CHAPTER65Basic Principles ofRhinoplastyJamesKoehler, DDSyMDPeter D.Waite,MPH,DDS,MDFormanycosmeticsurgeonsrhinoplasty isone of the mostchallenging surgical proce-dures. A clear understanding of nasal anato-my is critical in order to provide an estheticresult that does not compromise nasalfrxnc-tion. Developing a patternof analysis of thenoseisvitalforproperdiagnosisandfordeterminingthemostappropriatetreat-mentplan.Numerousrhinoplastictech-niques have beendescribed. Some surgeonsfavor an endonasal approach whereas othersbelievethatanexternalapproachismoredesirable. Each surgeon must become famil-iarwithalltechniqueoptionsinordertoaddressthewidevarietyofchallengesofrhinoplasty surgery.Thegoalofthischapteristogiveabroadoverview ofthediagnosisandtreat-ment of nasal deformities. It is by no meansexhaustive since multiple textbook volumeshave been written on this subject. The read-ershouldgainanunderstandingofnasalanatomyanddeterminehow tosystemati-cally analyze the nose. Bothendonasalandexternalrhinoplasty will be described.Nasal AnatomyA clearunderstandingof nasal anatomy isimportanttosuccessfullyperformnasalproceduresanddecreasetheincidenceofcomplications.SurfaceAnatomyThetermsusedtodescribethesurfaceanatomyofthenoseareimportantinnasal formanalysis andfortreatmentplanformulation(Table65-1).Fordescriptivepurposesthespatialrelationshipsaredescribed as cephalic, caudal, dorsal, basal,anterior,posterior,superior,andinferior(Figure 65-1).Skinand Soft TissueThesofttissuethatoverlies the boneandcartilage may influencethefinalresult ofrhinoplasty.Thethicknessoftheskinwilldeterminehowitwillre-drapeafterperformingarhinoplasty.Theskinthickness variesalong thedorsumoftheTable 65-1Surface AnatomyoftheNosenose. Theskinis fairlythickandmobileintheregionofthenasion.Itquicklythinsoverthenasaldorsumandisgen-erallythinnestandmostmobileinthemid-dorsalregion(rhinion).Inthedis-talthirdofthenosetheskintendstobemorethickandadherentandhasanincreasedsebaceouscontent.A patient with thin skin will show dra-maticchangeswithalterationoftheunderlyingboneandcartilage,andthislimits roomforerrorsince little is camou-flagedbythethicknessoftheskin.Con-versely forthick-skinnedindividualsmoreGiabella: the most forwardprojecting point of the foreheadin the midline at the level of thesupraorbitalridgesRadix: the junctionbetweenthe frontalboneand the dorsumof thenoseRhinion: the anteriortipat the endofthe suture of the nasalhonesDorsum: the anteriorsurfaceof the nose formedby the nasal bones andthe upperlateralcartilagesSupratip break: the slightdepressionin the nasal profileat the pointwhere the nasaldorsumjoins the lobule of the nasaltipInfratiplobule: the portionof the tip lobule that is foundbetween the tip-definingpointsand the columellar-lobularangleTip-definingpoints: there are fourtip definingpoints, whichinclude the supratip break, thecolumellar-lobularangle, and the most projectedarea on each side of the nasal tipformedby the lower lateralcartilagesAlar sidewall: the roundedeminenceformingthe lateralnostrilwallAlar-facialjunction: the depressedgroove formedonthe face where the ala joins thefaceColumella: the skin that separates the nostrils at the hase ofthenose1 3 4 6Part9: FacialEstheticSurgerySuperiorInferiorFIGURE65-1Spatialdescriptors.Indescribingtherelationshipofoneanatomicunittoanothermanytermsareused. Thestandardrelationshipsare anterior, posterior,superior, andinferior.Thenose is also described in terms of dorsal, basal, cau-dal,andcranial(orcephalic) positions.AdaptedfromAustermannK.Rhinoplasty:planningtechniquesandcomplications.In:BoothPW,HausamenJE,editors.Maxillofacialsurgery.NewYork: ChurchillLivingstone;1999. p.1378.aggressivesculpturingoftbenasalskele-tonmustbeperformedinordertoeffectsignificantcbanges.Altbougbthickskinmaymaskimperfectionsitdoesnotre-drapeas well andcanresultinunderlyingfibrosisandformationofapolybeakdeformity(supratipscarring).Betterresultsarepossiblewiththin-skinnedpatients,howevertbemarginforerrorissmaller.Thesurgeonmustsometimesmodifythetechniquedependingonthetype of skin of thepatient.Superficial MusculoaponeuroticSystem and Nasal MusculatureThe muscles of the nose are encased in thenasalsuperficialmusculoaponeuroticsys-tem(SMAS). This is a fibromuscular layerthatseparatestbeskinandsubcutaneoustissuefromthenasalcartilageandbone.TbeSMASofthenoseisincontinuitywiththe SMAS of theface. Duringrhino-plastic surgery the dissectionisperformedbeneaththeSMAS.ViolatingtheSMASwilloftenresultinincreasedbleeding,scarring, and postoperativeedema.Tbe musclesofthe nose can bedivid-edintofourcategories:theelevators,tbedepressors, tbecompressors,andtbedila-tors(Figure65-2). Themusclesofsignifi-cancearetbepaireddepressorseptinasi.Tbese muscles can result in drooping of thenasaltipduringsmiling.Thisaddedten-sionontbenasaltipmustberecognizedpreoperativelyandaddressedbyresectionin orderto achieve a cosmetic result.'Blood SupplyTbereisaricbbloodsupplytotbesub-dermalvascularplexusofthenosethatarisesfrombranchesofbothtbeinternalandexternalcarotidarteries.Thebloodsupplyfromtheinternalcarotidarterythatsuppliestheexternalnoseincludesthedorsalnasalarteryandtheexternalnasalartery.Thedorsalnasalarteryisabranchoftheophthalmicartery.Theexternalnasalarteryisabranchoftheanteriorethmoidartery.Theexternalnoseisalsosuppliedbybranchesof tbefacialartery andtbeinter-nalmaxillaryartery,whichoriginatefromthe external carotid artery. Tbe facialarterybranchesinclude the angularartery, lateralnasalartery,alarartery,septalartery,andsuperiorlabial artery(Figure 65-3).iTbeinternalnoseissuppliedbytbeinternalandexternalcarotidbranches.Theophthalmicartery,abranchoftheinternal carotid, brancbes into the anteriorandposteriorethmoidalarteries.Theanteriorethmoidalarterysuppbestbeanterosuperiorpartof tbe septumandtbelateralnasalwall.Tbeposteriorethmoidarterysuppliestheseptum,lateralnasalwall, andthesuperiorturbinate.^The internalmaxillary arterybrancbesincludethesphenopalatinearteryandtbegreater palatine artery. Tbespbenopalatinearterysuppliesmostoftbeposteriorpartoftbenasalseptum,lateralwalloftheProcerusmuscleLevatorlabii superiorisalaequenasimuscleAlar nasalismuscieTransversenasaiismuscieDiiatornarisanteriormuscleCompressornariumminormuscieDepressorseptinasimuscleOrbicularisorismuscieFIGURE 65-2Nasalmusculature.Themusclesof thenose are groupedintotheelevators(lightblue),thedepressors(darkblue),thecompressors(lightgray),andthedilators(darkgray). AdaptedfromfewettB. Anatomicconsiderations.In:BakerSR,editor.Principlesofnasalreconstruction.St.Louis(MO):Mosby:2002.p17.BasicPrinciplesof Rhinoplasty1 3 4 7SupraorbitalarteryInfraorbital arteryAngular arterySuperiorlabial arterySupratrochleararteryDorsal nasal arteryExternal nasal branchof anteriorethmoidalarteryLateral nasal arteryColumellarbranchSeptalbranchFacial arteryFIGURE65-3Arteriesoftheexternalnose.Thearterialsupplyoftheexternalnosecomesfrombranchesof the externalcarotidartery(dark blue)andtheinternalcarotidartery{light h\ue).Adapt-ed fromJewettB. Anatomicconsiderations.In: BakerSR,editor.Principlesof nasalreconstruction.St.Louis(MO):Mosby;2002.p.18.conclusionis thattheprimary bloodsup-plytothenasaltipcomesfromthebilat-erallateralnasalarteriesthatcourseinaplanesuperficialtothealarcartilagesinthesubdermalplexusapproximately2to3mmabovethealargroove.Thusacol-umellarincisiondoes notcompromisetipbloodsupply. Also there are nosignificantveinsandminimallymphaticsinthecol-umellarregion.