A Practical Approach to Rhinoplasty · 2017-10-17 · successful rhinoplasty include comprehensive...

Copyright © 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.

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Rhinoplasty continues to be one of the most commonly performed aesthetic surgical procedures, with over 217,000 performed in

2014.1 Over the past 25 years, the open approach has increased in popularity and is the focus of this article.2–4 The open approach has inherent advantages and disadvantages compared with the closed approach, and these are listed in Table 1.3,4 The principles for successful rhinoplasty include comprehensive clinical analysis and definition of goals, preoperative preparation, precise operative execution, postoperative management, and criti-cal analysis of one’s results.5

CLINICAL ANALYSIS AND DEFINITION OF GOALS

Nasofacial Proportions and Systematic Nasal Analysis

Comprehensive preoperative clinical analysis including evaluation of nasofacial proportions and systematic nasal analysis will help establish goals for rhinoplasty surgery (Table 2).3,6,7 In addi-tion to evaluating the patient’s primary areas of concern, a systematic approach to evaluating nasal

structures and their relationship to one another will help to achieve facial balance and harmony after rhinoplasty. Nasal skin thickness and qual-ity will also influence the results of surgery; the effects of osteocartilaginous manipulation in patients with thick nasal skin will have a less dra-matic effect on surface contour, whereas subtle changes will be visible in patients with thin skin.3,8 Thick, sebaceous nasal skin will tend to have pro-longed postoperative edema requiring a longer period to resolve compared with thin nasal skin.3,8

A myriad of descriptions of aesthetic ide-als and relationships have been described in detail,7,9–23 including sex-24–28 and age-specific29–36 characteristics. In addition, features and aesthetic ideals common to specific ethnic groups have been described extensively.37–59

Evaluation of the patient should include not only static views but also dynamic views. Smiling may reveal descent of the nasal tip, shortening of the upper lip,

Disclosure: Dr. Rohrich is a volunteer member of the Allergan Alliance for the Future of Aesthetics and receives instrument royalties from Eriem Surgi-cal, Inc., and book royalties from Taylor and Francis Publishing. Dr. Ahmad receives royalties from CRC Press, Inc. No funding was received for this article.

Copyright © 2016 by the American Society of Plastic Surgeons

DOI: 10.1097/PRS.0000000000002240

Rod J. Rohrich, M.D.Jamil Ahmad, M.D.

Dallas, Texas; and Mississauga and Toronto, Ontario, Canada

Learning Objectives: After studying this article, the participant should be able to: 1. Understand both preoperative aesthetic and functional assessment of the rhinoplasty patient. 2. Develop an operative plan to address aesthetic goals while preserving/improving nasal airway function.Summary: Rhinoplasty continues to be one of the most commonly performed aesthetic surgical procedures. Over the past 25 years, the open approach has increased in popularity and is the focus of this article. The principles for successful rhinoplasty include comprehensive clinical analysis and defining rhinoplasty goals, preoperative consultation and planning, precise operative execution, postoperative management, and critical analysis of one’s results. Systematic nasal analysis is critical to establish the goals of surgery. Techniques to address the nasal dorsum, nasal airway, tip complex, alar rims, and bony vault that provide consistent results are discussed. (Plast. Reconstr. Surg. 137: 725e, 2016.)

From the Department of Plastic Surgery, University of Texas Southwestern Medical Center; The Plastic Surgery Clinic; and the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Toronto.Received for publication April 12, 2015; accepted November 16, 2015.

A Practical Approach to Rhinoplasty

Related Video content is available for this article. The videos can be found under the “Related Videos” section of the full-text article, or, for Ovid users, using the URL citations published in the article.

CME


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Plastic and Reconstructive Surgery • April 2016

or a transverse crease in the midphiltral area.60–63 Careful observation of these subtleties will ensure thorough evaluation and appropriate discussion with the patient to define all of the goals of surgery.

Defining Rhinoplasty GoalsThe aesthetic goals following rhinoplasty

are dependent largely on the patient’s concerns

and expectations. In attempting to satisfy the patient, it is still important to restore naso-facial balance and harmony, and to preserve sex-specific characteristics and ethnic congru-ence. In patients with nasal airway obstruction, it is important to restore the nasal airway. For patients that present without nasal airway prob-lems, respecting and preserving the key struc-tures are requisite.

The goals should be defined and discussed with the patient in detail before surgery. The changes that will be done to address the patient’s primary concerns should be discussed, along with other potential changes that will be required to create the most balanced and proportionate result. A frank discussion of what is and is not achievable in surgery will help to set realistic expectations for the patient and help to reduce the risk of postop-erative patient dissatisfaction.

PREOPERATIVE CONSULTATION AND PLANNING

The preoperative consultation serves as an opportunity to evaluate the patient, discuss the patient’s concerns, and educate the patient on what may be possible to achieve.5,6 For the sur-geon, it is an opportunity for screening the patient for his or her suitability for rhinoplasty surgery. Patients with unrealistic expectations or underlying psychiatric problems should not be operated on. In addition, the surgeon should exercise caution in operating on a patient with different aesthetic goals from what the sur-geon recommends. During the consultation, the patient’s nasal history and medical history should be reviewed. Physical examination should involve both clinical analysis and examination of the nasal airway.

Focused Nasal HistoryIn addition to reviewing the patient’s medi-

cal history, the patient should be asked about a history of allergic disorders such as hay fever and asthma, and other problems, including vaso-motor rhinitis and sinusitis.64 Nasal obstruction secondary to inferior turbinate hypertrophy is usually found in patients with a long history of allergic rhinitis.65,66 Prior nasal trauma and oper-ations including rhinoplasty, septal reconstruc-tion/septoplasty, and sinus surgery should be noted. Smoking, alcohol consumption, and use of illicit drugs (in particular, cocaine)67 can com-promise outcomes. A review of current medica-tions and dietary supplements may reveal those

Table 2. Systematic Nasal Analysis*

Frontal view Facial proportions Skin type/quality: Fitzpatrick type, thin or thick,

sebaceous Symmetry and nasal deviation: midline, C-, reverse C-,

or S-shaped deviation Bony vault: narrow or wide, asymmetrical, short or long

nasal bones Midvault: narrow or wide, collapse, inverted-V deformity Dorsal aesthetic lines: straight, symmetrical or asymmetri-

cal, well or ill defined, narrow or wide Nasal tip: ideal/bulbous/boxy/pinched, supratip, tip-

defining points, infratip lobule Alar rims: gull shaped, facets, notching, retraction Alar base: width Upper lip: long or short, dynamic depressor septi muscles,

upper lip creaseLateral view Nasofrontal angle: acute or obtuse, high or low radix Nasal length: long or short Dorsum: smooth, hump, scooped out Supratip: break, fullness, pollybeak Tip projection: overprojected or underprojected Tip rotation: overrotated or underrotated Alar-columellar relationship: hanging or retracted alae,

hanging or retracted columella Periapical hypoplasia: maxillary or soft-tissue deficiency Lip-chin relationship: normal, deficientBasal view Nasal projection: overprojected or underprojected,

columellar-to-lobular ratio Nostril: symmetrical or asymmetrical, long or short Columella: septal tilt, flaring of medial crura Alar base: width Alar flaring*Adapted from Rohrich RJ, Ahmad J. Rhinoplasty. Plast Reconstr Surg. 2011;128:49e–73e.

Table 1. Advantages and Disadvantages of Open Rhinoplasty*

Advantages Binocular visualization Evaluation of complete deformity without distortion Precise diagnosis and correction of deformities Allows use of both hands More options with original tissues and cartilage grafts Direct control of bleeding with electrocauteryDisadvantages External nasal incision (transcolumellar scar) Prolonged operative time Protracted nasal tip edema Columellar incision separation and delayed wound healing Suture stabilization of grafts often required*Adapted from Gunter JP, Rohrich RJ. External approach for sec-ondary rhinoplasty. Plast Reconstr Surg. 1987;80:161–174.


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Fig. 1. The external nasal valve exists at the level of the inner nostril. It is formed by the caudal edge of the lateral crus of the lower lateral cartilage, the soft-tissue alae, the membranous septum, and the sill of the nostril. The internal nasal valve accounts for approximately half of the total airway resistance and is bordered medially by the sep-tum, inferiorly by the nasal floor, laterally by the inferior turbinate, and superiorly by the caudal border of the upper lateral cartilage. The junction between the septum and upper lateral cartilage is normally 10 to 15 degrees. (From Howard BK, Rohrich RJ. Understand-ing the nasal airway: Principles and practice. Plast Reconstr Surg. 2002;109:1128–1146. Reprinted with permission.)

Fig. 2. “Danger signs” that may indicate the patient has underlying psychological issues. (From Rohrich RJ, Janis JE, Kenkel JM. Male rhinoplasty. Plast Reconstr Surg. 2003;112:1071–1085. Reprinted with permission.)


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that can cause increased risk of bleeding and postoperative ecchymosis, including acetylsali-cylic acid, nonsteroidal antiinflammatory drugs, fish oil, and certain herbal supplements.68

Focused Nasal ExaminationNasal airway obstruction is a common

symptom among patients presenting for rhino-plasty.3,69,70 Evaluation of the nasal airway should be performed in all patients presenting for

rhinoplasty.69,71 The key structures that affect nasal airflow (Fig. 1) include the external and internal nasal valves, the inferior turbinates, and the nasal septum.64,69 The patient should be examined for collapse of the external nasal valves on deep inspiration, and a Cottle test should be performed to evaluate patency of the internal nasal valves. Internal nasal examina-tion is aided with the use of a nasal speculum. Oxymetazoline nasal spray facilitates mucosal constriction if mucosal edema is present. Nar-rowing or collapse of the internal valves with inspiration should be noted,72–76 along with inferior turbinate hypertrophy, which typically occurs on the side opposite septal deviation.64–66 Septal deformities,77–81 including deviation, tilt, spurs, and perforations, should be identified (Reference 81 Level of Evidence: Therapeu-tic, V). The availability of septal cartilage is assessed, as this is the primary source of autog-enous graft material.

