The authors generally use intranasal incisions for a deviated nose but will frequently use the open or external rhinoplasty technique when there are severe asymmetries, deviations, and tissue deficiencies.^2,⁵^–⁷ Some of the indications for use of the external rhinoplasty are as follows: (1) a nasal deformity that is difficult to precisely analyze; (2) one in which there is severe asymmetry of the lateral bony walls and the lower lateral cartilages; (3) when tissue deficiencies exist so that it is necessary to precisely place and suture implants in position⁸; (4) congenital anomalies such as the cleft-lip nose or other deformities in which profound asymmetries exist; (5) an extremely wide bony and cartilaginous dorsum, whether or not a hump is removed; and (6) for teaching purposes. The external approach involves a transverse midcolumella incision in a gull-wing curve rather than one with sharp angle. The authors use the gull-wing incision as opposed to the inverted gull-wing incision to create a single point rather than two points at the distal end of this diffuse random pattern flap. The incision is then extended upward along the caudal edge of the medial crus and laterally along the caudal margin of the lateral crus as an alar cartilage margin incision (Fig. 37-1). The elevation is initiated with sharp knife dissection, with the columella skin being elevated before the elevation is extended laterally over the lateral crura of the lower lateral cartilages. The external incision crossing the columella leaves a barely perceptible scar and offers excellent visualization by means of the “degloving” of the nose.

Figure 37-1. The external (open) approach. A, A gull-wing incision is made, crossing the columella just above the flare of the feet of the medial crura and then extending upward along the caudal edge of the medial crura and into marginal incisions laterally with the surgical knife. The skin is further elevated with the Stevens tenotomy scissors. B, Excellent exposure can be obtained to the root of the nose, which assists in evaluating asymmetry of the dorsum. The caudal septum and anterior nasal spine can be approached through the external approach, or a separate hemitransfixion incision may be made as shown by the dashed line.

Septal and Columella Modifications

It is impossible to discuss correction of the difficult nasal deformity without addressing surgery of the involved septum. The specific techniques required are determined by the amount of cartilage that remains and how angulated or dislocated it is. The septum must be considered as an ideal donor site for cartilage and bone implants. When adequate material is available, it is an excellent implant for the nasal dorsum, a columella strut, a shield implant to the tip, a filler for depressions in the area of the upper lateral cartilages, and for creating spreader and batten grafts. Once the incisions are made, elevation of the mucoperichondrial flaps is frequently difficult because of fibrosis through fracture sites and overlapping or lamination of the cartilage itself. In the previously operated nose, a practical approach involves beginning the elevation of the mucoperichondrium beneath the dorsum, because this area is often previously undisturbed. The elevation then proceeds downward toward the previous operative site, where cartilage and bone may have been removed.

For the severely deviated or previously operated nose, it is usually necessary to elevate the mucoperichondrium on both sides of the septal cartilage, although it is preferable whenever possible to leave it attached on one side as the bone and cartilaginous angulations are corrected. Freeing fibrous contractions and septal angulations is essential in allowing the septal framework to straighten. The extent to which cartilage and bone must be removed or repositioned is dictated by the particular deformity encountered and the direction of the angulations. Generally, scoring or removal of thin strips of cartilage along the existing angulations is required to achieve straightening (Fig. 37-2). Release of all tension vectors allows a buckled septum to straighten. Determination of the final position of the septum may not be possible until osteotomies have been performed, particularly if the nasal bones and upper lateral cartilages are severely deviated from the midline. A final determination of what more, if anything, needs to be done to the septum, therefore, must sometimes await the completion of medial and lateral osteotomies, when the entire nose is positioned in the midline (Fig. 37-3) regarding deviations of the central bony complex).

Figure 37-2. Correcting septal curvature. A, Vertical shave to reduce septal thickening. The shave may also be used to reduce bowing. B, Removal of cartilage wedges to straighten the septum in the midline. C, Scoring to allow the cartilage to open and return to the midline.

Figure 37-3. Correction of central component deviation. For deviations of the entire root of the nose or the remaining central component of the nose, it is necessary to establish a firm fulcrum with the osteotome to fracture this central portion toward the midline. This difficult maneuver requires a complete medial osteotomy paralleling the septum as close as possible, as opposed to the fading medial osteotomy.

Transseptal coaptation sutures, which bring the two mucoperichondrial flaps together and pass between angulations or cartilage pedicles to prevent overlap, are great aids in this surgery (Fig. 37-4). Polyethylene splints have been used for a number of years to stabilize the septum in the early postoperative period and to prevent the development of synechiae, particularly when turbinate surgery has been performed. Two through-and-through sutures are always placed through the polyethylene splints. The sutures are placed so that one arm of the suture goes between cartilage pedicles or beneath the septal cartilage for support. The second arm of the suture goes back through the mucoperichondrium and cartilage. One may splint the septum further at a major angulation with a straight portion of thin perpendicular plate of the ethmoid.

Figure 37-4. Coaptation sutures. Further modifications of the septal reconstruction in which it has been necessary to remove a significant amount of cartilage and bone. Coaptation sutures may be either single sutures through and through the mucoperichondrium or a continuous suture passed back and forth through and through and tied to the original free end.

Caudal Repositioning

When it is necessary to reposition the caudal portion of the septum, it is usually necessary to free the mucoperichondrium on both sides to release all extrinsic tension on the cartilage. The septal cartilage is then detached from the underlying anterior nasal spine and maxillary crest. Intrinsic tension of the septum is relieved by scoring, cross-hatching, and wedging. Once this caudal pedicle is freed of the tension vectors, it may be maintained in the midline by sutures that go around the anterior spine or through a burr hole in the spine (Fig. 37-5). To further prevent dislocation, an additional suture may be passed through the two mucoperichondrial flaps and between the bone of the spine and the cartilage. The cartilage pedicle is attached directly to the spine for alignment, and the two mucoperichondrial flaps when sutured together add further stability. When necessary, the caudal edge of the septum may be held in proper relation to the columella with interrupted sutures or direct through-and-through septocolumellar sutures (Fig. 37-6).

