Gunter and Gorney ³^–⁵ have both commented on ‘danger signs’ that may be exhibited (Box 11.1). Individuals who meet these criteria should be approached with caution because surgical intervention may not be in the best interests of either the patient or the surgeon.

• the first uses the acronym SIMON (single immature males overly expectant, narcissistic) to describe certain worrisome traits;

• the second plots the patient’s concern on one axis and the degree of deformity on the other (Fig. 11.1) – patients who have an appropriate level of concern relative to their degree of deformity are excellent candidates for treatment, but those who have minimal deformity and a disproportionate level of concern should be avoided because their expectations may exceed the amount of aesthetic improvement possible.

Fig. 11.1 Graphic relationship between perceived and actual deformity. This indicates that a disproportionate amount of concern should yield caution (red zone) for the surgeon.

If the level of skill and expertise required to perform the rhinoplasty exceeds the surgeon’s ability, the patient should be referred to another more proficient surgeon.

The surgeon must rely on both subjective and objective findings when considering the relative indications and contraindications for performing a rhinoplasty; the skills required to accomplish this develop with time and experience.

Preoperative History and Considerations

Patient Factors

When initially assessing a patient for potential rhinoplasty, the surgeon should concentrate on evaluating the patient’s desires and expectations prior to performing the comprehensive facial analysis. Although there are different methods for integrating the patient into the surgical process, we find that computer imaging provides an excellent way for patients to gain a realistic understanding of the anticipated outcome. Although the images are not a guarantee of surgical results, they do provide a visual representation and a means for patient education. These images, combined with standardized anterior, lateral, oblique, and basal photographs, provide the basis for the preoperative surgical plan.

To identify potential ‘problem patients’ preoperatively, we ask the patient to first describe what issues they have. We encourage them to be as specific as possible, listing their concerns in order of importance in their own words. A handheld mirror is useful in this situation. The patient’s desires are then documented in the chart verbatim. Frequently, the patient will state in general terms, ‘I just want a better nose. What would you do?’ This has been a red flag in our practice because it is usually a reflection of general dissatisfaction, poorly thought-out desires, or a poor self-image. We politely redirect these patients in an attempt to ascertain their specific concerns about their nose. Again, a disproportionate amount of concern in the presence of a minimal deformity is a cause for concern.

Other red flags in rhinoplasty include:

• those patients who desire a result that cannot be predictably or reliably delivered or that is outside the realm of the ‘aesthetic norm’;

• individuals who seem litigious as a result of a previous rhinoplasty, or who harbor hostility toward previous healthcare providers.

This second criterion is vague, but we place tremendous importance on the development of our interpersonal relationship with our patients, and if this cannot be forged, for whatever reason, we decline to perform the operation. In other words, ‘do not operate on a patient you don’t like’.

It should be noted that men tend to have a poorer understanding of their deformity than women and have a more difficult time elucidating the changes they want.⁶^–⁸

A second follow-up consultation is recommended to reiterate the patient’s desires, develop a realistic operative plan, and reaffirm the patient’s understanding of the anticipated procedure.

Nasal History

A full and complete nasal history should be obtained. This includes a prior history of:

• trauma;

• previous nasal, septal or sinus operations;

A list of current medications should also be obtained (both nasal and non-nasal related). Nonsteroidal anti-inflammatory agents and certain herbal supplements may increase bleeding complications after surgery and should be discontinued at least 7–10 days before a rhinoplasty. Furthermore, patients are instructed to avoid consumption of salicylic derivatives for 3 weeks prior and 1 week following surgery.

Anatomic Features

Having determined that the patient is an appropriate candidate for surgery, the next element to proper preoperative surgical planning is critical facial analysis.^9,¹⁰

Each individual nose has different proportions, morphology, and relative relationships with the surrounding face. To preserve nasofacial harmony, it is crucial to perform a systematic and meticulous analysis of the nose and face. The evaluation is performed in a systematic manner cultivated by the surgeon to assure consistency.¹¹^–¹³

Accurate diagnosis of the deformity(s) determines the optimal surgical plan for correction. The surgeon should point out natural facial asymmetries preoperatively so that the patient gains a better understanding of what is present before any operative intervention.

Skin type

The native skin quality influences the operative plan and subsequent techniques performed.

First, skin type, thickness, and texture are assessed.

Thicker skin will tend to camouflage changes to the underlying osseocartilaginous framework, and may therefore allow a more ‘aggressive’ surgery to demonstrate an appreciable change. Patients who have thicker skin that has a more sebaceous character tend to have more postoperative edema, especially in the tip or lobule area.

Thinner skin tends to reveal even minor changes to the underlying framework. Therefore patients who have thinner skin can be more challenging because there is less margin for error.

Systematic analysis of the nose and face

Next, a systematic analysis of the nose and face is undertaken.

Look for potential anomalies of the underlying facial skeleton

Initially we evaluate potential anomalies of the underlying facial skeleton, including the maxillomandibular relationship.

We divide the face into thirds using horizontal lines adjacent to the:

• hairline;

• brow (at the level of the supraorbital notch);

• nasal base;

• menton.

The upper one-third is the least important because it is the most variable.

The lower one-third of the face is then subdivided into thirds by visualizing a horizontal line between the oral commissures (stomion):

• the upper third of this subdivision lies between the nasal base and the oral commissures;

• the lower two-thirds lies between the commissures (stomion) and the menton.

If there are disproportions, the patient may have underlying craniofacial anomalies (e.g. vertical maxillary excess) that necessitate correction.

The nasal length (radix to tip [RT]) should be equivalent to the stomion-to-menton distance (SM), as described by Byrd and Hobar.

A natural horizontal facial plane is determined by drawing a line perpendicular to a plumb line superimposed over the head in repose and the eyes in straightforward gaze. This will serve as a future point of reference (Fig. 11.2).

Fig. 11.2 A natural horizontal facial plane. This is determined by drawing a line perpendicular to a plumb line superimposed over the head in repose and the eyes in straightforward gaze.

The lip-chin relationship is assessed by dropping a vertical line from a point one-half the ideal nasal length tangential to the vermillion of the upper lip. The lower lip should lie no more than 2 mm behind this line (Fig. 11.3). The ideal chin position is gender dependent. The female chin should be slightly posterior to the lower lip, but equal to the lower lip in men. Discrepancies in these relationships may warrant orthodontics, orthognathic surgery, or a chin implant.

Fig. 11.3 The lip-chin relationship. This is assessed by dropping a vertical line from a point one-half the ideal nasal length tangential to the vermillion of the upper lip. The lower lip should lie no more than 2 mm behind this line.

Nasal features

Frontal view

Nasal deviation is evaluated by drawing a line from the mid-glabellar area to the menton, bisecting the nasal ridge, upper lip, and Cupid’s bow. This line will also pass between the central incisors when occlusion is normal. Any deviation of the nose from this line will likely require septal surgery.

The nasal dorsum is then assessed. The curvilinear dorsal aesthetic lines are traced from the origin at the supraorbital ridges to the tipdefining points, slightly diverging from each other along the dorsum during their course. Ideally, the width of the dorsal aesthetic lines should match the width of either the tip defining points or the interphiltral distance.