Standardized Photography and Digital ImagingStandardized photographs including fron-

tal, lateral, oblique, and basal views should be obtained for every patient.3,6,82,83 In addition, dynamic views including a smiling view and inspiratory views may reveal deformities that are not readily apparent on static views. These are a critical component of the medical record, and can be used for preoperative planning and evaluation of postoperative results.2,5,6,82–85 The use of digital imaging is becoming more com-mon.86–90 It is a good tool for communicating with the patient and can be used as an oppor-tunity to evaluate the patient’s expectations. The patient should be informed that the images created with digital imaging do not guarantee a result.3,6,82

Managing Patient Expectations and Suitability for Rhinoplasty

Evaluation and management of patient expectations is a key component of the preop-erative consultation. The patient should list the top three specific concerns about his or her nasal appearance and/or function and should attempt to rank these in order of importance.3,6,83 Most patients have realistic expectations for sur-gery and can understand the limitations of rhi-noplasty with adequate discussion. Reviewing photographs with the patient allows the patient to appreciate different views of his or her face and nose that can help identify specific areas of

Table 3. Approach to Open Rhinoplasty*

AnesthesiaIncisions (transcolumellar and infracartilaginous)Skin elevation/dissection of lower lateral cartilage/upper

lateral cartilageTransnasal release of depressor septi muscle (if indicated)Intraoperative diagnosisAssessment of tip projectionComponent dorsal hump reduction/dorsal augmentationSeptal reconstruction/inferior turbinoplasty (if indicated)Correction of caudal septal deviation (if indicated)Reconstitution of dorsum with upper lateral tension

spanning sutures, autospreader flaps, or spreader graftsCephalic trim of lower lateral cartilage or lower lateral

crural turnover flaps (if indicated)Establish final tip projection (columellar strut graft and tip

suture technique)Invisible or visible tip grafts (if indicated)OsteotomiesFinal inspection/irrigationWound closureFive-step medial crural footplate approximation (if indi-

cated)Alar base surgery (if indicated)Transoral dissection and transposition of depressor septi

muscle (if indicated)Splints and dressings*Adapted from Rohrich RJ, Ahmad J. Rhinoplasty. Plast Reconstr Surg. 2011;128:49e–73e.

Video 1. Supplemental Digital Content 1 demonstrates primary open rhinoplasty and the correction of a boxy tip. This video is available in the “Related Videos” section of the full-text article on www.PRSJournal.com or at http://links.lww.com/PRS/B668.

http://www.PRSJournal.com

http://links.lww.com/PRS/B668



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concern. Certain deformities that may not have been apparent to the patient before consultation can be discussed using photographs. A patient that focuses on minor or uncorrectable problems or with unrealistic expectations despite extensive discussion will likely be disappointed after sur-gery regardless of the aesthetic improvement; it is better to avoid operating on these patients.3,6,83 One of the key elements is to make sure that you delineate what you can and, also, what you can-not do to improve the appearance of their nose.

Assessment of the emotional stability of the patient is critical when evaluating the patient

seeking rhinoplasty.3,6,83,91–101 Motivating factors should be identified, and the surgeon must differentiate between healthy and unhealthy reasons for seeking rhinoplasty. Feelings of inad-equacy, immaturity, family conflicts, divorce, and other major life changes may be unhealthy motivating factors behind the patient seek-ing aesthetic surgery.100,101 Poor postoperative patient satisfaction is often based on emotional dissatisfaction as opposed to technical failure, and this can be avoided by preoperative iden-tification of these unhealthy motivating factors (Fig. 2).3,6,83,100,101

Fig. 3. This patient is shown before (left) and 2 years after (center) primary rhinoplasty. Although there has been a significant improvement in the profile with dorsal hump reduction evident on the lateral view, the frontal view reveals asymmetric dorsal aesthetic lines and right midvault collapse. The same patient is shown 1 year after (right) secondary rhinoplasty with restoration of smooth and symmetric dorsal aesthetic lines.


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PERIOPERATIVE PREPARATIONIn addition to preoperative consultation and

defining the goals of treatment, it is helpful to prepare the patient for what to expect on the day of surgery and during the recovery. Providing the patient with written preoperative and postop-erative instructions is helpful. Informing patients before surgery about when results will be evident, how much time off work and away from daily routines will be required, and when follow-up visits will be will lay the foundation for a smooth recovery.6

KEY OPERATIVE ELEMENTSIntraoperatively, adequate anatomical expo-

sure of the nasal deformity through the open approach, preservation and restoration of the normal anatomy, correction of the deformity using incremental control, maintenance or res-toration of the nasal airway, and recognition of the dynamic interplays between the composite of maneuvers are required.3,5,83,102–112 The maneu-vers required for successful rhinoplasty and their sequence are dependent largely on the patient’s concerns and expectations, preoperative naso-facial analysis, and intraoperative diagnosis (Table 3).3,5,6,83,112 Several details are key to achiev-ing optimal results following rhinoplasty. (See Video, Supplemental Digital Content 1, which demonstrates primary open rhinoplasty and the correction of a boxy tip. This video is available in the “Related Videos” section of the full-text

Fig. 4. Component dorsal hump reduction. (Left) Creation of submucoperichondrial tunnels and separation of the upper lateral cartilages from the septum. (Center and right) Incremental reduction of the septum proper with reduction and preservation of the upper lateral cartilages, which results in a rounding of the dorsum. (Reprinted with permission from Rohrich RJ, Muzaffar AR, Janis JE. Component dorsal hump reduction: The importance of maintaining dorsal aesthetic lines in rhinoplasty. Plast Reconstr Surg. 2004;114:1298–1308.)

Video 2. Supplemental Digital Content 2 displays a component dorsal hump reduction. This video is available in the “Related Videos” section of the full-text article on www.PRSJournal.com or available at http://links.lww.com/PRS/B669.

Video 3. Supplemental Digital Content 3 displays a dorsal reconstitution. This video is available in the “Related Videos” sec-tion of the full-text article on www.PRSJournal.com or at http://links.lww.com/PRS/B670.








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article on www.PRSJournal.com or at http://links.lww.com/PRS/B668.)

Component Dorsal Hump Reduction and Reconstitution of the Dorsum

A prominent dorsal hump is a frequent com-plaint of patients seeking rhinoplasty. Much of the emphasis is placed on the nasal profile when dor-sal hump reduction is required. However, of equal importance is creating a frontal view with smooth

and straight dorsal aesthetic lines after dorsal hump reduction (Fig. 3). Reduction of the dor-sum can lead to problems, including the inverted-V deformity, internal valve collapse, and irregular dorsal aesthetic lines. Composite reduction offers little control and potentially contributes to these problems. Component dorsal hump reduction is a cartilage preservation technique that has the advantage of incremental control and greater pre-cision (Fig. 4) (Reference 113 Level of Evidence: Therapeutic, V).113–118 It involves the following:

Fig. 6. Suture placement (left) and following closure (right) with auto-spreader flap modification. (Reprinted with permission from Roostaeian J, Unger JG, Lee MR, Geissler P, Rohrich RJ. Reconstitution of the nasal dorsum following component dorsal reduction in primary rhinoplasty. Plast Reconstr Surg. 2014;133:509–518.)

Fig. 5. Suture placement (left) and following closure (right) with the upper lateral cartilage tension spanning suture. (Reprinted with per-mission from Roostaeian J, Unger JG, Lee MR, Geissler P, Rohrich RJ. Reconstitution of the nasal dorsum following component dorsal reduc-tion in primary rhinoplasty. Plast Reconstr Surg. 2014;133:509–518.)





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1. Release of the upper lateral cartilages from the dorsal septum.

2. Resection of the dorsal septum incre - mentally.

3. Rasping of the bony dorsum.4. Restoration of the dorsal aesthetic lines.

Using a component approach, cartilage of the dorsal septum and upper lateral cartilages that are routinely excised en bloc with a com-posite approach are preserved instead. With this technique, each structure can be manipulated independently. (See Video, Supplemental Digi-tal Content 2, which displays a component dor-sal hump reduction. This video is available in the “Related Videos” section of the full-text article on www.PRSJournal.com or at http://links.lww.com/PRS/B669.)

The upper lateral cartilages may or may not require reduction before reconstitution of the dor-sum. (See Video, Supplemental Digital Content 3, which displays a dorsal reconstitution, available in the “Related Videos” section of the full-text article

on www.PRSJournal.com or at http://links.lww.com/PRS/B670.) The upper lateral cartilages and dorsal septum can be reconstituted using several differ-ent methods including upper lateral cartilage ten-sion spanning sutures (Fig. 5)114,115 or autospreader flaps (Fig. 6),119–122 or may require placement of spreader grafts (Fig. 7).123–126 Incremental reduc-tion of each structure preserves cartilage and, in many cases, this obviates the need for routine use of spreader grafts to reconstruct the midvault. In some cases, spreader grafts have the disadvantage of excessively widening the dorsal aesthetic lines. In addition, significantly more cartilage graft material is required to perform these grafts. How-ever, spreader grafts may be necessary for correc-tion of the deviated nose, the narrow midvault, or collapsed internal valves, and in secondary cases.118

Fig. 7. Spreader graft placement.

Table 4. Classification of the Deviated Nose*

Type Description

I Caudal septal deviation a. Straight septal tilt b. Concave deformity (C-shaped) c. S-shaped deformity

II Concave dorsal deformity a. C-shaped dorsal deformity b. Reverse C-shaped dorsal deformity

III Concave/convex dorsal deformity (S-shaped)*Adapted from Rohrich RJ, Gunter JP, Deuber MA, Adams WP Jr. The deviated nose: Optimizing results using a simplified classification and algorithmic approach. Plast Reconstr Surg. 2002;110:1509–1523.

Video 4. Supplemental Digital Content 4 displays a septal reconstruction and cartilage harvest. This video is available in the “Related Videos” section of the full-text article on www.PRS-Journal.com or at http://links.lww.com/PRS/B671.