-'''Somesurgeonsbelievethatexternalrhinoplastyremainsmoreedematousforlongerpostoperativeperi-ods thananendonasalrhinoplasty.Bone and CartilageThestructureofthenoseconsistsofthepairednasalbonesaswellasthefrontalprocess of the maxilla. The bone is thick-estnearthejunctionwiththefrontalbone andtapers as it joins withtheupperlateralcartilages.Theupperlateralcartilagesareininti-matecontactwiththenasalbonesandunderliethenasalbonesforapproximately6to8mm.Theconnectionbetweenthenose, roof, andpartof the nasal floor. Thegreater palatine artery supplies a portion oftheanteriorandinferiorportionofthenasal septum(Figure 65-4).^Thesurgicallysignificantareaforinternal nasal bleeding is known as Kiessel-bach'splexus(alsotermedLittle'sarea).This is the area in the anteroinferiorpart ofthe nasal septum which is a common site ofexpistaxis.Itiswherethesphenopalatine,greater palatine, superiorlabial artery, andanterior ethmoidarteries anastamose (Fig-ure65-5).^Thevenousdrainageofthenose is primarilyfromthefacialandoph-thalmic veins.Oneconcernduringnasalsurgeryisthepossibilityofcompromisedbloodflowtothenasaltipifthesurgeonper-formsanexternalrhinoplasty.Thebloodsupplytothenasaltiphasbeenanalyzedbylymphoscintigraphicstudies,cadaverdissections, andhistologicsections.^''* TheLateral Internal nasal branch ofanterior ethmoidal arteryExternal nasal branchof anterior ethmoidalarteryLateral branch ofposterior ethmoidal arterySphenopalatinearteryDesQendingpalatine arteryLesserpalatine arteryGreaterpalatine arteryBranch ofangular arteryFIGURE 65-4Arteriesof the lateral nasalwall.The arterialsupplyof the lateral nasalwall arisesfrombranchesoftheexternalcarotidartery(black)andtheinternalcarotidartery(blue). AdaptedfromJewettB. Anatomicconsiderations.In:BakerSR,editorPrinciplesofnasalreconstruction.St.Louis(MO):Mosby;2002.p.23.1 3 4 8Part9: FacialEstheticSurgeryMedial internal nasal brancho( anterior ethmoidal arterySeptal branch ofposterior ethmoidal arteryNasal septalcartilagePosterior septalbranch otsphenopalatinearteryKiesselbach's plexusSeptal branch ofsuperior labial arteryFIGURE65-5Arteriesofthenasalseptum.Thearterialsupplyofthenasalseptumarisesfrombranchesoftheexternalcarotidartery(black)andtheinternalcarotidartery(blue).Kiesselbach'splexusis formedby the sphenopalatineartery, greater palatineartery,superiorlabialartery,andante-riorethmoidarteries.Itis acommonsiteofepistaxis.AdaptedfromJewettB. Anatomicconsidera-tions.In:BakerSR,editor.Principlesof nasalreconstruction.St.Louis(MO):Mosby;2002.p.23.52%20%17%11%Various configurations of the scrollFIGURE65-6Configurationsofthescroll.Therelationshipoftheupperlateralandlowerlater-al cartilagesis termedthescroll. Anatomicstud-ies haveidentifiedfourcommonconfrgurations:interlocked(52%),overlapping(20%),endtoend(17%),andopposed(11%).AdaptedfromLamSMandWilliamsEFilL^nasalbonesandupperlateralcartilagesshould not be violated since this may disrupttheinternalnasalvalvecausingnasalobstructionandasymmetry.Theinternalnasal valve is formedby the junaionof theupper lateral cartilages and the nasal septum.Thelowerlateralcartilagescomprisethe lower thirdof the nose andconnecttotheupperlateralcartilagesinauniondescribedasthescroll. Therearevariousconfigurationsof the scroll.^'' The scroll isdescribedasinterlocked(52%),overlap-ping (20%), end to end(17%), or opposed(11%)(Figure65-6).Thescrollprovidessignificantsupporttothenasaltip. Whenperforminganendonasalrhinoplastythisareaisviolatedbytheintercartilaginousincision(Figures65-7-^5-9).Thelowerlateralcartilageis dividedintomedialandlateralcrura. The medial cruraare ininti-matecontactwiththenasalseptumandprovidetipsupport.Thelateralcruraextendsuperiorlyandformdensefibroareolartissueattachmentswiththepyriformaperture.Theintermediatecrusis thedivergingofthemedialcrusbeforeturningtobecomethe lateralcrusproper.The highestpointof the intermediatecrusis animportantsurgicallandmarkknownas the tip-definingpoint(Figure 65-10).Thenasalseptumisformedbybothboneandcartilage.Theethmoidandvomerprovidebonysupportposteriorly.The quadrangularcartilage provides sup-portanteriorly(Figure65-11).|Supportforthenasaltipisclassi-fiedintomajorandminordivisions.Themajortipsupportcomesfromthesize,shape,andstrengthofthelowerlateralcartilages,theattachmentofthemedialcruraofthelowerlateralcarti-lagetothecaudalseptum,andthefibrousattachmentofthelowerlateralcartilagetotheupperlateralcartilage.Theminortipsupportcomesfromthenasalspine,themembranousseptum,thecartilaginousdorsum,thesesamoidcomplexes,theinterdomalligaments,andthealarattachmentstotheskin(Table65-2).5NervesThesensorynervesupplytotheskinoftheexternalnoseis suppliedby theoph-thalmicandmaxillarydivisionsoftheFIGURE65-7Partialtransfixion.Thepartialtransfrxionincisionthroughthemembranousseptumandshortofthemedialcrural footpads.Basic Principlesof Rhinoplasty1 3 4 9FIGURE65-8Intercartilaginousincision.Theintercartilaginousincision,betweentheupperandlowercartilage,allowsaccesstothenasaldorsum.Notetheincisiondoesnotviolatethenasalvalve.FIGURE65-9Connectingintercartilaginousandpartialtransfixionincisions.Theintercarti-taginousincisionextendsalongtheupperedge ofthelateralcrustoconnectwiththetransfixionincision.Thiswill provideaccess foraseptoplas-tyduringinternalrhinoplasty.Cribriform platePerpendicularplate ofethmoidboneNasal boneSeptalcartilageUpper lateralcartilageVomerAlar cartilageNasal crest ofmaxillaFIGURE 65-11Anatomyof thenasal septum.Thenasal septumis composedof the perpendicularplateof the ethmoid,thevomer,andthequadrangularcartilage. AdaptedfromJewett B. Anatomicconsider-ations.In: BakerSR,editor. Principlesof nasalreconstruction.St.Louis(MO):Mosby;2002. p.22.trigeminalnerve. Branchesofthesupra-trochlearandinfratrochiearnervessup-ply the skinin the regionof theradix andrhinion.Thelowerhalfofthenoseissuppliedbytheinfraorbitalnerveandtheexternalnasalbranchoftheanteriorethmoidalnerve(abranchofthenasociliarynervethatarisesfromtheophthalmicbranchofthetrigeminalnerve)(Figure65-12).Themainsensorynervesupplytothenasal septum comes from the internal nasalnerve(a branchoftheanteriorethmoidalnerve)andthenasopaiatinenerve(Figure65-13).Thelateralnasalwallsensationissuppliedbytheanteriorethmoidalnerve,branchesofthepterygopalatineganglion,branchesofthegreaterpalatinenerve, theinfraorbitalnerve, andthe anteriorsuperi-or alveolar nerve.ALateral crusintennedratecrus:domalsegmentlobularsegmentMedial crus{columellarsegment)Medial crus(footplatesegment)Lateral crusIntermediatecrusMedial crusBintermediate crus:lobularsegmentdomalsegmentLateral crusMedial crusFIGURE 65-10A-C, Anatomyof the lower lateral cartilages. Thelower lateral cartilages are oftendescribed as havinga lateral crus, medialcrus, andanintermediatecms.Tlie intermediatecmsis the most projected portionof the lower lateral cartilages andthese formtwo of thetip-definingpointsseen onnasal tip analysis.AdaptedfromJewettB. Anatomicconsiderations.In:BakerSR,editor.Principlesofnasalreconstruction.St.Louis(MO):Mosby;2002.p.21.1350Part 9:Facial EstheticSurgeryTable 65-2Tip SupportMechanismsThe three majortip supportmechanismsinclude1.The size, shape, andstrengthof the lower lateral cartilages2.The attachmentof the medialcrura to the caudalseptum3.The attachmentof the lowerlateral cartilages tothe upperlateral cartilagesThe minortipsupportmechanismsinclude1.The interdomalligament2.The sesamoidcomplexextending the supportof the lateralcrura to thepiriformaperture3.The attachmentof the alar cartilages to the overlyingskin4.Cartilaginousseptaldorsum5.Nasalspine6.ThemembranousseptumParasympatheticinnervationis derivedfrom branchesofthe pterygopalatinegan-glion whichare derivedfromcranialnerveVII. Somesympatheticbranchesreachthenasal cavity via the nasociliary nerve.