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318 Part VII&Facial Surgery
Answers
ANATOMY
1. After an open rhinoplasty via a transcolumellar incision, which of the following vessels is subsequently princi-
pally responsible for perfusion of the nasal tip?
D. Lateral nasal artery.
The lateral nasal artery is one of the most important vessels in nasal blood supply, and preserving it mit igate
against postoperative complications. The lateral nasal artery originates from the angular artery, coursing 2 to
3 mm cephalad to the alar groove and provides arterial inflow to the nasal tip. The transcolumellar incision
during open rhinoplasty results in division of the columellar vessels; therefore, vascularity of the nasal tip is
reliant upon inflow from the lateral nasal vessels. The superior labial artery is the source of the columellar
artery. The superior labial artery does not supply the nasal tip after open rhinoplasty. The dorsal nasal artery
supplies the upper third of the nose and provides axial inflow for the dorsal nasal artery flap. The angular
artery is incorrect because the lateral nasal artery branches from the angular artery; therefore, the lateral
nasal artery is the better answer choice (Fig. 45.1).
1
Fig. 45.1 The lateral nasal artery is one of the most important vessels in nasal blood supply, and preserving it
promotes healing and helps to prevent deleterious postoperative skin changes. (Source: Blood supply. In: Janis J,
ed. Essentials of Aesthetic Surgery. 1st Edition. New York: Thieme; 2018.)
REFERENCE
1. Rohrich RJ, Gunter JP, Friedman RM. Nasal tip blood supply: an anatomic study validating the safety of the transcolumellar incision in rhinoplasty. Plast Reconstr Surg 1995;95:795
ANATOMY
2. Which of the following best describes the most common relationship between the upper lateral and lower lat-
eral cartilage in the scroll area?
C. The upper lateral cartilages underlap the lower lateral cartilages.
The anatomy of the lowest portion of the upper lateral cartilage in relation to the lower lateral cartilages can
be quite variable. This region is called the scroll area and provides significant support to the nasal pyramid,
particularly the tip. It is most commonly described as the junction where the upper lateral cartilages
underlap the lower lateral cartilages. Although variations may exist, this orientation tends to be the most
common form encountered.
1
Chapter 45&Rhinoplasty 319
REFERENCE
1. Bitik O, Uzun H, Konaş E. Scroll reconstruction: fine tuning of the interface between middle and lower thirds in
rhinoplasty. Aesthet Surg J 2019;39(5):481–494
ANATOMY
3. A 24-year-old female presents to your clinic for a rhinoplasty consultation. On examination, the left alar base
is noted to be higher than the right. This alar base discrepancy is noted to be more prominent with smiling.
Action of which of the following muscles is responsible for this finding?
D. Levator labii alaeque nasi.
The levator labii alaeque nasi muscle is innervated by the buccal branch of the facial nerve and is composed of a
medial and lateral head, with the lateral head inserting onto the alar base. Contraction of this muscle helps
open the external nasal valve and elevat e s the alar base.
nerve palsy can result in alar base height asymmetry. The nasalis muscle has two components which
helps both compress and dilate the nostrils. The depressor septi nasi muscle may originate from incisive
fossa of the maxilla or orbicularis, inserting into the nasal septum. Contracture of the depressor septi
nasi muscle depresses the nasal tip.
levator labii superioris elevates the medial aspect of the upper lip lateral to the piriform aperture. The
levator angularis oris inserts into the modiolus and helps elevate the oral commissure (Fig. 45.2).
2,3
The levator labii superioris does not insert into the nasal base. The
1
Asymmetric hyperactivity or ipsilateral facial
Fig. 45.2 The depressor septi nasi muscle and other musculature can affect nasal shape and the tip posit ion.
(Source: Enhancing the Nasal Tip–Upper Lip Relationship: The Importance of the Depressor Septi Nasi Muscle in
Rhinoplasty. In: Rohrich R, Adams W, Ahmad J, Gunter J, ed. Dallas Rhinoplasty: Nasal Surgery by the Masters. 3rd
Edition. New York: Thieme; 2014.)