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Management the Nasal AirwayThe key structures that affect nasal airflow

include the nasal septum, the inferior turbinates, and the internal and external nasal valves, and these need to be preserved or reconstructed dur-ing rhinoplasty.3,6,64,69,70,126,127

Septal ReconstructionSeptal deviation may occur with or without

external nasal deviation.3,77,81,128–134 External nasal deviations can be classified into three basic types: caudal septal deviations, concave dorsal defor-mities, and concave/convex dorsal deformities (Table 4).128,134 Septal deviation occurs most com-monly as a septal tilt but can also occur in antero-posterior dimensions, craniocaudal dimensions, or as septal spurs.78 Correction of septal deviation is a key element in improving nasal airflow and correcting the external deformity (See Video, Supplemental Digital Content 4, which displays a septal reconstruction and cartilage harvest. This video is available in the “Related Videos” section of the full-text article on www.PRSJournal.com or at http://links.lww.com/PRS/B671.) Although anterior and inferior deviation tends to be poorly tolerated because of the smaller cross-section of the anterior nasal airway, posterior deviation may

Fig. 8. In many instances, the width of the dorsal and caudal L-strut should be 15 mm or more to ensure long-term support. Curving the transition points between the perpendicular plate of the ethmoid and the dorsal L-strut and between the dorsal and caudal L-strut can help add strength. (Reprinted with per-mission from Constantine FC, Ahmad J, Geissler P, Rohrich RJ. Simplifying the management of caudal septal deviation in rhi-noplasty. Plast Reconstr Surg. 2014;134:379e–388e.)

Fig. 9. Outfracture (above) and submucous resection (below) of the inferior turbi-nate. (Reprinted with permission from Rohrich RJ, Krueger JK, Adams WP Jr, Marple BF. Rationale for submucous resection of hypertrophied inferior turbinates in rhino-plasty: An evolution. Plast Reconstr Surg. 2001;108:536–544.)




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also contribute to nasal airway obstruction.64,69 During septal reconstruction, cartilage preserva-tion is essential. If possible, the deviated septum should be repositioned to the midline, and/or sig-nificantly deformed portions should be removed. The anterior septum should be preserved for sup-port, and an L-strut of 15 mm or greater may be necessary to maintain long-term support of the nose (Fig. 8).81

Inferior Turbinate Outfracture/Submucous Resection

The turbinates exist as three or four bilateral extensions from the lateral nasal cavity. The infe-rior turbinate consists of highly vascular muco-periosteum covering a thin semicircular conchal bone.3,64–66,69,135,136 In combination with the inter-nal nasal valve, the anterior extent of the inferior turbinate can be responsible for up to two-thirds of the upper airway resistance.-66,3,64,69 In patients with nasal airway obstruction secondary to infe-rior turbinate mucosal hypertrophy, inferior turbinate outfracture is performed, whereas in patients with bony hypertrophy, submucous resec-tion is required (Fig. 9).3,64–66,69,135,136 Overly aggres-sive surgical management may be complicated by bleeding, mucosal crusting and desiccation, cili-ary dysfunction, chronic infection, malodorous nasal drainage, or atrophic rhinitis.3,64–66,69

The Internal Nasal ValveThe internal nasal valve is formed at the junc-

tion of the septum with the caudal edge of the upper lateral cartilage. The anterior head of the inferior turbinate may project into its posterolat-eral aspect. The import role of the internal nasal valve in nasal airflow has been discussed in great detail, and this area typically accounts for half of

the total nasal airway resistance.3,65,69,70,72–76 Inter-nal nasal valve collapse can be associated with nasal deviation or iatrogenic internal nasal valve obstruction and can occur secondary to midvault collapse. Component dorsal hump reduction and dorsal reconstitution allow incremental control and greater precision to prevent iatrogenic mid-vault collapse.112–118

Fig. 11. Tip-suturing techniques. (Above) Medial crural-columellar strut suture. (Center) Transdomal suture. (Below) Interdomal suture. (Reprinted with permission from Rohrich RJ, Janis JE, Kenkel JM. Male rhinoplasty. Plast Reconstr Surg. 2003;112:1071–1085.)

Video 5. Supplemental Digital Content 5 displays a columellar strut graft. This video is available in the “Related Videos” section of the full-text article on www.PRSJournal.com or at http://links.lww.com/PRS/B672.





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The External Nasal ValveThe external nasal valve is composed of the

caudal septum and medial and middle crura medially, fibrofatty alar rim laterally, and nostril sill posteriorly.69 Common deformities including caudal septal deviation or alar rim collapse can cause external valve obstruction.3,6,64,69,81,137 Dur-ing forced inspiration, dynamic external valve collapse may be observed.3,6,64,69 The strength of the alar rims is dependent on both the quality of its fibrofatty composition and the lateral crus superiorly.

Correction of caudal septal deviation or medial crural deformities may be required.69,79,81,134,138–140 Alar rim collapse may be corrected by nonana-tomical alar contour or extended alar contour grafts, alar batten grafts, lateral crural strut grafts, or lateral crural turnover flaps.69,81,141–149

Altering Tip Position and ShapeThe length, strength, shape, and position of the

lower lateral cartilages and the fibrous/ligamentous attachments between these paired structures play a central role in supporting the nasal tip (Reference 150 Level of Evidence: Therapeutic, V).3,150–158 The upper lateral cartilages, nasal septum, nasal base, and piriform aperture provide additional stability and support to the nasal tip through their soft-tissue attachments.3

A graduated approach to nasal tip sur-gery requires a combination of techniques (Fig. 10),3,150–181 including narrowing of the alar rim strip, the use of a columellar strut graft, nasal tip suturing, and nasal tip grafting. Appli-cation of these techniques will help to correct tip deformities, improve tip shape, and minimize deformities secondary to loss of support. The open approach is advantageous, as release of soft-tissue supporting structures allows greater manipulation of tip position and shape. Both tip projection and rotation can be changed using an incremental approach with manipu-lating soft tissues and the cartilaginous frame-work. However, the open approach will also cause mild loss of tip projection because of dis-ruption of the soft-tissue supporting structures; thus, it is important to restore or increase sup-port using a combination of grafting and sutur-ing techniques. Both columellar strut grafts and septal extension grafts can help to maintain or increase tip projection, and a variety of suture techniques will help maintain nasal tip support following open rhinoplasty.3,150–158,182–184 (See Video, Supplemental Digital Content 5, which

Fig. 12. Shaping of the tip complex and alar rims with a mor-selized onlay graft and extended alar contour grafts.

Fig. 13. Alar rim collapse caused by lack of lower lateral car-tilage support. (Reprinted with permission from Rohrich RJ, Raniere J Jr, Ha RY. The alar contour graft: Correction and pre-vention of alar rim deformities in rhinoplasty. Plast Reconstr Surg. 2002;109:2495–2505.)

Video 6. Supplemental Digital Content 6 demonstrates tip suturing. This video is available in the “Related Videos” section of the full-text article on www.PRSJournal.com or at http://links.lww.com/PRS/B673.






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displays a columellar strut graft, available in the “Related Videos” section of the full-text article on www.PRSJournal.com or at http://links.lww.com/PRS/B672.)

Tip-Suturing TechniquesThe prudent use of three key tip-suturing tech-

niques can alter tip position and shape (Fig. 11).150–158 (See Video, Supplemental Digital Content 6, which demonstrates tip suturing, available in the “Related Videos” section of the full-text article on www.PRS-Journal.com or at http://links.lww.com/PRS/B673.) Medial crural sutures can be used in isolation to correct medial crural asymmetries, to reduce flar-ing, and to control the overall width of the colu-mella. Medial crural–columellar strut sutures are

Fig. 14. Techniques to alter the length and strength of the alar rims. (Left) Lateral crural turnover flap. (Reprinted with permission from Janis JE, Trussler A, Ghavami A, Marin V, Rohrich RJ, Gunter JP. Lower lateral crural turnover flap in open rhinoplasty. Plast Reconstr Surg. 2009;123:1830–1841.) (Center) Alar contour graft. (Reprinted with permission from Rohrich RJ, Raniere J Jr, Ha RY. The alar contour graft: Correction and prevention of alar rim deformities in rhinoplasty. Plast Reconstr Surg. 2002;109:2495–2505.) (Right) Lateral crural strut graft. (Reprinted with permission from Ghavami A, Janis JE, Acikel C, Rohrich RJ. Tip shaping in primary rhinoplasty: An algorithmic approach. Plast Reconstr Surg, 2008;122:1229–1241.)

Video 7. Supplemental Digital Content 7 displays alar contour grafts. This video is available in the “Related Videos” section of the full-text article on www.PRSJournal.com or at http://links.lww.com/PRS/B674.

Video 8. Supplemental Digital Content 8 displays lateral crural turnover flaps. This video is available in the “Related Videos” sec-tion of the full-text article on www.PRSJournal.com or at http://links.lww.com/PRS/B675.

Video 9. Supplemental Digital Content 9 displays percutaneous lateral nasal osteotomies. This video is available in the “Related Videos” section of the full-text article on www.PRSJournal.com or at http://links.lww.com/PRS/B676.
















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placed in the middle third of the medial crura to secure it to the columellar strut graft. Fixation to a columellar strut can increase both tip projec-tion and tip strength simultaneously, as the medial crura are elevated toward the anterior septal angle. These maneuvers are often required before other tip sutures are placed because the medial crural–columellar strut complex acts as a point of stabil-ity in the nasal tripod, and can limit the dynamic effects suture techniques have on the cartilaginous framework.3,150–158,182–184 Transdomal sutures can alter both tip shape and contour of the lateral crura. Differential placement of this suture can be used to correct domal asymmetries of position and shape. The transdomal suture is a powerful sutur-ing technique, and care should be taken to avoid creating unnecessary tension on the lateral crura, excess concavity adjacent to the domes, and more tip projection than required. Excess tension, in addition to placement of the transdomal sutures in a cephalic position, can cause or accentuate excess infratip fullness.185 The interdomal suture is a horizontal mattress suture placed between the domal segments of the middle crura of the lower lateral cartilages. The interdomal suture tech-nique decreases the angle of domal divergence, narrows the tip-defining points, can further cam-ouflage a columellar strut graft or septal extension graft, enhance the infratip lobule, and increase projection.