^'''Nasal ValveTheairflowthroughthenose isregulatedbytheinternalandexternalnasalvalves.Theexternalnasalvalveiscomprisedofthelowerlateralcartilageandthenasalseptumand floor. Collapse of theexternalnasal valve cansometimesbe notedwhenthe nares become occludedon evengentleinspiration.Thisproblemisseeninpatients withnarrow nostrils, a projectingnasaltip, andthinalarsidewalls. Externalnasalvalvecollapseisusuallyseeninpatientswhohavehadpreviousrhino-plastysurgeryandexcessivetrimmingofthecephalicportionofthelowerlateralcartilages.Itisalsoseenwithincreasedageandinfacialnerveparalysis.Theexternalnasalvalvecollapsecanbecor-rectedbydeprojectingtheoverprojectednose,realigningthelateralcruraintoamorecaudalorientation,andplacingalarbattengrafts to provide structuralsupportandpreventcollapse.^Theinternalnasalvalveisformedbythe junctionof the septumwiththeupperlateral cartilages. The angle formedshouldbeaminimumof10to15tomaintainpatency.Deviationofthenasalseptumorseparationoftheupperlateralcartilagesfromthenasal bonescanleadtoobstruc-tion. This problemis also seen afterrhino-plastyifthepatienthashadweakeningoftheupperandlowerlateralcartilages.ThesepatientsoftenhaveapinchedSupraorbitalnerveInfraorbitalnerveappearanceinthesupra-alarregion.TheCottletestisusedtoevaluateobstructionat the internal valve by using a fmger to dis-tractthe check andlateral wall ofthenosetherebyopeningthevalve. Ifnasalairflowis dramaticallyimproved, thentheinternalvalvemayrequirecorrection.Thesepatientsoftenhavesymptomaticreliefbythe use of externaltapingdevices. Surgicalcorrectioninvolvestheplacementofspreadergraftsbetweentheseptumandupperlateralcartilagestoincreasetheangle at this junction.^""^'Cosmetic EvaluationThecosmeticevaluationbeginsinthesame way as withany examination, by elic-itingthechiefcomplaintofthepatient.Thepatientshouldbegivenamirrorandcotton-tipped applicator to point out specif-ic cosmetic concerns. Following this a thor-oughmedicalhistoryshouldbeobtained.Specific attention should be directedtowardSupratrochlearnerveInfralrochlearnerveExternalnasalbranchof anteriorethmoidalnerveFIGURE 65-12Sensory nervesof the external nose. The sensory innervationof thenose isderivedfromtheV] (ophthalmic: coloredhlackjandfrom16(maxillary: coloredbluejdivisions ofthetrigeminal nerve. Adapted from Jewett B. Anatomic considerations.In: Baker SR, editor.Principles ofnasal reconstruction.St. Louis (MO): Mosby; 2002.p. 19.BasicPrinciplesof Rhinoplasty1 3 5 1Internainasal(anteriorethmoidai)FIGURE 65-13Sensorynervesofthenasalseptum.Themainsensorynervesupplycomes fromtheinternalnasalnerve(abranchoftheanteriorethmoidalnerveVi(black)andthenasopalatinenerveV2(blue).Adapt-ed fromJewettB. Anatomicconsider-ations.In:BakerSR,editor.Princi-plesof nasalreconstruction.St.Louis(MO):Mosby;2002.p.19.obtainingahistoryofnasaltrauma,nasalobstrucfion,previousnasalsurgery,andmedications(includingover-tbe-counterand herbal medications).IPsychiatric StabilityInadditiontoanalyzingtbenosethesur-geon needs to assess if the pafientis psycho-logically preparedfor a cosmetic procedure.Patientsshouldhaverealisticexpectationsandmotivations. A patient who is internallymotivated(eg, wishes to improve their self-esteem)tohavetheprocedureisabettercandidatetbanonewhodesirestheproce-dureforexternalreasons(eg, spouse wantsthem to have itMediaiposteriorsuperiorNasopaiatlneThe surgeonshouldbeware ofpatientswboareindecisive,rude,uncooperative,depressed,have unrealisticexpectations, orhavesignificantpersonalitydisordersbecausetheymayneverbe satisfied.Otherwarningsignsofpoorpatientsarethosewhooverlyflatter,aretalkative,considerthemselvestobea very importantpatient,have minimalorno deformity,are surgeonshoppers, price hagglers, orinvolvedin liti-gation. Most importantly, do not operate ona patient that you do not like.""'*General Facial AnalysisPriortoperforminga specificanalysisofthenose,aglobalassessmentofthefaceandits proportionsshouldbe done.RefertoCbapter54, "Database AcquisitionandTreatmentPlanning," foradditionalinfor-mationonfacialanalysisinortbognatbicsurgery.Nasal AnalysisThenasalexaminationshouldbeper-formedina systematicmannerso thattheproperdiagnosisis attained(Figures 65-14and 65-15).General AssessmentSkinTheskinsbouldbeassessedforitstbick-ness,mobility,andsebaceousglandcon-tent.Anypigmentationsorscarssbouldalsobenoted.Thickskindoesnotre-drape well afterrhinoplasty.SymmetryAny gross asymmetriesinall views sbouldbe noted.LateralViewNasofrontalAngleTbenasofrontalangleisdefinedastheangleformedfromlinesthataretangentialtotheglabellaandtbenasaldorsumandintersecttbrougbtheradixasseenonaprofileview. Thenormalangleis between125 and135 (Figure 65-16).A'HAFIGURE 65-14Preoperativerhinoplasty.A,Preoperative frontalviewshowsthewidthofthenose andalarbase. B, Preoperativelateralviewshowsthenasalpro-fileanddorsuminrelationtothenasofrontalangleandnasolabialangle.C,Preoperativethree-quarter,or obliqueview,is mostnaturalandoftenrevealingforharmonyoftheorbitalrimsandgullwingsthatflowintothenasaldorsum.D, Preoperativebasalviewis eithertakenfromaboveorbelowthe patientandis agoodviewoftipandbasemorphology.1 3 5 2Part9: FacialEstheticSurgeryFIGURE 65-15PostoperativerhinoplastyA,Postoperativefrontalviewshowsthechangeinthewidthofthenose.Thisisthepatient'smostcriticalanalysis.B,Postoperativelateralviewshowsthechangeindorsalreductionandtip position.C, Postoperativethree-quarter,orobliqueview,demonstratesthe symmetryandgracefulbalanceofthenose withthe face.D, Postoperativebasal viewshowsthewidthofthenose andanytipdeviationfromthedorsalmidline.Thepostionoftheradixshouldthenbe assessedintermsofitsanteroposteriorandverticalpositionsfroma profileview.TheradixshouldlieinaverticalplaneRadixFIGURE 65-16Positionofthenasaldorsumandradix.Thenasaldorsumis typically2mmbehindalinedrawnfromtheradixtonasaltipinwomen.Inmenthenasaldorsumtypicallyliesonthisline.Theradixshouldliebetweenthe uppereyelidmarginandthe supratarsalfoldsinavertical planeandapproximately4to9 mmanteriortothecornealplane.AdaptedfromAustermann,K.,Rhinoplasty:planningtechniquesandcomplications.In:BoothPW,Hausamen}E, editors.Maxillof'acialsurgery.NewYork: ChurchillLivingstone;1999. p.1380.somewherebetweenthelashlineandthesupratarsalfolds.Inadditionitshouldbe4to9mmanteriortothecornealplane(see Figure 65-16).Nasal DorsumInwomenthenasaldor-sum should lie approximately 2 mm poste-riortoa linedrawnfromtheradixtothenasaltip.Inmalesthenasaldorsumshould lie on this line or slightly in front ofit(see Figure 65-16).Thelengthofthenose(radixtotip)canbemeasuredclinicallyoronpho-tographs taken during the initialexamina-tion. The ideal nasal length should approx-imatethedistancefromstomiontomentonifthelowerfacialheightispro-portionatetothemiddlefacialheight(glabellatosubnasaie).Ifthelowerfaceheightisnotproportionateitisbesttoestimatethenasallengthas 0.67 timesthemiddlefacialheight.NasalTipDefinitionThenoseshouldhavefourtipdefiningpointswhichwhendrawnonthenoseinthefrontalviewappearas twoequilateraltriangles(Figure65-17). Thesepointsincludethesupratipbreak,thecolumellar-lobularangle,andthe two tip-defmingpoints(the most pro-jectedportionof the nasaltip)NasalTipProjectionNasaltipprojec-tioncanbedefinedasthedistancethatthetip(pronasale)projectsanteriorinthefacialplane.'"