REFERENCES
1. Howard BK, Rohrich R J. Understanding the nasal airway principles and practice. Plast Reconstr Surg
2002;109:1128
2. Rohrich RJ, Huynh B, Muzaffar AR, et al. Importance of the depressor septi nasi muscle in rhinoplasty: anatomic
study and clinical application. Plast Reconstr Surg 2000;105:376
3. Ghavami A, Janis JE, Guyuron B. Regarding the treatment of dynamic tip ptosis using botulinum toxin A. Plast
Reconstr Surg 2006;118:263
320 Part VII&Facial Surgery
ANATOMY
4. A 34-year-old female is displeased with her postoperative result 1 year after an open rhinoplasty. On profile
view in repose, she has a smooth dorsum with a nasolabial angle of 95 degrees. However, upon smiling, she
complains of a downward pointing nasal tip and her nasolabial angle decreases to 75 degrees. Which of the
following maneuvers would have prevented this patient's postoperative complaint?
A. Transposition of the depressor septi nasi muscle.
The depressor septi nasi arises from either the incisive foramen of the maxilla or orbicularis oculi muscle and
inserts into the caudal septum. Contracture of this muscle depresses the nasal tip, therefore explaining this
patient's dynamic nasal tip complaints during smiling. Rohrich et al described a technique to dissect and
transpose this muscle to improve dynamic tip descent in the appropriately selected patient.
1
REFERENCE
1. Rohrich RJ, Huynh B, Muzaffar AR, et al. Importance of the depressor septi nasi muscle in rhinoplasty: anatomic
study and clinical application. Plast Reconstr Surg 2000;105:376
ANATOMY
5. The internal nasal valve is formed by which of the following structures?
B. Caudal edge of upper lateral cartilage and septum.
The caudal aspect of the upper lateral cartilage should form an angle of >10 to 15 degrees with the nasal
septum—this is the narrowest segment of the nasal airway and is known as the internal nasal valve.
Although a prominent inferior turbinate can significantly contribute to nasal airflow resistance, the inferior
turbinate is not considered part of the internal nasal valve. The external nasal valve is formed by the caudal
edge of the lower lateral cartilage, alar soft tissue, membranous septum, and nostril sill (Fig. 45.3).
1,2,3,4
Fig. 45.3 The internal nasal valve is one of the most important aspects in septorhinoplasty and must be maintained open using spreader grafts and/or flaps. (Source: Incrementally Reduce the Dorsum. In: Rohrich R, Adams
W, Ahmad J, Gunter J, ed. Dallas Rhinoplasty: Nasal Surgery by the Masters. 3rd Edition. New York: Thieme; 2014.)
REFERENCES
1. Beekhuis GJ. Nasal obstruction after rhinoplasty: etiology, and techniques for correction. Laryngoscope
1976;86:540
2. Howard BK, Rohrich RJ. Understanding the nasal airway: principles and practice. Plast Reconstr Surg
2002;109:1128
Chapter 45&Rhinoplasty 321
3. Gunter JP, Rohrich RJ. Management of the deviated nose. The importance of septal reconstruction. Clin Plast Surg
1988;15:43
4. Rohrich RJ, Gunter JP, Deuber MA, et al. The deviated nose: optimizing results using a simplified classification and
algorithmic approach. Plast Reconstr Surg 2002;110:1509
ANATOMY
6. A postoperative rhinoplasty patient is seen in clinic and is diagnosed with “empty nose syndrome.” This is
most likely a result of aggressive resection of which of the following structures?
C. Inferior turbinate.
“Empty nose syndrome” is typically a consequence of aggressive resection of the inferior turbinate, which
results in turbulent airflow. The nasal turbinate's help humidify and regulate nasal airflow. If present, preoperative diagnosis of hypertrophied inferior nasal turbinates is critical as they can contribute up to twothirds of nasal airflow resistance. However, overaggressive resection of the inferior turbinate can result
in paradoxical increased airway resistance.
1,2
REFERENCES
1. Beekhuis GJ. Nasal obstruction after rhinoplasty: etiology, and techniques for correction. Laryngoscope
1976;86:540
2. Howard BK, Rohrich RJ. Understanding the nasal airway: principles and practice. Plast Reconstr Surg
2002;109:1128
ANATOMY
7. A Caucasian female patient is diagnosed with a wide alar base. On frontal view, which of the following find-
ings best supports the diagnosis of a wide alar base?