Invisible and Visible Tip-Grafting TechniquesCartilage grafting is commonly required

during rhinoplasty. Traditionally, visible grafts

including onlay tip and dorsal grafts have been used. However, these do have long-term conse-quences, including displacement, absorption, and increased visibility with changes to the overlying skin envelope with aging.5 The use of the open approach combined with tip-suturing techniques has decreased the necessity for visible tip grafts. In some cases, invisible grafts can be used to increase structural support and improve contour and avoid some of the untoward long-term consequences of visible grafts. Invisible grafts used to support and shape the tip complex include columellar strut grafts, alar contour grafts, anatomical cap grafts, and morselized onlay grafts.5

The columellar strut graft is used to maintain or increase tip projection. In combination with medial crural-columellar strut graft sutures, it can be used to unify the tip complex, and treat the hanging tip, the dynamic tip, the tension tip, alar-columellar dis-crepancies with columellar retraction, irregularities of the medial crura, and the aging nose.182–184

An anatomical cap graft can be used in instances where a small amount of volume aug-mentation or tip contouring is required. The cephalic trim of the lower lateral crus is ideal, given its smooth and soft consistency. A morselized onlay graft can be used if more volume augmen-tation or correction of irregularities is required. The cartilage can range from slightly bruised to crushed into a thin sheet (Fig. 12). If the use of tip-suturing techniques and invisible grafts cannot create adequate tip projection and shape, visible tip grafts including tip onlay, infratip lobular, and combination grafts should be used.

Fig. 15. Patterns of osteotomies. (Reprinted with permission from Rohrich RJ, Krueger JK, Adams WP Jr, Hollier LH Jr. Achieving consistency in the lateral nasal osteotomy during rhinoplasty: An external perforated technique. Plast Reconstr Surg. 2001;108:2122–2130..)



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Correction and Prevention of Alar Rim Deformities

The alar rims contribute to the alar-col-umellar relationship, nasal tip support, and the patency of the external nasal valve.186–191 In addition, the alar rims are intricately related to the tip complex. A well-defined and smooth light reflex starting at the tip complex and con-tinuing along the alar rim is ideal. To achieve this, the lateral crus should be straight in an anteroposterior direction, and the caudal edges of the lateral crus should be in approximately the same horizontal plane as the cranial edge. A weak lateral crus may buckle, causing a con-cave alar rim and a pinched tip appearance (Fig. 13) (Reference 142 Level of Evidence: Therapeutic, V).141,142,149

The presence of deformities of the alar rims such as alar notching or retraction, facets of the soft-tissue triangles, malposition of the lateral crura, or functional problems including external valve collapse should be addressed during rhi-noplasty.3 Various techniques to alter the length and strength of the lateral crura and the alar rims including lateral crural horizontal mattress sutures,165,166 lower lateral crural turnover flaps,145 alar and extended alar contour grafts,142,149,191 alar batten grafts,143,144 and lateral crural strut grafts145,192 have been described (Fig. 14). (See Video, Sup-plemental Digital Content 7, which displays alar contour grafts, available in the “Related Videos” section of the full-text article on www.PRSJournal.com or at http://links.lww.com/PRS/B674.) Follow-ing rhinoplasty, the failure to provide adequate

Fig. 16. (Above) Preoperative frontal, lateral, and basal views of a 19-year-old woman with nasal airway obstruction, a dorsal hump, mild alar retraction, and a severely boxy tip. (Below) The 1-year postoperative result demonstrates a straight dorsum with restora-tion of balanced dorsal aesthetic lines and improvement in tip definition.





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support to the alar rims may predispose to alar rim notching, retraction, or collapse. The use of grafts to strengthen the lateral crura and alar rims can help to prevent these problems. Maneu-vers such as cephalic trim may have the untoward effect of weakening the lateral crura, leading to these problems. Instead, where narrowing of the alar rim strip is required to achieve tip defini-tion, techniques such as lateral crural turnover flaps or the addition of lateral crural strut grafts will improve support. (See Video, Supplemental Digital Content 8, which displays lateral crural turnover flaps, available in the “Related Videos”

section of the full-text article on www.PRSJournal.com or at http://links.lww.com/PRS/B675.)

Nasal OsteotomiesNasal osteotomies may be required to narrow

a wide bony vault, close an open roof deformity, or straighten deviated nasal bones.3,112,113,128,193–207 (See Video, Supplemental Digital Content 9, which dis-plays percutaneous lateral nasal osteotomies, avail-able in the “Related Videos” section of the full-text article on www.PRSJournal.com or at http://links.lww.com/PRS/B676.) The goals of nasal osteoto-mies are maintenance or creation of smooth

Fig. 17. Gunter diagrams demonstrating operative plan. The dorsum was addressed using component dorsal hump reduction and bilateral autospreader flaps. Septal reconstruction was performed to correct the nasal airway obstruction. Tip shaping was achieved with a colu-mellar strut graft and tip-suturing techniques. Bilateral lower lateral crural turnover flaps and alar contour grafts were used to strengthen the alar rims.









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dorsal aesthetic lines and obtaining a desirable width of the bony vault.3,112,113,193 Osteotomies can be classified by approach (external or inter-nal), type (lateral, medial, transverse, or a com-bination), and level (low-to-high, low-to-low, or double-level) (Fig. 15).3,193 Relative contraindica-tions to the use of osteotomies during rhinoplasty include patients with short nasal bones, elderly patients with excessively thin nasal bones, those with relatively thick nasal skin, and some non-Caucasian patients with extremely low and broad noses.3,112,113,128,193–207 Multiple osteotomy tech-niques including intranasal, intraoral, and percu-taneous have been described.193–207 Percutaneous lateral discontinuous osteotomies have the advan-tage of producing a more controlled fracture with less intranasal trauma and minimizing morbidity, including bleeding, ecchymosis, and edema.3,193

POSTOPERATIVE MANAGEMENTPostoperative management of rhinoplasty

patients is an important component of rhinoplasty and an extension of what was performed in the operating room.208 Patients should be informed of activity restrictions, because these restrictions will often influence when they can return to their normal daily activities and to work. It is particularly important to recognize patients’ concerns and anx-iety in the early postoperative period. Many patients requesting rhinoplasty have expectations of how they will appear after their surgery, but because of swelling and bruising, it may be several weeks after surgery before patients can really begin to appreci-ate the changes to their appearance (Figs. 16 and 17). It is essential to provide support during this interval and reassure patients that what they are

seeing is a normal part of the recovery process. Ultimately, the final results after open rhinoplasty can take over 1 year to appreciate (Figs. 16 and 17). In patients with thick skin, edema may take even longer to fully resolve. (See Video, Supplemental Digital Content 10, which displays various closures and splints, available in the “Related Videos” sec-tion of the full-text article on www.PRSJournal.com or at http://links.lww.com/PRS/B677.)

ComplicationsThe incidence of significant complications

following rhinoplasty is low.209–215 Common com-plications following rhinoplasty include bleeding, infection, nasal airway obstruction, and deformi-ties (Table 5).208,215 Recognizing these complica-tions and timely treatment will help to prevent any untoward long-term problems.

CONCLUSIONSAccurate preoperative systematic nasal analy-

sis and evaluation of the nasal airway, along with identification of both the patient’s expectations and the surgeon’s goals, form the foundation for

Table 5. Complications of Rhinoplasty*

Hemorrhagic Epistaxis Septal hematomaInfectious Cellulitis Septal abscess Toxic shock syndromeTraumatic L-strut fractures Lacrimal sac/nasolacrimal duct injury and epiphora Intracranial injury and cerebrospinal fluid leakFunctional Septal perforation Intranasal synechiae Vestibular stenosis Internal/external valve collapse Septal deviation Rhinitis Gustatory rhinorrheaAesthetic Deformities of dorsum or nasal tip Deviation Asymmetry Alar notching/retraction Supratip (“pollybeak”) deformity “Inverted-V” deformity “Rocker” deformitySoft tissue Prolonged edema Visible/depressed transcolumellar scar Contact dermatitis Skin necrosis Nasal cyst*Adapted from Rohrich RJ, Ahmad J. Rhinoplasty. Plast Reconstr Surg. 2011;128:49e–73e.

Video 10. Supplemental Digital Content 10 displays various closures and splints. This video is available in the “Related Vid-eos” section of the full-text article on www.PRSJournal.com or at http://links.lww.com/PRS/B677.






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success. Intraoperatively, key elements of success include adequate anatomical exposure of the nasal deformity, preservation and restoration of the normal anatomy, correction of deformities using techniques that provide consistent results, and maintenance and restoration of the nasal airway. During postoperative recovery, care and reassurance combined with an ability to recognize and manage complications leads to successful out-comes following rhinoplasty.

Jamil Ahmad, M.D.The Plastic Surgery Clinic

1421 Hurontario StreetMississauga, Ontario L5G 3H5, [email protected]

PATIENT CONSENTPatients provided written consent for the use of their

images.

REFERENCES 1. American Society of Plastic Surgeons. National

Clearinghouse of Plastic Surgery Procedural Statistics. 2014 Plastic Surgery Statistics Report. Available at: http://www.plasticsurgery.org/Documents/news-resources/statistics/2014-statistics/cosmetic-procedure-trends-2014.pdf. Accessed April 1, 2015.

2. Warner J, Gutowski K, Shama L, Marcus B. National interdis-ciplinary rhinoplasty. Aesthet Surg J. 2009;29:295–301.

3. Rohrich RJ, Ahmad J. Rhinoplasty. Plast Reconstr Surg. 2011;128:49e–73e.

4. Gunter JP, Rohrich RJ. External approach for secondary rhi-noplasty. Plast Reconstr Surg. 1987;80:161–174.

5. Rohrich RJ, Ahmad J. Getting rhinoplasty right the first time. In: Rohrich RJ, Adams WP Jr, Ahmad J, Gunter JP, eds. Dallas Rhinoplasty: Nasal Surgery by the Masters. 3rd ed. St. Louis: Quality Medical; 2014:159–176.