A relationship between the bony base width and the alar base is then assessed. The bony base width should be 80% of the normal alar base width, and a normal alar base width 2 mm wider than the inter-canthal distance, or the width of one eye (Fig. 11.4A&B). If the bony base is greater than 80% of the alar base width (assuming the alar base width is normal), osteotomies will be required to narrow the dorsum. Males tend to have a wider bony base than females and it is important not to over-narrow the male dorsum creating a feminized result.

Fig. 11.4 The width of the bony base relative to the alar base is then assessed.

A, The bony base width should be 80% of the normal alar base width. B, A normal alar base width is equal to the intercanthal distance or the width of one eye.

Next the alar base and alar rim are analyzed. If the alar base width is over 2 mm and greater than the intercanthal distance, it must be determined whether the cause is a narrow intercanthal distance, a true increased interalar width, or alar flaring:

• if the intercanthal distance is smaller than one eye width, it is better to maintain a slightly wider alar base;

• if there is true increased interalar width, a nostril sill resection may be indicated;

• if the increase in width is secondary to alar flaring (>2–3 mm outside the alar base), an alar base resection should be considered.

The alar rims should also be assessed for symmetry, and should flare slightly outward in the inferolateral direction.

The tip is assessed to determine:

• the supratip break;

• the tip-defining points;

• the columellar-lobular angle (Fig. 11.5).

Fig. 11.5 Frontal view of the nose. The tip is assessed to determine the supratip break, the tip-defining points, and the columellar-lobular angle. These points serve as landmarks to draw two equilateral triangles with their bases opposed.

These points serve as landmarks to draw two equilateral triangles with their bases opposed. If these triangles are asymmetric, the underlying reason should be investigated, and the patient will likely require tip modification.

The final assessment on frontal view is of the outline of the alar rims and the columella, which should resemble a seagull in gentle flight, with the columella lying just inferior to the alar rims. If the curve is too steep, the patient likely has an increased infratip lobular height, which will need correction. If, on the other hand, the curve is flattened, it is likely the patient has decreased columellar show which may require columellar augmentation or alar rim modification.

Patient Counseling

After the initial history and physical examination, the procedure is fully discussed with the patient. The risks and benefits of the procedure are detailed, and all questions answered. The patient is provided with a written, detailed estimate of surgical charges with complete explanations. It is recommended that patients sign a form accepting financial responsibility. A second clinic visit is encouraged to review the previous discussions. The deformities are reiterated, questions answered, and the consent reviewed and signed. A preoperative instruction sheet and a list of medications to be avoided are also provided (Box 11.3).

Box 11.3 Preoperative instruction sheet

Two weeks before surgery

1. Some medications can interfere with anesthesia and cause undesirable side effects that can affect your surgery. Please read the enclosed medication information list and let us know if you take any of them. Aspirin should not be taken for at least 2 weeks before or after surgery. Acetaminophen is a good medication to take for any aches or pains you may have before surgery.

2. Smoking will affect how you heal. It is very important to stop smoking 4 weeks before your surgery.

3. If you develop a cold, facial sore, or any other illness before surgery, please notify us.

4. If you are having surgery as an outpatient, please be sure arrangements have been made for a responsible adult to drive you to and pick you up after your surgery and to stay with you for the first 24 hours.

Evening before surgery

1. Shampoo your hair and wash your face. Do not use conditioner or hair spray after shampooing.

2. Make some Jell-O and/or soup for after surgery.

3. Get a good night’s rest.

4. Do not eat or drink anything after midnight.

Morning of surgery

1. Be at the surgery center/hospital by …

2. Do not eat or drink anything if your surgery is scheduled before noon. If your surgery is scheduled after noon, you may have coffee or tea and dry toast no later than 6 hours before your scheduled surgery time.

3. Do not wear wigs, hairpins, hairpieces, or jewelry. Dress in old, loose, comfortable clothes. Do not wear pullover tops or panty hose. Wear slip-on shoes.

4. Have someone drive you to your surgery and make certain a responsible adult will be available to take you home and stay with you for 24 hours. Put a pillow and blanket in the car for the trip home.

Prior to surgery we convert our operative plan into a graphic re presentation (using Gunter Graphics ⁵) to assist us in the operating room. Modifications to the plan are documented intraoperatively, transposed to the graphic depictions postoperatively, and placed in the patient’s chart for future reference.

Operative Approach

Relevant Anatomy

A complete knowledge of anatomy is paramount to obtaining the superior result. The nose is divided into:

• external skin and soft tissue;

• underlying framework (bony and cartilaginous);

• ligamentous support.

The rhinoplasty surgeon must be familiar with each structure’s native morphology and its variants and have an appreciation for the dynamic interplay between these components.

Skin

The thickness, mobility, and sebaceous character of the nasal skin vary along its length, with the upper two-thirds being thinner, more mobile, and less sebaceous than the inferior one-third.¹⁸

The nasal dorsum thickness averages approximately 1300 μm, whereas the lobule skin thickness averages 2400 μm. A straight dorsum actually has a slight underlying convexity of its osteocartilaginous framework in the cephalic area; therefore a straight dorsal profile is actually produced by the combination of this convexity in the osteocartilaginous framework with the variation in dorsal skin thickness.

Some ethnic subgroups, such as Africans, Hispanics, and those of Mediterranean descent, can have thicker, more sebaceous skin. These differences are important because the skin over the underlying nasal framework can either reveal or mask changes depending on its characteristics. For instance, it is advisable to err on the conservative side when operating on a Caucasian woman with thin skin compared with a man of African descent who has thick, sebaceous skin. More dramatic changes to the underlying framework are tolerated in the patient who has thick skin to obtain an appreciable change in the external appearance.

Muscles

Two muscles, in particular, are important in rhinoplasty:

• the levator labii alaeque nasi, which assists in maintaining the patency of the external nasal valve;

• the depressor septi nasi, which can alter the upper lip length and tip projection (Fig. 11.15).^19,²⁰

Fig. 11.15 Levator labii alaeque nasi and the depressor septi nasi. These two muscles are important in rhinoplasty.

Evaluation of the depressor septi nasi is routine in our preoperative assessment. Its effect on depressing the nasal tip and shortening the upper lip can be appreciated in some patients on animation (especially when smiling). In the subgroup of patients in whom this muscle significantly alters the nasal appearance, we dissect and transpose the muscle. By doing so, several goals are achieved:

• enhancement of the tip-lip relationship;

• relative upper lip lengthening;

• relative fullness to the upper lip;

• maintenance of tip rotation/projection on animation.

Blood supply

The vascular supply to the nose is derived from branches of the ophthalmic and facial arteries (Fig. 11.16).

Fig. 11.16 Vascular supply to the nose. This is derived from branches of the ophthalmic and facial arteries.

It is important to note the vascularity to the nasal tip because an open rhinoplasty approach using a transcolumellar incision will transect the columellar vessels (when present), leaving the lateral nasal and dorsal nasal arteries as the remaining blood supply.

In our 1995 study,²¹ we found the lateral nasal arteries to be present (either singularly or bilaterally) in 100% of cases, with the columellar branches present 68.2% of the time.

The lateral nasal vessels are found approximately 2–3 mm above the alar groove, so extended alar resections to this level are prohibited because injury to these vessels after the transcolumellar approach would severely compromise blood flow to the nasal tip. Furthermore, be cautious when debulking the nasal tip after an open approach because the subdermal vascular plexus connecting the dorsal nasal and lateral nasal blood supplies may be damaged, leading to a similarly disastrous result.