Figure 37-5. Repositioning and suturing of the caudal septum. The dislocated septum is repositioned on the anterior spine and maxillary crest. Reconstruction is augmented by scoring or cross-hatching and proper placement of sutures such that one suture is passed submucosally around the anterior spine. The next fixation suture is passed through one mucoperichondrial flap, between the bone of the anterior spine and the septal cartilage and out through the mucoperichondrium on the other side, and then back through flap, septum, and flap to complete the loop. The other sutures are passed between the mucoperichondrial flaps and between the cartilage pedicles to prevent dislocation.

Figure 37-6. Stabilization of the caudal septum with draw sutures through the center of the columella, reestablishing the septocolumellar relationship. At the end of the procedure, the draw sutures may be removed or may be tied loosely against the columellar skin.

Shortening the Caudal Septum

For the deformed nose with a drooping tip and columella retraction, the entire septocolumellar complex must be critically evaluated. In correcting the drooping tip, the lower lateral cartilages must be rotated cephalically, and strong tip support is needed. Both the caudal septum and the soft tissue may need modification to achieve this (Fig. 37-7). Frequently, there is an associated columella retraction, resulting in an acute nasolabial angle. Correction of the retraction requires straightening the caudal septum and placement of a columellar strut or a plumping graft (Fig. 37-8). Some limited resection of the caudal edge of the septum may be necessary to remove a portion of deformed septum that is dislocated off the anterior spine and projecting into one nostril. When the caudal edge of the septal cartilage is severely dislocated, it often creates distortion and retraction of the columella, even though adequate cartilage is present. Straightening and repositioning of the caudal septum within the columella sometimes corrects the retraction (Fig. 37-9). Rarely is it necessary to shorten the upper lateral cartilages, although reduction of the scroll along their caudal border may be necessary to reduce excessive width in that area.

Figure 37-7. Modifications for shortening the nose. A, Ideal limited shortening and elevation of the tip involving only the outer one third to one half of the caudal septum and limited transfixion incision. B, Shortening of the entire caudal septum with slight angulation extending to the spine. C, Shortening of the entire caudal inferior nose with a deepening of the nasolabial angle. The obtuse nasolabial angle is corrected. A right-angle wedge of bone is removed from the anterior spine, and a suture is passed from the cartilage to the base of the membranous columella, reinforcing the angulation and eliminating the dead space.

Figure 37-8. Correction of acute septolabial angle. A, The columella strut adds columellar fullness. B, When the columella strut is not required, a simple plumping graft serves as a filler and gives support to the feet of the medial crura. An implant may be necessary over the face of the maxilla and beneath the anterior spine to create fullness of the lip portion.

Figure 37-9. Correction of columella retraction. A, Marked columella retraction and drooping tip (preoperative). B, After septal reconstruction with tip rotation and columella filling.

Making the Final Septal Assessment

It is not until all septal reconstructive surgery and the osteotomies are completed that the final analysis of the position of the septum can be made. This position is particularly critical at the junction of the bony and cartilaginous portions of the nose, both internally and externally. At this point, the surgeon can determine whether adequate dorsal support has been maintained. If there is any tendency for the cartilaginous dorsum to sink inward, a draw suture can be passed through the skin to pick up either the septum alone or the upper lateral cartilages and the septum along the dorsum (Fig. 37-10). The suture is passed upward through the skin and held in position while all coapting and supporting sutures are placed and packing is completed. The draw suture can then be removed. In extreme cases, the draw suture can be passed through a thin external splint and tied over a bolus to remain in place for a week until the splint is removed.

Figure 37-10. Dorsal draw suture. If there is loss of support either from injury or surgery at the junction of the septal cartilage with the nasal bones and perpendicular plate of the ethmoid, the remaining caudal septum tilts downward (arrow). A draw suture may be passed through the skin of the dorsum of the nose and then used to pick up either the septum alone or the septum with the upper lateral cartilages. The draw suture is then passed through a soft thin metal nasal splint and tied over a bolus. Dorsal draw sutures may be used simply to maintain the position and support while all intranasal surgery is completed and the nose is packed. The sutures are then removed. When necessary, the sutures may remain in position for one week and are removed with the splint.

The Septocolumellar Complex

The columella and caudal septum must often be addressed in rhinoplasty. There may be columellar retraction caused by retraction of the caudal septum or there may be other abnormalities of the septum and columella that distract from the appearance of the nose. Ptotic lower lateral cartilages with a convex caudal margin can cause increased columellar show. This may be exacerbated by a prominent caudal margin of the septum and/or an excessive membranous septum.

These deformities can be addressed by trimming or sculpturing the medial crura and caudal septum as demonstrated in Fig. 37-11. Other structures that may contribute to the perceived or actual abnormalities of the caudal septum and columella include either ptosis of the lateral crus of the lower lateral cartilage, causing what appears to be a retracted columella, or retraction of the ala, resulting in excessive columella show (Fig. 37-12). These abnormalities must be corrected when addressing the lower lateral cartilages, either through reduction or augmentation (Fig. 37-13). Repositioning of the anterior maxillary spine, division of the depressor nasi musculi, sectioning of the frenulum, and defatting or augmentation of the nasolabial angle may also be necessary when addressing the caudal septum and columella.⁹

Figure 37-11. The septocolumella complex. Apart from abnormalities of the lateral ala and its relation to the columella, this complex involves at least the caudal septum, the membranous septum, and the curvature and strength of the medial crura. The exaggerated convex caudal edge of the medial crura, as occurs in the hanging columella, may be partially sectioned to allow the crura to straighten with suturing. The caudal cartilaginous septum and membranous septum may require partial resection. The septocolumella complex is reestablished with sutures, including through-and-through septocolumella sutures. The medial crura may be approached retrograde through the transfixion incision and with subcutaneous elevation of the skin or directly by the external approach.

Figure 37-12. Cephalad retraction of the alar margin. A, Postoperative complications: the all-too-frequent supratip swelling or pollybeak deformity and cephalic retraction of the lateral alar margin. B, Correction is accomplished by reducing the cartilaginous nasal septum and removing supratip fibrous tissue, further sculpturing the lower lateral cartilages, freeing the lateral crus, and inserting a cartilage implant retrograde along the alar margin. (See also Fig. 37-13.)