6. Rohrich RJ, Ahmad J. Preoperative concepts for rhinoplasty. In: Rohrich RJ, Adams WP Jr, Ahmad J, Gunter JP, eds. Dallas Rhinoplasty: Nasal Surgery by the Masters. 3rd ed. St. Louis: Quality Medical; 2014:63–84.

7. Rohrich RJ, Ahmad J, Gunter JP. Nasofacial proportions and systematic nasal analysis. In Rohrich RJ, Adams WP Jr, Ahmad J, Gunter JP, eds. Dallas Rhinoplasty: Nasal Surgery by the Masters. 3rd ed. St. Louis: Quality Medical; 2014:85–110.

8. Janis JE, Ahmad J, Rohrich RJ. Clinical decision-making in rhinoplasty. In: Nahai F, ed. The Art of Aesthetic Surgery: Principles and Techniques. 2nd ed. St. Louis: Quality Medical; 2010:1875–1894.

9. Ricketts RM. Divine proportion in facial esthetics. Clin Plast Surg. 1982;9:401–422.

10. Farkas LG, Katic MJ, Hreczko TA, Deutsch C, Munro IR. Anthropometric proportions in the upper lip-lower lip-chin area of the lower face in young white adults. Am J Orthod. 1984;86:52–60.

11. Farkas LG, Hreczko TA, Kolar JC, Munro IR. Vertical and horizontal proportions of the face in young adult North American Caucasians: Revision of neoclassical canons. Plast Reconstr Surg. 1985;75:328–338.

12. Farkas LG, Sohm P, Kolar JC, Katic MJ, Munro IR. Inclinations of the facial profile: Art versus reality. Plast Reconstr Surg. 1985;75:509–519.

13. Farkas LG, Kolar JC, Munro IR. Geography of the nose: A morphometric study. Aesthetic Plast Surg. 1986;10:191–223.

14. Daniel RK, Farkas LG. Rhinoplasty: Image and reality. Clin Plast Surg. 1988;15:1–10.

15. Byrd HS, Hobar PC. Rhinoplasty: A practical guide for surgical planning. Plast Reconstr Surg. 1993;91:642–654; discussion 655.

16. Chait LA, Widgerow AD. In search of the ideal nose. Plast Reconstr Surg. 2000;105:2561–2567; discussion 2568.

17. Leong SC, White PS. A comparison of aesthetic proportions between the healthy Caucasian nose and the aesthetic ideal. J Plast Reconstr Aesthet Surg. 2006;59:248–252.

18. Ahmed J, Patil S, Jayaraj S. Assessment of the chin in patients undergoing rhinoplasty: What proportion may ben-efit from chin augmentation? Otolaryngol Head Neck Surg. 2010;142:164–168.

19. Woodard CR, Park SS. Nasal and facial analysis. Clin Plast Surg. 2010;37:181–189.

20. Doddi NM, Eccles R. The role of anthropometric measure-ments in nasal surgery and research: A systematic review. Clin Otolaryngol. 2010;35:277–283.

21. Armijo BS, Brown M, Guyuron B. Defining the ideal nasola-bial angle. Plast Reconstr Surg. 2012;129:759–764.

22. Brown M, Guyuron B. Redefining the ideal nasola-bial angle: Part 2. Expert analysis. Plast Reconstr Surg. 2013;132:221e–225e.

23. Sinno HH, Markarian MK, Ibrahim AM, Lin SJ. The ideal nasolabial angle in rhinoplasty: A preference analysis of the general population. Plast Reconstr Surg. 2014;134:201–210.

24. Farkas LG, Kolar JC. Anthropometrics and art in the aesthet-ics of women’s faces. Clin Plast Surg. 1987;14:599–616.

25. Gunter JP. Rhinoplasty. In: Courtiss EH, ed. Male Aesthetic Surgery. 2nd ed. St. Louis: Mosby; 1990.

26. Daniel RK. Rhinoplasty and the male patient. Clin Plast Surg. 1991;18:751–761.

27. Rohrich RJ, Janis JE, Kenkel JM. Male rhinoplasty. Plast Reconstr Surg. 2003;112:1071–1085; quiz 1086.

28. Springer IN, Zernial O, Nölke F, et al. Gender and nasal shape: Measures for rhinoplasty. Plast Reconstr Surg. 2008;121:629–637.

29. McGrath MH, Mukerji S. Plastic surgery and the teenage patient. J Pediatr Adolesc Gynecol. 2000;13:105–118.

30. van der Heijden P, Korsten-Meijer AG, van der Laan BF, Wit HP, Goorhuis-Brouwer SM. Nasal growth and maturation age in adolescents: A systematic review. Arch Otolaryngol Head Neck Surg. 2008;134:1288–1293.

31. Chauhan N, Warner J, Adamson PA. Adolescent rhinoplasty: Challenges and psychosocial and clinical outcomes. Aesthetic Plast Surg. 2010;34:510–516.

32. Rees TD. Rhinoplasty in the older adult. Ann Plast Surg. 1978;1:27–29.

33. Guyuron B. The aging nose. Dermatol Clin. 1997;15:659–664. 34. Rohrich RJ, Hollier LH. Rhinoplasty with advancing age:

Characteristics and management. Otolaryngol Clin North Am. 1999;32:755–773.

35. Rohrich RJ, Hollier LH Jr, Janis JE, Kim J. Rhinoplasty with advancing age. Plast Reconstr Surg. 2004;114:1936–1944.

36. Cochran CS, Ducic Y, DeFatta RJ. Restorative rhinoplasty in the aging patient. Laryngoscope 2007;117:803–807.

37. Rohrich RJ, Bolden K. Ethnic rhinoplasty. Clin Plast Surg. 2010;37:353–370.

38. Farkas LG, Katic MJ, Forrest CR, et al. International anthro-pometric study of facial morphology in various ethnic groups/races. J Craniofac Surg. 2005;16:615–646.

mailto:[email protected]

http://www.plasticsurgery.org/Documents/news-resources/statistics/2014-statistics/cosmetic-procedure-trends-2014.pdf






743e

39. Leong SC, Eccles R. Race and ethnicity in nasal plastic sur-gery: A need for science. Facial Plast Surg. 2010;26:63–68.

40. Farkas LG, Forrest CR, Litsas L. Revision of neoclassical facial canons in young adult Afro-Americans. Aesthetic Plast Surg. 2000;24:179–184.

41. Rohrich RJ, Muzaffar AR. Rhinoplasty in the African-American patient. Plast Reconstr Surg. 2003;111:1322–1339; discussion 1340.

42. Porter JP, Olson KL. Analysis of the African American female nose. Plast Reconstr Surg. 2003;111:620–626; discussion 627.

43. Guyuron B, Griffin AC, Hoefflin SM, Stal S. African-American rhinoplasty. Aesthet Surg J. 2004;24:551–560.

44. Gruber R, Kuang A, Kahn D. Asian-American rhinoplasty. Aesthet Surg J. 2004;24:423–430.

45. Momoh AO, Hatef DA, Griffin A, Brissett AE. Rhinoplasty: The African American patient. Semin Plast Surg. 2009;23:223–231.

46. Mao GY, Yang SL, Zheng JH, Liu QY. Aesthetic rhinoplasty of the Asian nasal tip: A brief review. Aesthetic Plast Surg. 2008;32:632–637.

47. Bergeron L, Chen PK. Asian rhinoplasty techniques. Semin Plast Surg. 2009;23:16–21.

48. Toriumi DM, Pero CD. Asian rhinoplasty. Clin Plast Surg. 2010;37:335–352.

49. Dong Y, Zhao Y, Bai S, Wu G, Wang B. Three-dimensional anthropometric analysis of the Chinese nose. J Plast Reconstr Aesthet Surg. 2010;63:1832–1839.

50. Jang YJ, Kim JH. Classification of convex nasal dorsum defor-mities in Asian patients and treatment outcomes. J Plast Reconstr Aesthet Surg. 2011;64:301–306.

51. Rohrich RJ, Ghavami A. Rhinoplasty for Middle Eastern noses. Plast Reconstr Surg. 2009;123:1343–1354.

52. Daniel RK. Middle Eastern rhinoplasty in the United States: Part I. Primary rhinoplasty. Plast Reconstr Surg. 2009;124:1630–1639.

53. Daniel RK. Middle Eastern rhinoplasty in the United States: Part II. Secondary rhinoplasty. Plast Reconstr Surg. 2009;124:1640–1648.

54. Daniel RK. Middle Eastern rhinoplasty: Anatomy, aesthetics, and surgical planning. Facial Plast Surg. 2010;26:110–118.

55. Daniel RK. Hispanic rhinoplasty in the United States, with emphasis on the Mexican American nose. Plast Reconstr Surg. 2003;112:244–256; discussion 257.

56. Higuera S, Hatef DA, Stal S. Rhinoplasty in the Hispanic patient. Semin Plast Surg. 2009;23:207–214.

57. Ishii CH. Current update in Asian rhinoplasty. Plast Reconstr Surg Glob Open 2014;2:e133.

58. Li Z, Unger JG, Roostaeian J, Constantine F, Rohrich RJ. Individualized Asian rhinoplasty: A systematic approach to facial balance. Plast Reconstr Surg. 2014;134:24e–32e.

59. Patel SM, Daniel RK. Indian American rhinoplasty: An emerg-ing ethnic group. Plast Reconstr Surg. 2012;129:519e–527e.

60. Rohrich RJ, Huynh B, Muzaffar AR, Adams WP Jr, Robinson JB Jr. Importance of the depressor septi nasi muscle in rhino-plasty: Anatomic study and clinical application. Plast Reconstr Surg. 2000;105:376–383; discussion 384.

61. Kalantar-Hormozi A, Beiraghi-Toosi A. Smile analysis in rhinoplasty: A randomized study for comparing resection and transposition of the depressor septi nasi muscle. Plast Reconstr Surg. 2014;133:261–268.