Extended alar resections to the level of the alar groove are discouraged with the transcolumellar approach because injury to the lateral nasal vessels, which are approximately 2–3 mm above the alar groove, may severely compromise blood flow to the nasal tip.

Toriumi et al.²² studied the vascular and lymphatic anatomy of the nose and determined that the transcolumellar incision itself did not compromise major venous or lymphatic outflow. Furthermore, they recommend dissection just above the perichondrium in the deep areolar plane, leaving the musculoaponeurotic layer intact, which preserves the major arterial vascular supply and avoids damage to the venous and lymphatic vasculature that lies in a more superficial (subcutaneous) plane. In this way, bleeding and postoperative edema are minimized.

Nasal vaults

The osteocartilaginous nasal framework can be subdivided into three separate vaults: bony, upper cartilaginous and lower cartilaginous.

Bony vault

The bony vault (Fig. 11.17) constitutes the upper one-third to one-half of the nose and is made up of the paired nasal bones and the ascending frontal process of the maxilla. It is important to note that the nasal bones are narrowest and thickest above the canthal level. As a result, osteotomies are rarely indicated above this level.

Fig. 11.17 The bony vault. This constitutes the upper one-third to one-half of the nose and is made up of the paired nasal bones and the ascending frontal process of the maxilla.

Upper cartilaginous vault

The upper cartilaginous framework begins where the nasal bones overlap the upper lateral cartilages (ULCs) and septum for 4–6 mm, creating what is known as the keystone area. This area should be the widest part of the dorsum, and resembles a T shape in cross-section. The remainder of this vault is comprised of the paired ULCs and dorsal cartilaginous septum. Over-resection during dorsal hump reduction in this area can lead to deformities such as the inverted-V deformity and/or disruption of the dorsal aesthetic lines. A component dorsal septal reduction is advised to avoid these complications.

Lower cartilaginous vault

The lower cartilaginous framework begins where the ULCs interdigitate with the lower lateral cartilages (LLCs) in the scroll area. The lower lateral cartilages comprise medial, middle, and lateral crura. These cartilages are connected to each other, the ULCs, and the septum by fibrous tissue and ligaments (Fig. 11.18). Disruption of these ligaments can result in diminished tip projection during rhinoplasty. Therefore if these structures are violated, maneuvers that increase tip support (e.g. columellar struts, extended spreader grafts, batten grafts, suture techniques) may be necessary.

Fig. 11.18 Cartilaginous framework. The cartilages are connected to each other, the upper lateral cartilages and the septum by fibrous tissue and ligaments.

The lower lateral cartilages comprise medial, middle, and lateral crura, which are connected to each other, the ULCs, and the septum by fibrous tissue and ligaments. Disruption of these ligaments during rhinoplasty can result in diminished tip projection.

Nasal function – septum, turbinates, and nasal valves

The septum, turbinates, and nasal valves (internal and external) serve as the anatomic functional foundation for the nose, contributing to respiration, filtration, humidification, temperature regulation, and protection (Fig. 11.19).

Fig. 11.19 The septum. This is made up of the septal cartilage, the perpendicular plate of the ethmoid, the nasal crest of the maxilla, and the vomer.

Septum

The septum is made up of the septal cartilage, the perpendicular plate of the ethmoid, the nasal crest of the maxilla, and the vomer.

Deformities in the septum can significantly impaire airflow through the nose and result in compensatory turbinate pathology. When addressing septal deformities, it is important to assess all septal components. When performing a septal resection, it is important to remember that the perpendicular plate of the ethmoid is contiguous with the cribriform plate posterosuperiorly. Therefore, a side fracture of the perpendicular plate should be performed with care to prevent iatrogenic fracture of the cribriform plate and its untoward consequences (e.g. cerebrospinal fluid rhinorrhea, potential ascending infection/meningitis). Restoration of a normal straight septum will help re-establish laminar airflow.

Turbinates

The turbinates (Fig. 11.20) help to guide the transport of air during respiration and condition/humidify inspired and expired air. They are mucosa-lined extensions of the lateral nasal cavity and undergo a normal autonomically mediated cycle of expansion and contraction.

Fig. 11.20 The turbinates.

Of all the turbinates, the inferior turbinate has the greatest impact on airway resistance, providing up to two-thirds of total airway resistance from its most anterior aspect.²³

Over-resection of the anterior inferior turbinate can have a deleterious effect on its regulatory and physiologic functions, and can lead to crust formation, bleeding, and nasal cilia dysfunction.

Over-resection of the anterior inferior turbinate can lead to crust formation, bleeding, and nasal cilia dysfunction.

Internal nasal valve

The internal nasal valve (Fig. 11.21) can contribute up to 50% of the total airway resistance and is the narrowest segment of the nasal airway. It is composed of the angle formed by the intersection of the nasal septum and the caudal margin of the ULC, and is usually 10–15 °.^24,²⁵

Fig. 11.21 Internal nasal valve. This is composed of the angle formed by the intersection of the nasal septum and the caudal margin of the upper lateral cartilage, and is usually 10-15 °.

In some cases, the anterior portion of the inferior turbinate may be a significant contributor to the decrease in the cross-sectional area of this region.²⁶

Patients with short nasal bones and long, poorly supported ULCs have a propensity to have collapse at this area.

Traditionally, lateral traction on the cheek (positive Cottle’s sign) diagnoses collapse of the internal nasal valve and signals the need for spreader grafts to increase the valve angle and stent the airway open.

External nasal valve

The external nasal valve is the cartilaginous vestibule bounded by nares and lateral alar sidewalls. It is caudal to the internal valve.

Obstruction at this area may be caused by foreign bodies, weak or collapsed lower lateral cartilages, loss of vestibular skin, or scar tissue. Several options are available to re-establish proper airflow through this area, including alar batten grafts, lateral crural strut grafts, lysis of adhesions, scar revision, mucosal grafts, skin grafts, or composite grafts.

Options for re-establishing airflow when the area of the external nasal valve is obstructed include alar batten grafts and lateral crural strut grafts.

Incisional Approaches

The two basic incisional approaches to rhinoplasty are:

• the open technique;

• the closed (endonasal) technique.

Each has its advocates who use them successfully in the practice of rhinoplasty.

Open approach

The open approach involves a transcolumellar incision, which can assume varying geometries, depending on surgeon choice. Our preference is a stairstep configuration, which facilitates reapproximation while breaking up the scar and preventing contracture deformities. The open approach also involves skeletonizing the underlying osseocartilaginous framework, which gains enormous exposure for the manipulation and correction of deformities.

Closed approach

The closed (or endonasal) technique can be performed using a cartilage-delivery approach or a nondelivery approach.

Delivery approach

The delivery approach involves an intercartilaginous incision, a marginal incision, and either a transfixion or hemitransfixion incision with subsequent transposition of the lower lateral cartilages to a location outside the skin envelope.

Nondelivery approach

A nondelivery approach uses either a transcartilaginous incision or an eversion (retrograde) incision, with the lower lateral cartilages remaining in their native positions. Manipulation and modifications of the osseocartilaginous framework are then carried out, but the skin envelope is not reflected, as in the open approach.