Figure 37-13. Retrograde alar margin implant. A, Creation of the retrograde pocket through the alar cartilage margin incision down to the rim. B, The sculptured cartilage implant is brought into the pocket with draw sutures and held in position with transalar sutures tied over a thin polyethylene film.

Nasofrontal Angle Modifications

Subtle modifications in the nasofrontal angle can significantly enhance a patient’s nasal and facial profile. In patients with a shallow nasofrontal angle, the nose often appears to have excessive length. In this type of patient a 2-mm osteotome can be inserted through a stab incision in the midline over the nasal bones (Fig. 37-14). The nasal bones can be scored or weakened on either side with transverse osteotomies, thereby controlling the cephalic fracture site. This will allow the surgeon to control the site of the nasofrontal angle when the bony hump is removed. After removal, the angle may be smoothed or further deepened by the use of the rasp or rongeur.

Figure 37-14. The nasofrontal angle is reduced by placing a 2-mm osteotome through a stab incision and creating a deeper angulation by joining the two lateral osteotome cuts at right angles.

In patients with a deep nasofrontal angle, the nose often appears to be short and often overprojected. In these patients, the nasofrontal angle can be augmented with autogenous cartilage, bone, or any of the alloplastic materials mentioned earlier. Autogenous cartilage is the material of choice secondary to their low rate of absorption and nonreactivity. A precise pocket should be made that does not allow movement of the graft. The graft can be further stabilized by placing transcutaneous sutures through the graft and tying them over a bolster.

Tip and Alar Asymmetries

Tip Grafts

This section considers correction of severe asymmetries and deficiencies of the nasal tip that occur in the traumatized or congenitally deformed nose. For these noses, wide exposure of the lower lateral cartilages is absolutely essential and may be achieved either through delivery of the cartilages or by the external approach.

When there are severe asymmetries of the lower lateral cartilages, management usually requires modification of the more normal cartilage and the more abnormal side if one is to achieve a symmetric tip. The cephalic portion of the lower lateral cartilage is an excellent implant to be used in the nasal tip to overlie angulations, to fill small depressions, or for splinting cartilage by direct suturing. When more sturdy cartilage is necessary, sculptured or laminated septal or auricular cartilage is useful (Fig. 37-15). In the tip, these implants may be combined and sutured directly to a columella strut or to the domes of the lower lateral cartilages. If there is marked distortion with associated soft tissue contracture, it may be necessary to free the lateral crus of the lower lateral cartilage on the involved side of both dorsal and vestibular skin and then advance the lateral crus into the nasal tip between the two skin layers as in the technique used in the cleft-lip nose repair (Fig. 37-16).

Figure 37-15. Revisional surgery with implants for nasal tip. A, A simple onlay implant, which may be sutured in position to the cartilage or held in position by a draw suture through the external skin. B, Implant to the tip and columella, most commonly using auricular cartilage. C, Contouring of the implant by scoring. D, Asymmetric implant. E and F, Tip button with stabilization between the medial crura.

Figure 37-16. Freeing of the alar cartilage for the cleft-lip nose or certain asymmetries of the lower lateral cartilage. The lower lateral cartilage is freed of both surface and vestibular skin, allowing the cartilage to be rotated medially to project the tip of the nose. The cartilage is then sandwiched between the two skin surfaces in the new position and held with transalar sutures tied over a flat plastic film on the external surface. This technique is used for unilateral and bilateral nasal deformities and can be accomplished by either the intranasal or the external approach. Boluses on both surfaces are to be avoided.

The septum is an ideal source of grafts to be placed in the nasal tip. Such an implant has the effect of stabilizing the medial crura and domes in proper relationship and giving some increased tip projection. This technique is useful in both the severely traumatized tip and the previously operated nose, in which all too often too much tissue has been removed from the lower lateral cartilages. A nasal tip graft or shield graft should be sutured directly to the lower lateral cartilages. This may be accomplished readily through intranasal incisions (alar cartilage margin incisions) or can be placed with greater ease and less chance of dislodgment through an external rhinoplasty (Fig. 37-17). Migration of the shields has been the major problem with their use, and direct suturing prevents this displacement. By removal of a wedge from the inferior border of the shield, two points are created along the inferior border, assisting in stabilization to prevent movement.

Figure 37-17. The external rhinoplasty allows the shield to be sutured into position.

(Courtesy of Dr. Calvin Johnson, New Orleans, LA.)

Alar Batten Grafts

The nasal airway immediately beneath the upper lateral cartilages is of particular importance functionally. This valve area requires special consideration when there is inward collapse of the upper or lower lateral cartilages at the level of the limen vestibuli. Here it may be necessary to place cartilage implants from the auricle or the septum, shaped into an outward convexity to create a flying buttress effect. The cephalic portion of the lower lateral cartilages with its vestibular skin may be rotated into a supratip defect. Often both skin and cartilage are required, and the natural curvature of the concha of the auricle with its thin anterior skin is an ideal composite graft to use in the valve area. The graft overrides the septal cartilage, and the auricular skin of the graft is sutured to the nasal mucosa (Fig. 37-18). This composite graft is a source of support and lining for the constricted valve area.

Figure 37-18. A, Auricular cartilage may be used as a composite graft, with its attached thin anterior skin being used to open the valve areas when there is marked loss of support and intranasal contracture. The skin is excised from the central portion of the graft, which rides over the septum like a saddle, and the skin is inserted into the mucosal opening. To avoid excessive thickness in the dorsum, it may be necessary to excise a strip of cartilage along the dorsum of the septum. The skin edges are precisely sutured to the nasal mucosa. B, Position of spreader graft. C, Spreader graft being sutured in position. D, Batten sutured into position.

Suture Techniques

Suture contouring of the nasal tip is a reversible and nondestructive technique that allows recontouring and repositioning of the nasal tip without structural disruption. Suture contouring is performed from “the ground up.”^10,¹¹ Multiple suture techniques allow contouring of the lower lateral cartilages. The lateral crural spanning suture, the transdomal suture, and the interdomal sutures are suture techniques that the authors commonly use to allow precise changes to be performed in a reversible manner.