A. Alar base located lateral to the medial canthus.
In Caucasian patients, the alar base should (generally) coincide with the medial intercanthal width, as is
shown with facial analysis using vertical fifths (Fig. 45.4). The alar base is generally considered wide if it
extends lateral to the medial canthus. Generally, the alar base is approximately two-thirds the width of
the oral aperture. Although the medial brow margin should approximately coincide with the medial canthi, this is variable and the alar base width is traditionally compared to the medial canthi, not the medial
brow margin. The nasal dorsal aesthetic lines should be narrowest at the medial canthi, corresponding to
the bony nasal vault. The nasal bony base should be 75 to 80% of the alar base width; therefore, answer D
is incorrect. In general, the alar base width will be less than the length of the upper and lower cartilaginous vaults combined; however, comparison of the two is not traditionally used in this assessment of
alarbasewidth.
1,2,3
322 Part VII&Facial Surgery
Fig. 45.4 (a) Dorsal aesthetic contour lines are curvilinear in females and descend from the medial brow toward
the tip-defining points. (b) Nasal bones are generally narrower than the alar base width by about 20-25%.
(c) Alar base width is generally equivalent to the medial canthi; however, many variations exist. (d) Generally,
aesthetically pleasing nasal tip highlights are diamond shaped.
Rohrich R, Adams W, Ahmad J, Gunter J, ed. Dallas Rhinoplasty: Nasal Surgery by the Masters. 3rd Edition. New York:
Thieme; 2014.)
(Source: Incrementally Reduce the Dorsum. In:
Chapter 45&Rhinoplasty 323
REFERENCES
1. Sheen JH, Sheen A, eds. Aesthetic Rhinoplasty. 2nd ed. St Louis: CV Mosby; 1987
2. Janis JE, Ahmad J, Rohrich RJ. Clinical decision-making in rhinoplasty.In: Nahai F, ed. The Art of Aesthetic Surgery.
2nd ed. New York: Thieme Publishers; 2010
3. Byrd HS, Hobar PC. Rhinoplasty: a practical guide for surgical planning. Plast Reconstr Surg 1993;91:642
ANATOMY
8. A patient presents with a deep and inferiorly located nasal radix and a radix graft is planned. What effect
will placement of the radix graft have on nasal appearance?
E. Lengthen the nose and increase the nasofrontal angle.
A deep and inferiorly located radix is correlated with a short nose and a more acute nasofrontal angle. Placement
of a radix graft will increase the apparent nasal length by raising the location of the radix superiorly. Furthermore,
a radix graft will decrease the apparent depth of the radix and therefore make the nasofrontal angle more obtuse.
Radix grafts are useful for treatment of the short nose with an acute nasofrontal angle (Fig. 45.5).
1,2,3
Fig. 45.5 Dorsal graft orientation. Placed with concave side down. If concave side is up, warping can occur resulting in fullness in the radix and supratip.
Edition. New York: Thieme; 2018.)
(Source: Dorsal grafting. In: Janis J, ed. Essentials of Aesthetic Surgery. 1st
REFERENCES
1. Rohrich RJ, Muzaffar AR. Rhinoplasty in the African-American patient. Plast Reconstr Surg 2003;111:1322
2. Daniel RK. Hispanic rhinoplasty in the United States with emphasis on the Mexican American nose. Plast Reconstr
Surg 2003;112:244
3. Rohrich RJ, Ghavami A. Rhinoplasty for Middle Eastern noses. Plast Reconstr Surg 2009;123:1343
ANATOMY
9. Which of the following is an advantage of the open versus closed rhinoplasty approach?
B. Improved visualization of the cartilaginous framework.
There are several advantages and disadvantagesto open rhinoplasty. Advantages of open rhinoplasty include
improved visualization and correlation of internal deformities with external appearance. Disadvantages
include an external nasal scar, prolonged nasal edema, and the need for suture stabilization of most grafts.
Advantages of closed rhinoplasty included decreased tip edema, faster recover, the ability to limit dissection
and place grafts in precisely dissected pockets without fixat ion, and possible preservation of more nasal support structures due to more limited dissection. Disadvantages of closed rhinoplasty included decreased visualization and greater reliance on experience and preoperative diagnosis.
1
REFERENCE
1. Gunter JP. The merits of open approach in rhinoplasty. Plast Reconstr Surg 1997;99:863
324 Part VII&Facial Surgery
ANATOMY
10. Which of the following grafts is used to improve internal nasal valve patency?
B. Spreader graft.
Spreader grafts are placed between the upper lateral cartilage and cartilaginous septum and can serve several roles including maintaining patency of the internal nasal valve, straightening of a deviated dorsal septum, and improvement of dorsal aesthetic lines (Fig. 45.6). Furthermore, extended spreader grafts can be
used to lengthen the nose and provide an additional method to fixate a columellar strut or caudal septal
extension graft to control tip rotation and projection.