Open versus closed approach

Most of our cases involve the open approach because it:

• provides excellent exposure and control;

• allows manipulation of the osseocartilaginous framework under direct visualization;

• has minimal negative consequences, aside from the external scar and occasional prolonged tip edema, which resolves in virtually all patients and is not an issue provided the expectation level is set preoperatively.

In our hands, the open approach allows for predictable and reproducible results. Furthermore, the increased accuracy and versatility of the open approach results in a negligible external scar. Patients rarely object to the transcolumellar scar because it is usually invisible at conversation distances.

We reserve a closed approach for isolated deformities of the dorsum or when minor tip modifications are necessary.

We perform all secondary rhinoplasties and post-traumatic rhinoplasties exclusively using the open approach.

There are advantages and disadvantages to both rhinoplasty techniques (Table 11.1), but the correct approach is dictated by the patient’s anatomic deformity and the surgeon’s experience. Clearly, what is performed to alter the underlying anatomy is far more important than the type of incision used.

Table 11.1 Relative advantages of open vs closed (endonasal) technique.

	Open technique	Closed technique
Binocular visualization	+++	++
Evaluation of deformity without distortion	+++	+
Precise diagnosis and correction of deformities	+++	+
Direct control of bleeding	++	+
Nasal incision	+	+++
Operative time	+	++
Prolonged nasal tip edema	+	+++

The open approach provides full visualization of the nasal framework to more accurately diagnose the cause of the nasal airway obstruction or the cosmetic deformity. The manipulation of the various structures, including the dorsum, septum and the tip, can be done with precision and can yield predictable results. We strongly recommend the open approach when addressing a posttraumatic deformity, cleft lip nose deformity, in secondary/revisional surgery, or when complex tip modifications are necessary (Box 11.4).²⁷

Box 11.4 Endonasal approach

Disadvantages

• Requires experience and great reliance on accurate preoperative diagnosis

• Prohibits simultaneous visualization of surgical field by teaching surgeon and students

• Does not allow direct visualization of nasal anatomy

• Makes dissection of alar cartilage difficult, particularly in cases of malposition

We find the closed approach to be advantageous in patients who have an isolated dorsal hump deformity or where there is minimal change necessary to modify the tip structure. In these instances, we prefer access through a marginal incision (situated approximately

1 mm cephalad to the caudal margin of the lateral crus). We combine this with an intercartilaginous incision in cases of minor tip refinement to allow for adequate cartilage delivery and exposure. If the caudal septum also needs to be addressed, we perform a concomitant hemitransfixion or transfixion incision (Box 11.5).

Operative Technique

Preparation for surgery

• On the morning of surgery, any final questions are answered.

• The patient is taken to the operating room and positioned supine on the operating table.

• Noninvasive hemodynamic monitoring devices are placed, and all pressure points are padded appropriately.

• Cefazolin 1 g is administered intravenously as a perioperative antibiotic.

• We prefer general anesthesia for our patients, though local anesthesia with intravenous sedation is a viable alternative.

• After the administration of anesthetic, the nasal vibrissae are clipped and the nares are prepared with povidone iodine solution.

• The anticipated incisional approach is marked and injected with approximately 10 mL of 1% lidocaine with 1 : 100 000 epinephrine into the nasal mucosa, along the septum and the soft tissue envelope (Table 11.2).

• If performing an inferior turbinoplasty, these are likewise injected.

• Next, the mucosa is treated with cottonoid pledgets soaked in either oxymetolazone or 4% cocaine to facilitate shrinkage of the tissue.

• A throat pack is placed in the oropharynx to prevent blood from entering the gastrointestinal tract and causing postoperative nausea or vomiting.

• Finally, the patient is prepared and draped for the procedure.

Table 11.2 Location/volume distribution of 1% lidocaine with 1 : 100 000 epinephrine.

Location	Amount (mL)
Vestibules/aperture	2
Dorsum	1
Lateral walls	2
Tip/columella	2
Distal septum	2
Inferior turbinates	1
Total	10

Incision

Closed approach

Accurate preoperative analysis is essential when deciding which incision to use. There are two basic techniques for access in closed (endonasal) rhinoplasty: nondelivery or delivery.

Nondelivery approach

The nondelivery approach uses either a transcartilaginous (cartilage splitting) incision or a retrograde or eversion incision.

Transcartilaginous Incision

• The transcartilaginous incision (Fig. 11.22) is made several milli-meters cephalad to the caudal margin of the lateral/middle crura, so preserving a rim strip to support the ala. Double hook retraction combined with digital alar eversion provides the necessary exposure to facilitate this. The vestibular skin is carefully dissected off the overlying cartilage to expose the cartilage for resection.

Fig. 11.22 Nondelivery approach via the transcartilaginous (cartilage splitting) incision made several millimeters cephalad to the caudal margin of the lateral/middle crura.

Retrograde Approach

• In the retrograde approach (Fig. 11.23), the vestibular incision is made at the most cephalic margin of the lower lateral cartilage rather than through it. A double hook retractor and digital manipulation are used to facilitate exposure. The theoretic advantage to this incision is that it maintains the caudal alar margins and prevents potential scar contracture deformities in this area.

Fig. 11.23 Nondelivery approach via the retrograde or eversion incision. The vestibular incision is made at the most cephalic margin of the lower lateral cartilage rather than through it.

Delivery approach

• The delivery approach (Fig. 11.24) is used in cases where moderate tip modifications are necessary, especially if the angle of divergence (as a measure of tip bifidity) is large.

• Using a double hook retractor in the ala and digital counterpressure to expose the cartilaginous margins, a no. 15 blade scalpel is used to create an intercartilaginous incision starting laterally just above the cephalic margin of the lateral crus. It is extended medially approximately 2 mm caudal and parallel to the limen vestibule.

• A marginal incision is then created along the caudal margin of the lower lateral cartilage (from lateral crus to medial crus), ending at the columellar-lobular junction.

• Sharp scissors are then used to dissect the soft tissue off the cartilage just above the perichondrium, including over the dorsal cartilaginous septum.

• The same incision is made on the contralateral side, and the two incisions are connected in the midline over the anterior septal angle, ending in a hemitransfixion incision.

• If necessary, this may be extended to a full (complete) transfixion incision.

• The lower lateral cartilage is then dissected free from the surrounding tissue and ‘delivered’ outside the incision.

• If there is difficulty delivering the cartilages, the incisions may be extended and the soft tissue undermined to a greater extent.

• Once the cartilages (and domes) are delivered, modifications may be made.

Fig. 11.24 Delivery approach via the intercartilaginous, marginal and transfixion incisions. This approach is used when moderate tip modifications are necessary.

Open approach

• In the open approach (Fig. 11.25), we use a stairstep transcolumellar incision across the narrowest portion of the columella with a no. 15 blade scalpel. The stairstep is important because it helps to provide landmarks for accurate closure, prevents linear scar contracture, and camouflages the scar.

• Bilateral infracartilaginous extensions are then performed (Fig. 11.26). These begin first from lateral to medial along the caudal border of the lower lateral cartilage, and then from medial to lateral, from the level of the transcolumellar incision to the apex of the middle crus where it joins the lateral incision. A double-pronged skin hook placed along the alar rim is used to perform this maneuver. External digital pressure is used to evert the ala and augment visualization of the lateral crus.

Fig. 11.25 Open approach 1. A stairstep transcolumellar incision is made across the narrowest portion of the columella.