Transposition Techniques

Transposition of the lateral crura may be used in patients with extreme concavities of the lateral crura, which cause dimpling of the lateral nasal lobule and ala with narrowing of the nasal valve. After dome division has been performed, the lateral crura are completely freed from all attachments. The free segment of the concave lateral crura can then be flipped and sutured to the medial crus and vestibular skin. The previously concave lateral crura now presents a convex surface to the external nose, thus correcting the dimpling and collapse.

The Twisted Nose

Surgical management of the twisted nose remains one of the most difficult challenges in facial plastic surgery. The patient and surgeon should have realistic expectations to the degree of correction that can be obtained without compromising nasal support and function. To correct the twisted nose, the surgeon must determine the specific deformities that are present. A thorough nasal examination including external and internal inspection with palpation must be performed. The structural support, symmetry, and deviation of the nasal bones, the upper lateral cartilages, and the lower lateral cartilages need to be evaluated during the external examination (Fig. 37-19). The internal examination allows inspection and palpation of the septum and nasal spine. It is important to determine the position of the septum and the nasal spine relative to the midline.

Figure 37-19. A variety of nasal deformities, including the anatomic components involved. Each anatomic component of the deviated or twisted nose influences the remaining components, particularly those immediately adjacent, just as each step of the surgery influences the other steps. A, Deviation of the entire nose, including the nasal bones up to the radix. B, Twisted nose with the tip and caudal septum returning to the midline. The nasal bones are deviated from the midline up to the radix. The greatest convexity or concavity of the bony and cartilaginous vaults is frequently at their junction. C, Deviation of the cartilaginous components of the nose, including the septum, with caudal dislocation off the anterior spine. D, Deviation of the dorsal septum and septal angle, with the remainder of the nose in the midline. This creates distortion of the lower lateral cartilage, with actual or simulated asymmetry. E, Deviation of the dorsal septum and septal angle with the distortion of the entire tip of the nose and medial crura.

The twisted nose is best managed by the external approach. If the patient’s primary deformity is in the bony pyramid, then the closed approach will suffice. It should be noted that the twisted nose is often associated with an asymmetric face. This feature should be pointed out to the patient preoperatively, because complete straightening of the nose on such a patient is often undesirable.

Septal Reconstruction

It cannot be overemphasized that if the septum is not straightened aggressively, a less than ideal result is usually obtained. To release the septum, the surgeon may need to elevate bilateral mucoperiosteal flaps from the floor of the nose to beneath the upper lateral cartilages (ULCs). The ULCs should be freed from the dorsal septum to allow them to be reoriented to the midline. Subluxation of the caudal septum often contributes to the twisted nose deformity. The subluxation diminishes tip support and can cause asymmetries of the alar cartilages. To correct the subluxation, the caudal septum must be freed from the nasal spine and either the septum or the nasal spine trimmed. The caudal septum is then sutured to the nasal spine in the midline. Various septal modifications are discussed elsewhere and are not repeated here.

Osteotomies

Before performing osteotomies to realign the nasal vault, the surgeon must determine exactly how much, if any, hump reduction should be carried out. Often in the traumatized nose, a “relative” hump is created by loss of support and flattening in the cartilaginous portion of the dorsum. In these patients, initial attention should be devoted to increasing the cartilaginous projection with combined septal surgery and nasal tip surgery.¹² If the dorsal hump is to be removed, then the deviation of the bony vault must be taken into consideration. In the externally deviated nose, there is usually asymmetry of the lateral vaults, both bony and cartilaginous. This may be corrected with an asymmetric hump removal, with more bone and cartilage being removed on the longer or concave side (Fig. 37-20). In some patients, it is desirable to section the mucosa and the bone or cartilage during hump removal. This is particularly true when a large hump has been removed; the redundant mucosa beneath the dorsum can herniate upward beneath the skin and result in an undesirable dorsal fullness.

Figure 37-20. A, Asymmetric lateral vaults, both osseous and cartilaginous, in the deviated nose. An asymmetric hump removal is used to even the lateral vaults. B, The corrected relationship with combined septal reconstruction. Occasionally, grafts may be placed over the short side rather than reducing the long side. Insert shows deformity, which may occur with the long lateral vault remaining longer than the short after hump removal if this asymmetry is not considered.

The medial osteotomies are performed first.^2,^12,¹³ If there is to be an intermediate osteotomy halfway between the medial and lateral osteotomies, it is done second. The lateral osteotomy is performed last. If there is a thick plate of bone just at the upper edge of the now-open roof, it may act as a fulcrum over which the nasal bones rock outward at the nasion as the lower border is moved medially. This wedge of bone is removed with an osteotome, with an incision being made in the plane of the septum and then in the plane of the nasal bones (Fig. 37-21).^12,¹³ After this, the medial osteotomies are extended to the radix, either in a plane paralleling the nasal septum or curving laterally toward the position of the upper end of the lateral osteotomy. Extending the bone incision to the radix is considered the complete osteotomy and is often essential in a twisted nose, particularly if the deviation extends up to the radix (Fig. 37-22). When this is required, the osteotome is reinserted into the medial osteotomy after completion of the medial and lateral osteotomies and carried into the firm bone of the radix, where a strong fulcrum for the osteotome is developed. The osteotome is used to fracture the nasal bone and perpendicular plate of the ethmoid toward the midline. This is not an outfracturing maneuver but rather a fracturing of the central portion of the superior nasal complex to include the midline root of the nasal bones and perpendicular plate of the ethmoid (see Fig. 37-3).

Figure 37-21. A, When performing medial osteotomies, it is important to undercut the thick portion of the bone between the dorsum and the lateral bony vault of the nose. B, The osteotome is placed vertical in the plane of the nasal septum. The osteotomy is carried slightly higher than the hump removal. C, A second cut is made at a beveled angle to undercut the nasal bones. This opens the root of the nose to a higher level, assisting in a more superior back or transverse fracture and prevents the “rocker” phenomenon that leads to widening of the nose in the postoperative period.