^ Perceptionofnasaltipprojectioncan be influencedby mayfac-tors:upperliplength,nasolabialangle,nasofrontalangle,dorsalhump,andFIGURE 65-17Nasaltip-definingpoints.Anoseshouldhavefourtip-definingpoints.Thesearedefinedbythesupratip,columellar-lobularangle,andthetip-definingpointsofeachinter-mediatecrusofthelowerlateralcartilages.BasicPrinciplesof Rhinoplasty1 3 5 3chinprojection.Thereareseveralmeth-odstodetermineifthenasaltipprojec-tionisadequate.Mostcosmeticrhino-plastyproceduresaredesignedtopreservetipprojection.ThesimplestmethodtorememberisSimons' method, which states that the lip-to-tipratiois1:1. Essentially thelengthoftheupperlip(fromsubnasale to labrale superi-oris)shouldequalthenasalprojection(measuredfromsubnasaletopronasale).This methodmay beinvaUd because of thewide variation in lip lengths.'^TheGoodemethodisanotherway ofdeterminingnasalprojection.UsingtheGoodemethodalineisdrawnfromtheradix to the nasal tip. A second line is drawnfromtheradbttothealarcolumellar junc-tion. A thirdline is drawnperpendiculartothisandpassesthroughthenasaltip.Goode's analysis states thatif thenasofacialangle is between 36 and 40, then the lengthoftheperpendicularlinepassingthroughthenasaltipshouldbe0.55to0.6ofthelength ofthenasal dorsum(Figure 65-18)."^Rohrichdescribesanothertechniqueofassessingnasaltipprojection.Ifthenasaldorsallengthisappropriate,thetipprojectionshouldbe0.67timestheidealnasal length. The ideal nasal lengthshouldbeequaltothedistancefromstomiontomentonor1.6times the distancefromthenasaltipto stomion.Thetip projectionismeasuredfromthealarfacialjunctiontothe nasal tip.''' Thismethodis subjectto agreat deal of facialvariation.Additionallyaverticallinedrawnfromthemostprojectedportionoftheupperlipshoulddividethenoseintwoequal halves betweenthe alar facialgrooveandthe nasal tip. If the anterior portionisgreater than60%, thenthe nose is likely tobe overprojected(Figure 65-19).'''Nasal tip RotationThenasaltiprotationis evaluatedby thenasolabial angle andthecolumellar-lobular angle. Nasolabial angle isdefinedas the angle formedby lines that aretangentialtothecolumellaofthenoseandthe philtrumof the lip andintersectatthesubnasale.Inwomenthisshouldbeapproximately95to110,whereasinmenthis shouldbe 90 to95. Lip positionmaybedependentontoothposition.Thecolumellar-lobularangleisdefinedastheangleformedbytheintersectionofalinetangentialtothecolumellaanda linetan-gentialtotheinfratiplobule. Thisangle isnormally between 30 and 45.Tip SupportThe strength ofthecartilagein the tip of the nose is apparent whenonepressesonthetip. A nose withpoorsup-portmayrequirecartilaginousstrutstocounteracttheinherentlyweakenedtipfromtherhinoplasty.Theeffectoffacialanimationshouldalsobenoted.Somepatientshaveoveractivedepressorseptinasimuscles,whichresultinadroopingnasaltiponsmiling.Thecolumellashowonalateralviewshouldbe3to4mmbelow the inferioralar riFrontalViewWidthofNasalDorsumThewidthofthenasalbodyandtipshouldbeapproximately80%ofthealarbase width.Thisis assumingthatthealarbaseisinproperanatomicproportions.Thealarbasewidthshouldapproximatetheintercanthaldistance.Ifthewidthofthenasaldorsumissignificantlygreaterthan80%,thenlateralnasalosteotomiesshouldbeconsidered.Theeyebrowsshouldgracefullyflowintothenasaldor-sumanalogousto a gull wing in fiight.Thealarrimsandcolumellashouldalsobeagentlycurvinglinethatappearsas a birdinflight.AlarWidthThealarbasewidthshouldapproximate the intercanthal distance. Sel-domis the nasal widthless thantheinter-canthaldimension.BasalViewFromabasalviewthecolumella-to-lobuleratioshouldbe2:1.Nostrilsizeandshapeshouldalsobenoted.Anestheticnostrilisteardrop36-40'FIGURE 65-18Goode methodofnasal projec-tion.Thismethodis sometimesused to deter-mineadequacyofnasalprojection.Ifthenasofrontal angle is between 36 to 40, then thelength of a perpendicularline through thenasaltip should be 0.55 to 0.6 the lengthofthenasaldorsum. x-nasal length.Adapted jrom Auster-mann, K., Rhinoplasty: planning techniques andcomplications.In: Booth PW, Hausamen JE,edi-tors.Maxillofacial surgery.NewYork:ChurchillLivingstone;1999. p. 1380.FIGURE 65-19Nasal projection.Averticallinethrough the most projected partof the upper lipshould divide the nose into two equal parts. If thenasal tip comprises >60%, then the nose may beoverprojected.1 3 5 4Part9: FacialEstheticSurgeryshaped, butthere is a great amountof eth-nic variation(Figure 65-20).ObliqueViewTheobliqueviewismostnaturaland sometimes more revealing thanstandardphotographs.Itdemonstratestheflow ofsubunitsandfacialharmony.Thethree-quartersviewishowweusuallyseeeach other in routineinteraction.Functional ConsiderationsAlthoughthepatientdesirescosmeticcor-rection of their nose, the functionalsignifi-cance of the nose should be closely consid-ered.Nasalairflowthroughboththeinternal and external nasal valves should beevaluated. The septumshould be evaluatedfor deviation and perforations. The septumisoftenagoodsiteforharvestingautoge-nouscartilageforgrafting.Theturbinatesshouldbeevaluatedforhypertrophy.Rhinoscopywitha nasalspeculumcanbeperformedbothbeforeandaftertheadministrationof a topicaldecongestant.PhotographsTheexaminationis notcompletewithoutstandardizedfacialphotographs.Thestandardfacialphotographsshouldincludefrontal,right,andleftlateralviews; rightandleftobliqueviews; andahighandlowbasalview.Close-upviewsaretakenifwarranted.Thephotographsarebeneficialfromamedicolegalstand-point,andtheyalsoallowthesurgeontoFIGURE65-20Columella-to-lobuleratio.Thecolumella-to-lobuleratioshouldbe 2:1.studythenoseinmoredetailandtodevelop a surgicalplan.AnesthesiaProperanesthesiaof the nose is importantto ensureminimal distortionof the tissuesas well as toprovideadequatehemostasis.Priortoinjectingthenose,cottonoidsorcotton-tippedapplicatorssoakedin4%cocaineoroxymetazolineareplacedineach nostril to constrict the mucousmem-branes of the turbinates. If therhinoplastyistobeperformedundersedation,thencocaineispreferredbecauseofitsanes-theticproperties.Iftheprocedureisper-formedundergeneralanesthesia,thenoxymetazolineissufficient.Threecottonoidsareplacedineachnostril:onealongthemiddleturbinate,onealongthesuperiornasalvault,andonealong the inferomedialseptum.Localanesthesiaisachievedwith2%lidocainewith1:100,000epinephrine.Inanendonasalrhinoplastythefollowingareas areinjected:0.5ccdepositedatthejunctionofeachupperandlowerlateralcartilage(intercartilaginousarea)0.5cc depositedintheregionofeachmarginalincision3 cc along the nasal dorsumandlater-al nasalbones(huggingperiosteum)1 cc alongthe nasalseptum0.5cc at eachalar base1 cc ateachinfraorbitalnerve1 cc at the nasal tipFor external rhinoplasty thefollowingadditionalareaisinjected:1 cc to thecoiumeilaIncisions/SequencingTherearemultipleincisiontechniquesusedtogainaccesstothecartilageandbonesupportof the nose.Complete TransfixionThis incisionprovides access to the caudalseptum,medialcrura,andnasalspine.Theincisionis madewitha no.15 blade,beginning justcaudalto the superiorcau-dalendofthenasalseptum. Theincisionextendsinferiorlythroughthemembra-nousseptum,followingthe cephalicmar-ginofthemedialcrura(seeFigures65-7and65-21A).Itresultsinptosisanddeprojectionof thenose.Partial TransfixionThisincisionissimilartothecompletetransfixionincisionexceptthatit stopsatthelevelofthemedialfootpadsofthelowerlateralcartilages.Theadvantageofthis incisionis thatthe attachmentsofthemedialfootpadsof thelowerlateralcarti-lagestothecaudalseptumarenotdis-rupted(see Figures 65-7 and65-21B).HemitransfixionThis incision is a complete transfixioninci-sionthatis performedononlyoneside ofthemembranousseptum.Itdoesnottra-versebothmucosalsurfacesandthereforesomeattachmentsofthemedialcruratothecaudalseptumaremaintained.Accesstothenasalseptumis goodwiththisinci-sion; however,deliveryofthelowerlateralcartilage on the side opposite to the incisionis difficult(see Figures 65-7 and 65-21C).Killian IncisionThis incision