62. Kosins AM, Lambros V, Daniel RK. The plunging tip: Illusion and reality. Aesthet Surg J. 2014;34:45–55.

63. Rohrich RJ, Adams WP Jr, Ahmad J. Enhancing the nasal tip-upper lip relationship: Importance of the depressor septi nasi muscle in rhinoplasty. In: Rohrich RJ, Adams WP Jr, Ahmad J, Gunter JP, eds. Dallas Rhinoplasty: Nasal Surgery by the Masters. 3rd ed. St. Louis: Quality Medical; 2014.

64. Howard BK, Rohrich RJ. Understanding the nasal air-way: Principles and practice. Plast Reconstr Surg. 2002;109: 1128–1146; quiz 1145.

65. Rohrich RJ, Krueger JK, Adams WP Jr, Marple BF. Rationale for submucous resection of hypertrophied inferior tur-binates in rhinoplasty: An evolution. Plast Reconstr Surg. 2001;108:536–544; discussion 545.

66. Pollock RA, Rohrich RJ. Inferior turbinate surgery: An adjunct to successful treatment of nasal obstruction in 408 patients. Plast Reconstr Surg. 1984;74:227–236.

67. Guyuron B, Afrooz PN. Correction of cocaine-related nasal defects. Plast Reconstr Surg. 2008;121:1015–1023.

68. Broughton G II, Crosby MA, Coleman J, Rohrich RJ. Use of herbal supplements and vitamins in plastic surgery: A practi-cal review. Plast Reconstr Surg. 2007;119:48e–66e.

69. Ahmad J, Rohrich RJ, Lee MR. Surgical management of the nasal airway. In: Rohrich RJ, Adams WP Jr, Ahmad J, Gunter JP, eds. Dallas Rhinoplasty: Nasal Surgery by the Masters. 3rd ed. St. Louis: Quality Medical; 2014:975–998.

70. Becker DG, Ransom E, Guy C, Bloom J. Surgical treat-ment of nasal obstruction in rhinoplasty. Aesthet Surg J. 2010;30:347–378; quiz 379.

71. Murrell GL. Components of the nasal examination. Aesthet Surg J. 2013;33:38–42.

72. Constantian MB, Clardy RB. The relative importance of sep-tal and nasal valvular surgery in correcting airway obstruc-tion in primary and secondary rhinoplasty. Plast Reconstr Surg. 1996;98:38–54; discussion 55.

73. Wittkopf M, Wittkopf J, Ries WR. The diagnosis and treat-ment of nasal valve collapse. Curr Opin Otolaryngol Head Neck Surg. 2008;16:10–13.

74. Rhee JS, Arganbright JM, McMullin BT, Hannley M. Evidence supporting functional rhinoplasty or nasal valve repair: A 25-year systematic review. Otolaryngol Head Neck Surg. 2008;139:10–20.

75. Spielmann PM, White PS, Hussain SS. Surgical techniques for the treatment of nasal valve collapse: A systematic review. Laryngoscope 2009;119:1281–1290.

76. Rhee JS, Weaver EM, Park SS, et al. Clinical consensus state-ment: Diagnosis and management of nasal valve compro-mise. Otolaryngol Head Neck Surg. 2010;143:48–59.

77. Gunter JP, Rohrich RJ. Management of the deviated nose: The importance of septal reconstruction. Clin Plast Surg. 1988;15:43–55.

78. Guyuron B, Uzzo CD, Scull H. A practical classification of septonasal deviation and an effective guide to septal sur-gery. Plast Reconstr Surg. 1999;104:2202–2209; discussion 2210.

79. Guyuron B, Behmand RA. Caudal nasal deviation. Plast Reconstr Surg. 2003;111:2449–2457; discussion 2458.

80. Mowlavi A, Masouem S, Kalkanis J, Guyuron B. Septal car-tilage defined: Implications for nasal dynamics and rhino-plasty. Plast Reconstr Surg. 2006;117:2171–2174.

81. Constantine FC, Ahmad J, Geissler P, Rohrich RJ. Simplifying the management of caudal septal deviation in rhinoplasty. Plast Reconstr Surg. 2014;134:379e–388e.

82. Afrooz PN, Amirlak B. Digital imaging and standard-ized photography in rhinoplasty. In: Rohrich RJ, Adams WP Jr, Ahmad J, Gunter JP, eds. Dallas Rhinoplasty: Nasal Surgery by the Masters. 3rd ed. St. Louis: Quality Medical; 2014:111–132.

83. Janis JE, Ahmad J, Rohrich RJ. Primary rhinoplasty. In: Nahai F, ed. The Art of Aesthetic Surgery: Principles and Techniques. 2nd ed. St. Louis: Quality Medical; 2010:1895–1974.

84. Galdino GM, DaSilva D, Gunter JP. Digital photography for rhinoplasty. Plast Reconstr Surg. 2002;109:1421–1434.


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85. Swamy RS, Sykes JM, Most SP. Principles of photography in rhinoplasty for the digital photographer. Clin Plast Surg. 2010;37:213–221.

86. Mühlbauer W, Holm C. Computer imaging and surgi-cal reality in aesthetic rhinoplasty. Plast Reconstr Surg. 2005;115:2098–2104.

87. Adelson RT, DeFatta RJ, Bassischis BA. Objective assessment of the accuracy of computer-simulated imaging in rhino-plasty. Am J Otolaryngol. 2008;29:151–155.

88. Mahajan AY, Shafiei M, Marcus BC. Analysis of patient-determined preoperative computer imaging. Arch Facial Plast Surg. 2009;11:290–295.

89. Moscatiello F, Herrero Jover J, González Ballester MA, Carreño Hernández E, Piombino P, Califano L. Preoperative digital three-dimensional planning for rhinoplasty. Aesthetic Plast Surg. 2010;34:232–238.

90. Punthakee X, Rival R, Solomon P. Digital imaging in rhino-plasty. Aesthetic Plast Surg. 2009;33:635–638.

91. Gorney M. Patient selection in rhinoplasty: Patient selec-tion. In: Daniel RK, ed. Aesthetic Plastic Surgery: Rhinoplasty. Boston: Little, Brown; 1993.

92. Gorney M, Martello J. Patient selection criteria. Clin Plast Surg. 1999;26:37–40, vi.

93. Goin MK, Rees TD. A prospective study of patients’ psychological reactions to rhinoplasty. Ann Plast Surg. 1991;27:210–215.

94. Guyuron B, Bokhari F. Patient satisfaction following rhino-plasty. Aesthetic Plast Surg. 1996;20:153–157.

95. Veale D, De Haro L, Lambrou C. Cosmetic rhinoplasty in body dysmorphic disorder. Br J Plast Surg. 2003;56:546–551.

96. Honigman RJ, Phillips KA, Castle DJ. A review of psychoso-cial outcomes for patients seeking cosmetic surgery. Plast Reconstr Surg. 2004;113:1229–1237.

97. Amodeo CA. The central role of the nose in the face and the psyche: Review of the nose and the psyche. Aesthetic Plast Surg. 2007;31:406–410.

98. Tasman AJ. The psychological aspects of rhinoplasty. Curr Opin Otolaryngol Head Neck Surg. 2010;18:290–294.

99. Pecorari G, Gramaglia C, Garzaro M, et al. Self-esteem and personality in subjects with and without body dysmorphic disorder traits undergoing cosmetic rhinoplasty: Preliminary data. J Plast Reconstr Aesthet Surg. 2010;63:493–498.

100. Constantian MB, Lin CP. Why some patients are unhappy: Part 1. Relationship of preoperative nasal deformity to number of operations and a history of abuse or neglect. Plast Reconstr Surg. 2014;134:823–835.

101. Constantian MB, Lin CP. Why some patients are unhappy: Part 2. Relationship of nasal shape and trauma history to surgical success. Plast Reconstr Surg. 2014;134:836–851.

102. Guyuron B. Dynamics in rhinoplasty. Plast Reconstr Surg. 2000;105:2257–2259.

103. Toriumi DM. Structural approach to primary rhinoplasty. Aesthet Surg J. 2002;22:72–84.

104. Gruber RP. Open rhinoplasty. Clin Plast Surg. 1988;15:95–114. 105. Friedman GD, Gruber RP. A fresh look at the open rhino-

plasty technique. Plast Reconstr Surg. 1988;82:973–982. 106. Gunter JP. The merits of the open approach in rhinoplasty.

Plast Reconstr Surg. 1997;99:863–867. 107. Tebbetts JB. Open and closed rhinoplasty (minus the “ver-

sus”): Analyzing processes. Aesthet Surg J. 2006;26:456–459. 108. Rohrich RJ, Gunter JP, Friedman RM. Nasal tip blood

supply: An anatomic study validating the safety of the transcolumellar incision in rhinoplasty. Plast Reconstr Surg. 1995;95:795–799; discussion 800.

109. Adams WP Jr, Rohrich RJ, Hollier LH, Minoli J, Thornton LK, Gyimesi I. Anatomic basis and clinical implications for

nasal tip support in open versus closed rhinoplasty. Plast Reconstr Surg. 1999;103:255–261; discussion 262.

110. Rohrich RJ, Muzaffar AR, Gunter JP. Nasal tip blood supply: Confirming the safety of the transcolumellar incision in rhi-noplasty. Plast Reconstr Surg. 2000;106:1640–1641.

111. Ponsky D, Eshraghi Y, Guyuron B. The frequency of surgi-cal maneuvers during open rhinoplasty. Plast Reconstr Surg. 2010;126:240–244.

112. Rohrich RJ. Ahmad J. Rohrich’s approach. In: Rohrich RJ, Adams WP Jr, Ahmad J, Gunter JP, eds. Dallas Rhinoplasty: Nasal Surgery by the Masters. 3rd ed. St. Louis: Quality Medical. 2014:1417–1460.

113. Rohrich RJ, Muzaffar AR, Janis JE. Component dorsal hump reduction: The importance of maintaining dorsal aesthetic lines in rhinoplasty. Plast Reconstr Surg. 2004;114:1298–1308; discussion 1309.