Figure 37-22. Fading medial and curved lateral osteotomies in a twisted nose with a narrow nasal root. A, The narrow nasal root with deviation only in the inferior portion of the nasal bones. Dislocation of the caudal edge of the septum is also apparent in this anterior view. Fading or curved medial osteotomies combined with the slightly higher curved lateral osteotomy are advocated in such a case. B, Postoperative result where there was no need to fracture the narrow medial portion of the nasal bones. C and D, The same patient with the obvious caudal dislocation of the septum and some long-term distortion of the flare of the medial crus on the right side. The nose was adequately straightened, the tip projection maintained, and the caudal septum held in position. There is persistent flaring of the distorted foot of the medial crus. E, The profile also demonstrates the caudal dislocation of the septum into the right nostril, the need for conservative hump removal, tip projection, and a small chin implant. F, Postoperative result.

In the wide flat nose in which it is not necessary to change the profile line, the flat roof of the bony vault and of the upper lateral cartilages must be narrowed. The intermediate osteotomy is useful in narrowing such a nose (Fig. 37-23). The intermediate osteotomy is carried out through the intercartilaginous incision above the upper lateral cartilages.

Figure 37-23. Complete and intermediate osteotomies. A, This case demonstrates the flattened, wide nose with outward splaying of the nasal bones, and only minimal change in the profile is required. This patient would require narrowing of the nose, which is accomplished in many cases by the use of an intermediate osteotomy placed halfway between the complete medial and low lateral osteotomies. B, Results of this surgery combined with an autogenous cartilage columella implant. The cartilaginous dorsum has been narrowed without changing the profile. C and D, Basal views of the same patient before and after narrowing with tip sculpturing and increases in tip projection and columella support.

In the deviated nose, the lateral osteotomy follows the curvature of the nasofacial groove—that is, against the face of the maxilla—and with rotation of the osteotome, it curves upward to join the medial osteotomy. Provided the medial osteotomy has been done first as recommended, back fracture and bony spicules are rare.^12,¹⁴ High osteotomies—that is, away from the maxillary face—are satisfactory for some cosmetic rhinoplasties, but with deviated external noses, low complete osteotomies are advised. These require the creation of a transverse fracture that joins the medial and lateral osteotomies at their cephalic ends.

Debate exists as to the benefits of elevating the periosteum overlying the osteotomy to preserve it or simply performing the osteotomy through the periosteum. The authors are firm believers in the subperiosteal approach. This is an avascular plane, and with minimal elevation laterally, a periosteal blanket is preserved to drape over the osteotomy site. Without the periosteal elevation, the edge of the osteotome will lacerate the periosteum and perhaps traumatize the subcutaneous tissue as well. The lateral osteotomy may be performed through a horizontal intranasal incision at the piriform rim, an intraoral incision, or at the alar attachment if this has been done as for the Weir procedure or for the cleft-lip nose. For the cases under discussion, in which there is often already a great deal of intranasal scarring resulting from mucosal trauma or extensive earlier surgery, the authors prefer to approach through the buccal sulcus, avoiding additional intranasal incisions and possible circumferential scarring. In revision surgery when there is prominence of the previous osteotomy site, multiple osteotomies or fragmentation over this site seems to produce a more acceptable result than simply rasping the area or repeating the single osteotomy.

Spreader Grafts

Once the ULCs have been freed from the septum, the degree of dorsal deviation can be determined. If there is a minor degree of dorsal deviation, the osteotomies may realign the nose to the midline, and the ULCs only need to be sutured to the septum. If there is a significant dorsal septal deviation, as seen in the C-shaped deformity, then an onlay graft can be placed on the concave side to camouflage the deformity. Another method to help efface the concavity of the septal deformity is by inserting a spreader graft. The spreader graft is carved from septal cartilage and is placed above the intact intranasal mucosa between the septum and ULC (Fig. 37-24). The graft will fill the concavity of the C-shaped deformity and preserve the cross-sectional area of the nasal valve. These grafts will also correct the depression seen from ULC collapse. If the dorsum is reduced more than 3 mm, the confluent width of the cartilaginous dorsum is dramatically compromised, and spreader grafts should be considered to avoid a narrowed dorsum and inverted V deformity.

Figure 37-24. A, Bilateral spreader grafts being sutured in position. B, Spreader grafts in position, extramucosal.

Saddle Nose Deformity

The saddle nose deformity is seen in patients secondary to loss of support of the nasal framework with subsequent collapse. This deformity can be iatrogenic secondary to overzealous reduction on the nasal dorsum or can be traumatic or congenital in origin. This loss of support may involve the bony or cartilaginous dorsum. It is often associated with columellar retraction and internal and external deformities. A critical analysis must be made regarding which nasal components are involved in the particular deformity. By analyzing which nasal components are involved, a reconstructive plan can be developed preoperatively.

Augmentation

Once the reconstructive plan has been developed, the surgeon must decide what type of implant material will be used for augmentation. Many different implants have been used in the nose, including autogenous tissue (cartilage, bone, fascia, and dermis), homologous material (irradiated cartilage, lyophilized cartilage, bone, and acellular dermis), and alloplastic material (Gore-Tex, Supramid, Proplast, Mersilene, and Silastic). Heterograft materials such as bovine cartilage and bone are used less frequently because of resorption.

The authors prefer using autogenous materials in the nose.¹⁵^–²² Septal cartilage is preferred, but auricular and rib cartilage are also useful. If the bony pyramid needs augmentation, then autogenous iliac crest, calvarial bone, or rib can be used. Temporalis fascia and dermis are easily harvested and can be used to fill, contour, and soften certain nasal defects. Alloderm is processed from human dermis and can be used for augmentation in the same way as fascia or dermis. Homologous materials have been used with success,²³ but in general are less desirable because of long-term unpredictability with resorption and buckling.^24,²⁵

Surgeons are still awaiting the development of the ideal alloplastic implant. Today’s implants still have increased risk of rejection, inflammation, and extrusion. Vicryl, Gore-Tex, Mersilene, Proplast, and Supramid are mesh materials that become partially incorporated into surrounding tissues and provide a thin layer of scar over the irregular dorsum. Silastic implants have been used successfully on the dorsum of the nose but have a higher extrusion rate and artificial feel in the lower third of the nose.