Nasal sidewall onlay grafts can be used to improve the contour of a narrow middle vault. Alar spreader
grafts are placed between the lateral crura of the lower lateral cartilage and vestibular skin to improve
patency of the external nasal valve. The septal extension graft is used to control tip rotation and projection.
The alar rim graft is placed in a subcutaneous pocket along the alar rim to treat alar retraction.
1,2,3
Fig. 45.6 Spreader grafts allow internal nasal valve patency. (Source: Spreader graft. In: Rohrich R, Adams W, Ahmad
J, Gunter J, ed. Dallas Rhinoplasty: Nasal Surgery by the Masters. 3rd Edition. New York: Thieme; 2014.)
REFERENCES
1. SheenJH. Spreader graft: a method of reconstructing the roof of the middle nasal vault followingrhinoplasty. Plast
Reconstr Surg 1984;73:230
2. Gunter JP, Rohrich RJ. Management of the deviated nose. The importance of septal reconstruction. Clin Plast Surg
1988;15:43
3. Rohrich RJ, Gunter JP, Deuber MA, et al. The deviated nose: optimizing results using a simplified classification and
algorithmic approach. Plast Reconstr Surg 2002;110:1509
ANATOMY
11. When performing nasal osteotomies, what is the reason for preserving the caudal aspect of the frontal pro-
cess of the maxilla (i.e., Webster's triangle)?
E. Avoid infracture of the inferior nasal turbinate.
The caudal aspect of the frontal process of the maxilla, i.e., Webster's triangle, should be preserved if
nasal osteotomies are planned as this corresponds to the location of the anterior aspect of the inferior
turbinate. Infracture of Webster's triangle results in nasal airway collapse due to inferior turbinate
infracture (Fig. 45.7).
1,2
Chapter 45&Rhinoplasty 325
Fig. 45.7 Various starting points and endpoints of osteotomy patterns exist. (Source: Rohrich RJ, Adams WP Jr,
Ahmad J, Gunter JP, eds. Dallas Rhinoplasty: Nasal Surgery by the Masters, ed 3. New York: Thieme Publishers, 2014.)
REFERENCES
1. Guyuron B. Nasal osteotomy and airway changes. Plast Reconstr Surg 1998;102:856
2. Gruber R, Chang TN, Kahn D, et al. Broad nasal bone reduction: an algorithm for osteotomies. Plast Reconstr Surg
2007;119:1044
ANATOMY
12. An Asian patient presents for rhinoplasty and dorsal nasal augmentation is planned. Which of the following
methods of dorsal augmentation is most prone to postoperative warping?
E. Autologous rib cartilage.
Autologousribisthe strongest cartilagesourceandusefulwhen>3 mm of dorsal augmentation isrequired; however, warping is common and likely underreported. Suture stabilization and threading with a K-wire is
recommended to help prevent movement and warping. Furthermore, it is recommended that rib cartilage
sculpting be performed a minimum of 30 minutes prior to graft placement to predict warping characteristics.
Septal cartilage is less prone to warping than rib cartilage. Acellulardermal matrix may be used for minimal dorsal enhancement or to camouflage underlying surface irregularities. Irradiatedrib cartilage has the convenience
of avoiding non-nasal donor site and is less prone to warping; howev er, resorption may be unpredictable.
1,2,3
REFERENCES
1. Gruber RP, Nahai F, Bogdan MA, et al. Changing the convexityand concavity of nasal cartilages and cartilage grafts
with horizontal mattress sutures: part II. Clinical results. Plast Reconstr Surg 2005;115:595
2. Byrd S, Andochick S, Copit S, et al. Septal extension grafts: a method of controlling tip projection, rotation, and
shape. Plast Reconstr Surg 1997;100:999
3. Lee MJ, Song HM. Asian rhinoplasty with rib cartilage. Semin Plast Surg 2015;29(4):262–268
ANATOMY
13. A 30-year-old woman undergoes rhinoplasty to correct a droopy nasal tip. Which of the following suture
techniques can help correct this deformity?