Fig. 11.26 Open approach 2. Infracartilaginous extensions are then performed with a double-pronged skin hook placed along the alar rim and external digital pressure to facilitate visualization.

When using the open approach and performing the stairstep transcolumellar incision and bilateral infracartilaginous extensions:

• take your time – most mistakes are made trying to obtain exposure;

• keep the incisions superficial to prevent unnecessary injury to the underlying cartilages;

• identify the caudal border of the lower lateral cartilage before cutting.

Skin envelope dissection

• Dissection of the skin envelope (Fig. 11.27) should be done meticulously. It is important to perform the dissection in the suprapericondrial/submusculoaponeurotic plane because this avoids injuring the arterial, venous, and lymphatic supply to the nose.

• There should be no residual soft tissue remaining on the lower lateral cartilages if the dissection is performed properly.

• This dissection is then continued in a superior direction, exposing the cartilaginous dorsum and ULCs.

• At the level of the bony pyramid, the scissors are traded for a Joseph periosteal elevator, which continues the dissection in a subperiosteal plane to the radix.

• It is important to limit the extent of the subperiosteal dissection to just the area of the bony dorsal hump that needs to be addressed; otherwise, all periosteal attachments to the nasal bones may be disrupted, leading to prolonged wound healing and potential nasal bone malposition, especially after osteotomy.

Fig. 11.27 Meticulous skin envelope dissection should be done in the suprapericondrial/submusculoaponeurotic plane.

When carrying out skin envelope dissection:

• it is easier to go slowly through the correct dissection rather than to spend more time fixing mistakes from inadvertent mishaps resulting from haste;

• stay just above the perichondrium in the submusculoaponeurotic plane;

• limit lateral subperiosteal dissection over the bony pyramid;

• make sure the ULCs are not detached from the nasal bones by accidental dissection under the nasal bones (rather than on top).

Reducing the osteocartilaginous hump

We prefer to reduce the osteocartilaginous hump in component fashion. This process involves the following four basic steps, after the skin envelope dissection just described:

• separation of the ULCs from the septum;

• incremental reduction of the septum proper;

• incremental dorsal bony reduction (using a rasp);

• three-point palpation test.

Separation of the ULCs from the septum

• To minimize mucosal trauma resulting in potential internal nasal valve stenosis or vestibular webbing, it is critical to create bilateral superior subperichondrial tunnels before embarking on the reduction of the dorsal hump. This is done by elevating the mucoperichondrium of the dorsal septum from caudal to cephalad with a Cottle elevator until the nasal bones are reached.

• The transverse processes of the ULCs are then sharply separated from the septum using a no. 15 blade scalpel without damaging the mucosa.

• If necessary, spreader grafts or dorsal grafts can then be placed in this enclosed space.^28,²⁹

Incremental component cartilaginous dorsal septal reduction

• At this point, the cartilaginous dorsal septum is separated into three components: the septum centrally and the transverse portions of the ULC laterally.

• The cartilaginous septum is addressed by serially shaving the dorsal hump deformity down with a sharp scalpel under direct vision. This maneuver is done carefully, avoiding damage to the adjacent ULCs. If the septum and ULCs were taken down en bloc and not in component fashion, the patient would end up with a rounded dorsum. The same result would apply if the ULCs were resected to a greater extent relative to the septum.

• Although reduction of the ULCs is not routinely performed, certain instances may warrant consideration. If so, it must be done after the septal cartilaginous hump and bony dorsal hump are addressed. Again, over-resection of the ULCs must be avoided to prevent internal nasal valve collapse and long-term dorsal irregularity. Maintaining the transverse portions of the ULC also preserves the dorsal aesthetic lines.

Incremental dorsal bony reduction

• The method of reducing the bony dorsum depends on the amount of deformity that requires resection.³⁰

• Large humps (>5 mm) are reduced either by a power burr with a dorsal skin protector or a guarded 8 mm osteotome.

• For humps smaller than 5 mm, a sharp rasp (we prefer a downbiting diamond rasp) is used. When rasping, it is important to maintain a slightly oblique bias to minimize potential mechanical avulsion of the ULCs from the nasal bones. The rasping is done in a controlled, methodical fashion, proceeding along the left and right dorsal aesthetic lines, and then centrally. The nondominant thumb and index finger are used simultaneously for maximal control.

Three-point dorsal palpation test

• The three-point dorsal palpation test is performed repeatedly throughout the component dorsal hump reduction process, after redraping the skin envelope. This test is performed with a saline moistened dominant index fingertip, which is used to gently palpate the left and right dorsal aesthetic lines, as well as centrally, to detect any dorsal irregularities or contour depressions.

Septal reconstruction/cartilage graft harvest

If the septum is deformed or if cartilage is needed for graft construction, the septum is harvested. The septum is an ideal source for cartilage graft harvest in rhinoplasty because of its close proximity to the operating field and its minimal donor site morbidity.

• In the closed approach, a Killian or hemitransfixion incision is generally used because a full transfixion incision can lead to decreased tip projection, especially if dissected down over the anterior nasal spine.

• In the open approach, the cartilage harvest is begun by separating the middle crura, incising the interdomal suspensory ligament, and exposing the anterior septal angle. A no. 15 blade scalpel is used to incise the septal perichondrium, exposing the distinct bluishgray underlying cartilage. A Cottle elevator is used to create a submucoperichondrial plane posteriorly to the perpendicular plate of the ethmoid down to the nasal floor and across the face of the septum.

• The dissection should be more difficult at the junction of the cartilaginous and bony septum, and therefore proceed with caution in this area because perforation of the overlying mucoperichondrium is more likely.

• It may be advantageous to dissect two separate tunnels, one sub-perichondrial and one subperiosteal, and then divide the junction sharply to help avoid potential perforation in this area.

• The same dissection is then performed on the contralateral side.

• Next, a Vienna speculum is used to directly visualize both sides of the septum to identify underlying deformity and help achieve exposure for the septal harvest.

• When harvesting the graft, it is necessary to preserve an L-strut with 10 mm of dorsal septum and 10 mm of caudal septum retained to support the lower nasal vault. After the cartilage is resected, it is preserved in saline. Any residual deviations in the ethmoid or vomer are rongeured or resected, and any mucosal perforations are repaired.

Inferior turbinoplasty

In patients with symptomatic nasal airway obstruction secondary to inferior turbinate hypertrophy that is refractory to medical management, an inferior turbinoplasty is performed. This can be done by:

• turbinate outfracture;

• conservative composite tissue removal followed by gentle cauterization;

• submucous morselization of the turbinate bone; or

• submucous resection of the anterior one-third to one-half of the inferior turbinate.^23,²⁶

The submucous resection is done by developing medial mucoperiosteal flaps, exposing the conchal bone using a Cottle elevator, and sharply resecting the proper amount. The flaps are replaced after this resection without the need for suture repair.

It is important to note that the extent of the conchal bone resection is limited to the anterior portion. This is done mainly to avoid complications of bleeding if the posterior portion is resected.

Cephalic trim

When the tip is boxy or bulbous and requires better refinement and definition, if the tip-defining points need medialization, or when rotation of the tip is desired, a cephalic trim (Fig. 11.28) is performed. This is done by using a caliper to measure along the caudal margin of the lower lateral cartilage to preserve a 6 mm rim strip. After this is demarcated, the cephalic portion of the middle and lateral crura is resected.