At this time Gore-Tex is our preferred alloplast for dorsal augmentation. The tolerance of Gore-Tex as an implant material has been well documented.^11,^26,²⁷ In addition, minimal amounts of fibrous ingrowth lead to stability of the implant but do not restrict its removal when necessary. The reinforced sheets of 4 to 7 mm are much easier to sculpt for augmentation. With these implants and the sheeting, it is important to taper the edge to ensure smooth transition to the surrounding soft tissue. This can be done through sharp beveling with a scalpel or by crushing the margins with a hemostat or needle holder. For the saddle nose deformity in which extensive septal surgery and osteotomies are required, it is sometimes best to stage the procedure, with the implants being placed at a second operation. Extensive septal reconstruction may be essential in completely straightening the nose and in increasing the vertical height, thereby making the required size of the implant smaller (Fig. 37-25). In the saddle nose, the anterior valve is frequently circular rather than oval or piriform, and the septal reconstruction should be combined with intranasal Z-plasties to release the scar contractures and open the anterior valve areas.

Figure 37-25. A, The septum and the saddle nose deformity. Straightened septal cartilage can be reinserted as a large columella strut to increase the vertical height of the nose and provide support for the dorsal implant. B, Cartilage implants taken from the nasal septum. C, Laminated cartilage implants to be sutured in position by the open approach. Irregularities may be smoothed out by a blanket of temporalis fascia or Gore-Tex sheeting. (See also Fig. 37-26.)

One of the difficulties of rhinoplasty, and especially of revision rhinoplasty, is ensuring a smooth contour over the nasal dorsum. This can be especially difficult in thin-skinned patients when implants are used. Where there are skin irregularities and scarring or cicatricial adhesions to the underlying framework, it is necessary to prevent recurrence once elevated. Sculpted laminated autogenous cartilage implants of any sort may leave irregular edges or an irregular surface. One way of softening these edges and other irregularities involves draping a piece of temporalis fascia over the entire bony and cartilaginous nasal framework. The temporalis fascia graft can be placed through either an intercartilaginous incision or an open rhinoplasty approach. The graft is secured in position with draw sutures, which are then tied over a soft plastic bolus at the level of the nasal frontal angle at each corner and with direct suturing inferiorly, laterally, and at the dorsum. Precise, direct suturing can be accomplished through the open rhinoplasty approach. Temporalis fascia has been shown not to resorb significantly in vivo,²⁸ and donor site morbidity is minimal. This fascial graft technique is an important part of the surgical armamentarium, particularly for revision rhinoplasty, dorsal irregularities, scars, and overlying implants (Fig. 37-26). Gore-Tex 0.4-mm cardiovascular sheeting or Alloderm can be used in place of fascia with little risk of reaction or extrusions (see Figs. 37-26D and E).

Figure 37-26. In addressing the nose with thin skin and bony cartilaginous irregularities, such as laminated implants, a temporalis fascia graft may be useful. A, The template fashioned to the size of the graft to be taken. B, Harvesting the temporalis fascia graft through a vertical incision through a shaved portion of the temporal scalp. C, Fascial graft draped over the nasal dorsum before insertion into the subcutaneous pocket over the nasal dorsum. D, Cardiovascular Gore-Tex sheeting placed as a blanket over the dorsum to smooth out any irregularities. E, As with temporalis fascia, Gore-Tex sheeting is carried into position with draw sutures. Inferiorly, the thin sheeting may be precisely sutured into position, especially with the open approach.

Indications

Mild saddle nose deformities are seen in patients with increased supratip depression. The nose appears wide and, if a dorsal hump is present, it is accentuated by the supratip depression. This deformity can be corrected by augmenting the supratip with crushed cartilage or fascia. The implant should be placed in the smallest pocket possible to promote stability. The implant should be carved and beveled to reduce any irregularities and to soften its edges.

The more severe saddle nose deformities have columellar retraction secondary to loss of quadrangular cartilage and a prolapsed dorsum. The cartilaginous and bony pyramid may be broadened and flattened, requiring multiple osteotomies. The dorsal implant should be carefully shaped with particular attention paid to preparing the recipient site and corresponding surface of the implant, so that the implant will fit snugly against roughened nasal bones. The undersurface of the implant should be concave to fit the curvature of the dorsum of the nose. A three-dimensional concept must be kept in mind when shaping the graft. The dorsal aspect of the graft should be nearly straight and extend the full length of the nose (Fig. 37-27). Grafts may be layered to increase the magnitude of augmentation. Bone grafts should be fixed to the nasal bones with a Kirschner wire or a miniplate. An external nasal splint should be applied for several days.

Figure 37-27. A, Dorsal implants should be precisely contoured in three dimensions and preferably should extend the entire length of the nasal dorsum. Autogenous material is used, and when nasal tissue or auricular cartilage is not sufficient, cancellous bone from the hip is used. Iliac bone grafts have now largely been replaced by calvarial bone grafts. If iliac bone is used, more cortex is allowed to remain on the cancellous bone. B, Laminated Gore-Tex sheet for dorsal augmentation with tapering of the Gore-Tex margin by crushing the edge of the Gore-Tex with the hemostat and separate soft tissue patch. C, Preoperative view of mild saddle nose deformity and soft tissue irregularity of the cartilaginous dorsum. D, Postoperative view with dorsal augmentation and soft tissue filler of the left cartilaginous nasal dorsum.

Dynamic Adjustable Rotational Tip Graft

Dynamic adjustable rotational tip (DART) grafts are extended dorsal spreader grafts that extend beyond the caudal septum the desired length of derotation.⁸ The DART is particularly useful in the overrotated nose when the inferior displacement of the entire tip complex is necessary and placement of a tip graft would exacerbate columellar show.⁸ The DART reestablishes the spring tension of the nasal tip. This helps establish a reliable nasal tip complex position and improves nasal valve collapse. Through an open approach, extended dorsal spreader grafts are typically sutured to a columellar strut and the medial crura of the lower lateral cartilage (Fig. 37-28). The extended spreader grafts can be slid along the anterior-posterior axis of the quadrangular cartilage. This allows the tip complex to be repositioned until the desired tip rotation and projection have been created. Once the desired tip position and tension have been created, the extended spreader grafts are sutured to the quadrangular cartilage. This extended graft helps derotate the tip and strengthen the dorsal septum and anterior septal angle.