is seldom used inrhinoplasty.Itis ausefulincisiontogainaccess tothenasalseptumifonlya septoplastyis tobeperformed.Theincisionismadeseveralmillimeters cephaladtothe caudaledge oftheseptum.Itcanbeextendedontothenasal floorifneeded.Intercartilaginous IncisionThis incision is made at the junctionof theupperandlowerlateralcartilages.Thenareiselevatedsuperiorlywithadoubleskinhook.Ano.15bladeshouldpassbelow the lower lateral cartilage andabovethe upper lateral cartilages. This incision istypicallymade aftera transfixionincision.TheintercartilaginousincisionisthenBasic Principlesof Rhinoplasty1 3 5 5ACompletetransfixionPartial transfixionHemitransfixionFIGURE65-21Transfixionincisions.A, Acomplete transfixion incisionis made caudal to both themedial crura and throughthe membranous septum. B, A partial transfixionincisionis similar exceptthe incision stops short of the medial foot pads of the medial crura.C, Ahemitransfixion incisionis acompletetransfixion incisionthat is performed only on one side,therefore the other medial cruraandfootpadis not violated.connectedtothetranslEixionincision(seeFigures 65-8, 65-9, and65-22).Intracartilaginous IncisionThisincisionismadethroughhoththevestibularnasalmucosaandaportionofthe lower lateral cartilages. This incisionissimilartotheintercartilaginousincisionexceptthatit is made 3 to 5 mmposteriorto the junctionof the upperand lower lat-eralcartilages. Thisincisionineffectper-formsacompletecephalicstripofthelowerlateralcartilageswithouttheneedfordeliveringthecartilage. Thedisadvan-tage is thatthe lower lateral cartilage is notdirectly visualizedanditmay thereforebedifficultoachievesymmetrybetweentheright and leftsides.Rim/MarginalIncisionThisincisionparallels thecaudaledgesofthe lowerlateralcartilages. Theincisionisusedincombinationwithanintercarti-laginousincisioninanendonasalrhino-plasty.Thetwoincisionsallowthelowerlateralcartilageto be deliveredand visual-ized.Thisallowsthesurgeontomoreaccuratelytrimthecartilageifneeded.Inanopenrhinoplastythisincisioniscom-binedwithatranscolumellarincisioninordertogainaccesstothelowerlateralcartilage and nasal dorsum(Figure 65-23).Transcolumellar IncisionThis incisionis made throughthethinnestportionofthecolumellaataleveljustsuperiorto the flaringof the medialcrura.TheincisioncanbemadewithanotchedVinthecenterofthecolumellaorasa"stair step." This will break up the scar andassist in closure. This incisionis connectedwithamarginalincisionbilaterallyforopenrhinoplasty(see Figure 65-23).Thetwoprincipletechniquesaretheendonasalandexternalrhinoplasty.Eachofthesetechniqueswillbedescribedingeneralterms,intheorderinwhichtheauthorsperformthem.Othersurgeonsmayperformthesequenceinadifferentorder(Tables 65-3 and65-4).SeptoplastyIn rhinoplasty surgery there are several rea-sons to access the nasal septum: (1) to cor-rectnasalairflowobstruction,(2)toassistinthecorrectionofasymmetries,and(3)to harvestcartilage fortipgrafting.Accesstothenasalseptuminanendonasalapproachisthroughapartial-transfixionincision, whichis connectedtobilateralintercartilaginousincisions.Thepartial-transfixionincisioncanheextend-edtothenasalflooronthe side onwhichtheseptoplastyistobeperformed.Aftercompletingtheincisionsthe caudalaspectofthenasalseptumis exposedbydissect-ingthemucoperichondriumfromone1356Part 9:Facial EstheticSurgeryFIGURE 65-22Intercartilaginousincisions.The intercartilaginousincisionis made at the junction ofthe upper and lower lateralcarti-lages.The blade should pass belowthelowerlateral andabove theupperlateralcartilage. AdaptedfromAlexanderR. Fundamentalterms,considerations,andap-proachesin rhinoplasty.In:WaitePD, editor. Atlasof theoral andmaxillofacialsurgeryclinics ofNorthAmerica:rhinoplasty.Philadelphia(PA): W.B.Saun-ders;1995. p.19.FIGURE 65-23Marginal incision.Thisincision is made parallel tothe caudaledge of the lowerlater-alcartilage.Thisincision canbecombined withbilateralintercar-tilaginousincisions foracartilagedeliverytechniquein endonasalrhinoplasty orcombinedwithatranscolumellarincisionforanexternalrhinoplasty.AdaptedfromAlexanderR. Fundamentalterms,considerations,andap-proachesin rhinoplasty.In:WaitePD, editor.Atlasoftheoralandmaxillofacialsurgeryclinics ofNorthAmerica:rhinoplasty.Philadelphia(PA): W.B.Saun-ders;1995. p.19.side.Twotunnelswillbedeveloped,onesuperiorandthe otherinferior,whichwillultimatelybe joinedso that wideexposureoftheseptumisobtained.'^Intiallysharpdissectionisdonewitbano.15bladeorscissorstoexposeaportionofthecaudalseptum.Thepericbondriumisgentlyscored using a no. 15 blade. A dental amal-gamcondenseris thenusedina sweepingmotiontodevelopaplanebetweentheperichondriumand tbe nasal septum(Fig-ure 65-24). Once tbis plane of dissection isstartedaFreerorCottleelevatorcanbeused tocompletethe septal envelope(Fig-ure65-25).Themucoperichondriumistightlyboundatthejunctionofthesep-tumandthe maxillarycrest.Oncetbeseptumis exposeditcanbetreatedinfourways:(1)resection,(2)morselization,(3)segmentaltransection,and(4)swingingdoorflaps.'^Submucos-al resectionallows a significantportionofcartilagetobebarvestedforgrafting.Atleast1 cm sbould be maintainedsuperior-ly andanteriorlyinanL-shapedconfigu-rationtoprovidesupportforthenose(Figure 65-26). In order to resect the carti-lage a Cottle elevator is used to cut the car-tilage.FomonscissorsmaybeusedtomaketbesuperiorandinferiorcutsTable 65-3SurgicalSequence forEndonasalRhinoplastyThe1.2.3.4.5.6.7.8.9.!0.11.general sequence isLocalanesthesiaPartialtransfixionincision(see Figure65-7)Intercartilaginousincision(joinwithpartialtransfudon)(see Figures 65-8, 65-9, 65-21,and65-22)Septoplasty(if needed)(see Figures 65-24 and 65-25)Dorsal reduction(see Figures65^28-65-30)Lateral nasal osteotomies(see Figure 65-31)Marginalincision(seeFigure 65-23)Delivery of lowerlateraicartilages(seeFigure 65-37)Tip modification(ie, cephalicstrips/cartilagegrafting/suturetechniques)Alar basemodification(see Figure 65-41)Closure, taping, andsplintingTable 65-4Surgical Sequence forExternalRhinoplastyThe generalsequence is1.2.3.4.5.6.7.8.9.10.11.12.LocalanesthesiaBilateralmarginalincisions(see Figure 65-23)Columellarincision(see Figure65-23)Skeletonizationof upperand lowerlateralcartilages and nasaldorsumDorsalreductionDome divisionif access is neededto the septumfor septoplasty orgraftharvestSeptopiasty(if needed)TurbinatereductionLateral nasalosteotomiesTip modification(ie, cephalicstrips/cartilagegrafting/suturetechniques)Alar basemodificationClosure, taping, and splintingBasicPrinciplesof Rhinoplasty1 3 5 7FIGURE 65-24Identifyingperichondrium.Theperichondriumiselevatedwithadentalamal-gamcondenser.Onewillnoticeaslightblue-graycartilageanda distinctplaneofdissection.FIGURE65-25Elevationofmucoperichondri-um.TheCottleelevatoris specificallydesignedtoelevatethenasalenvelopewithoutperforation.throughthebonyseptum.Thecartilagecan also be removed with a Ballenger swiv-elblade.Ifnocartilageisneededfortherhinoplasty,theresectedcartilagecanbemorselizedandreplaced.Morselizationcanbeperformedinsitu.Anothertech-niquefor aligning the septumis through asegmentaltransection.Inthistechniquethemucoperichondriumiselevatedononesideoftheseptum.Cross-hatchingwitha no.15 bladeis performedto weak-enthecartilage(Figure65-27).Themucoperichondriumontheothersideofthe septum provides support. 