114. Geissler PJ, Roostaeian J, Lee MR, Unger JJ, Rohrich RJ. Role of upper lateral cartilage tension spanning suture in restoring the dorsal aesthetic lines in rhinoplasty. Plast Reconstr Surg. 2014;133:7e–11e.

115. Roostaeian J, Unger JG, Lee MR, Geissler P, Rohrich RJ. Reconstitution of the nasal dorsum following component dorsal reduction in primary rhinoplasty. Plast Reconstr Surg. 2014;133:509–518.

116. Lee MR, Unger JG, Rohrich RJ. Management of the nasal dorsum in rhinoplasty: A systematic review of the literature regarding technique, outcomes, and complications. Plast Reconstr Surg. 2011;128:538e–550e.

117. Mojallal A, Ouyang D, Saint-Cyr M, Bui N, Brown SA, Rohrich RJ. Dorsal aesthetic lines in rhinoplasty: A quanti-tative outcome-based assessment of the component dorsal reduction technique. Plast Reconstr Surg. 2011;128:280–288.

118. Rohrich RJ, Ahmad J, Roostaienen J. Evaluation and surgi-cal approach to the nasal dorsum: Component dorsal hump reduction and dorsal reconstitution. In: Rohrich RJ, Adams WP Jr, Ahmad J, Gunter JP, eds. Dallas Rhinoplasty: Nasal Surgery by the Masters. 3rd ed. St. Louis: Quality Medical; 2014:219–248.

119. Byrd HS, Meade RA, Gonyon DL Jr. Using the auto-spreader flap in primary rhinoplasty. Plast Reconstr Surg. 2007;119:1897–1902.

120. Gruber RP, Park E, Newman J, Berkowitz L, Oneal R. The spreader flap in primary rhinoplasty. Plast Reconstr Surg. 2007;119:1903–1910.

121. Gruber RP, Perkins SW. Humpectomy and spreader flaps. Clin Plast Surg. 2010;37:285–291.

122. Neu BR. Use of the upper lateral cartilage sagittal rotation flap in nasal dorsum reduction and augmentation. Plast Reconstr Surg. 2009;123:1079–1087.

123. Sheen JH. Spreader graft: A method of reconstructing the roof of the middle nasal vault following rhinoplasty. Plast Reconstr Surg. 1984;73:230–239.

124. Rohrich RJ, Hollier LH. Use of spreader grafts in the external approach to rhinoplasty. Clin Plast Surg. 1996;23:255–262.

125. Boccieri A, Macro C, Pascali M. The use of spreader grafts in primary rhinoplasty. Ann Plast Surg. 2005;55:127–131.

126. Sheen JH. Rhinoplasty: Personal evolution and milestones. Plast Reconstr Surg. 2000;105:1820–1852; discussion 1853.

127. Burstein FD. Prevention and correction of airway compro-mise in rhinoplasty. Ann Plast Surg. 2008;61:595–600.

128. Rohrich RJ, Gunter JP, Deuber MA, Adams WP Jr. The deviated nose: Optimizing results using a simplified clas-sification and algorithmic approach. Plast Reconstr Surg. 2002;110:1509–1523; discussion 1524.



745e

129. Byrd HS, Salomon J, Flood J. Correction of the crooked nose. Plast Reconstr Surg. 1998;102:2148–2157.

130. Stepnick D, Guyuron B. Surgical treatment of the crooked nose. Clin Plast Surg. 2010;37:313–325.

131. Kim DW, Toriumi DM. Management of posttraumatic nasal deformities: The crooked nose and the saddle nose. Facial Plast Surg Clin North Am. 2004;12:111–132.

132. Foda HM. The role of septal surgery in management of the deviated nose. Plast Reconstr Surg. 2005;115:406–415.

133. Hsiao YC, Kao CH, Wang HW, Moe KS. A surgical algorithm using open rhinoplasty for correction of traumatic twisted nose. Aesthetic Plast Surg. 2007;31:250–258.

134. Rohrich RJ, Gunter JP, Adams WP Jr, Constantine FC, Ahmad J. Comprehensive management of the deviated nose. In: Rohrich RJ, Adams WP Jr, Ahmad J, Gunter JP, eds. Dallas Rhinoplasty: Nasal Surgery by the Masters. 3rd ed. St. Louis: Quality Medical; 2014:1029–1065.

135. Dixon FW. The nasal turbinates. Trans Am Acad Ophthalmol Otolaryngol. 1949;54:107–112, illust.

136. Batra PS, Seiden AM, Smith TL. Surgical management of adult inferior turbinate hypertrophy: A systematic review of the evidence. Laryngoscope 2009;119:1819–1827.

137. Constantian MB. The incompetent external nasal valve: Pathophysiology and treatment in primary and secondary rhi-noplasty. Plast Reconstr Surg. 1994;93:919–931; discussion 932.

138. Lee MR, Malafa M, Roostaeian J, Unger JG, Rohrich RJ. Soft-tissue composition of the columella and potential rel-evance in rhinoplasty. Plast Reconstr Surg. 2014;134:621–625.

139. Lee MR, Tabbal G, Kurkjian TJ, Roostaeian J, Rohrich RJ. Classifying deformities of the columella base in rhinoplasty. Plast Reconstr Surg. 2014;133:464e–470e

140. Geissler PJ, Lee MR, Roostaeian J, Unger JG, Rohrich RJ. Reshaping the medial nostril and columellar base: Five-step medial crural footplate approximation. Plast Reconstr Surg. 2013;132:553–557.

141. Janis JE, Trussler A, Ghavami A, Marin V, Rohrich RJ, Gunter JP. Lower lateral crural turnover flap in open rhino-plasty. Plast Reconstr Surg. 2009;123:1830–1841.

142. Rohrich RJ, Raniere J Jr, Ha RY. The alar contour graft: Correction and prevention of alar rim deformities in rhino-plasty. Plast Reconstr Surg. 2002;109:2495–2505; discussion 2506.

143. Toriumi DM, Josen J, Weinberger M, Tardy ME Jr. Use of alar batten grafts for correction of nasal valve collapse. Arch Otolaryngol Head Neck Surg. 1997;123:802–808.

144. Cervelli V, Spallone D, Bottini JD, et al. Alar batten carti-lage graft: Treatment of internal and external nasal valve collapse. Aesthetic Plast Surg. 2009;33:625–634.

145. Gunter JP, Friedman RM. Lateral crural strut graft: Technique and clinical applications in rhinoplasty. Plast Reconstr Surg. 1997;99:943–952.

146. Gruber RP, Kryger G, Chang D. The intercartilaginous graft for actual and potential alar retraction. Plast Reconstr Surg. 2008;121:288e–296e.

147. Boahene KD, Hilger PA. Alar rim grafting in rhinoplasty: Indications, technique, and outcomes. Arch Facial Plast Surg. 2009;11:285–289.

148. Weber SM, Baker SR. Alar cartilage grafts. Clin Plast Surg. 2010;37:253–264.

149. Rohrich RJ, Roostaienen J, Ahmad J. Correction and pre-vention of alar rim deformities: Alar contour grafts. In: Rohrich RJ, Adams WP Jr, Ahmad J, Gunter JP, eds. Dallas Rhinoplasty: Nasal Surgery by the Masters. 3rd ed. St. Louis: Quality Medical; 2014:569–590.

150. Ghavami A, Janis JE, Acikel C, Rohrich RJ. Tip shaping in primary rhinoplasty: An algorithmic approach. Plast Reconstr Surg. 2008;122:1229–1241.

151. Rohrich RJ, Adams WP Jr. The boxy nasal tip: Classification and management based on alar cartilage suturing techniques. Plast Reconstr Surg. 2001;107:1849–1863; discussion 1864.

152. Rohrich RJ, Griffin JR. Correction of intrinsic nasal tip asymmetries in primary rhinoplasty. Plast Reconstr Surg. 2003;112:1699–1712; discussion 1713.

153. Lee MR, Geissler P, Cochran S, Gunter JP, Rohrich RJ. Decreasing nasal tip projection in rhinoplasty. Plast Reconstr Surg. 2014;134:41e–49e.

154. Gunter JP, Yu YL. The tripod concept for correcting nasal-tip cartilages. Aesthet Surg J. 2004;24:257–260.

155. Gunter JP, Lee MR, Ahmad J, Rohrich RJ. Basic nasal tip sur-gery: Anatomy and technique. In: Rohrich RJ, Adams WP Jr, Ahmad J, Gunter JP, eds. Dallas Rhinoplasty: Nasal Surgery by the Masters. 3rd ed. St. Louis: Quality Medical; 2014:321–350.

156. Rohrich RJ, Janis JE, Ghavami A, Ahmad J. A predictable and algorithmic approach to tip refinement and projec-tion. In: Rohrich RJ, Adams WP Jr, Ahmad J, Gunter JP, eds. Dallas Rhinoplasty: Nasal Surgery by the Masters. 3rd ed. St. Louis: Quality Medical; 2014:441–472.

157. Rohrich RJ, Ahmad J, Kurkjian TJ, Byrd HS. Predictable control of tip projection and rotation: Septal extension grafts. In: Rohrich RJ, Adams WP Jr, Ahmad J, Gunter JP, eds. Dallas Rhinoplasty: Nasal Surgery by the Masters. 3rd ed. St. Louis: Quality Medical; 2014:495–514.

158. Rohrich RJ, Tabbal GN, Kurkjian TJ, Ahmad J. Adjusting rotation of the nasal tip. In: Rohrich RJ, Adams WP Jr, Ahmad J, Gunter JP, eds. Dallas Rhinoplasty: Nasal Surgery by the Masters. 3rd ed. St. Louis: Quality Medical; 2014:529–556.

159. Daniel RK. The nasal tip: Anatomy and aesthetics. Plast Reconstr Surg. 1992;89:216–224.

160. Toriumi DM. New concepts in nasal tip contouring. Arch Facial Plast Surg. 2006;8:156–185.

161. Tebbetts JB. Shaping and positioning the nasal tip without structural disruption: A new, systematic approach. Plast Reconstr Surg. 1994;94:61–77.