Figure 37-28. The dynamic adjustable rotational tip (DART) graft consists of a columellar strut sutured to the nasal spine and to extended spreader grafts. The extended spreader grafts are sutured between the upper lateral cartilages and the quadrangular cartilage to improve rotation and projection.

The Noncaucasian Nose

Aesthetic surgery of the noncaucasian nose requires a detailed preoperative analysis to identify the structural deformities present. Once the deformities have been identified, the appropriate surgical modifications can be undertaken. The generalities that follow pertain mostly to the African-American nose, although the Asian and several other ethnic noses have similar characteristics. In general, the noncaucasian nose has thick skin, weak cartilages, a flat broad dorsum, and an underprojected poorly defined tip with a wide alar base (see Fig. 37-30A). The thick sebaceous inelastic skin limits the degree of nasal tip sculpting that can be appreciated. The adipose tissue in the tip can be removed, and postoperative subdermal injections of Kenalog can help decrease supratip edema and scar formation.

The external approach allows the surgeon excellent visualization and the ability to precisely place grafts. The transcolumellar incision in the noncaucasian nose should be placed slightly lower than in the caucasian nose, because the augmentation of the noncaucasian nose advances the columellar skin cephalically.¹¹ If the incision is placed at the midcolumellar level, it may be advanced into the region of the infratip lobule.

If septal cartilage is available, it should be harvested for possible use as a columellar strut, tip grafts, and possibly a dorsal only graft. The columellar strut graft is sutured to the medial crura to help maintain projection. A tip graft is shaped and used to provide tip definition and to help stabilize the weak lower lateral cartilages. The tip graft may have to be layered to provide length to the nose and to prevent overrotation of the tip.

One of the most consistent findings in the noncaucasian nose is the acute nasolabial angle.²⁵ The underdeveloped anterior nasal spine contributes to the acute nasolabial angle. Plumping grafts of solid or crushed cartilage or bone can be placed into the premaxillary area to correct the acute nasolabial angle. A columellar strut may also be used to fill this area and provide tip support.

Dorsal Augmentation

The flat and broad appearance of the noncaucasian nose is generally related to the low dorsum. The nasal bones are usually short, and even though the bony pyramid looks wide, it is rare that osteotomies are required to narrow them. Dorsal augmentations give the illusion of narrowing the bony pyramid. The types of grafts available and the techniques for augmentation of the dorsum are described earlier in the section on saddle nose deformities. The same decision process and techniques are applicable for augmentation of the noncaucasian nose.

Nasal Base Sculpting

The thick, wide-based, flaring ala can be modified by reduction and thinning of the ala. There are numerous modifications of the Weir procedure, which involve the excision of triangles, wedges, or crescents from the alar base on either side. These are done to narrow the nasal base and are usually combined with procedures to increase tip projection through added columella support and lengthening. The technique used most often for the extremely wide nose combines narrowing the nasal base and reducing the length of the ala.

Reduction of the ala should be performed in a conservative and symmetric manner. In general, the alar width should equal the distance between the medial canthi. From a lateral view, 2 to 3 mm of columellar show should be visible below the ala. In the noncaucasian nose, the ala have a more caudal insertion into the face, creating a disproportional bulbous alar lobule. This results in alar hooding and an inadequate amount of columellar show.

The planned approach and site of incisions used for reduction of the nasal base is dictated by the patient’s needs. The ala and nostrils can be reduced individually or in combination, depending on the need to reduce alar flare and nostril size. In general, the noncaucasian nose would need alar reduction with medial repositioning of the ala. An incision is made from the base of the sill and carried out 1 to 2 mm above the alar-facial crease (Fig. 37-29). The alar flap can be advanced medially, and a conservative amount of the ala can be excised. To avoid visible scaring, the cut edges should be carefully reapproximated. A 5-0 chromic suture should be used to reapproximate the alar rim, and one or two subcutaneous 5-0 Vicryl sutures should be placed to reapproximate the alar-facial junction incision. A few 6-0 nylon sutures are used to reapproximate the skin edges (Fig. 37-30).

Figure 37-29. Management of the nasal base. A, The authors’ technique done predominantly to narrow the nasal base. The superior incision, which is the inside of a curve, is lengthened by curving to meet the outer incision in the floor of the nose and laterally. This equalizes the two sides of the excision for closure. The authors use subcuticular sutures and fine skin sutures. B, Narrowing the nasal base by excising a wedge from the floor of the nose. C, A commonly performed procedure that narrows the base and reduces the height of the alae.

Figure 37-30. Noncaucasian rhinoplasty, including placement of a columellar strut; shield graft; Weir excisions; and medial, intermediate, and lateral osteotomies. A, Preoperative frontal. B, Preoperative lateral. C, Preoperative basal. D, Postoperative frontal. E, Postoperative lateral. F, Postoperative basal.

Alar Soft Tissue Sculpturing

Reduction of the nasal base may be combined with surgery for the thick inferior border of the ala, which requires excision and thinning (Fig. 37-31). Further sculpturing may be required to arch the ala to correct alar hooding. In sculpturing or thinning the ala or nostril margin, one should make the excision slightly toward the nostril side. This not only makes the scar less visible but also creates a more natural roll to the border. The procedure is usually combined with a columella strut or other procedure to create greater columella “show” relative to the alar margin. Other techniques may be used to create greater columella prominence, such as the use of a composite auricular graft or skin and cartilage transposition flaps from the cephalic border of the lower lateral cartilages.

Figure 37-31. Combined reduction and thinning of the alae. For noses with excessive thickening of the ala, a wedge of skin is removed extending toward the tip. This incision should be slightly internal or toward the nasal side of the vestibule to create a more desirable roll and hide the incision.

The Cleft-Lip Nose

The cleft-lip nasal deformity requires special attention to the asymmetric and retrodisplaced lower lateral cartilage in the unilateral cleft and to the depressed tip with a relatively short columella in the bilateral cleft. Associated with the deformity is hypoplasia of the maxilla on the cleft side or bilaterally, with midfacial hypoplasia resulting from the lack of mesodermal penetration (Fig. 37-32).

Figure 37-32. Cleft-tip nasal deformities. A, Unilateral cleft-lip deformity. B, Bilateral cleft-lip deformity.