4-0 gutmat-tresssuturescanhepositionedthroughthe septumto assist in realignment. A sep-talsplintisplacedfor1 week.Finallyaswingingdoortypeflapcanbeusedtorepositiona large segmentof flat cartilage1 cmL-shapedstrutRemoval of deviatedseptum or cartilageobtained for graftingFIGURE 65-26Resection of cartilage/bonefromthe nasal septum.Thismaybe doneto harvest cartilageforgrafring procedures or forremoval of grossly deviatedseptum.It is importantto maintain1 cmdorsal-ly andcaudally fornasalsupport.SeptumScoring on concavesideSection of crest andseptumremovedFIGURE 65-27Septalrepositioning.Adeviatednasalseptumcanberepositionedbyremovingtheobstructioninferiorly(A)andcross-hatchingthecartilageto allowthedeviatedportiontohereposi-tioned(B).AdaptedfromRobinsonRC.Functionalseptorhinoplasty.In:WaitePD, editor. Atlasoftheoral andmaxillofacialsurgeryclinicsof NorthAmerica:rhinoplasty.Philadelphia(PA):WB.Saun-ders;1995.p.35.thatisimproperlyangulated.Themucoperichondriumiselevatedononeside.Throughandthroughincisionsaremadeoneithersideofthedeviatedcarti-lage.Thecartilageisalsoseparatedfromthe maxillary crest so thatit can hinge intoa more normal position. Septal splints maybe requiredfor1week. In all septalproce-dures a 4-0 gut on a straightneedle is rou-tinelyusedtoperformamattresssuturethroughtheseptumandmucosa.Thisdecreasesthelikelihoodofaseptalhematomaformationandcircumvents theneedfornasal packs.1 3 5 8Part9: FacialEstheticSurgeryTearsintheseptalmucosaarenotuncommon. However, it is notproblemat-ic as longas the tears are only onone sideoftheseptum.Unilateraltearsrequirenoelaborateclosure.Ifthetearisthroughandthrough,atleastonesideshouldbeclosed.Thisisbestdonewitha5-0chromicgut suture.TurbinectomyAlthoughthefocusofthischapteristhecosmetic rhinoplasty, some mentionneedsto be made onmaintainingfunction.Infe-riorturbinatehypertrophyisaproblemthatcanresultinnasalobstructionaftercosmeticrhinoplasty, if the problemis notrecognizedpreoperatively. Hypertrophy oftheinferiorturbinatesisthemostcom-mon cause of nasal airway obstruction.'^'^"Hypertrophycanbecausedbynumerousfactors.Mostcommonlyitisrelatedtoallergic symptoms. Hypertrophy caused byallergy shouldbe managedmedically withantihistaminesand topicalcorticosteroids.If this fails, then surgical managementcanbeconsidered.^'Incasesofadeviatednasalseptumtheturbinateonthesideatwhichthenasalpassageisenlargedcanbecomehypertrophicwithtime.Inpatients with anatomic enlargementoftheturbinate,theproblemneedsto berecog-nizedsothatthenasalpassagedoesnotbecomeobstructedwhentheseptumisstraightened.Managementofinferiorturbinatehypertrophyiscontroversialandoutsidethe scope of this chapter. The surgical pro-ceduresusedtotreatthisproblemhaveincludedcorticosteroidinjection,turbinateout-fracture,electrocautery,cryosurgery,laserreduction, partialturbinateresection,totalturbinateresection,submucousturbinateresection,andvidianneurecto-j^y 20-24 g(-|^ Qf theseprocedureshas vari-ousadvantagesanddisadvantagesandtheprocedurechosendependsonthepatient.Themostcommoncomplicationsfromturbinatesurgery are hemorrhage, atrophicrhinitis, and ozena.NasalDorsumReductionOneofthemostdramaticchangesthatcanbeachievedinrhinoplastysurgeryiscorrectionofadorsalhump.Therearemanywaystoremovethehump.Somesurgeonsuseascalpelandosteotome,whereasothersuserasps,andafewusepowerrasps. TheauthorsrecommendtofirstincisethecartilaginousconvexitybelowthenasalbonesandthentouseaRubinosteotometoremovethebonyhump(Figures65-28-65-31).Caremustbetakentokeeptheosteotomedirectedsuperficially,sinceitcandefiectdown-wardandresultinover-reduction.Afterremovingthegrosshump,sequentialraspingcanbeusedforrefinement.Afterremovalofanysignificantdorsalhump,the patientis leftwith an openroofdefor-mity.Thismustbeclosedwithlateralnasalosteotomies(see Figure 65-31).AugmentationAugmentationis indicated whenthere hasbeenexcessivereductionfrompreviousrhinoplastyorfromapost-traumaticdefect.Several techniquesare used to aug-mentthe nasaldorsum.AutogenousAugmentationIntheset-tingofacutetrauma,cranialbonegraftscanbe used to provide support. Thesearecantileveredoffthefrontalbonewithaminiplate.ThegraftmustbeproperlyUpper lateralcartilagesNasal bonesFIGURE 65-28Removal of a dorsal hump. A, Vie dorsal hump is removed by first using a scalpel to incisethroughthe upper lateral cartilages.B, Next, a Rubin osteotomeis usedto reducethe bony prominence.Care is needed to keep the osteotome from being directed too far posteriorly thereby over-reducing the dor-sum. Adapted from Austermann, K., Rhinoplasty: planning techniques and complications.In: Booth PW,Hausamen JE,editors. Maxillofacial surgery.New York:Churchill Livingstone;1999.p. 1389.BasicPrinciplesof Rhinoplasty1 3 5 9FIGURE65-29Dorsalreduction.AnAufrichtretractorliftsthedorsaldrapeandcanprotecttheskinduringhumpreduction.Ano.15bladeis usedtoincisethecartilaginousdorsum.Work-ingthroughthisincision,anosteotomeor rasp isusedtoreducetheboneofthedorsum.FIGURE65-30Dorsalreduction.Thedorsumshouldbeabouttwo-thirdsofthecartilageandone-thirdof thebone.FIGURE65-31Lateralnasalosteotomies.Removalofalarge dorsalhumpwilloftenleaveaflatopenroofdeformity,andthiscanbereducedbylateralnasalosteotomieswithaninvertchisel,saw,orrasp.shapedsothatitprovidessupportbutdoesnotdistorttheshapeofthenose,''^"^^Ribcartilagecanalsobehar-vestedforaugmentationofthe nasaldor-sum.Siliconesizerscanbeusedtoesti-matethesizeandshapeofgraftneeded.Oncethegraftisharvested,a0.035inchK-wirecanbeplacedinthecenterofthegrafttostabilizeit.Ribgraftshaveaten-dency to distortwithtime andtheK-wiremay helplimitthistendency.'*^Foralessaggressiveaugmentation,autogenouscartilageharvestedfromthenasalseptumcanbeused.Thiscanbelayeredandsuturedtogether.Itisthenplacedthroughtraditionalrhinoplasty29-31mcisions.Alloplastic AugmentationAnother tech-niqueis touse cadaveric dermisalongthenasaldorsum.Theadvantagehereisthatnoharvesting is requiredandthematerialispliable.However,theresorptionofthismaterialisunpredictable.Otherimplantablematerialsincludesiliconeandexpandedpolytetrafluoroethylene(ePTFE)implants. These can be contouredtotheappropriatesizeintraoperatively.Theissuewithimplantsisthatthegraftscanextrudeorbecomeinfected.Meticu-lous placementis essential.^ ^"^''OsteotomiesOsteotomiesareperformedafterthenasalreductionhasbeenperformed.Thepur-posesoflateralnasalosteotomiesincludereduction of the open nasal roof, correctionof deviated nasal bones, and narrowing of awide nasal base (see Figure 65-31).Therearetwoprincipaltypesofnasalosteotomy:lateralandmedial.Thelateralnasalosteotomycanbeperformedatdif-ferentlevels. It typicallybeginslow onthepiriformrimandcanendeitherhighorlowinitsrelationshiptothenasalbones.Thustheosteotomyisoftentermedasalow-to-lowosteotomyoralow-to-highosteotomy. Theseosteotomiescanbeper-formedviaaninternalorexternaltech-nique.Regardlessofwhichtechniqueisused,limitedperiostealdissectionisfavoredsothatsupportis providedtothenasalbones.Medialosteotomiesaresel-domneededbutcanbeusedtoobtainacontrolledfractureinpatientswiththicknasalbonesorwhenalow-to-lowtech-niqueisused.Also,regardlessoftheosteotomytechnique,theosteotomiesshouldnotbecarriedabovetheintercan-thalline.Theboneabovethispointbecomesmuchthickerandmobilizationbecomesdifficult.Careshouldbetakenwhenperformingmedialosteotomies,since the thickerportionofthenasalbonecanbeincludedinthelateralosteotomysegmentandresultinwideningoftheupper nasal dorsum. This is termeda rock-er deformity.,Lateralnasalosteotomiesarenotalwaysrequiredtocloseanopenroofdeformityafterdorsalhumpreduction.Somesurgeonsbelieveitis bettertoplacespreadergraftsin those patients withshortnasalbonessothatcompromiseoftheinternalnasalvalvedoesnotoccur.Ifanosteotomyisperformedinapatientwithshorternasalbones,thenalow-to-hightechnique is preferred.Nasal TipUnderstandingthemechanismsofnasaltipsupportiscriticalwhenperformingrhinoplasty.Thesurgeonmustunder-standboththedesiredandundesiredchangesthatoccurfromthesurgicalapproachor technique.