162. Daniel RK. Rhinoplasty: A simplified, three-stitch, open tip suture technique. Part I: Primary rhinoplasty. Plast Reconstr Surg. 1999;103:1491–1502.

163. Gruber RP. Suture correction of nasal tip cartilage concavi-ties. Plast Reconstr Surg. 1997;100:1616–1617.

164. Gruber RP, Friedman GD. Suture algorithm for the broad or bulbous nasal tip. Plast Reconstr Surg. 2002;110:1752–1764; discussion 1765.

165. Gruber RP, Nahai F, Bogdan MA, Friedman GD. Changing the convexity and concavity of nasal cartilages and cartilage grafts with horizontal mattress sutures: Part I. Experimental results. Plast Reconstr Surg. 2005;115:589–594.

166. Gruber RP, Nahai F, Bogdan MA, Friedman GD. Changing the convexity and concavity of nasal cartilages and car-tilage grafts with horizontal mattress sutures: Part II. Clinical results. Plast Reconstr Surg. 2005;115:595–606; dis-cussion 607.

167. Gruber RP, Weintraub J, Pomerantz J. Suture techniques for the nasal tip. Aesthet Surg J. 2008;28:92–100.

168. Gruber RP, Chang E, Buchanan E. Suture techniques in rhi-noplasty. Clin Plast Surg. 2010;37:231–243.

169. Dosanjh AS, Hsu C, Gruber RP. The hemitransdomal suture for narrowing the nasal tip. Ann Plast Surg. 2010;64:708–712.

170. Behmand RA, Ghavami A, Guyuron B. Nasal tip sutures part I: The evolution. Plast Reconstr Surg. 2003;112:1125–1129; discussion 1146.

171. Guyuron B, Behmand RA. Nasal tip sutures part II: The interplays. Plast Reconstr Surg. 2003;112:1130–1145; discus-sion 1146.


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172. McKinney P. Management of the bulbous nose. Plast Reconstr Surg. 2000;106:906–917; discussion 918.

173. Constantian MB. The boxy nasal tip, the ball tip, and alar cartilage malposition: Variations on a theme. A study in 200 consecutive primary and secondary rhinoplasty patients. Plast Reconstr Surg. 2005;116:268–281.

174. Sheen JH. Achieving more nasal tip projection by the use of a small autogenous vomer or septal cartilage graft: A pre-liminary report. Plast Reconstr Surg. 1975;56:35–40.

175. Sheen JH. Tip graft: A 20-year retrospective. Plast Reconstr Surg. 1993;91:48–63.

176. Peck GC. The onlay graft for nasal tip projection. Plast Reconstr Surg. 1983;71:27–39.

177. Peck GC Jr, Michelson L, Segal J, Peck GC Sr. An 18-year experience with the umbrella graft in rhinoplasty. Plast Reconstr Surg. 1998;102:2158–2165; discussion 2166.

178. Gunter JP, Rohrich RJ. Correction of the pinched nasal tip with alar spreader grafts. Plast Reconstr Surg. 1992;90:821–829.

179. Rohrich RJ, Deuber MA. Nasal tip refinement in primary rhinoplasty: The cephalic trim cap graft. Aesthet Surg J. 2002;22:39–45.

180. Daniel RK. Tip refinement grafts: The designer tip. Aesthet Surg J. 2009;29:528–537.

181. Dobratz EJ, Tran V, Hilger PA. Comparison of techniques used to support the nasal tip and their long-term effects on tip position. Arch Facial Plast Surg. 2010;12:172–179.

182. Rohrich RJ, Kurkjian TJ, Hoxworth RE, Stephan PJ, Mojallal A. The effect of the columellar strut graft on nasal tip position in primary rhinoplasty. Plast Reconstr Surg. 2012;130:926–932.

183. Unger JG, Lee MR, Kwon RK, Rohrich RJ. A multivari-ate analysis of nasal tip deprojection. Plast Reconstr Surg. 2012;129:1163–1167.

184. Rohrich RJ, Hoxworth RE, Kurkjian TJ. The role of the col-umellar strut in rhinoplasty: Indications and rationale. Plast Reconstr Surg. 2012;129:118e–125e.

185. Rohrich RJ, Liu JH. Defining the infratip lobule in rhino-plasty: Anatomy, pathogenesis of abnormalities, and cor-rection using an algorithmic approach. Plast Reconstr Surg. 2012;130:1148–1158.

186. Gunter JP, Rohrich RJ, Friedman RM. Classification and correction of alar-columellar discrepancies in rhinoplasty. Plast Reconstr Surg. 1996;97:643–648.

187. Guyuron B. Alar rim deformities. Plast Reconstr Surg. 2001;107:856–863.

188. Hackney FL. Diagnosis and correction of alar rim deformi-ties in rhinoplasty. Clin Plast Surg. 2010;37:223–229.

189. Neu BR. A problem-oriented and segmental open approach to alar cartilage losses and alar length discrepancies. Plast Reconstr Surg. 2002;109:768–779; discussion 780.

190. Gubisch W, Eichhorn-Sens J. Overresection of the lower lateral cartilages: A common conceptual mistake with functional and aesthetic consequences. Aesthetic Plast Surg. 2009;33:6–13.

191. Guyuron B, Bigdeli Y, Sajjadian A. Dynamics of the alar rim graft. Plast Reconstr Surg. 2015;135:981–986.

192. Cochran CS, Gunter JP. Lateral crural strut grafts. In: Rohrich RJ, Adams WP Jr, Ahmad J, Gunter JP, eds. Dallas Rhinoplasty: Nasal Surgery by the Masters. 3rd ed. St. Louis: Quality Medical; 2014:605–622.

193. Rohrich RJ, Adams WP Jr. Nasal osteotomies. In: Rohrich RJ, Adams WP Jr, Ahmad J, Gunter JP, eds. Dallas Rhinoplasty: Nasal Surgery by the Masters. 3rd ed. St. Louis: Quality Medical; 2014:249–274.

194. Rohrich RJ, Minoli JJ, Adams WP, Hollier LH. The lateral nasal osteotomy in rhinoplasty: An anatomic endoscopic comparison of the external versus the internal approach. Plast Reconstr Surg. 1997;99:1309–1312; discussion 1313.

195. Rohrich RJ, Krueger JK, Adams WP Jr, Hollier LH Jr. Achieving consistency in the lateral nasal osteotomy dur-ing rhinoplasty: An external perforated technique. Plast Reconstr Surg. 2001;108:2122–2130; discussion 2131.

196. Rohrich RJ, Janis JE, Adams WP, Krueger JK. An update on the lateral nasal osteotomy in rhinoplasty: An anatomic endoscopic comparison of the external versus the internal approach. Plast Reconstr Surg. 2003;111:2461–2462; discus-sion 2463.

197. Rohrich RJ. Osteotomies in rhinoplasty: An updated tech-nique. Aesthet Surg J. 2003;23:56–58.

198. Guyuron B. Nasal osteotomy and airway changes. Plast Reconstr Surg. 1998;102:856–860; discussion 861.

199. Harshbarger RJ, Sullivan PK. Lateral nasal osteotomies: Implications of bony thickness on fracture patterns. Ann Plast Surg. 1999;42:365–370; discussion 370.

200. Becker DG, McLaughlin RB Jr, Loevner LA, Mang A. The lateral osteotomy in rhinoplasty: Clinical and radiographic rationale for osteotome selection. Plast Reconstr Surg. 2000;105:1806–1816; discussion 1817.

201. Harshbarger RJ, Sullivan PK. The optimal medial osteot-omy: A study of nasal bone thickness and fracture patterns. Plast Reconstr Surg. 2001;108:2114–2119; discussion 2120.

202. Gryskiewicz JM, Gryskiewicz KM. Nasal osteotomies: A clini-cal comparison of the perforating methods versus the con-tinuous technique. Plast Reconstr Surg. 2004;113:1445–1456; discussion 1457.

203. Gryskiewicz JM. Visible scars from percutaneous osteoto-mies. Plast Reconstr Surg. 2005;116:1771–1775.

204. Yücel OT. Which type of osteotomy for edema and ecchymo-sis: External or internal? Ann Plast Surg. 2005;55:587–590.

205. Gruber R, Chang TN, Kahn D, Sullivan P. Broad nasal bone reduction: An algorithm for osteotomies. Plast Reconstr Surg. 2007;119:1044–1053.

206. Erişir F, Tahamiler R. Lateral osteotomies in rhino-plasty: A safer and less traumatic method. Aesthet Surg J. 2008;28:518–520.

207. Dobratz EJ, Hilger PA. Osteotomies. Clin Plast Surg. 2010;37:301–311.

208. Rohrich RJ, Ahmad J. Postoperative management of the rhinoplasty patient. In: Rohrich RJ, Adams WP Jr, Ahmad J, Gunter JP, eds. Dallas Rhinoplasty: Nasal Surgery by the Masters. 3rd ed. St. Louis: Quality Medical; 2014.

209. Klabunde EH, Falces E. Incidence of complications in cos-metic rhinoplasties. Plast Reconstr Surg. 1964;34:192–196.

210. Miller T. Immediate postoperative complications of septo-plasties and septorhinoplasties. Trans Pac Coast Otoophthalmol Soc Annu Meet. 1976;57:201–205.

211. Goldwyn RM. Unexpected bleeding after elective nasal sur-gery. Ann Plast Surg. 1979;2:201–204.

212. McKinney P, Cook JQ. A critical evaluation of 200 rhinoplas-ties. Ann Plast Surg. 1981;7:357–361.

213. Holt GR, Garner ET, McLarey D. Postoperative sequelae and complications of rhinoplasty. Otolaryngol Clin North Am. 1987;20:853–876.

214. Dziewulski P, Dujon D, Spyriounis P, Griffiths RW, Shaw JD. A retrospective analysis of the results of 218 consecutive rhi-noplasties. Br J Plast Surg. 1995;48:451–454.

215. Cochran CS, Landecker A. Prevention and manage-ment of rhinoplasty complications. Plast Reconstr Surg. 2008;122:60e–67e.

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