The unilateral cleft-lip nasal deformity is asymmetric and complex, and one drawing cannot bring out all three-dimensional aspects of the deformity. Major characteristics include the retrodisplacement of the lower lateral cartilage on the involved side, with an S-shaped deformity of the cartilage and soft tissue. There is thickening of the ala laterally, and the alar base is laterally and inferiorly displaced, with a loss of the alar-facial angle. Classically, the caudal end of the septum is dislocated toward the normal side, along with the anterior nasal spine and columella base. Internally, there is often a large posterior spur extending into the cleft side. The maxilla is underdeveloped on the involved side because of the lack of mesodermal development and penetration. The dome of the lower lateral cartilage on the cleft side is depressed, resulting in a lack of tip projection on that side. There is usually an excessively wide nasal floor on the cleft side, although stenosis may occur after childhood surgical repair of the lip and nasal floor.

The bilateral cleft-lip nasal deformity is much more complex than the unilateral deformity, and the surgical challenges are compounded. There is frequently underdevelopment of the entire premaxilla and prolabium, with a short caudal septum and a short columella. Furthermore, in the secondary deformity, there is flattening of the ala with little tip angulation or projection and bilateral widening of the nasal floor and flattening of the alar-facial angle.

Although soft tissue repair can be readily accomplished at the time of initial lip repair or as revisional surgery, reconstruction will be inadequate if the asymmetry of cartilage and bone is not addressed. The authors most often use the external approach for both the unilateral and the bilateral cleft-lip nasal deformities.^29,³⁰ In the unilateral cleft-lip nasal deformity, the lateral crus of the lower lateral cartilage on the cleft side is dissected free of both surface and vestibular skin, and the cartilage is advanced medially to match the normal side (Fig. 37-33). The position is maintained with sutures to the opposite dome to project the tip on the cleft side, along with sutures through the vestibular skin, cartilage, and surface skin (see Fig. 37-33). These 5-0 nylon transalar sutures are tied over a thin flat plastic bolus on the surface skin side only. With the open rhinoplasty it is possible, under direct vision, to stabilize the involved lateral crus further by suturing it directly to the upper lateral cartilage or septum (Fig. 37-34). This is particularly important when the cleft side is caudally displaced, resulting in a hooding deformity of the columella.

Figure 37-33. External rhinoplasty approach for cleft-lip nasal deformities. A, The inverted gull-wing incision is made below the base of the medial crura. B, The lower lateral cartilages are dissected free of the overlying dorsal skin and underlying vestibular skin. The two lateral crura are trimmed and shaped until they are symmetric. In this case the upper lateral cartilages have been sutured under direct vision to the septum along the dorsum. C, Complete exposure of the lower lateral cartilage on the cleft side, freeing it of both surface and vestibular skin, allows precise repositioning and sandwiching between the two skin surfaces. D, The two medial crura are sutured together, recruiting the lateral crus on the cleft side to project the tip on the unilateral cleft side or on both sides in the bilateral cleft deformity.

Figure 37-34. Suturing the medial crura together in the dome, sometimes with slight overcorrection for the retrodisplaced cartilage on the cleft side. Lower lateral cartilage overlaps inferior edge of upper lateral cartilage.

In the unilateral cleft-lip deformity, particular attention must be paid to the dislocation of the caudal septum toward the normal side and the posterior nasal septal spur on the cleft side. All septorhinoplasty techniques may be necessary in correcting the cleft-lip nasal deformity, and onlay grafts are frequently necessary beneath the alar base on the cleft side (Figs. 37-35 and 37-36). In the bilateral cleft-lip deformity, the cartilages can be precisely sculptured bilaterally and dissected free of both skin surfaces to allow medial recruitment and suturing to project the tip (Fig. 37-37).

Figure 37-35. Lateral alar thinning and placement of maxillary implants. A, Any excessive fibrous tissue at the alar attachment is removed subcutaneously between the vestibular skin and external skin surfaces. B, Through the alar incision, implant material of cartilage or bone, usually obtained from the nose, is placed over the face of the maxilla beneath the lip scar and the alar base.

Figure 37-36. Repositioning and suturing of the lower lateral cartilage. A, The alar cartilage is repositioned in a slight overcorrection. A subcutaneous suture should be used to reinforce the repositioning of the alar base in a symmetric position. B, A composite of the complete operation shows the septal reconstruction, correction of the distorted alar cartilage, and correction of the laterally displaced alar base. Bone and cartilage grafts are placed subperiosteally over the face of the maxilla. Fixation sutures are tied over flat, plastic boluses externally.

Figure 37-37. Bilateral cleft-lip procedure with Abbé flap to upper lip. A, An external approach by use of a transfixion incision. This differs from the external approach more recently popularized, in which the exposure is external to the medial crura rather than internal to the medial crura in the membranous septum. The synchronous lip repair is done with an asymmetric Abbé flap because of the stenosis on the right side. B, The lower lateral cartilages are presented bilaterally through the standard alar cartilage margin incisions and dissected free of both surface and vestibular skin so that they may be advanced into the tip, sutured together, and fixed between the surface and vestibular skin. C, Preoperative profile, demonstrating the disparity between the lips and between maxilla and mandible and illustrating the fact that the prolabium had been removed. D, Postoperative appearance. Autogenous cartilage implants have been placed in the columella, and bone and cartilage from the nose have been placed over the face of the maxilla. E, Basal view showing the absence of a prolabium and the stenosis of the right nasal vestibule. The palate has never been repaired. F, Postoperative view showing the tip projection, columella lengthening, and asymmetric Abbé flap. The flap was later defatted in the floor of the right nostril.

Grafts are combined with high Le Fort I osteotomies to advance the maxilla in severe deformities associated with both unilateral and bilateral cleft lips.^31,³² Both maxillary and mandibular osteotomies may be required. There is some choice between suspension and intermaxillary wiring and miniplate fixation.^31,³³ Occlusion must be precise and is combined with interdental splinting and fixation. Bone grafts are placed between the advanced maxilla and the pterygoid plates, over the face of the maxilla, and about the piriform rim (Figs. 37-38 and 37-39).