D. Medial crural septal suture.
Medial crural septal sutures attach the medial crura to the septum and assist with tip positioning, columellar show, and changing the columellar and nasolabial angles. Medial crural septal sutures help to
326 Part VII&Facial Surgery
reposition the drooping nasal tip. Transdomal sutures are horizontal mattress sutures placed at the lateral
and medial genu of the middle crura to help sharpen and refine the dome and can moderately increase tip
projection. Interdomal sutures are placed between the domes of each lower lateral cartilage to decrease
interdomal width or improve symmetry in domal height. Lateral crural mattress sutures can be used to
correct lateral crural convexity.
1,2,3,4
REFERENCES
1. Gruber RP, Friedman GD. Suture algorithm for the broad or bulbous nasal tip. Plast Reconstr Surg 2002;110:1752
2. Ghavami A, Janis JE, Acikel C, et al. Tip shaping in primary rhinoplasty: an algorithmic approach. Plast Reconstr
Surg 2008;122:1229
3. Behmand RA, Ghavami A, Guyuron B. Nasal tip sutures part I: the evolution. Plast Reconstr Surg 2003;112:1125
4. Guyuron B, Behmand RA. Nasal tip sutures part II: the interplays. Plast Reconstr Surg 2003;112:1130
ANATOMY
14. A 51-year-old male presents with a droopy and overprojected nasal tip. Which of the following maneuvers
can be performed to address both of these deformities?
E. Lateral crural resection/overlay.
The nasal tripod is defined by the medial crura and lateral crura of the paired lower lateral cartilage. Variation in
the length and structural support of each of these structures influences tip position and shape. In the droopy
and overprojected nasal tip, transection and overlay of the lateral crura will help cephalically rotate the nasal tip
and decrease projection.
spring flap is an autospreader flap technique in which the cephalic margin of the upper lateral cartilage
is turned in without scoring and sutured to the dorsal septum to open the internal nasal valve. Lateral
crural strut grafts are secured to the undersurface of the lateral crura and are a powerful technique to
inferiorly position cephalically oriented lateral crura and can extend to the piriform aperture to increase
tip projection. A subdomal graft is a bar-shaped graft placed beneath the domes tocorrect domeasymmetry and a pinched nasal tip. Interdomal sutures are placement between the domes of each lower lateral cartilage to decrease interdomal width or improve symmetry in domal height (Fig. 45.8).
1
Lateral crural mattress sutures can be used to correct lateral crural convexity. A
Fig. 45.8 The nasal tip “tripod concept” helps when trying to understand dynamic changes in nasal tip shape
and position defined by the central medial crura and bilateral lower lateral cartilages. (Source: Background. In:
Rohrich R, Adams W, Ahmad J, Gunter J, ed. Dallas Rhinoplasty: Nasal Surgery by the Masters. 3rd Edition. New York:
Thieme; 2014.)
Chapter 45&Rhinoplasty 327
REFERENCE
1. Toriumi DM. New concepts in nasal tip contouring. Arch Facial Plast Surg 2006;8:156
ANATOMY
15. A 19-year-old female presents for rhinoplasty with a deviated nose and an S-shaped septal deformity.
Bilateral mucoperichondrial flaps are elevated and septal cartilage is harvested leaving a 12-mm L-strut.
Severe convexity of the base of the caudal L-strut is observed. Which of the following maneuvers should be
performed next to address this problem?
C. Releasing the caudal septum from the anterior nasal spine and caudal septal reduction.
Caudal septal deviations should be addressed by release of the caudal septum from the anterior nasal spine.
This deformity is usually associated with buckling due to excessive length of the caudal septum, which
requires detachment and reduction of this excess in order to centralize and fixate the caudal septum to
the anterior nasal spine.
Spreader grafts can be used to help straighten deviations of the dorsal septum. Spreader grafts do not
address caudal septal deviations. Leaving a 6-mm caudal L-strut could result in nasal collapse due to insufficient support and is not recommended. Lateral crural strut graf ts can be used to correct cephalically oriented lower lateral crura, alar notching, and to support the nasal tip. Neither a lateral crural strut graft nor
lateral crural mattress sutures will correct a caudal septal deviation.
1,2
REFERENCES
1. Beekhuis GJ. Nasal obstruction after rhinoplasty: etiology, and techniques for correction. Laryngoscope
1976;86:540
2. Guyuron B, Behmand RA. Caudal nasal deviation. Plast Reconstr Surg 2003;111:2449