^^Thethreemajortipsupportmecha-nisms include thefollowing:1.Thesize,shape,andstrengthofthelower lateral cartilages2.The attachmentof the medialcruratothe caudalseptum3.The attachment of the lower lateral car-tilages to the upper lateral cartilagesTheminortipsupportmechanismsincludethefollowing:1 3 6 0Part9: Facial EstheticSurgery1.The interdomalligament2.Thesesamoidcomplex,extendingthesupportof the lateralcrurato the pir-iformaperture3.Theattachmentofthealarcartilagesto the overlying skin4.The cartilaginousseptaldorsum5.The nasalspine6.ThemembranousCertainsurgicalprocedurescanaffecttipsupport.Forexampleacom-plete transfixionincisionwill disruptthefibrousattachmentsofthecaudalsep-tumtothemedialcrurathusleavinglit-tlesupportforthenasaltip.Suturingtechniquesandcartilagestrutgraftsmaybe necessary to reestablishsupportif thisincisionis performed.Intercartilaginousincisions, whichareusefultogainaccesstothenasaldorsum,interrupttheliga-mentousconnectionsoftheupperandlower lateralcartilages. This canresultincephalictiprotation,whichmayormaynotbedesirable. Acephalicstripproce-durecreatesevenfurtherdisruptionandrotationofthelowerlateralcartilages.Mostoftentiprhinoplastyis designedtorefineanddecreasethetiplobulewhilemaintainingorevenincreasingrotationandprojection.The cartilaginous supportof the nasaltipis oftendescribedintermsofatripodconcept.^**'^^ Themedialcruraof boththelowerlateralcartilagestogetherformonestrutofthe tripod,andeachofthelateralcrura of the lower lateral cartilages forms astrut.By selectivelyshorteningorlength-eninganyofthesestruts, thetippositioncan be altered.Thetippositionchangesarereferredtointermsofbothprojectionandrota-tion.Tipprojectionisthedistancefromthetipofthenosetothealar-facialjunc-tion. Increasing tip projectionis one of themostdifficultprocedurestoperforminrhinoplastysurgery.Nasaltipprojectioncan be increased by both graftingand non-graftingtechniques.TipProjectionIncreasingTipProjec-tionNongraftingtechniquestoincreasenasal projectioninclude thefollowing:1.Suturing of divergent medial crura: Forthis technique to be effective there mustbedivergingmedialcrura.Interveningsoft tissue may require excision prior tosuturing with mattress sutures.*'2.Lateralcruralsteal:Thelowerlateralcartilage is skeletonizedand the lateralcruracartilagesaresuturedwithamattresssuturesothatthelateralcruranowcontributestothemedialcrura(Figure65-32).Thisresultsinincreasedprojectionandsomerota-tion asGraftingtechniques toincreaseprojectioninclude thefoUowing:1.Collumellarstrut:Thistechniqueinvolves the placement of a strut of sep-talcartilagebetweenthefeetofthemedialcruraandabuttedagainstthenasal spine. The medial crura are elevat-edsuperiorlywithdoubleskinhooksandthe cartilage strutis suturedto themedial crura via mattress sutures. Onlyaminoramountoftipprojectioncanbe increased with this method.2.Peck graft:Thisis anonlay graftintheregionofthenasal tip. Layers ofcarti-lage areplacedinthedomalregiontoincreaseprojection.Thegraftmaterialis either conchal or septal cartilage. Thecartilageissecuredtothedomebysutures.Thistechniquecanincreaseprojection by 2 to 6 mm (Figure 65-33).3.Umbrella graft: This technique involvesthe creation of a cartilaginous structurethatresemblestheappearanceofanumbrella.Itisusefulwhenbothtipprojectionandsupportof weak medialcruraarerequired.Theumbrellagraftisconstructedfromharvestedseptal,ear, or rib cartilage. It is then sutured inpositionsothatthe"handle"oftheumbrellaisbetweenthemedialcruraandthe "canopy" oftheumbrellarestsatop the dome. The canopy portion canbemodifledtoincorporatethePeckgrafttechniquebystackinglayersofcartilage (Figure 65-34).^^4.Shieldgraft:Thisgraftwasfirstdescribed by Sheen.^" A piece of septalcartilageisshapedtoformatrape-zoidalconfigurationmeasuring6to8 mmsuperiorly and5 mminferiorly.The graftis usually10 to12 mmlongandis beveledsothatthecornersareblunted. The graftis placedin a pock-etthroughanendonasalapproachorsuturedinpositionviaanopenapproach.Thesuperiorandlateralaspectofthegraftformsthetip-definingpoints(Figure 65-35).^BFIGURE 65-32Lateral crural steal A, B, Ahorizontal mattress suture is placed in the lateral crurainorderto increasenasal projectionandnarrowthe nasaltip. Adapted fromTaylorCO. Surgery of thenasal tip. In: Waite PD, editor.Atlas of the oralandmaxillofacial surgeryclinicsof NorthAmerica:rhinoplasty Philadelphia(PA): W.B.Saunders;1995. p. 61.Basic Principlesof Rhinoplasty1 3 6 1FIGURE65-33Peck graft.Thisinvolves the place-mentof layers of cartilage grafts in the region of thenasal tip to increase nasal projection. AdaptedfromTaylor CO.Surgeryof thenasaltip. In:WaitePD,editor. Atlasoftheoral andmaxillofacialsurgeryclinicsofNorthAmerica:rhinoplasty.Philadel-phia(PA):W.B. Saunders;1995.p.62.DecreasingTipProjectionDecreasingtipprojectioninvolvesreductionoftbetipsupportingmechanisms.Acbievingacceptableresultswhendecreasingpro-jectioncanbe difficultsince nasaldefini-tioncanbelost.'''Iftbenasalprojectionneedstobedecreased,becertaintofirstconfirmtbatthe problemis not theresultofanopticalillusioncausedbyalowradixposition.Iftheproblemisalowradix,thenadorsalradixgraftistheappropriatetreatment.Methods to decrease projectionincludethe following:1.Completetransfixionincision: As dis-cussedabove,acompletetransfixionincisionwilldecreasetipsupport.Intercartilaginousincisions or cephal-ic stripswillalsoweakentbetipsup-portbutwillincrease tiprotation.2.Lowertheseptalangle:Iftbeseptumis providing significantsupportfor thenasal tip, then the septal angle must belowered. Thisis doneby excisionof aportionofthecaudalseptum.Addi-tionallythe medialcruracanbe sepa-ratedfromtbecaudalseptumtodecreaseprojection.3.Cruralexcision:Todramaticallydecrease tip projectionthe medial andlateral crura may need to be sectioned,overlapped,andsuturedintoanewpositionwitblessprojection.Tbistecbnique maintains the naturalshapeof the tip at the domes(Figure 65-36).Excisionofa segmentcartilageinthedomesandsuturingthembacktogetbercanbedone,butitwillcbange the shape of the nasal tip.Sometimes,afterdecreasingthenasalprojection,the patientmay have flaringofthealaandincreasedinfratipcolumellarshow. This can be treatedwith an alar baseresection butshouldbeusedjudiciously.TipRotationIncreasingTipRotationUnderstandingthetripodconceptandtipsupportingmechanismsisimportantwbendeterminingwbichof thefollowingmethods touse toincreasetiprotation.1.Removal of dorsal hump: A subtle waytoincreaserotationofthetipistoreduce a dorsal humpif present.2.Resectionofthecaudalseptum:Asmall triangular piece of caudal septumcan be removed. Tbe base of thistrian-gular shape is at the nasal dorsum.3.Cephalic strips fromlower lateral carti-lages: A complete strip of cephalic carti-lage fromthe lower lateral cartilages willresultinincreasedtiprotation. Even anintercartilaginousincisionwill resultinsome tip rotation(Figure 65-37).4.Shortenthe lateralcrura5.Shieldgraft:Ashieldgraftgivestheillusioncfincreasedtiprotation.6.Augmentationofpremaxiila:Place-mentof cartilage or ePTFB in the pre-maxiilaregionbelowtheanteriornasal spine will also give the illusion ofincreasedtiprotation.Decreasing TipRotationDecreasingtiprotationis doneby two methods:6-8 mmFIGURE65-34Umbrella graft.Thisisessentiallyacolumellarstrutgraft placedbetweenthemedi-al crura, combinedwitha tip graft.Thistechniqueimprovessupportofthemedialcruraaswellasincreasesnasalprojection.AdaptedfromTaylorCO.Surgeryofthenasaltip.In:WaitePD,edi-tor. AtlasoftheoralandmaxillofacialsurgeryclinicsofNorthAmerica:rhinoplasty.Philadel-phia(PA):W.B. Saunders;1995.p.61.10-12 mmFIGURE 65-35Shieldgraft.A, B, Thisis a graftingtechniqueusedto redefinethetip-definingpointsofthenose.Thegraftis typically6to 8mmwidesuperiorly,5mtnwideinferiorly,and10 to12mmlong. AdaptedfromTaylor CO. Surgeryof the nasaltip. In: WaitePD, editor. Atlasof the oral andmax-illofacial surgeryclinics of NorthAmerica:rhinoplastyPhiladelphia(PA):W.B. Saunders;1995.p.62.1362Part 9:FacialEstheticSurgery1.Trim the caudal septumnear the ante-riornasalspine2.Augment the nasal dorsum: this createsthe illusion of decreased tip rotation.Tip ShapeIn additionto changing the tipposition, the tip shape must also be consid-ered.Historicallychangestothenasaltipwereperformedbyselectivecartilage exci-sionandreapproximation.TheGoldmantipis anexampleofsucha technique. Thecurrenttrendistopreserveandre-orientexistingcartilageandplacecartilaginousgraftsifrequired.