Fig. 11.28 A cephalic trim of the lateral crura cartilage is performed for nasal tip refinement and definition.

The cartilage is preserved for possible use later in the case.

Spreader grafts

Failure to preserve the middle vault can result in collapse of the internal nasal valve as well as cosmetic deformity, such as the inverted V or saddlenose deformity. In this situation, spreader grafts (Fig. 11.29) can be used to help stent open the internal valve, stabilize the septum, and preserve the dorsal aesthetic lines.^28,^29,³¹ These grafts are usually obtained from septal cartilage, and are designed to measure approximately 25–30 mm by 3 mm. Their cephalic ends can be trimmed obliquely to fit snugly underneath the bony dorsum and their caudal ends can be placed either at:

• the septal angle (if lengthening of the nose is not desired); or

• extending past it (if lengthening is desired).

Fig. 11.29 Spreader grafts can be used to help stent open the internal valve, stabilize the septum, and preserve the dorsal aesthetic lines.

Furthermore, the grafts can be placed in a visible position (secured in a higher position along the septum) or in an invisible position (positioned lower) (Fig. 11.30). We secure the grafts with 5–0 PDS in horizontal mattress fashion.

Fig. 11.30 Spreader grafts can be placed in a visible position (secured in a higher position along the septum) or in an invisible position (positioned lower).

Tip modification

Altering tip projection

It is important to recognize the factors that contribute to tip projection in situ before embarking on a discussion on how to precisely alter tip projection.^27,³² There are six key anatomic elements to tip projection (Box 11.6). Alteration of any of these anatomic structures can result in incremental changes in tip projection.

Box 11.6 The six key anatomic elements to tip projection

1. Supporting ligament between the anterior septal angle and the overlying dermis

2. Length and strength of the lower lateral cartilages

3. Suspensory ligament bridging the anterior septal angle

4. Fibrous connections between the upper and lower lateral cartilages (and septum)

5. Abutment of the cartilages with the piriform aperture

6. Anterior septal angle

A graduated approach to tip projection is dependent on precise, incremental, nondestructive changes made to the tip complex, beginning with suture modification, proceeding to columellar struts, and finishing with the use of tip grafts.

The algorithm begins with suture techniques,³³ which are able to achieve an increase of 1–2 mm of tip projection. Suture techniques are ideal for controlling cartilage in a precise, nondestructive fashion. Although the choice of particular suture material is surgeon dependent, the underlying premise is to choose a material that one can easily work with that will hold the cartilage in its altered position long enough to allow for the natural fibrotic reaction to solidify the result. Although many suture techniques can be performed in both open and closed rhinoplasty (with cartilage delivery), we find them easier to place using the open method, because it affords greater visualization and ease of placement.

The four general types of suture technique used to alter projection are:

• medial crural, medial crural septal, interdomal and transdomal.

Medial crural sutures

Medial crural sutures (Fig. 11.31) unify the medial crura of the lower lateral cartilages and are often used in conjunction with a columellar strut (to help stabilize the strut). They can also be used to straighten out flaring of the medial/middle crura (either on the caudalmost aspect or near the domal area), thereby effecting an increase in projection, albeit to a limited degree. We generally use 5–0 PDS suture in horizontal mattress fashion for this technique, but the suture choice can vary by individual preference.

Fig. 11.31 Medial crural sutures serve to unify the medial crura of the lower lateral cartilages and are frequently used in conjunction with a columellar strut (to help stabilize the strut).

Medial crural septal sutures

Medial crural septal sutures (Fig. 11.32) anchor the medial crura to the caudal septum, and can alter projection as well as rotation. They are often used in conjunction with columellar struts. We frequently use 5–0 clear nylon suture in spanning fashion for this technique.

Fig. 11.32 Medial crural septal sutures. A, Medial crural septal sutures. B, Medial crural septal sutures anchor the medial crura to the caudal septum and can alter projection as well as rotation.

Interdomal sutures

Interdomal sutures (Figs 11.33 and 11.34) are placed through the medial walls of the domes in mattress fashion and are tied so as to narrow the interdomal distance. This results an increase in both tip refinement and projection.

Fig. 11.33 Interdomal and transdomal sutures.

Fig. 11.34 Interdomal sutures are placed through the medial walls of the domes in mattress fashion. They are tied to narrow the interdomal distance.

Transdomal sutures

Transdomal sutures (Figs 11.35 and 11.36) are placed across the dome of the middle crura in mattress fashion, such that the vestibular skin is not perforated. Local anesthetic can be used to hydrodissect a plane between the cartilaginous dome and the adherent underlying mucoperichondrium to help prevent inadvertent incorporation into the suture bite. We generally use 5–0 PDS in horizontal mattress fashion and leave the knots on the medial aspect of the dome.

Fig. 11.35 Transdomal sutures are placed across the dome of the middle crura in mattress fashion with one end left long on each side.

Fig. 11.36 Transdomal sutures are tied together in spanning fashion to narrow the tip-defining points.

Transdomal sutures can be made:

• asymmetrical to correct anatomic asymmetries, if necessary;

• fashioned with one end left long on each side, and then subsequently tied together in spanning fashion (resembling an interdomal suture) to narrow the tip-defining points.

It is important to prevent overtightening of this suture, which can result in an unnaturally sharp tip-defining point.

Placement of a columellar strut

The next step in altering tip projection involves the placement of a columellar strut, which:

• is usually fashioned from septal cartilage;

• measures approximately 25 × 4 mm;

• can be placed in a ‘fixed’ (secured to the anterior maxilla) or a ‘floating’ (not secured to the maxilla) fashion (Figs 11.37 and 11.38);

• not only controls the columellar profile, but also bolsters tip projection.

Fig. 11.37 A columellar strut is placed in a nonsecured (fixed) fashion to alter tip projection.

Fig. 11.38 Columellar strut secured to the anterior maxilla in (floating) fashion.

The strut is placed by dissecting a pocket between the medial crura. A double-pronged hook is then used to gently retract the middle crura anteriorly to set the desired projection and symmetry. The strut is positioned in the pocket, and a 25-gauge needle is used to stabilize this configuration. Most are left floating on a soft tissue pad between the base of the pocket and the nasal spine.

Medial crural sutures (see above) are placed in horizontal mattress fashion to secure the complex. Further medial crural sutures can be placed more caudally on the medial crura to control flaring, if necessary.

Tip grafts

If more tip projection or definition is desired after the preceding maneuvers, tip grafts may be used. We find it easier to place these grafts using the open approach because it allows excellent visualization, precise placement, and facilitates subsequent manipulation, if necessary. Grafts in general have a tendency to be visible, however, so their use is reserved only for the patient in whom the prior, more predictable methods do not result in satisfactory tip projection. There are three general types of tip grafts (Box 11.7):

• onlay tip graft (Fig. 11.39);

• infratip lobular graft (Fig. 11.40);

• columellar tip graft (Fig. 11.41).

Box 11.7 The three general types of tip graft

Onlay tip graft (see Fig. 11.39)

• Can be fashioned from any type of cartilage, but cartilage obtained from the cephalic trim harvest works exceptionally well.

• Placed in a position overlying the dome of the middle/lateral crura and fixed in place using the techniques described in text.

• We generally use 5–0 PDS suture, with the knots hidden underneath the dome.