**^Excessivegraftingcanbe unpredictable in the long run.Althoughcartilagepreservationisemphasizedthereis stiU sometimesa needto remove cartilage. There are three princi-paltechniquesofcartilageexcisioninthenasal tip region: a complete strip technique,aweakenedcompletestriptechnique,andaninterruptedstriptechnique.AgreaterOverlappedcartiiageFIGURE 65-36Crural excision. Thisis usedwhenthenasaltipneeds dramaticdeprojection. Apor-tionof the lateral crura is excised andthe ends aresuturedback together.resectiongenerally results in moredramat-ic tip narrowing androtation.Completestriptechniquesinvolve theremovalofacompletepieceofcartilagefromthecephalicendofthelowerlateralcartilages(seeFigures65-37and65-38).This procedureis thoughtto bemoresta-blesinceitleavesanintactstripoftheinferiorborderofthelowerlateralcarti-lage. Aggressive resectioncan result in lossoftipsupport,alarnotching,alarretrac-tion, andthe appearanceofincreasedcol-lumellarshow.Mostsurgeonsfeelthataminimumwidthof6mmisrequiredtomaintainthestructuralintegrityofthelower lateral cartilage.The weakened complete strip techniqueinvolves the removal of a complete cephalicstrip followedby weakening of the cartilageby selective morselizationof the medial andlateral crura with a scalpel blade.Aninterruptedstripinvolvesdivisionofthe lateral crurafromthe dome(Figure65-39).Thistechniqueprovidesgreaterrotationthana completestrip butcan alsoresultincomplications,includinglossoftip support,alarnotching, andalarretrac-tion. In additionthe nasal tip can develop apinchedappearance. TheclassicGoldmantipisanexampleofaninterruptedstripFIGURE65-37Deliveryoflowerlateralcarti-lage.Thelowerlateralcartilageisbestdeliveredbyamarginalincisionorexposedthroughanopenrhinoplastyfordirectvisualizationandsurgicalmanipulation.Tiprefinementisimprovedinthiscasebycompletetipreductiontoreducethevolumeofthetip.Maintain6mmwidthFIGURE65-38Completestriptechnique.Thisinvolvestheexcisionofastripofcartilage onthecephalic portionof the lower lateral cartilage. Thiswillresult inincreased tip rotation.Itisimportanttomaintainaminimumoj 6mmwidthofcarti-lage forstructuralsupportofthenose.AdaptedfromTaylorCO.Surgeryofthenasaltip.In:WaitePD, editor. Atlasof theoral andmaxillofa-cial surgeryclinics of NorthAmerica:rhiiioplasty.Philadelphia(PA):W.B.Saunders;1995.p.58.technique(Figure 65-40). In this techniquethelateralcruraaredividedlateraltothetip-defmingpoints.Themedialsegmentsare suturedtogether, whichresultsinitiallyinincreasedtipprojection.Thelateralcruralsegmentsareleftaloneasindepen-dentunits.Thisprocedureisnolongercommonlyused becauseofproblemswithtipasymmetry, pinchedappearanceofthenasal tip, and long-termtip ptosis.Forpatientswithabroadnasaltip,transdomalsuturingtechniquesareoftenused to narrow the tip. Volume reduction isperformedfirstif neededby cartilage exci-sionasdescribedabove.Next,excisionofexcessiveinterdomalsofttissueisper-formed.A 4-0polydioxanonetransdomalsutureisplacedinahorizontalmattressfashiontonarrowandre-orientthealarcartilages. The advantageof thistechniqueisthatthesuturingcanbedonemultipletimes until the surgeonis satisfied withtheresult. Additionally the long-termresults ofthis technique have beenfavor able.'BasicPrinciplesof Rhinoplasty1 3 6 3ExcisedcartilageFIGURE 65-39Interruptedstriptechnique.Thisis similarto the completestripexcepttheremain-ingcartilageis also dividedinaverticalfashion.Thisallows forevengreatertiprotation,asindi-catedbythearrow;however,itcanresultinapinchednasaltipandfunctionalproblems.Thecartilage canbe weakenedby scoring itin averti-cal fashionandthisistermedaweakenedcom-pletestriptechnique.AdaptedfromTaylorCO.Surgeryofthenasaltip.In:WaitePD,editor.Atlasoftheoral andmaxitlofacialsurgeryclinicsofNorthAmerica:rhinoplasty.Philadelphia(PA):W.B. Saunders:1995.p.59.Nasal Base AlarReductionThealarbaseshouldapproximatetheintercanthaldistance andbe no more than1to2mmwiderthanthis.Thenostrilsshouldhaveasymmetricappearance.Asymmetryof the nostril is oftendue to adeviatednasalseptumandthisshouldbereevaluatedpriortoconsiderationofanalarbaseresection.The primary proceduretoreducethealarbasewidthisanalarbaseresection.Alarmodificationisoftenconsideredincases wherethenose hastobedeproject-edortobalancetheanatomyincertainethnictypes.Itismandatorytobecon-servative whenperformingalarreductionsinceitisdifficulttocorrectanover-reduction.Ifthereisanydoubt,thesur-geonshoulddelay the alar basereductionuntila later date.^^Theprocedureis performedby excis-ingasmallwedgeofvestibularmucosaArea of skinto be excisedFIGURE65-40Coldmantip.Thisisaninter-ruptedstriptechniqueinwhichthelateralcruraare dividedlateralto thetip-definingpoints.Tlicmedialsegmentsarethensuturedtogethertoincreasenasaltipprojectionandtonarrowthenasaltip. AdaptedfromWillis AE,Costa LE.Sur-gicalmanagementofthenasalbase.In:WaitePD,editor.AtlasoftheoralandmaxillofacialsurgeryclinicsofNorthAmerica:rhinoplasty.Philadelphia(PA):W.B. Saunders;1995.p.61.andskin.Theangulationcanbeadjustedsothatgreaterreductionoftheouterperimeterofthealaisreducedandonlylimited reduction oftheinternalperimeterisperformed.^^Theexcisionshouldbeconservative and will rarely be greater than3 mmin width(Figure 65-41).PostoperativeManagementAfterperformingtherhinoplastythesurgeonmustdecidewhetherintranasalstentsorpackingis necessary. We gener-allydonotplacenasalpacking.Iftheseptumrequiresadditionalsupportdur-inghealing,thensiliconestentsareplaced. Thesestents are alsousedif therearemucosaltearsorifaturbinectomywasperformed.Thestentshelpreducetheincidenceofsynechiaeformation.Thestentsare securedtoeachotherby a3-0silksuturepassedthroughthecol-umellaandaretypicallyleftinplacefor1week.Next the nasal dorsumis splinted. Ben-zoin or mastisol is painted on the nasal dor-sumandl/iinchbrownpapertapeisapplied.Afterplacementofthetapethesphntis applied. A metalDenversplintorthermoplasticsplintiscontouredandapplied.Additionalpapertapecanbeplaced over the splint.FIGURE 65-41Alarbase reduction(Weir'sexci-sion).A,Thisismedtonarrowanoverlywidenostril.B, A smallamountofvestibularmucosaandskinisexcisedandsuturedtogether.Theexcisionis usuaUy1 to 2mmwideReferences1.RohrichRJ, HuynB, MuzaflarAR, et al.Impor-tanceofthedepressorseptinasimuscleInrhinoplasty:anatomicstudyandclinicalapplication.PtastReconstrSurg2000;105:.'576-83; discussion 384-8.2.HollinsheadW.Anatomyforsurgeons:theheadandneck.3rded.Philadelphia(PA):Lippincott-Raven;1982.3.RohrichRJ, MuzaffarAR. GunterJR Nasaltipbloodsupply:confirmingthesafetyofthetranscolumellarincisioninrhinoplasty.PlastReconstr Surg2000;106;1640-l.4.ToriumiDM, Mueller R, GroschT, et al. 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