Infratip lobular graft (see Fig. 11.40)

• Positioned with its superior margin overlying the dome/tip-defining points and extending inferiorly a variable distance, usually 10–12 mm.

• Usually shield-shaped, and has rounded graft edges to avoid a visible and palpable step-off.

• Increases infratip lobular definition and projection.

• Secured in the same fashion as described previously (see Fig. 11.41).

Columellar-tip graft (see Fig. 11.41)

• A more aggressive type of graft that we generally use in difficult primary rhinoplasties, thick-skinned patients, and secondary rhinoplasties with inadequate tip projection.

• Its superiormost aspect is anchored to the ULCs.

• Its inferiormost aspect is secured to the caudal margin of the medial crura.

• Essentially a ‘combination’ graft and can be visible, so it must be placed carefully (see Fig. 11.41).

Fig. 11.39 Onlay tip graft.

Fig. 11.40 Infratip lobular graft.

Fig. 11.41 Columellar tip graft. This is essentially a ‘combination’ graft.

Decreasing nasal tip projection

When attempting to decrease nasal tip projection, again it is important to recognize the anatomic factors that contribute to tip projection in the first place.

If the support derived from the fibroelastic and ligamentous attachments is disrupted, tip projection becomes primarily dependent on the length and strength of the lower lateral cartilages. Therefore, in the open approach, if the skin envelope has been undermined and these fibroelastic tissues have been severed, the primary means of decreasing tip projection lies in altering these lower lateral cartilages. This may include techniques such as transection, setback, and resuturing of the medial or lateral crura.

If the tip projection is decreased significantly, alar flaring or columellar bowing may result and necessitate concomitant correction.

Altering tip rotation

Using the nasofacial analysis techniques described, rotation is evaluated generally by the nasolabial angle. This angle, found by measuring the angle between a line coursing through the most anterior and posterior edges of the nostril and a plumb line dropped perpendicular to the natural horizontal facial plane, should be between 95 and 100 ° in women and between 90 and 95 ° in men (see Fig. 11.11).

When changing tip rotation, the extrinsic forces holding the tip at its current angle must be released. This is generally done by severing the connection between the lower and upper lateral cartilages. This frequently takes the form of a cephalic trim, as described above. Furthermore, the fibrous attachments of the medial crura and the caudal septum can be transected to release tension on the nasal tip and allow for more cephalad rotation. This is generally achieved by resecting a variable amount of the caudal septum (Fig. 11.42). This maneuver can also affect tip projection.

Fig. 11.42 Resecting a variable amount of the caudal septum along with release of the fibrous attachments can also affect tip projection.

Depending on the amount of tip rotation, it may be necessary to perform a limited resection of the nasal mucosa and membranous septum to maintain proper nasal balance and harmony.

After the tip is rotated, its position is maintained with suture techniques (medial crural septal sutures) and/or a columellar strut or septal extension graft.

Correcting the alar-columellar relationship

Class I deformity

When a class I deformity exists (see Fig. 11.14A), or when the long axis-columellar rim distance (BC) is greater than 2 mm and the alar rim-long axis distance (AB) is normal, that is an example of a true hanging columella.

Correcting this involves resecting either the caudal septum, the caudal portion of the medial crus, the caudal portion of the middle crus, or a combination of these – whichever is responsible for the deformity (Fig. 11.42).

Class II deformity

A class II deformity (see Fig. 11.14B) or a retracted ala (AB > 2 mm, BC < 2 mm) can be treated in several ways:

• one method is to insert an elliptically shaped composite graft from an access incision made in the vestibular skin (Fig. 11.43A&B) the graft is made slightly larger than needed to compensate for secondary contraction;

• if the retraction is mild and there is no tissue deficiency, an alternative technique is used with the lateral crura detached from the accessory chain and repositioned inferiorly;

• a final method is to place an alar contour graft (nonanatomic position) in a pocket created along the vestibular rim to displace the ala inferiorly.

Fig. 11.43 Correction of class II deformity. A&B, An alar contour graft (nonanatomic position) is placed in a pocket created along the vestibular rim to displace the ala inferiorly. This can be done through an anterior (A) or posterior (B) incision.

Class III deformity

A class III deformity (see Fig. 11.14C) is a combination of a class I and class II deformity, and is corrected with a combination of the procedures outlined above to correct class I and class II deformities.

Class IV deformity

A class IV deformity (see Fig. 11.14D) is a hanging ala (AB < 1 mm, BC < 2 mm).

This is usually treated with an elliptical excision of vestibular skin (Fig. 11.44). Care is taken to avoid over-resection of skin because an abnormal, rolled-in appearance of the alar rim can result.

Fig. 11.44 Correction of a class IV deformity. This is usually treated with an elliptical excision of vestibular skin.

Class V deformity

A class V deformity (see Fig. 11.14E) is a retracted columella (AB < 2 mm, BC < 1 mm)

The treatment of choice for this deformity is the placement of a columellar strut (Fig. 11.45), which is positioned more caudally to extend the caudal dimension of the columella.

Fig. 11.45 Correction of a class V deformity. Treatment of choice is placement of a columellar strut.

Class VI deformity

A class VI deformity (see Fig. 11.14F) is a combination of class IV and class V, and is treated with a combination of the techniques described above.

Osteotomy Techniques

Osteotomies are a powerful technique in rhinoplasty.³⁴^–³⁶ The indications to perform osteotomies, regardless of technique are:

• to narrow the lateral walls of the nose;

• to close an open-roof deformity (after dorsal hump reduction);

• to create symmetry by straightening the nasal bony framework.

Contraindications to osteotomies can include:

• patients with short nasal bones;

• elderly patients with thin, fragile nasal bones;

• patients with heavy eyeglasses.

There are several osteotomy techniques, including medial, lateral, transverse, or a combination of these. Furthermore, they can be performed through either an external or internal approach ³⁷^–³⁹ (Figs 11.46 and 11.47).

Fig. 11.46 Lateral osteotomy. This may be performed as ‘low to high,’ ‘low to low,’ or as a double level.

Fig. 11.47 Webster’s triangle. This is a triangular area of the caudal aspect of the maxillary frontal process near the internal valve.

A lateral osteotomy may be performed as ‘low to high’, ‘low to low’, or as a double level (Fig. 11.46) and may be combined with medial, transverse, or greenstick fractures of the upper bony segment.

No matter how the osteotomy is performed, however, it is necessary to preserve Webster’s triangle (Fig. 11.47), which is a triangular area of the caudal aspect of the maxillary frontal process near the internal valve. Preserving this area maintains support to the valve and prevents functional nasal airway obstruction from collapse.

Regardless of the technique used to perform the lateral osteotomy, it is important to maintain a smooth fracture line by staying low along the bony vault, thereby preventing the potential for a step-off deformity. The cephalic margin of the osteotomy should not be higher than the intercanthal line (the medial canthal ligament); the thick nasal bones above this area increase the technical difficulty, and it is possible to cause iatrogenic injury to the lacrimal system (with resultant epiphora).

‘Low to high’ osteotomy

A ‘low to high’ osteotomy is generally used to:

• correct a small open-roof deformity; or

• mobilize a medium-wide nasal base.

It begins low at the piriform aperture and ends ‘high’ medially on the dorsum. The nasal bones are then ‘greensticked’ to medialize them, with predictable fracture patterns obtained based on nasal bone thickness.

Occasionally, a separate superior oblique osteotomy is necessary to mobilize thicker nasal bones enough to be greensticked.

‘Low to low’ osteotomy

A ‘low to low’ osteotomy is generally a more powerful technique in that it results in more medial movement of the nasal bones, and is therefore classically used for:

• a large open-roof deformity; or

• to correct a wide bony base.

It starts low along the piriform aperture and continues low along the base of the bony vault to end in a lateral position along the dorsum near the intercanthal line.

Because there is more bone between the cephalic aspect of this osteotomy and the midline, this type of osteotomy is frequently accompanied by a medial osteotomy to better mobilize the nasal bones to achieve the desired result.

Our technique of external perforated lateral osteotomy

We have refined our preferred technique of external perforated lateral osteotomy, which has proven to be well-controlled, predictable, and reproducible.

The unique advantages of this technique are based on the preservation of the periosteal attachments,⁴⁰ namely:

• decreased amount of dead space;

• reduced subluxation and subsequent airway compromise;

• greater overall stability after positioning.

Procedure

Our technique is as follows (Figs 11.48A-H).

• Inject intranasally and along the lateral nasal sidewalls with 2 mL of 1% lidocaine with 1 : 100 000 epinephrine and allow 5–7 minutes for the hemostatic process to take effect.

• Introduce a sharp 2 mm osteotome percutaneously on the midportion of the bony nasal pyramid at the level of the inferior orbital rim and nasofacial junction. It must be held at a plane parallel to the surface of the maxilla.

• To avoid injury to the angular artery, sweep the osteotome down the lateral nasal sidewall in a subperiosteal plane.

• Position the osteotome at an angle such that one edge is in contact with the bone and strike with the mallet. The endpoints are a change in the feel and sound at that location.

• Extend the osteotomy in an inferior, superior, and superior-oblique manner at the level of the piriform (Fig. 11.48A-D). Leave a 2 mm gap between each individual osteotomy.

• Perform the same procedure on the contralateral nasal wall.

• After the osteotomies are completed, use gentle pressure between the thumb and forefinger to perform a greenstick fracture of the nasal bones to position them in the desired location.

• Cover with flesh-colored Steri-Strips and apply a dorsal compression splint (Denver splint) for 7 days to minimize postoperative edema (Fig. 11.48E-H).

Fig. 11.48 Our technique of external perforated lateral osteotomy. A-C, The osteotomy is extended in an inferior, superior, and superior-oblique manner at the level of the piriform. D, Outline of the projected level and extent of the osteotomy. E-H, Cover with flesh-colored Steri-strips and apply a dorsal compression splint (Denver splint) for 7 days to minimize postoperative edema.

Medial osteotomies

Medial osteotomies are used to facilitate medial positioning of the nasal bones. They are generally indicated in patients with thick nasal bones or a wide bony base to achieve a more predictable result; greenstick fractures in these subgroups can sometimes be difficult and can lead to unpredictable fracture patterns.⁴¹

Medial osteotomy used in conjunction with lateral osteotomy

Medial osteotomies can be used in conjunction with lateral osteotomies, but it is not necessary to use both types in all cases. When using both techniques, the medial osteotomy is usually performed first because this makes it technically easier to perform subsequent lateral osteotomies.

Although the cant of the medial osteotomy can be varied (i.e. medial oblique, paramedian, transverse), for the reasons stated above, the cephalic margin should not cross the intercanthal line.

Furthermore, it is paramount to avoid placing the medial osteotomy too far centrally as it connects with the lateral osteotomy causing a rocker deformity, where the upper portion of the fractured nasal bone ‘kicks out’, resulting in a widened upper dorsum (Fig. 11.49). This can be avoided by following an oblique angle.

Fig. 11.49 Rocker deformity. Placing the medial osteotomy too far centrally as it connects with the lateral osteotomy can cause a rocker deformity, where the upper portion of the fractured nasal bone ‘kicks out’, resulting in a widened upper dorsum.

After the medial and lateral osteotomies are created, the nasal bones are greensticked to the desired position.

Double-level lateral osteotomy

Occasionally a double-level lateral osteotomy ³⁵ is needed to correct lateral wall convexities that are too great to be corrected with a standard single-level lateral osteotomy or when there are significant lateral nasal wall asymmetries. This is done by:

• first making the upper (more medial) lateral osteotomy along the nasomaxillary suture line;

• then creating the lower (more lateral) osteotomy in standard low-to-low fashion.

Closure

After meticulous hemostasis is achieved and any excess debris removed, the skin envelope is redraped. If the patient has thick skin, and especially if the patient is a woman, we may choose to place a single 5–0 Vicryl suture from the dermis (underside of the skin envelope) to the underlying cartilaginous framework in an attempt to recreate a supratip break.

The transcolumellar incision is then closed using 6–0 nylon suture in simple interrupted fashion, making sure the coaptation of the incision margins is precise (Fig. 11.50A&B). The stairstepping of the original incision helps us close this accurately.

Fig. 11.50 Closure. A&B, The transcolumellar incision is closed using 6-0 nylon suture in simple interrupted fashion.

The infracartilaginous incisions are reapproximated using 5–0 chromic suture in simple interrupted fashion. We take special care to prevent overbiting with the suture, which can create contour irregularities and notching, especially in the soft triangle area.

If septal work has been performed, we place intranasal silastic splints coated with antibiotic ointment. These are secured with a transseptal 3–0 nylon suture.

The nasal dorsum is then carefully taped, and a malleable metal splint is applied over the dorsum (Figs 11.51).

Fig. 11.51 The nasal dorsum is carefully taped, and a malleable metal splint is applied over the dorsum.

A drip pad is fashioned from a gauze 2 × 2 and secured under the nose with paper tape. The throat pack is removed, and the oropharynx and stomach are carefully suctioned to help evacuate any blood that may result in postoperative nausea and vomiting.

Alar Base Surgery

If alar base surgery is necessary, it is generally performed after closure of the transcolumellar and infracartilaginous incisions, but before intranasal and external splints are placed. Alar base abnormalities include wide or excessive nostril sills, a wide alar base, asymmetric or malpositioned alar bases, or any combination of these.

Wide nostril sills

Wide nostril sills (or alar flaring) is relatively common. It is corrected by performing a small crescentic resection of the alar base, making sure to avoid extending the incision into the actual vestibule (Fig. 11.52). The incision is placed approximately 1–2 mm above the base to prevent alar notching. The soft tissue at the base is mobilized with judicious use of electrocautery and transposed medially to the desired aesthetic endpoint, where it is sutured in place. We suture using the ‘halving principle’ in this region, because the interior incision is shorter than the exterior incision.

Fig. 11.52 Correction of wide nostril sills. A small crescentic resection of the alar base is performed, making sure to avoid extending the incision into the actual vestibule.

Wide alar base

A wide alar base is corrected in a similar fashion, but the crescentic excision assumes a more wedge-type geometry and may include a small portion of the nostril sill (Fig. 11.53). If a transcolumellar incision was used at the start, it is crucial that the alar base excision stays within 3 mm of the lateral alar groove because the blood supply to the nasal tip can be jeopardized if the lateral nasal artery is inadvertently injured. Although some have advocated suture techniques for narrowing the nasal base, we generally perform this with excisional techniques.